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  • ACADEMY OF MEDICAL PSYCHOLOGY

    TENETS FOR PSYCHOPHARMACOLOGYTRAINING FOR PSYCHOLOGISTS 2002

    Copyright 2002 Revised October 2003

    Includes:

    1. Course Curriculum Recommendations*2. Preceptorship Module Recommendations*

    *These are the criteria utilized by AMP to accredit psychopharmacology trainingprograms, psychopharmacology preceptorship experiences, and to evaluate AMP

    applicants.

    Acknowledgements:

    American Psychological AssociationRecommended Guidelines for Psychologist Psychopharmacology Training (1996)

    The Psychopharmacology InstituteCoursework and Preceptorship Training in Psychopharmacology for Psychologists

    (1997)

    American Society for The Advancement of Pharmacotherapy(APA Division 55)

    Approved By The Academy of Medical Psychology BoardOctober 2003

  • ACADEMY OF MEDICAL PSYCHOLOGYTENETS FOR MEDICAL PSYCHOLOGY & PSYCHOPHARMACOLOGY TRAINING &

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    Acknowledgement

    The board wishes to express its gratitude to Dr. Matthew B.R. Nessetti for his extensiveand encompassing review of the medical psychological literature. Dr. Nessetti s effortshave resulted in a concise operationalization of those things that the board considers to bethe relevant tenets for the practice of medical psychology. Others have contributed to thiseffort but the creative work of Dr. Nessetti allowed it to become a reality.

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    Clinical Anatomy & PhysiologyA. Anatomical and Medical TerminologyB. Anatomical VariationsC. Skin and FasciaD. Skeletal SystemE. Muscular SystemF. Circulatory & Cardiovascular SystemG. Lymphatic SystemH. Respiratory SystemI. Reproductive SystemJ. Endocrine SystemK. Gastrointestinal SystemL. Urinary SystemM. Nervous System

    BiochemistryA. Psychoactive brain receptor responsesB. Functioning of neurotransmittersC. Enzymatic actionsD. Generating energyE. CarbohydratesF. LipidsG. Amino acidsH. PeptidesI. ProteinsJ. EnzymesK. HormonesL. VitaminsM. Genetics

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    PathophysiologyA. Concepts of Health & DiseaseB. Genetic and Congenital DisordersC. Alterations in Nutrition and MetabolismD. Dysfunctions of Hematopoietic FunctionsE. Alterations in ImmunityF. Cardiovascular DysfunctionsG. Respiratory DysfunctionsH. Pathologies in Renal Functions, Electrolytes and Fluid BalanceI. Review of Imbalances in Acid/Base of the Human BodyJ. Gastrointestinal DysfunctionsK. NeoplasmsL. Endocrine PathologyM. Genitourinary and Reproductive PathologiesN. Nervous System DysfunctionsO. Alterations in Vision, Vestibular and Auditory FunctionP. Dysfunctions in Musculoskeletal SystemQ. Review of pathologies of the Integumentary SystemR. Special Consideration of the Iatrogenic Pathologies

    1. General Care2. Specific to Psychopharmacology

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    NeurobiologyA. Neuroanatomy

    1. Overview of anatomy, physiology, and pathophysiology2. Brain: basic anatomy3. Functional neuroanatomy (anatomy, normal brain functioning, and

    manifestations of pathology)a. Brain stem, hind brain, mid-brain, and reticular formation,b. Pathways for major neurotransmitter systems.c. Complex inter-relationships between limbic system, hypothalamus and the

    pituitary glandd. Diencephalone. Basal gangliaf. Cortical regionsg. Lateralization and inter-hemispheric communications

    4. Nervous system on a cellular levela. Intercellular communication,b. Intracellular electrochemical activity

    i. Gene expressionii. Second messenger systems

    c. Receptors5. Functional neuroanatomy, neurophysiology and psychiatric disorders

    a. Depression / bi-polar depression and monoamine hypothesisb. Photic stimulation and seasonal affective disordersc. Medication effects, side effects, on multiple organ systems

