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Role of Psychiatry in the Practice of Medicine

1) Describe the most important diagnostic tool for a doctor - Ears  listening

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2) Discuss the relevance of “There is no health without mental health” - Depression and anxiety effect the immune system  Kiecolt-Glazer Study: Higher T-Cell count in Med Students when less stressed -Psychoneuroimmunology – study of the effect of mood states and stress on the immune system  Hypothalamus secretes hormones (including Cortisol) in response to stress  Cortisol downregulates the immune system 3) Compare and contrast the bio-psycho-social model with the biomedical model regarding public literacy - bio-psycho-social model: - Meine Model: rat pups frequently licked by their mother grow up to be more stress resistant - Epigenetics: Their offspring were more stress resistant  non-genetic mechanism for expressions - bio-medical model: The way most of the populace thinks medicine works  Does not account for societal, familial and psychological factors

4) Discus the role of “context dependency” in understanding pathology

White Coat Effect: people get stressed when they see a doctor Cultural Context  behavior is informed by their background 5) List the DSM – IV axis diagnostic system I – Major Psychopathology: thought to arise from a functional breakdown in either the cognitive and neurocognitive systems in the brain  Depression  Hallucination II – Personality Disorder  Schizophrenia  Narcissism  Multiple Personalities III – Medical Conditions  Pancreatic Cancer  Effects of Drugs IV – Psychosocial Factors  Divorce  Loss of Person  Financial Stressor V – Global Assesment of Function: (10-100) although 0 = dead

Human Behavior: Brain Connected to the Body
1. Understand the relevance of psychiatry for all physicians in all specialties

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- All physicians see pts with biopsychosocial & behavioral problems - many of these pts will have psychiatric dx‟s. Lifestyle and personal habits account for 70% of illness/death & also for 70% of health care costs (This 70% doesn‟t include indirect costs of illness, e.g., lost work) - 70 – 80% of visits to physicians are for emotional or behavior issues - 40 – 70% of the population have some diagnosable psychiatric illness 2. Understand the role of psychiatric functioning in biologic and psychic health, wellness, and disease - Biopsychosocial & behavioral variables influence the predisposition, onset, course, & outcomes of most illnesses. Psychosocial interventions can improve outcomes. 3. Describe what constitutes mental health and mental illness

Defining Normal/Abnormal/Pathological – Physical, Mental & otherwise Defining Normal/Abnormal/Pathological can be done in various ways: 1. Professionally – certain conditions are considered absolutely pathological across all cultures. Ex: a child with a high fever who suddenly develops bizarre perceptions, thoughts, & behavior  Creating a distinctive construct 2. Deviation from the mean – abnormal lies a certain distance from the arithmetic average. Ex: high blood pressure; over and underweight; obesity 3. Assessment of function – Do thoughts, feeling, and/or behavior have a healthy (functional) or unhealthy (dysfunctional) effect on the individual. Ex: normal level of anxiety supports test performance, abnormally high anx interferes. Exercise supports desirable mood and longevity.

4. Social (and political) definitions – Social, cultural, and/or political considerations determine normality. Ex: Parents arrange marriage is for the child at a given age. 4. Elaborate the continuum between mental health and illness What is normal for you is informed by your habits and your socioeconomic and cultural background. These may not be healthy habits. 5. Discuss four different methods of defining normal, abnormal, and pathological. Relate the unique & critical role played by physicians is making such determinations. 6. Describe - and provide examples of - how and why “normal” & “healthy” do not always coincide. - Heavy Smoking - Obesity - Cultural factors  arranged marriage - HIV in Africa 7. Understand how Mental Disorders are currently diagnosed. - A psychiatric diagnosis is made when a patient meets the diagnostic criteria given in the DSM-IV - Empirical Foundation - Etiology is rarely important - No assumption that individuals with the same mental disorder are alike - ADDICTION IS NOT YET A DIAGNOSIS 8. Differentiate between the conscious and unconscious mind, and discuss the importance of this differentiation. Conscious Mind: Aware, rational decisions based on a real or perceived need - linear, analytical, intellectual, deliberate, voluntary, logical Unconscious Mind: All psychic material not in the immediate field of awareness - experiential, intuitive, access to and utilization of a great deal more information which is simultaneously processed

