Download Behavioral Science – Test 1

Behavioral Science – Test 1
 Concepts of Behavioral Science
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More than ½ of the mentally ill are treated solely by PCPs
Physical symptoms are part of emotional illness
Behavior – observable actions and responses
Causes of death related to behavior are on the rise and chronic
Mental disorders are the 4th most costly condition
Behavioral indicators of morbidity – days of absenteeism, days of institutional confinement, days of disability,
and loss of social interactions (measured in # of events missed)
Epidemiology – study of factors determining the occurrence and distribution of diseases in the human population
Prevalence – number of individuals in the population who have an illness divided by the total population
 Prevalence of mood disorders – anxiety > mood > substance abuse > psychotic disorders
 Lifetime prevalence of all mental disorders = 45%
 Women have ↑ rates of mood and anxiety disorders, use mental health services and restrict activities more
 Men have ↑ rates of substance abuse
Incidence - # of new individuals that develop an illness in a given time period divided by the total number of
individuals at risk for the illness during that period
Ages of onset for psychiatric disorders
 Anxiety disorders (11), impulse control (11), substance abuse (20), mood disorders (30), cognitive (65)
Timing of first mental illness affects likelihood of recurrence & severity
22% of psychiatric patients have 2+ psychiatric disorders
Comorbidity – ex people with anxiety disorders more frequently have acid reflux (note – anxious patients can
get really worried about physical symptoms)
 Ex. people with heart attacks often have mood disorder and are 3x more likely to die
 Thus, depression is an independent risk factor for mortality
 Mortality and morbidity due to physical causes is ↑ in persons with severe mental illness
Biopsychosocial Model of Disease – considers psychological and social variables in addition to biological
factors in predisposition, onset, course, treatment and outcome of illness (personality, family, social class, social
support, life events, culture)
Social Class – composite measure of income, education and occupation
 Increase in bad stuff comes with lower class
 People who are simply assigned a lesser rank have higher incidence of disease
Psychosocial Factors in Disease
 Personality – locus of control (internal, external, chance) can affect adherence to treatment
 Family – belief in lifestyle, attitudes (body size, eating habits, exercise, etc.)
 Life Events - # of recent major life events (including positive ones) affects mental health
 Social Support – numbers of interactions and social roles affect outcomes
Illness Behavior - the ways people respond to bodily sensations or symptoms and to the perceptions, values,
attitudes and interpretations that lead people to behave in particular ways in reference to their bodies
 This affects decision to seek care
 There are many more factors influencing decision time to act with mental problems
 Stages of Illness Behavior – 1. experience of the symptom, 2. the sick role, 3. medical contact, 4. dependent
patient role, 5. recovery
Illness Worry – poorly related to severity of disease
Service Utilization
 40% of patients with chronic physical illness have symptoms of depression
 people with mental disorders are 2x as likely to use medical services as those with mental illness??
 3x higher in people with anxiety disorders (they miss work a lot too)
 Proper treatment of mental health leads to cost savings
 ↓ use of other medical services
 earlier hospital discharge
 coping skills can help patient change unhealthy behaviors
 Theories of Human Behavior
Freud’s Theory of Behavior – internally driven and unconscious
Behaviorism – externally driven through personal experience of reward & punishment (via conditioning)
Social Learning Theory – externally driven by observing rewards & punishment of others’s behavior
Freud
 Assumptions
 Unconscious Mind – governed by internal forces we are unaware of. Are the primary determinants of why
we behave as we do
○ Primary Process Thinking - Associated with primitive drives (sex, hunger, thirst) and must be satisfied
 Conscious Motivation - secondary process thinking – logical, mature, delays gratification
 Intrapersonal conflict - is inevitable due to complexities in life
 The past has profound influence on adult behavior
 Unconscious
 ID – ruled by pleasure principle; repository of biologic urges (hunger, thirst, sex)
 Ego – takes reality into account. Negotiates between ID and Superego
○ Cognitions, relationships and defenses
 Superego – contains social values and enforces rules
○ Last to develop; strives for moral perfection and can never be achieved
 Note – ego and superego you are a little aware of, but not fully
 Conflict – stems from the unconscious and the Ego keeps these conflicts in check
 Drives behavior
 Process – ID impulses become overwhelming → results in ↑ anxiety → ego defends against anxiety with
defense mechanisms
 Defense Mechanisms
 Mature Defenses
○ Altruism – breast cancer patient leads breast cancer group
○ Humor – amputee joking about one-legged people
○ Supression – conscious form of repression, putting aside unwanted thoughts or feelings but still
acknowledging them (push thoughts of illness aside until after childbirth)
○ Sublimation – ID instincts displaced or converted to socially acceptable outlets (voyeurism to photog)
 Neurotic Defenses
○ Denial – struggle with external stimuli (pushups day after open heart surgery)
○ Repression – struggle with internal stimuli (soldier unaware of the civilian deaths he caused)
○ Displacement – redirecting emotion
○ Reaction Formation – deny unacceptable feelings and adopt opposite attitudes (homophobe)
○ Intellectualization – sealing off feelings so that all is left is the cognitive component
○ Somatization – emotion expressed purely through physical symptoms
○ Dissociation – mentally separate part of conciousness from reality (I was never in the military)
 Immature Defenses
○ Projection – one’s own unacceptable impulses and desires are disowned and attributed to another
(blame someone else for the same action you are doing without acknowledging you are doing that thing)
○ Regression – return to earlier stage of development and more childish behavior
 Transference – displacement of patient’s feelings & fantasies onto their doc due to personal unconscious
needs and conflicts
○ Can cause expectations and sentiments attached to Dr that Dr. is unaware of
○ Occurs in all interpersonal interactions
 Countertransference – uncontrolled ‘transference’ response of the Dr to the patient’s transference
○ Behaviorism
 Contiguity Theory – any stimulus and response connected in time and/or space will tend to be associated
 Conditioning
 Acquisition – CR acquired
 Extinction – CRs weaken when CS isn’t paired with US anymore
○ Spontaneous recovery – once extinct it can come back more easily (maybe without retraining)
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 Pseudoconditioning – when a person becomes supersensitized to things and everything causes CR?