    6. Neuropathology: overview of clinical features of common neurologicaldisorders (focusing specifically on those disorders that may presentwith psychiatric symptomatology)

    7. Neuroimaging technologies: CT, MRI, PET, SPECT, functional MRI, andapplications in psychiatric disorders.

    8. Chronobiology biological rhythms, e.g. the circadian rhythm

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    B. Neurophysiology1. Neurotransmitters that play a role in biologic rhythms, environmental cues

    and their impact on biologic rhythms2. Advanced study of cellular and molecular biology: structure and

    functioning of the neuron with special emphasis on mechanismsa. Underlying intraneuronal signaling, synthesis of neurotransmittersb. Second messengersc. The impact of second messengers on gene expressiond. Gene expression

    i. DNA and RNAii. Transcription and translation into proteinsiii. Posttranslational regulation of proteinsiv. Action potential and events at the synaptic terminal,

    3. Rapid post-synaptic responses (glutamate and GA/BA receptors),4. Longer term modulatory post-synaptic responses (including long term

    potentiation) and neural plasticity5. Clinical aspects of neurotransmitters and neurochemicals

    C. Neurochemistry

    1. Neurocellular Anatomy

    2. Neurocellular Excitation

    3. Second Messenger Systems

    4. Synaptic Transmission

    5. Basal Ganglia

    6. Neurochemistry at the Cell Membrane

    7. Myelination

    8. Biological Brain Differences

    9. Neurochemistry of Psychological/Brain Disorders

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    10. Neurotransmitter systems

    a. Serotonin

    b. Acetylcholine

    c. Catecholamines

    d. Excitatory Amino Acids

    e. GABA

    f. Glycine

    D. Neuroendocrinology

    a. Review of neuroendocrine pathways (e.g. HPA axis),b. Their anatomy and physiologyc. Hormones (detailed review of classes of hormones and the specific

    actions)d. Fight or flight responsese. Activation of the sympathetic nervous systemf. Additional endocrine responses relationshipg. Relationship between emotional stress and psychiatric disordersh. The development of psychosomatic illnesses (mechanisms of action,

    pathophysiology).

    E. Genetics

    a. Modes of inheritanceb. Dominant, recessive, and sex-linked traitsc. Concepts of penetrance and expressivityd. Familial transmission of psychiatric disorders: twin and adoption

    studiese. DNA polymorphisms and linkage markersf. Gene-environment interactions

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    Basic & Advanced Principles of Pharmacology

    A. Emotional affect improvement enhanced by administration of medicationsB. Prescribing rationales for psychotropic medicationC. Language of psychotropic medication, psychopharmacology, and

    prescribing methods1. Generic and brand names of drug explained.2. Pharmacodynamics: Effect of drug on the brain, and/or the CNS.3. Long term, short term, low and high potency utilization of

    medications4. Review of all classes of drugs other than psychotropics.5. Classes of prescribed psychotropic medications

    a. Anti-depressantsb. Monoamine-oxidase inhibitors

    c. Anti-anxiety agentsd. Pro-drugse. Benzodiazepines

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    f. Mood stabilizers

    g. Antipsychoticsh. Hypnotic sedatives are examples of prescribed drugs.

    D. Basic pharmacology1. Drug administration2. Formulation3. Route of administrated

    E. Dosing regimens and associated concepts1. Half life2. Loading dose3. Maintenance dose4. Dose response variables

    F. Pharmacokinetics1. Absorption2. Biotransformation3. Excretion and drug clearance discussed.

    G. Drug actions1. Cellular and organism levels

    a. Receptors and receptor theoryb. Affinityc. Agonists and antagonists

    H. Effects of drug actionsa. Pharmacologicalb. Side effects & Therapeutic monitoringc. Allergic reactions.d. Drug interactionse. Dependence, tolerance, and withdrawal presented.