9. Define Defense Mechanisms and give examples Repression – Exclusion of unpleasant reality from conscious awareness. “My child did not die in that automobile accident.” Regression – return to a more immature level of functioning. Adult acts childlike before surgery - I want my mommy Denial – failure to acknowledge a disturbing portion of reality. “It is not domestic violence - she provoked me.” “My drinking does not cause problems in my life.” - Ignoring part of the problem Projection – attributing one‟s own thoughts or feelings to another. “He really hates me,” Displacement – Emotions generated in one situation are expressed in another context. After being reprimanded by his boss, an employee comes home and kicks the dog - or hits his children. Reaction formation – An unacceptable thought or feeling is transformed into its opposite. Greeting a detested individual with “It is so good to see you again.” - Passive aggression Rationalization – Distortion of reality that makes an undesirable circumstance seem desirable. “Sour grapes” Intellectualization – conceptualizing a disturbing event as purely a cognitive (thinking) problem. Upon diagnosis, one widely searches the internet for information to determine how this condition could have occurred. Sublimation – the unacceptable is channeled into more acceptable activities. A person with devastating neurological illness establishes a foundation & raises money. Humor – using amusement to cope. Telling funny stories about one‟s hair loss from cancer chemotherapy treatment 10. Define and give examples of transference & countertransference: Transference: Others The unconscious assignment to a current person those feelings, attitudes and expectations originally associated with others, (esp parents and family). This assignment may have a positive or negative emotional tone. Clinical

correlation: A patient who had harsh and untrustworthy parents will expect similar treatment from you as a physician, and there can be much greater difficulty establishing & maintaining a therapeutic relationship. Countertransference: Yourself Transference on the part of the clinician arising toward the patient. Ex: a physician whose parents were nurturing, forthright and truthful may experience strong reactions when a patient is reserved, “cagy” and omits important information. Or a surgeon becomes quite emotional as he prepares to operate on a teenager who unconsciously reminds him of his daughter. - Specific to physicians 11. Be able to identify a patient‟s stage of change when presented with clinical information - Pre-contemplation: Before acknowledging the problem - Contemplation: Patient recognizes problem and is considering change - Determination/ Preparation Stage: I have a problem and need to change  Considering how to change - Action Stage: Implementing changes in behavior  Behavior are tenuous & unstable - Maintenance: New behaviors are stable, automatic  behavior change has been met Relapse is not a stage, but is common and “normal”

Human Life Cycle
Human Life Cycle I and II

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Objectives 1) Explain the concept of developmental lines a. Metaphorical description of childhood development b. A quick, visual way describe the simultaneous nature of normal child development Developmental Lines ___________________Growth of Body____________________ (bigger, taller, stronger) ex. Size of an infant vs. size of a kindergartener ______________________Growth of Brain________________________ (neural growth/pruning, develops from the back aka reptile brain to the front) ex. Brain development/ability of preschooler vs. med student _______________________Control of body________________________ (toilet training, motor skills both gross and fine) ex. Learning how to write or build legos ________________________Cognition________________________ (language, visuospatial skills, imagination vs. reality, hypothetical situations, executive functioning) ex. Prioritizing school over socializing (or the other way around!) ______Social/Emotional development (we could also include Freud here)___ (self-control, relationships, empathy, morality, identity) ex. Having views on euthanasia 2) a. Explain how developmental lines interact with one another Common themes of all the lines: i. Interplay of nature and nurture ii. Interconnectedness between the lines

1. If development lags behind on one line, another lag will also present (ex. A child has never had a real best friend, and compensates by having a very intense imaginary world) 2. OR, a strength in one line may compensate for a weakness in another (ex. A football player might be incredibly confident on the field, but not so much in English class talking about poetry... but still maintain normal social growth) 3) Explain the concept of regression to an earlier stage of development with stress a. In times of stress or illness, adults and children will regress to earlier developmental stages b. This is something we‟ll all be seeing a lot of as physicians c. Ex. Wanting mom‟s chicken soup and getting whiny when sick 4) Explain the interaction of nature and nurture in child development and discuss how temperament and attachment theory relate to the nature/nurture ideas

Attachment

Child‟s Rxn

Parent/infant Relationship

Child‟s future personality -likely to be more robust to stressors

Secure

-Soothed by parent‟s return -stays close to parent

-trusts parent -relationship is a source of security and comfort -parent not responsive to child‟s needs -child has learned it‟s safer/better to not bother parent