 Classical Conditioning
○ Subjects develop expectation that CS signals the arrival of US
○ Unconditioned Stimulus (US) always (involuntarily) causes Unconditioned Response (UR)
○ Conditioned Response (CR) causes same response, now called Conditioned Response after training
○ Subtypes
 Higher Order Conditioning – stimulus associated with the CS becomes the CS itself
 Taste Aversion – can occur after only one pairing of taste to illness (biologically programmed for it)
 Operant Conditioning
○ Thorndike’s Law of Effect – behavior consistently rewarded will become learned behavior
(reinforcement)
○ Definition – learning to make or withhold a certain response because of its consequences
 Subjects develop expectation that a response will be reinforced or punished
○ Differences from Classical Conditioning
 Behavior is voluntary here
 In classical conditioning the behaviors involved are elicited by stimuli that come before the behavior
○ Ex. – friendliness results in large tip → increased likelihood of being friendly
○ Reinforcement – event or stimulus that makes behavior it follows more likely
 Positive Reinforcement (reward) –
 Negative Reinforcement (relief) – after behavior, something annoying is removed (seatbelt alarm)
○ Punishment – event or stimulus that makes behavior it follows less likely
 Positive Punishment (discomfort) – after behavior, something aversive is added
 Negative Punishment (loss) – after behavior, something valuable is removed (ex. grounded causes
loss of freedom)
 Problems with punishment
○ Punished behavior is not forgotten, only suppressed until punishment is no longer present
○ Creates a fear that can generalize to desirable behaviors (eg fear of school)
○ Does not guide toward desired behavior
○ Schedules of Reinforcement
 Continuous Reinforcement – reinforcing behavior each time it occurs.
○ Works rapidly, but also becomes extinct rapidly
 Partial Reinforcement – learning occurs slowly, but has higher resistance to extinction
○ Response Based Partial Reinforcement – occurs after a # of responses
 Can be Fixed # or Variable #
○ Time Based Partial Reinforcement – occurs after a time interval
 Can be Fixed Interval or Variable Interval
 How this relates to Psychiatry
○ Depression – learned helplessness (ex. learn that every action is met with punishment)
○ Phobias & Panic – classical conditioning causes panic response to be associated with neutral stimuli
○ OCD – fear of germs mediated by washing hands (negative reinforcement takes away fear by taking
away germs)
○ PTSD – smells sights etc. of past cause CR
○ Social Learning Theory
 Behavior does not occur because of past reinforcement but due to anticipated future reinforcement
 Anticipation is a cognitive process and this distinguishes SLT from conditioning
 People tend to model those who they like and respect, consider attractive or powerful, etc. and those behaviors
that are seen to have a positive outcome
 Ex. person in car accident anticipates reward for pain complaints (after seeing news of someone sueing)
and fakes pain complaints
 Biology and Behavior
○ Behaviors that appear at a specific developmental stage are observed in individuals raised in isolation occur
entirely without practice
○ Learning – ability to change behavior in response to experience
 Slowly develop by observing others
○ Personality Traits – enduring patterns of thinking, feeling and behaving
 Not controlled by single genes
○ Fear – an emotion related to a specific, definite threat (has to be due to an object)
 Triggered by threatening situations and individual will act to protect themselves
 Core fears – isolation, rejection or embarrassment, losing control, death or injury, confinement
 Fear Behaviors – primitive response to fear are adaptive and essential (fight, flight or freeze)
 Note – infants have nonselective fear responses (thus respond same way to lots of things)
 Lab monkeys must be trained to fear snakes, but they do so very easily. They can’t be trained to fear roses,
thus have a biological predisposition to fear snakes
 Personality trait of fearfulness – tendency to develop an extreme fear response is partially inherited
 Formerly fearful children have greater risk of developing anxiety disorders as adults
 Gender Influences
 Girls more frightened of insects or rodents
 Everyone afraid of public speaking
 Men more likely to use alcohol to blunt fear
 Fear of Rejection – can cause isolation, overcompensation, anxiety and depression
 Fear of Confinement – can cause anxiety and feelings of loss of control, need to be around others
 Intentional Frightening – roller coasters, need more and more due to habituation
○ Anxiety – experienced subjectively without reference to a specific object or situation
 Neurotransmitters – norepinephrine is ↑, GABA is ↓, serotonin is ↓
 Distinct facial muscle movementss and posture/movements can be a response of anxiety
 Autonomic nervous system overactivated in anxiety
 Brain regions involved
 Primitive fear response – hypothalamus, limbic system, amygdale
 Hippocampus – memory
 Cerebral cortex – rational fear system allows us to differentiate if something is harmful or not
 Visualization – can evoke the same/similar response as that seen when what is visualize actually occurs
(especially in facial muscle tension)
○ Mass Emotional Responses – fear and panic developed by a group of people in response to a perceived threat
 Note – people may be too paniced to think to verify if the treat is real
○ Mass Psychogenic Physical Illness – when fear produces physical symptoms unsubstantiated by real physical
findings or environmental cause.