    Basic & Advanced Principles in PsychopharmacologyA. Stimulus-response specificity and psychological factors in individual

    responses to psychotropic medicationsB. Medications

    1. Presumed mechanisms of action2. Choice of medication3. Variables to consider4. Treatment strategies5. Monitoring response with eye to titration6. Adequate trial7. Adjustments to dosage

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    8. Laboratory tests monitoring blood levels for antidepressants.C. Psychotropic medication options

    1. Medications action2. Adverse effects3. Tolerance and withdrawal syndromes4. High risk groups

    D. Psychotropic medication treatment strategies1. Initial dosing (levels and schedules)2. Patient education including side effects, dosing adjustment3. Monitoring the response4. Dosage adjustment5. Length of treatment related to follow-up6. Discontinuation7. Maintenance doses8. Relapse prevention9. Failures and alternative options.

    E. Basic medication treatment strategies in adverse effects1. Defining adequate trial dosage ranges2. Factors influencing decisions for increasing / decreasing doses3. Length of treatment4. Follow-up5. Discontinuation6. Maintenance doses and relapse prevention7. Combining Benzodiazepines and antidepressant treatment in panic

    disorder8. Role of concurrent psychotropic and psychotherapy treatment in panic

    disorder and O.C.D.9. Alternative options in cases of treatment failures

    F. Antidepressants1. Usual action2. Presumed action in panic disorders and O.C.D3. Brief review of side effects.

    G. Anxiolytics-Special treatment considerations1. High potency role of Benzodiazepines in panic disorder treatment2. Acute stress reactions and other adjustment disorders time limited

    treatment use3. Pros and cons of sleep disorder treatment4. Agitated/anxious depressives treated5. Noting risk of Benzodiazepine use6. Generalized anxiety disorders7. Withdrawal of alcohol and the role of Benzodiazepines.

    H. Other medications to treat anxiety disorders1. Buspirone and other atypical anxiolytics

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    2. Beta blockers3. MAO inhibitors

    I. Chemical dependency/ Substance AbuseJ. Advanced child and adolescent psychopharmacologyK. Depression and stimulantsL. Advanced geriatric psychopharmacology

    Pharmacopsychology: The Integration of Diagnostics,Psychopharmacological Interventions, & Psychotherapy

    A. Brief history of biological Psychiatry and PsychologyB. Mood Disorders

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    1. Diagnostic issuesa. Particular signsb. Symptomsc. Historyd. Course of illnesse. Lab tests that indicate biological basis

    2. Diagnostic groupsa. Normal sadness (dysphoria) - grief reactionb. Major clinical depressionsc. Atypical unipolar major depressiond. Seasonal affective disordere. Bipolar illness-specific symptom and onset characteristicsf. Substance induced mood disordersg. Depression or mania due to general medical conditionsh. Minor chronic depression (dysthmic disorder)i. Psychotic depressionsj. Axis II coincidence - Characterological factors.k. Premenstrual dysphoriam. Depressive disorders NOS

    C. Anxiety Disorders1. Diagnostic Issues

    a. Biology of the flight-or-flight responseb. Role of GABA in anxiety disordersc. Nor-adrenergic hypothesis of panic disordersd. Neurobiological dysfunction associated with traumatic stress

    e. Pathophysiology of OCD2. Diagnostic groups addressed

    a. Panic disorder (i.e., societal phobia)b. Obsessive compulsive disorderc. Post traumatic stress syndromed. Generalized anxiety disordere. Adjustment disorders with anxiety symptomatologyf. Sleep disordersg. Anxiety disorders NOSh. Phobic disorders without panic attacksi. Anxiety associated with general medical conditionsk. Withdrawal syndromes seen in chemically dependent patients.

    3. Steps to rule out general medical conditions and substance abuse4. Review of theories of biological etiology5. Presumed pathophysiology

    a. Role of nor-epinephrine in anxiety disordersb. Role of serotonin in anxiety disorders

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    c. Role of GABA in anxiety disordersd. Role of serotonin in O.C.D.

    6. Treatment of anxiety in context ofa. Post traumatic stress disorderb. Psychosisc. Depressiond. Substance abusee. Head traumaf. Sleep disordersg. Treatment options with psychotropics.