Insecure-avoidant

-child avoids parent

-not as robust to stressors

Insecure-Resistant

-child is angry and

-wants comfort but

-less robust to

aka Ambivalent

rejecting of parent

anticipating parental rejection

stressors

Disorganized

-switching between styles -freezing

-associated w/ severe child abuse

-high risk for psychiatric illness

a. Potential connection: epigenetics and the effect of environment versus genetics b. Most importantly from this lecture: today‟s physicians and social scientists see nature and nurture as interconnected in a child‟s development i. Temperament 1. Based primarily on nature 2. Thomas and Chess: anticipate adult‟s personality based on infant/toddler personality 3. Conclusion: a big failure EXCEPT that avoidance/approach to new stimuli is a good indicator of increased probability of anxiety in later life ii. Attachment 1. Bowlby‟s work on animal attachment 2. Ainsworth‟s “Strange Situation” 3. Attachment styles after the parent reunites with the child says the most about the parent-infant bond and the child‟s future personality

5) State the five basic stages of child development: infancy, toddlerhood, preschool, school-age, and adolescence (see question 6) 6) For each stage of development, be able to state a. Fine and gross motor milestones b. Language milestones c. d. e. Cognitive milestones Normal social/emotional development Eriksonian conflict

Stage

Brain Dev

Milestones + Play

Cognitive Dev

Socioemotional/

Erikson

Infancy (0-12 mo)

-very environmentally sensitive -rapid growth, fastest in the first 2 years -includes neuron growth, pruning, and myelination

-6 wk: social smile, eyes follow object across midline (=two sides of the brain have connected) -makes noises -7-12 mo: crawling -12 mo: should have 1st word and walking

0-24 mo: sensorymotor phase, knows things by acting and perceiving objects 4-16wk: objects aren‟t permanent 4-6 mo: objects are permanent 7-10 mo: object is permanent, and I know where you hid it.

-7 mo: anxiety to strangers -10 mo: attached to identified caregivers -0-12 mo Oral phase -12 mo. Transitional object in place, expression of emotions such as distress and joy

Trust vs. Mistrust

Toddler (12-36 mo)

-immature frontal lobes (short attention span, no impulse control, poor judgment) -neurons still growing, esp in left temporal lobe (language)

-ALL play at this period is done to maximize motor and language skills -18 mo: 50 words, Parallel play -24 mo: 2-3 word phrases -24-36 mo: fantasy play, cooperative play -36 mo: toilet training for most (culturally dep)

-lack of impulse control and a great ability to act on the impulse leads to „terrible twos‟ -beginnings of conceptual thought -by 2-6 yrs, should be pre-operational period

-10-16 mo- begin to separate from parent and find self-identity -16-25 moincreased independence, tantrums -24-36 mointerest/fear with body wholeness (the fear of injury) -Anal Stage

Autonomy vs. Shame/ Doubt

Preschool (3-6 yr)

-corpus callosum myelinates, increasing coordination

-imitative play -storytelling -imaginary friends -mastering of basic

Piaget PreOperational Stage: -sense of time and memory

Phallic/Oedipal -interest in genitals -masturbation,

Initiative vs. Guilt (different from

between brain regions (ex. Language with motor play)

social skills to alleviate the use of violence (sharing instead of biting) -older preschoolers form friendships, increase in size and strength -apx 5000 words expressed

-no multitasking -no understanding of conservation -egotistical fantasy and reality blurred -magical thinking -may believe medical procedures or illness are „their fault for being bad‟

playing doctor -realize not every relationship is about them (ex. mom and dad) -should have empathy

shame, guilt is a failing in one‟s personal moral code)

School-Age (6-11 yrs)

-frontal lobe and prefrontal cortex dev (pruning) -planning, control of emotions and impulses improved

School and friendships are critical -initiation of formal schooling -best friend relationships (important buffer against future psychological stressors) -bullying is present -play now involves rules and, goalorientation, and groupings (collecting things, board games, sports with an emphasis on winning and fairness)

Piaget Concrete Operations: -conservation is understood -abstract thought and understanding is understood -7 yo: reality is different from imagination -executive functions have developed (ex. Planning, concentration)

Latency Stage -break from bodily urges allows room for mental, athletic, moral, and social skills -strong conscience that has no room for grey zones (moral absolutism)

Industry vs. Inferiority

Adolescence

Second surge of

-onset of puberty

Formal Operations

-struggle to control

Identity vs.