 Commonly manifests itself as headaches, dizziness, nausea, weakness
 Could be due to people observing others being sick or people suggesting you are sick
○ Genetics, Environment and Psychiatric Illness
 Study Techniques
 Pedigree Studies – study occurrence of diseases within a family
 Family Risk Studies – compare how frequently a disease occurs in the 1st degree relatives of an affected
individual with how frequently it occurs in the general population
 Twin Studies – concordance (presence of the same trait in both twins) or discordance
 Adoption Studies – distinguish effects of genetic factors from environmental factors in disease
 Genes may increase sensitivity to environmental events
 If parents are depressed then their children with substance abuse have 3x greater risk of becoming depressed
 Schizophrenia – estimation of risk may allow for some degree of prevention
 Risk – monozygotic twin of affected person (50% risk) > children with two affected parents > children with
one affected parent > sibling of an affected person
 Mood Disorders – unipolar disorder has low heritability but bipolar disorder has high heritability
 Alcoholism
 Abusers siblings have 5-8x greater risk than general population
 Adoptees with abuser biological parents are more likely to become abusers
 4x more prevalent in children of alcoholics (sons of alcoholics at even more risk)
 Familial alcoholism doesn’t just present as a yes or no thing, they will have earlier onset of heavy drinking,
more severe abuse, poorer response to treatment
○ Genetics, Environment and Psychiatric Disorders
 For twins they also have a non-shared environment which involves preferential parenting or life experiences
 60% of the variance in adolescent antisocial behavior and 37% of the variance in depressive symptoms can be
explained by poor parenting
 Sibling Barricade – protective effects of harsh parental behavior on the sibling of the adolescent who is
treated harshly
 Thus the favored child does all right even if there is bad parenting in the house they they don’t experience?
 Health and Behavior
○ Health Related Behavior – any activity undertaken by a person believing himself to be healthy for the purpose
of preventing disease or detecting it at an early stage
○ Illness Behavior – any activity undertaken by a person who feels ill to define their state of health and find cure
○ Sick Role Behavior – activity undertaken for the purpose of getting well by those who consider themselves ill
○ Health Belief Model – attempts to explain health behavior and/or adherence to treatment regimens
 Says that an individual’s subjective state of readiness to take action and engage in health-related behaviors,
relative to a particular health condition, is a function of several factors
 Individual Perception – of susceptibility and seriousness of the illness
 Modifying Factors – demographic variables, sociopsychological variables
 Cues to action – ex. mass media campaigns, advice from others, etc.
 → Likelihood of Action – benefits outweigh barriers to prevent?ative action
 Useful for predicting if someone will get their yearly screens for cancer
 Useful for predicting if someone will adhere to a treatment
 ↑ belief that one is vulnerable to a disease and/or understanding of seriousness → ↑ adherence to various
health-related behaviors
 note – very high levels of perceived severity can be inhibiting
○ Transtheoretical Model of Stages of Change – for changes that require discreate motivational stages over time
 Precontemplation – not intending to change in the near future
 People could be defensive about current behavior and resistant to outside pressure to change
 Contemplation – intending to change in the next 6 months. Open to consultation
 Preparation – actively planning change and experiementing with limited action
 Action – actually making overt changes; less than 6 months of success
 Maintenance – sustaining change over time and taking steps to resist relapse (after first 6 months)
 Backsliding – is common and to be expected, need to know how and when to help them
○ Adherence
 Adherence rate is between 30-60%
 Physicians often overestimate adherence
 Threats don’t increase adherence
 Influencing factors – attitudes and perception of illness, environmental factors, complexity of therapy,
physician-patient interaction
 Ways to facilitate adherence – education, accommodate gender, culture etc of patient, increase social support
(support group), listen to the patient, change therapeutic regimen
 Health Regimen and Delivery Considerations
 Provide health knowledge that operationalizes the recommended behavior
 Communicate the importance of health behaviors and motives
 Maximize rewards for prescribed behaviors
 Instill a sense of personal responsibility for health maintenance
○ Risk Reduction
 Type A Personality – ambitious, aggressive, irritable, etc. Has increased risk of CHD
 Assess risk by 1. structured interview where behavior is noted, 2. Jenkins Activity Survey (a 50 item self
report inventory OR, 3. Framingham Type A Scales (a 10 item self report)
 Have double the risk of CHD, but not predictive of disease progression
 Modification of Type A behavior - Roskies and Avard multimodal treatment
○ Muscle relaxation training, rational emotive therapy, communication skills training, problem solving
skills training (type a’s delegate problem solving instead of do it), stress inoculation (imagine a stress
and then mentally try and reduce it)
 Anger and Hostility – actually a better predictor of CHD than type A personality
 Can be assessed by Cook-Medley Hostility Scale (a 27 item self report)
 Smoking - $50 billion annually spent on direct medical care for smoking related illnesses
 Average cessation treatment is $165
 90% of former smokers quit on their own but weren’t successful on first try
 Cessation treatment even as brief as 3 minutes is effective
 The more intense the treatment the more likely it will be effective
 AHRQ (not complete)
○ Strategies to get more people to quit
 Promote hospital policies that support and provide smoking cessation services
 Include smoking cessation treatments as paid services in all health benefits packages
 Provide clinicians compensation for cessation treatment
○ Intervention Recommendations
 Offer treatment to all smokers
 Determine and document all patients’ tobacco use
 Provide at least a minimal amount of intervention to all tobacco users (nicotine replacement, social
support, skills training)
○ Brief Intervention Recommendations
 5 A’s – ask, assess, advise, assist, arrange
 Make sure tobacco use status is obtained at every visit
 Advise users to quit and help them create a plan to do so
 Encourage nicotine replacement therapy
○ Intensive Treatment Recommendations
 4-7 sessions over 2 weeks. Provide social support, problem solving skills, reinforce motivation to
quit, help prevent relapse, nicotine replacement therapy
 HIV – risk is large with comparatively low rates of risk taking behavior, thus success in prevention requires
consistent behavioral changes
 Provide behaviorally specific risk education