    D. Psychosis1. Neuromaturational and genetic factors in schizophrenia2. Pathophysiology of Type I and Type II schizophrenia3. Theories of biologic etiology and presumed pathophysiology

    a. Dopamine hypothesisb. Modifications in the dopamine hypothesis

    i. The role of D4ii. The role of 5-HTz receptors

    c. Positive vs. negative symptoms in schizophrenia4. Newer theories of etiology of schizophrenia5. Characterological disorders6. Substance abuse7. Psychotic disorders due to general medical conditions8. Miscellaneous disorders9. How antipsychotic medications work

    a. Theories regarding the effects ofb. Antipsychotics on the blockade of D2 receptorsc. Newer medications that effect Dopamine receptors and 5HT receptors.

    10. Choosing an antipsychotic medicationa. Client profileb. Symptoms may dictate first choices of medicationsc. Patient variables

    i. Medical statusii. Ageiii. Ethnicityiv. Genderv. Other concurrent medication usevi. Chemical dependency

    d. Adverse effectse. Risk factorsf. Side effectsg. Allergic reactionsh. Drug interactions

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    i. Toxicityj. Special attention to tardive dyskinesiak. Impaired temperature regulationl. Narcoleptic syndromesm. Agranulocytosis

    11. Treatment failures and augmentation strategies12. Side effect management13. Assuming a positive response

    a. Treatment lengthb. Related issues to follow-upc. Discontinuationd. Maintenance dosee. Relapse prevention

    14. Special considerations in treating psychosisa. in the context of a dementing illnessb. and treatment of impulse control disordersc. and severe irritability and aggression seen in patients who have

    sustained a closed head injuryd. transient psychotic symptomse. combined treatment with antidepressant and antipsychotic medicationsf. with affective componentsg. in the context of Tourettes disorder

    E. Special Issues1. Bi-Polar Disorder treatment (Type I, Type II)

    a. Side effectsb. Lab workc. Combined treatment of medicationsd. Toxic symptomse. Relapse preventionf. Chronic treatmentg. Role of anticonvulsantsh. Drug interactions

    2. Paranoid disorders3. Transient psychosis

    a. As in dissociative disordersb. As in borderline personality disorderc. As in psychotic affective disorders

    4. Drug interactions5. Uses of antidepressants in

    a. Chronic painb. Bulimiac. Fibromyalgiad. Chronic fatigue

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    e. Sleep disordersf. Panic disorder

    6. MAO inhibitorsa. Special treatment indicationsb. Prescribingc. Precautions

    F. Severe personality disorders1. Hypothesized neurobiological dysfunctions in severe personality

    disorders2. Treatments targeting

    a. Impulsivity and irritabilityb. Mild level thought disturbances such as schizotypalc. Transient psychosisd. Other manifestations of ego dysfunctions in low level borderline

    patientse. Extreme separation stress, co-morbid Axis I disorders

    G. Medical Issues1. Depression-mania due to a general medical condition

    a. Clinical features raising suspicion it is primarily a medical conditionb. Steps to rule out medical condition as primaryc. Consulting physicians for

    i. diagnosisii. evaluationiii. treatmentiv. specific physical conditions commonly presenting mood

    disorder symptoms.2. Serious medical complications with antidepressants, their management

    a. Serious allergic reactionsb. Overdosesc. Seizuresd. Other issues

    3. Treating medically ill /compromised patientsa. Drug interactionsb. Comorbid illnesses such as

    i. Epilepsyii. Cardiac diseaseiii. Pregnancyiv. Others

    4. Medical illnesses presenting with psychiatric illnesses resultinga. Peripheral nervous system, cardiovascular system, blood, elctrolyte,

    body fluids, as related to administration of psychotropics andother drugs prescribed for medical conditions.

    b. Endocrine glands, hormones normal and abnormal functioning

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    c. Digestive system absorption and biotransformation, with specialemphasis on liver functioning, and G.I. side effects, occurring inpresence of psychotropic medications

    d. Kidney functioning and special consideration to role in excretionof medications/ metabolites which influences treatment

    e. Reproductive system as involved when psychotropics influence sexualside effects

    f. Medical conditions that often present with psychiatric symptoms:headaches, endocrine diseases, primary neurology diseases (e.g. braintumors, dementing illnesses, traumatic brain injuries, multiplesclerosis, CNS effects of HIV, cerebral vascular disorders,neurological syndromes associated with toxins

    5. Basic medical screening: history, systems review, and basic lab tests, theoverall diagnostic and decision-making strategy used by physicians.