(12-20)

neuron growth, pruning, and myelination -sex hormones start at puberty -maturation of prefrontal cortex not complete until mid-20s

(9-10 for girls, 11 for boys) -play is social (develop relationships, cliques, dating) -early adolescent peer groups mostly same-sex, but later mixed

Stage -can form hypotheses and deductive reasoning (so now we can do calculus!) -judgment and risk assessment aren‟t so well developed yet

aggression and sexual impulses -self esteem and mood swings -conscience now has grey zones (moral relativism), experimentation with identity, departure from parents‟ rules/values, risktaking -occasional conflict with parents is okay -begins to have concerns with larger social welfare

Role Diffusion

7) So seven isn‟t actually a question that needs to be answered. Rather, the point is that PLAY isn‟t just for fun or pointless. 3 major points a. PLAY is a means to further development (motor, cognitive, social) b. PLAY is a way to practice and hone future skills c. A lack of age-appropriate PLAY is of concern and suggests underlying problems (abuse, schizophrenia, etc.)

Adult Development

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Psych-5: Human Life Cycle III – Adult Development Dr. Shoemaker 8.30.11 Define Erikson’s Epigenetic Model of Development. Development grows out of internal (psychological) and external (social) events, and the foundation of development is change, not stability. Define Erikson’s Eight Ages of Man and briefly describe the psychological conflict associated with each stage. Age 0-1: Basic Trust vs. Mistrust Focus on parenting as foundation for interpersonal relationships Inability to trust parent (unpredictable or chaotic parenting)  distrust  serious pathology Age 1-3: Autonomy vs. Shame & Doubt Trying to form self-control without losing self-esteem Age 3-6: Initiative vs. Guilt Children are given more responsibilities but may feel guilty if they can‟t meet expectations Conscious development begins Age 6-12: Industry vs. Inferiority Feel competent as school skills develop but everyone is aware of who fastest runner is, etc – causing feelings of inferiority Age 12-20: Identity vs. Role Confusion Sense of self/identity evolves during adolescence along with the confusion of finding role in society, relationships, family Age 20-40: Intimacy vs. Self Absorption/Isolation Intimacy in sexuality, caring, and sharing If young adult is still dealing with role confusion they will not be able to be truly intimate and will result in isolation Age 40-60: Generation vs. Stagnation There is a focus on education and training the younger generation, but if unable the person would feel stagnant Age 60+: Integrity vs. Despair Person looks back on their life with satisfaction of accomplishments and integrity about self

If one reflects on missed opportunities and misfortune, they may feel despair Define “Mid-Life Crisis” and list six areas in a person’s life which may be impacted. Feeling unwell in context of uncertainty, anxiety, agitation, or depression Areas of change that are concerning: Bodily– change in biological function Time Perception – „how long do I have left?‟ Career – aspirations vs. achievements Relationships – in the middle & feeling pressure from spouse, children, parents Social– divorce Financial pressures – saving for kids, retirement Discuss the relationship between age and timing regarding smooth vs tumultuous transitions in adult development. Unexpected events may or may not invoke crisis depending on timing Age norms and expectations change with society, and timing of these changes may impact development Biological – early puberty can be difficult, particularly for females Social – young adults waiting longer to enter job market, women choosing to postpone marriage & having kids Midlife crisis may arise if Dramatic emotional upheaval & turmoil for individ or others Abrupt changes Limited insight Person feels „unwell‟ Discuss the major biological, psychological, and social issues characteristic of early, middle, and late adulthood Early adulthood Biological: peak of biological development Psychological – intimacy vs isolation (see #2) Social – assumption of major roles (education, job, marriage, parenthood) Middle adulthood Bio – climacterium (decreased bio fxn)

Psycho – Generativity vs stagnation (see #2) Social – re-evaluation of roles Relationships, family, career Midlife transition vs crisis Late adulthood Bio – aging Psycho – integrity vs despair (see #2) Social – economics, retirement, social/sexual activity Vulnerable to stress & dealing with loss