 Accurately communicate patient’s risk level, encourage patient self-appraisal of risk, provide realistic
perception of threat
 Provide skills training – condom use, assertiveness to resist unwanted sexual pressure, negotiation of sex
practices, self-management to identify patterns, habits or activities that ↑ risk and ways to handle them
 Reinforcement – very helpful to follow up and reinforce good behavior
 People most likely to make behavioral changes to reduce HIV risk when
○ They fully understand the risk and rational for change, personally believe that AIDS and HIV could
affect them but that risk can be avoided, can be enlisted to make strong change-commitment responses,
have gained comfort and skill in condom use, safe sex negotiation, assertiveness, and when they
function in sexual relationships and social environments in which risk avoidance or precaution-taking is
accepted and expected
 Prevention Study – proved that this stuff works
 Stress and Illness
○ Stress – mentally and emotionally disruptive of upsetting condition occurring in response to adverse external
influences and capable of affecting physical health, usually characterized by increased heart rate, a rise in BP,
muscular tension, irritability and possibly anxiety or depression
 Nonspecific adaptive response of the body to any agent or situation
 Stress – normal, Distress – stress that begins to hurt the organism, Eustress – optimal amount of stress
 Allostasis – process of achieving homeostasis
 Allostatic Load – cumulative, multi-systemic view of physiological toll that may be exacted on the body
through attempts at adaptation
 Stressor – stimulus events requiring some form of adaptation or adjustment
 Can be internal or external, may be positive or negative
 Stress Response – physiological, cognitive and behavioral
 Physiological
○ Neural Axes – sympathetic, parasympathetic, neuromuscular (tension)
○ Neuroendocrine Axes – fight flight response stimulated by adrenal medulla (sympathetic innervation)
 Remember this can cause ↑ free fatty acids and endogenous opioids
○ Endocrine Axes – adrenal cortical axis
 Corticotrophin releasing factor → ACTH → circulation → adrenal cortex → releases cortisol and
corticosterone (glucocorticoids)
○ Causes ↑ glucose production, ↑ urea, ↑ FFA, immune suppression, ↑ ketones, ↑
catecholamines
 CNS can regulate the immune system through the pituitary-adrenocortical axis
○ Immune cells have receptors for epinephrine
○ Organs of the immune system are innervated by both branches of the ANS
○ Models of Stress Response System
 Physiological-Appraisal and Response Model
○ Appraisal process first goes through primary appraisal (based on beliefs and commitments) if still
a threat then it goes through secondary appraisal (based on resources, options & effectiveness) if
still a threat then biological stress response kicks in
 Here coping methods are also used including behavioral responses and psychological
responses
 ??? Page 92
 Neurological-Block Model of CNS areas involved in appraisal and response
○ ?? Page 93
○ Sensory intake & interpretation of the environment – in association areas like prefrontal cortex and
hippocampus
○ Generation of emotions based on appraisals – prefrontal-amygdala activity & insula-hippocampal
connection
 Initiation of autonomic & endocrine responses – HACER (hypothalamic area controlling
emotional responses) & paraventricular nucleus
 Autonomic & endocrine outflow – nucleus of solitary tract, intermediolateral cell column,
pituitary and adrenal gland
 Feedback to cortex & limbic system – brainstem aminergic nuclei (locus ceruleus, raphe
nucleus, ventral tegmental nucleus (use norepinephrine, serotonin and dopamine respectively)
 Cognitive
○ Can cause fluctuation in mood
○ Cognitive coping responses – what we say to ourselves changes our response to stress
 Positive Comparisons – ‘we’re all in the same boat’
 Catastrophising – ‘I’ll never make it through this day’
 Behavioral
○ Active Attack – confront the stressor (violence, hostility, competitiveness, assertiveness)
○ Passive Escape – shut down (avoidance, withdrawl, passivity)
 Measuring Stress
 Stressors
○ Life Events
 Holmes and Rahe-Social Readjustment Rating Scale – quatitative index of stress following a
situation requiring adjustment
○ Shows relationship of accumulated life change to onset of illness
○ Greater magnitudes of change cause increased risk of illness
○ Younger people often have ↑ life events, women and singles usually have ↑ life event scores,
○ Social class does not relate to # of life events
 Hassels and Uplifts Scale – assesses daily and cumulative impact of everyday demands
○ Better predictor of psychological symptoms
○ Really focuses on hear and now problems
 Stress Response
○ Measured by physiological characteristics (eg cortisol, HR, etc) or neurological (fMRI)
 Problems measuring because it fluctuates during the day, varies between people and data collection
itself may cause stress
 Models of Stress and Illness
 Selyes G.A.S. (General Adaptation Syndrome)
○ Older Theory
○ Skipped a lot here
○ Stage 1 – Alarm Reaction – basically the adrenaline response; can cause ↑ susceptibility to illness
 If prolonged then can lead to stage 2
○ Stage 2 – Resistance – physiological arousal stays high, but parasympathetic system counteracts
 Individual can endure the stressor and resist further debilitating effects
 Hightened sensitivity to stress
 If stress continues then hormone levels become depleted and can lead to stage 3
○ Stage 3 – Exhaustion – basically doesn’t happen in humans
 Enlargement/dysfunction of lymphatic structures, ↑ hormone levels, depletion of adaptive hormones,
↓ ability to resist stressors, affective experience of depression
 Allostatic Load
○ Allostasis – processes of getting back to homeostasis
○ Allostatic Load – cumulative, multisystem view of physiological toll that may be exacted on the body
through attempts at adaptation
 Can be a problem if
○ Repeated, novel events cause repeated elevations of stress mediators over long periods of time
○ Lack of adaptation – failure to adapt to a stressor, system stays out of homeostasis
○ Prolonged responses – failure to shut off either the hormonal stress response or to display the
normal trough of the diurnal cortisol pattern
○ Inadequate response – inadequate hormonal stress response which allows other systems, such as
the inflammatory cytokines, to become overactive
○ Allostatic Overload – allostatic load continues for long periods becoming independent of original
adaptation effort
 Ie – one first reacted to one event with stress, that clears up but you are still stressed
 Stress and PTSD – Triple Vulnerability Model
○ True Alarms (stress response to trauma) lead to learned alarms
○ Learned Alarms – occur during exposure to situations that symbolize or resemble an aspect of the
traumatic event (memory triggers)
 Can result in persistent avoidance or numbing (can be substance abuse) of stimuli associated with the
trauma
○ Essential problem is a lack of adaptation (inability to prevent learned alarms from having effect??)