    6. Special issues in treating the medically ill patient:a. General principles and challenges, commonly encountered

    medical illnesses (co-morbid with psychiatric disorders,described).

    b. Treatment strategies, and collaboration with the internist (primarycare physician) and other physicians

    H. Associative Disorders- treatment strategies1. Refractory patients

    a. Psychological factorsb. Symptom break-through/unexplained relapsec. Variables to consider with treatment strategies

    2. Dysthymia3. Premenstrual dysphoria4. Psychotic depression with ECT5. Seasonal affective disorders, presented.6. Disorders due to primary brain pathology

    a. Multiple sclerosisb. Frontal lobe syndromec. Postconcussion/closed head injuryd. Parkinsons disease

    I. Physical assessment with accompanying lab exams

    J. Psychodynamics of prescribing1. Process of prescribing medications2. Impact of therapeutic relationship(i.e. transference, countertransference)3. Generic issues raised when medication is introduced into treatment4. Responses in certain types of clients (e.g. dependent, obsessional,

    paranoid, etc.)K. Children and adolescents

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    a. Special issues in treating children:i. Metabolic functioning in children and how this relates to medicationii. Dosing strategies, demonstrated.

    b. Diagnostic issuesi. Attention deficit disorderii. Depressioniii. Anxiety disordersiv. Psychosisv. Hyperactivity

    c. Overview of treatment options and strategiesL. Geriatrics

    a. Diagnostic issuesi. biological basis-neurochemically based disturbance and/or

    neurochemical deregulation)ii. Signs and symptomsiii. Disease onset and courseiv. Family historyv. Laboratory tests that verify diagnosis

    b. Diagnostic groupsi. Acute psychotic reactions

    a) schizophrenia and schizophreniform psychosisb) psychosis due to medical conditionsc) substance induced psychosis

    ii. Dementiasa) Alzheimers diseaseb) Multi infarct dementiac) Other primary neurological syndromes and disordersd) Systemic, toxic, and alcoholic illnesses

    iii. Late onset psychotic disordersiv. Post partum depressionv. Disorders associated with Parkinsons disease

    c. Special Issuesi. Metabolic functioning in the elderly and how this relates to

    medication dosing strategiesii. Common problematic adverse affects of psychotropic medications in

    the elderly and side effect management.iii. Challenges of psychopharmacology in treating patients taking a host

    of other medicationsiv. Treating psychiatric symptoms in patients with dementing illnessesv. Recommended pre-treatment lab tests and precautions

    M. Eating disorders1. Hypothesized neurobiological dysfunctions in anorexia2. Bulimia

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    N. Pain management1. Neurobiology of pain2. Cortical modulation of pain3. Peripheral sensory receptors and afferent transmission (neuroanatomy)4. Subcortical pathways5. Cognitive factors in experience of pain, described.6. Pharmacology of pain: neural blockade, opiates, electrical stimulation,

    anti-inflammatory drugs, and antidepressants, presented.7. Co-morbidity: depression and chronic pain and their treatment

    implications, explained.8. Medication compliance: psychological issues such as: problems that are

    commonly causing non-compliance, anticipating these problems,strategies aimed toward increasing compliance, discussed.

    9. Specific psychotherapies effective as adjuncts to psychopharmacology,(e.g. family therapy in treatment . schizophrenia, and bi-polar disorder,behavioral therapy in treatment of panic and OCD; cognitive therapy andinterpersonal therapy in the treatment of depression), pros and consfor the use of these approaches in combination with pharmacotherapy,explained.