 Theories of Development
○ Freud’s Structural Theory
 Id – present at birth and consists of person’s life and death instincts; operates on pleasure principle
 Ego – develops at 6 months in response to the Id’s in ability to gratify all needs
 Operates based on reality, defers gratification of Id’s instincts until appropriate
 Involves rational thinking
 Superego – develops around age 4-5; represents internalization of society’s standards
 Attempts to permanently block all of Id’s socially unacceptable desires
 Basically the conscience
○ Freud’s Theory of Psychosexual Development
 Emphasizes sexual drives of ID
 Person’s personality is formed during childhood as a result of experiences
 Theorized that a person’s sexual energy (id) centers on different parts of the body during each stage of
development and personality traits result from the ways those conflicts are resolved at each stage
 Stages
 Oral Stage (birth-1yr)– mouth is focus of sensation/stimulation and weaning is source of conflict
○ Fixation – results in dependence, passivity, gullability, orally focused habits
 Anal Stage (1-3) – focus on control of bodily wastes
○ Fixation – produces stinginess, obsessive behavior or cruelty (anal retentive or anal repulsiveness)
 Phallic Stage (3-6) – focus on genitals; Oedipal conflict must be resolved so that identification with the
same sex parent occurs and superego develops
○ Fixation – sexual exploitation of others
 Latency Stage (6-12) – sexual energy is diffuse; goal is to develop social skills
 Genital Stage (12+) – libido is centered on genitals
○ Successful outcome occurs when sexual desire is blended with affection to produce mature sexual rel.
○ Erikson’s Developmental Tasks
 Trust vs. Mistrust (0-18m)
 Social mistrust demonstrated via ease of feeding, depth of sleep, bowel relaxation
 If basic trust is strong then child maintains hopeful attitude, if not then depression or thrill seeking
 Autonomy vs Doubt (18-3yr)
 Learn to walk, feed, talk, potty train
 Need for outer control of caretaker for autonomy to develop
 Self doubt can occur if parents overly shame child
 Initiative vs Guilt (3-5)
 Initiative arisesin relation to tasks for the sake of activity, both motor and intellectual
 Guilt may arise if aggressive goals contemplated
 Desire to mimic adult world and Oedipal struggle leads to resolution via social role identification
 Industry vs. Inferiority (5-13)
 Child is busy building, creating and accomplishing; child takes pride in accomplishments
 May start to compare themselves with others and feel inferior
 Socially decisive stage
 Identity vs Role Confusion (13-21)
 Struggle to establish sense of inner sameness
 Preoccupation with appearance, hero worship, ideology
 Group identify develops (peers become primary influence)
 Psychosocial Moratorium – stage between morality learned by the child and the ethics to be developed by
the adult
 Intimacy vs Isolation (Young adulthood) (21-40)
 Tasks of this stage are to love and to work
 Intimacy is characterized by self abandonment
 Without intimacy with another, person can become self absorbed and self-indulgent/isolative
 Generativity vs. Stagnation (Adulthood) (40-65)
 Generativity concerns a person having or raising children and guiding the oncoming generations and
improve society
 Stagnation is a barren state, inability to transcend the lack of creativity. Unable to accept that death is
inevitable and an integral part of life
 Ego Integrity vs. Despair – (Maturity) (65+)
 Conflict between the sense of satisfaction from reflecting on life productively lived and despair
 Despair results from the sense that life has had little purpose or meaning and that time is too short to make
a difference
 Comes to terms with one’s own mortality
○ Piaget’s Theory of Cognitive Development
 Intellectual development occurs in 4 distinct stages where intellectual operations are different
 Progression through stages is at different rates, but same order
 Stages blend together
 Environment and genetics play a role in this
 Stages
 Sensorimotor Stage (0-2) – child learns about their relationship with various objects and how to
manipulate them
○ Learns fundamental movements and perceptual activities
○ Develops meaning for symbols and uses words
○ Starts to think about events that are not immediately present
○ Develops Object permanence – can maintain a meaningful image of an object even when not visible
 Preoperational Stage (2-7)
○ Preoperational Phase – use language to make sense of the world
 Still have difficulty with cause and effect
○ Intuitive Phase – moves away from drawing conclusions based solely on concrete experiences with
objects
 Can carry on a conversation with the child
 Develop ability to classify objects on basis of criteria, learn to count etc.