    10. Role of psychotherapy in brain changes, addressed.O. Multicultural Perspectives in

    Pharmacopsychology/Ethnopsychopharmacology1. Differences Between Groups2. Differences within Groups3. Pharmacokinetics & Pharmacodynamics of differing ethnic populations

    a. Hispanicb. Asianc. African Americand. Native Americane. Eastern Indianf. Other Ethnic/Racial Population

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    Assessment and LaboratoryA. Basic concepts of behavioral medicineB. Laboratory tests in clinical practice

    1. Common lab tests used in medicine2. Reading reports3. Consulting with others regarding the results4. Ordering appropriate lab tests in practice (for example: pre-medication,

    prescribing, EKG for children prior to prescribing tricyclics, monitoringchanges during follow-up treatment process

    C. Physical assessment-Basic medical screening: history, systems review, and basiclab tests, the overall diagnostic and decision-making strategy used.

    D. Physical assessment with accompanying lab examsE. Referral for Neuropsychological assessmentF. Scans - MRI, CT, SPECT, etc.

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    Advanced Pharmacotherapeutics/ Ethical/ Legal/ AdvocacyA. Professional, Ethical, & Legal Issues

    1. Co-relations, referral and collaboration with professionals fromother disciplines

    2. Informed consent, risk management, liability, writing prescriptions,record keeping of individual patients prescriptions, etc., demonstrated.

    3. Legal and ethical issuesB. Pharmacoeconomics: prescribing cost factors influencing medications faced

    by the individual practitioner, economic / political issues decision makingon larger-scale (e.g. HMO chosen formulary medications), cost factorsshort and long term, effective psychiatric treatment as it impacts health carecosts,

    C. Advanced InterrelationsD. Internet

    1. Computer/Internet application, professional use2. Computers and Internet use

    E. PharmacoepidemiologyF. Epidemiology including genetic psychiatric illnesses.

    G. Formulary SchedulesH. Advocacy - legal and legislative for patients and for psychology.

    PRECEPTORSHIP PSYCHOPHARMACOLOGYPROBLEM BASED TRAINING MODULES

    These are intended to be completed over the course of the 1Year/100 Patient Preceptorship

    Consistent with Association of State and Provincial PsychologyBoard and American Psychological Associationrecommendations, The Academy of Medical Psychology requiresthe post-doctoral fellowship for licensed psychologists to bethe equivalent of one full time year (1500 hours) of supervised

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    experience. Fifteen hundred (1500) hours may consist of patientcare, supervision, professional education, grand rounds andother associated activities. There will be no less than 100 hoursof supervision with a qualified supervisor. The objective is forthe post-doctoral fellowship to provide an opportunity forthe fellow to integrate knowledge in medical psychology uponevery patient contact, including the direct responsibility forpsychopharmacological evaluation and management for aminimum 100 patients.

    1. Review of Antidepressants2. Review of Anxiolytics & Antiobsessionals3. Review of Psychostimulants4. Review of Antipsychotics5. Review of Mood Stabilizers6. Review of Antiparkinsonian Agents7. Review of Sedatives and Emerging Agents8. Problem #1 Depression - Adult9. Problem #2 Parkinsons Dementia10. Problem #3 Attention Deficit Disorder11. Problem #4 Premenstrual Dysphoric Disorder12. Problem #5 Schizophrenia Adolescent Onset13. Problem #6 Borderline Personality Disorder14. Problem #7 Adjustment Disorder15. Problem #8 Panic Disorder16. Problem #9 Insomnia17. Problem #10 Depression Geriatric18. Problem #11 Pervasive Developmental Disorder19. Problem #12 Polysubstance Abuse20. Problem #13 The Suicidal Patient21. Problem #14 Management of Florid Psychosis22. Problem #15 Severe Mania in the Bipolar Patient23. Problem #16 Management of Bulimia/Anorexia24. Problem #17 A Medical Patient with Psychological

    Symptoms25. Problem #18 Generalized Anxiety Disorder26. Problem #19 Schizoaffective Disorder