○ Limitations they may experience
 Egocentrism – can’t take another’s perspective
 Magical Thinking – thinking can cause things to happen
 Animism – human attributes to inanimate objects
 Centration – can’t understand conversion of ice and water
 Conservation – don’t understand law of conservation of mass
 Concrete Operational Stage (7-12) - Can do more advanced mental processes, but only with concrete
objects or situations
○ Can now take another person’s perspective
○ Can group things into classes based on common attributes
○ Can understand conservation; has better logical reasoning
○ Evidence that this form of thinking predominates in 30-60% of adults
○ College freshmen are often concrete operational thinkers and only move on later
 Formal Operational Stage (12+) – can do abstract thinking and enjoys abstract thought
○ Can formulate hypotheses without actually manipulating concrete objects
○ Able to think ahead to plan solution
○ Can think about thinking
○ Problems
 Imaginary Audience – tendency to believe they are center of attention
 Personal Fable – belief that one is unique and not subject to natural laws that govern others
○ Margaret Mahler’s Theory of Development
 Normal Autistic Phase (0-2mo) – state of half-asleep, half-awake
 Major task is to achieve homeostatic equilibrium with environment
 Normal Symbiotic Phase (2-5mo) – dim awareness of caretaker, functions in fusion with caretaker
 Develops social smile
 Separation-Individuation Phase
 1st Subphase – Differentiation (5-10mo) – process of hatching from autistic shell, becomes more alert
○ can differeniate mother and can have stranger anxiety
 2nd Subphase – Practicing (10-18mo) – upright locomotion results in new perspective and elation
○ mother used as home base
 3rd Subphase – Rapprochment (18-24mo) – now a toddler and more aware of physical separateness,
which dampens mood
○ child tries to bridge gap between himself and mother by bringing stuff to her
○ mother’s attempts to help may not feel helpful – temper tantrum
○ Rapproachment Crisis – wanting to be soothed by mother, yet not wanting to accept her help
○ Symbol of rapproachment – child standing on threshold of door not knowing which way to turn in
frustration
○ Eventually child better at doing things by himself
 4th Subphase – Object Constancy (24mo-5yrs) – better able to deal with mother’s absence
○ Moral Development
 Research
 Children everywhere start life with caring feelings toward others close to them and adversive to unjust
 Some believe children aquire behavioral norms through observation and reward
 Theories
 Piaget’s Three Stage Moral Theory – children learn morals from watching others
○ Premoral Stage (>6) – children exhibit little concern for rules
○ Heronomous Morality (7-10) – children believe that rules are set by authority figures and are
unalterable
 When judging whether an act is “right or wrong” they consider whether a rule has been violated and
what the consequences of the act are
 The greater the negative consequences the worse the act (utilitarian)
○ Autonomous Morality (11+) – they focus more on intent of the actor than consequences(deontological)
 Kohlberg’s Moral Stages – expansion of Piaget’s theory
○ Level 1 - Preconventional/Premoral Theory (>11) – child views acts in terms of pleasant or
unpleasant consequences or in terms of physical power of those who impose them
 Stage 1 – Obedience and punishment orientation – they obey authority to prevent punishment
○ Believes morality is external (kinda like religion)
 Stage 2 – Instrumental Hedonism – right action is based on satisfying the self’s needs and
occasionally others
○ Values can be based on each person’s needs and perspectives
○ Level 2 - Conventional/Role Conformity (11-late adolescence) – moral values reside in performing
the right role and maintaining expectations of others. (corresponds to concrete cognition stage)
 Stage 3 – Good-boy/Good girl Orientation – want to please others and be perceived as a ‘good
person’
○ Actions evaluated deontologically
 Stage 4 – Law and Order Orientation – maintain social order for its own sake
○ Moral judgements based on rules and laws established by legitimate authorities
○ Concern is based on society as a whole
○ Level 3 - Postconventional/Self-Accepted Moral Principles (late adolescence-early adulthood) –
morality is definited in terms of conformity to shared standars, rights or duties apart from supporting
authority. Actions based on inner processes of thought and judgement concerning right and wrong
 Stage 5 – Contractual/Legalistic Orientation – the morally right action is the one that is consistent
with democratically determined laws (which can and should be changed if they don’t align with basic
morality)
 Stage 6 – The morality of Universal Ethical Principles – ‘most moral stage’
○ Action is controlled by internalized ideals that exert a pressure to act accordingly regardless of
the reactions of others in the immediate environment
○ If one acts otherwise, self-condemnation and guilt result
○ Right and wrong determined on basis of broad, self-chosen universally applicable ethical priciples
 Heinz Dilemma
 Read case and then respond to it. The reasoning of the response is indicitave to moral reasoning
 Early Childhood
○ Attachment
 Attachment Behavior – any behavior that has a predictable outcome of increasing the proximity of the child
to an attachment figure. (ex. looking, smiling, etc.)
 Healthy Signs of Attachment
 Social Referencing – 6 months and up. Involves looking to caregiver to determine how to respond in new
or ambiguous situations
 Separation Anxiety – (begins at 6-8 months, peaks at 14) refers to severe stress after separation
 Stranger Anxiety – (8-10 months to 2 years) anxious or fearful of stranger
○ Depends on temperament of child and past experiences with strangers
 Patterns of Attachment – based on Ainsworth Strange Situation (8 brief separations and monitoring)
 Secure Attachment (65%) – best type of attachment
○ Child - mildly upset at mother’s absence and actively seeks contact with her upon return
○ Mothers - emotionally sensitive and responsive to babies’ cues
○ Outcome – more curious, popular and ↑ self esteem as adults
 Insecure/Ambivalent Attachment (10-15%) – very upset at mother’s absence, but ambivalent when they
return, may become hostile if mother tries to touch them
○ Mothers – often moody and inconsistent in their caregiving
 Insecure/Avoidant Attachment (20%) – very little upset at mother’s absence, ignores her when return
○ Mothers – often impatient and unresponsive OR excessive stimulation
 Disorganized/Disoriented Attachment (5-10%)
○ Child – shows fear of caregiver, confused facial expressions, disorganized attachment behaviors
 80% of these children have been mistreated
○ Outcome – tendency to display hostility towards others
 This seems to be highly stable (hard to change)
 Trends
○ Securely attached babies more often maintain attachment status than insecure attachment babies
○ Well-adjusted mothers can move their baby from insecure to secure
○ Babies in low SES or high stress more often change from secure to insecure (or to other insecures)
○ Insecure attachment is often associated with behavior problems
○ Temperament
 A person’s basic disposition which influences how they respond to a certain situation
 Highly influenced by heredity; predictive of later personality and adjustment
 Reactivity and self regulation are the basic components of temerament
 Reactivity – quickness and intensity of emotional arousal, attention and motor activities
○ ↑ inhibition → ↑ physiological response (stress response)
 Self-Regulation – strategies that modify reactivity
 Temperament can also be changed by parenting practices
 Thomas and Chess
 9 basic temperament qualities – activity level, rhythmicity, approach or withdrawal to novel stimuli,
adaptability to environmental change, intensity of reaction, threshold of responsiveness, quality of mood,
distractibility, attention span and persistence
 Types of Temperament
○ Easy Child (40%) – Positive moods, regular sleeping and eating patterns, adapts easily to change, mild
intensity, positive approach to novelty
 the best type
○ Difficult Child (10%) – negative moods, unpredictable sleeping and eating patterns, resists change,
intense emotional reactions intensity, withdrawl from novelty
 This has most risk for adjustment problems
○ Slow to warm up Child (15%) – more inactive, low-key reactions to environmental stimuli, somewhat
negative moods, takes time to adjust to new people
○ For the most part, children stayed in a certain temperament, but not always
 Goodness-Of Fit Model – the degree of match between parents behaviors and child’s temperament
affects child’s temperament
○ Thus if you change parent’s behaviors you might be able to change child
○ Parenting Styles
 Baumrind believed that there were two dimensions of parenting
 Responsivity – warmth
 Demandingness – control
 4 types of Parenting Styles based on this
○ Authoritarian – parents display ↑ warmth and ↑ control
 Absolute standards of conduct that are difficult to comply with, threats, punishment
 Children – often irritable, aggressive, ↓ sense of responsibility, ↓ self-esteem
○ Authoritative – parents display ↑ warmth and rational control
 Consistent family rules and firm limits
 Encourages open discussion and clear communication to explain rules and change if needed
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 Use of praise to gain compliance
 Children – often assertive, self-confident, socially responsible, achievement oriented
○ Permissive – parents display ↑ warmth and ↓ control
 Avoids rules
 Children – impulsive, self-centered, easily frustrated, low in achievement and independence
○ Rejecting-Neglecting – parents disply ↓ warmth and ↓ control, maybe even hostile
 Children - ↓ self-esteem, impulsive, moody, aggressive
 Result – often juvenile delinquents
○ Trends – authoritarian and permissive parenting styles often result in same result → poor self control
and low social responsibility
Brain Development
 Especially rapid growth from 3-6 years in frontal lobe → ↑ inhibition of impulses, ↑ thoughtful responses
 Growth in left cerebral hemisphere – language development
 Improvements in motor coordination
Gender Identity – begins at 18 months and often fixed by 24-30 months
 Evidence shows that boys have more active and competitive play; girls have more intimate exchanges
Play
 Make Believe Play – shows evidence of representation?
 Parallel Play – 2.5-3 years; solitary play next to each other with little or no interaction
 Associative Play – 3 years; playing with same toy in pairs, but without real interaction
 Cooperative Play – by 4 years; real interactions between children, and turn taking
 Sociodramatic Play – starts at 2.5, developed by 4; make-believe with others
 Play is the most important thing for a child, it helps them develop in all aspects
Vygotsky’s Sociocultural Theory – Language is the foundation of higher cognitive processes
 Private Speech – language used for self-guidance
 Self directed speech prominent during difficult tasks and imaginative play in very early childhood
 With age/increasing development the speech is internalized as silent, inner speech
 Social Interactions that Promote Cognitive Functioning –
 Zone of proximal development – a tasks too difficult for the child to do alone but possible with adults
○ Montesori schools based on this
 Scaffolding – adjusting support offered to fit the child’s current level of performance
Care
 How to Bolster Intellectual Development – be affectionate, stimulate language and knowledge, provide
exposure to a variety of places and things, make age-appropriate demands, use age-appropriate language,
resolve conflicts with reason
 Head Start – is incredibly effective; for children with low SES; nutrition; cost-effective
 Daycare – high quality environments; few children per staff member; reduced staff turnover
 Research shows it is best for parents to be with child for first 12 months (1st 4 years are most important)
 TV
 Official recommendation is ‘no tv before 2’, but educational programs can be helpful in early childhood for
low SES/children with uninvolved parents
 Preschoolers watch an average of 3-4 hours a day
 Can lead to obesity and poorer reading achievement
 What to do and not to do
 Make sure to help children label and appropriately express their own emotions
 Point out feelings of others
 Don’t dismiss children’s feelings as unimportant
 No corporal punishment; don’t discipline involving threats of punishment or withdrawl of love
 Child Maltreatment
 Mothers engage in neglect more often than fathers
 Fathers engage in sexual abuse more often
 Mothers and fathers engage in similar amounts of physical and emotional abuse
 Infants and young preschoolers are at greatest risk of neglect
 Preschool and school age are at greatest risk for physical, emotional and sexual abuse
○ Language Development
 Vocabulary – early childhood critical for language development
 They learn really quickly (maybe after hearing once)
 Learn pragmatics by age 4
 Best predictor of vocabulary is how many words are spoken by parent to child in very early childhood
○ Age and Agression
 2-4 year olds – physical aggression ↑, goal of aggression is instrumental, most conflicts with parents
 4-8 year olds – mainly verbal aggression, goal of aggression is hostile, most conflicts with peers
 Adolescence
○ Early Adolescence – 11-14, Middle – 14-17, Late – 17-20
○ Puberty – most observable changes occur over 4 years. Girls from 8-13, boys from 10-14 (ave 13)
 Begins and ends about 18 months earlier in girls
 Puberty continues to occur earlier, could be due to nutrition (more fat), health, chemicals (estrogen homologs),
toxins?
 Puberty in boys often causes ↑ mood, ↑ academic and social functioning
 Puberty in girls often causes poor body image, increased eating disorders and behavioral problems
 ‘Storm and Stress’ – some believe adolescence is a period of storm and stress necessarily
 but maybe it isn’t – normally family and social functioning is unimpaired
○ goes through identity exploration
○ prevalence of some disorders increases but is consistent with adulthood
 Reflects adolescent’s attempt to separate psychologically from parents (do this by going to extremes)
 Erikson saw adolescence as a time of identity crisis
○ Identity confusion occurs if a coherent identity cannot be achieved
○ Fidelity to an ideology develops
 Identity Achievement – reasonably firm commitment to an occupation ideology which occurs after person
has identity crisis and comes out with a commitment to some sort of value system and a clear, consistent
personality
○ Those that achieve this do better in general
 Problems
○ Identity Diffusion – neither a crisis nor a commitment to an identity has occurred.
 This is the least mature outcome
○ Moratorium – a crisis is currently being experienced, but no commitment yet. Philosophically
concerned, rebellious, nonconforming. Can be pendulous
○ Identity Foreclosure – identity commitment has been made without a crisis and without much of an
exploration of alternatives and by accepting (often) parental choices. These people are excessively rigid
in their thinking, conventional and moralistic
 Good Things
○ Self-Concept – they begin to define self in increasingly abstract terms
○ Possible Selves – can contrast between real self and possible selves
 Moodiness
 Pubertal hormones weakly associated with moodiness
 More explained by ↑ negative life events plus the heightened stress reactivity due to changes in
neurotransmitter activity during adolescence
○ Note – during puberty, neurons become more responsive to excitatory neurotransmitters and thus they
experience more intense highs and lows
 Sexual Behavior
 Average for both sexes is 16 years and about 50%
 Only 1/3 use condoms
 Teenaged pregnancy rates higher in US than other industrialized cultures
 Sexual Orientation – prenatal hormones and environment are involved
 Homosexual contacts are frequent before age 15, but only 50% of those end up identifying as homosexual)
 Social Functioning
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 Friendships become more intense; more reciprocity, loyalty, sharing
 Strongest influences come from friends, not necessarily peers
Empathy – develops greatly during adolescence
Morality – develops from rigid acceptance of rules to more flexibility and what is best for society at large
Cognitive Changes – brain has a growth spurt between 13-15, which corresponds closely with self-reflection
and abstract thinking
 Becomes a qualitatively different neural network
 Dopamine inputs in prefrontal cortex grow markedly during adolescence
 Circuitry for impulse control (prefrontal cortex) is not fully mature in early adolescence
 Formal Operational Thinking – greater ability to generate and explore hypotheses and abstractions; more
thinking in relative terms, better self reflection
 Heightened Egocentrism – ‘the imaginary audience’, related to an outgrowth of gains in perspective
 ‘Personal Fable’ – inflated opinion of own importance and uniqueness – related to risk-taking behavior
 Higher capacity for working memory –
 Metacognitive skills – greater ability to think about thinking
Note - # of cell-cell connections in brain reaches a plateau by end of 20s and persists until old age
Sleep - ↑ activity and ↑ neuronal sensitivity to light results in later bedtimes
 But they need 9 hours of sleep → thus many are sleep deprived during the week
Psychiatric Disorder – 20% under 18 suffer from dev, emo, behave difficulties
 Risk of eating disorder, substance abuse, increases
 Eating Disorders – risk factors include (90% women), early puberty, poor body image
 Depression - irritable mood or flatness/emptiness (instead of depressed mood in adults)
○ Social impairment
○ Somatic symptoms like insomnia, loss of appetite etc.
○ Negative thoughts of self, the world and future
○ Mid-adolescence is when self-esteem is at it’s lowest
 Suicide – 3rd leading cause of death in this age group
 Substance Abuse – drug use is on the rise, 32% binge drink
 Violence – aggressive behavior is almost normative for adolescents because it is so common
○ Teens that act out are often depressed
○ Causes of death – accidents > homicides > suicides
 Coping – greater use of avoidant coping strategies (sleeping, music) to deal with negative affective
experiences instead of approach-oriented coping strategies
○ Talk to family and friends the most about their problems
○ Psychologically disturbed teens talk about problems to parents less and only 1/3rd are seen by mental
health professionals
 Primary Care Physicians are essential in diagnosing mental illness in adolescents
○ 70% of youth visit PCP each year, but only 40% ask about mental health
 Adulthood
○ Adult development is shaped primarily by cultural demands (whereas child and adol. has a stronger biological
component)
○ Biological changes tend to be more related to decreases in biological functions rather than growth
○ Developmental Concepts
 Transition – juncture between successive steps (courtship)
 Normative Crisis – period of rapid change or turmoil that strains a person’s adaptive capacity (pregnancy)
 Can be the struggle before reaching a desired goal
 Stage – period of consolidation of skills and capacities (established career, now just getting better at career)
 Plateau – period of developmental stability
 Rite of Passage – social/cultural ritual that facilitates a transition (graduation)
 Regression – midlife crisis (revival of more childlike behavior)
○ Erikson’s Psychological Stages Relevant to Adulthood
 20-35 – Intimacy vs. Isolation –
 35-65 – Generativity vs. Stagnation – seeks satisfaction through productivity in career, family etc.
 65+ - Ego Integrity vs. Despair – review life accomplishments, deal with loss, prepare for death
○ Colarusso’s Tasks of Young Adulthood (20-27)
 Lots of stuff including, become biological and psychological parent, mutual relationship with parents, adult
work identity, adult forms of play, integrate new attitudes towards time, establish identity as a novice,
integrate idealism with real life
○ Courtship, Marriage, Marital Crisis
 Courtship - stage of pair identity, usually progresses towards marriage
 Marriage – people get married later, and # of people who never marry is also increasing
 Divorce rate is declining, but the marriage rate is declining faster
 Marital Crisis – childbirth, parenting (requires acceptance of pair’s parenting culture), empty nest syndrome
(can’t avoid marital problems anymore), affairs (often end in divorce)
 Heterosexual cohabitation – in ’74 it was 10%, in ’94 it was 50%
○ Parenting
 Provide holding environment for children (a safe place)
 Divorce and single parenting are tough
○ Midlife Transition – signs of physical aging, medical illness, ‘tragic’ awareness that things aren’t as good as they
used to be, midlife crisis
○ Bereavement – loss of a person to whom one has been attached
 5 Stages – 1. denial, 2. grief, 3. ambivalence, 4. over-idealizing, 5. detachment from the lost person
 Middle Childhood
○ Physical Development
 Between 6-12, children grow a lot, at age 9 girls are bigger than boys
 Increased muscle strength and loose attachments of ligaments gives them extra flexibility
 Bones of body lengthen and they may have growing pains
 Small muscle control improves (see a change in handwriting because they start to use their fingers not arm
 Drawings more likely to be in 3D
 Brain attains 90% of adult weight by age 7
 Handedness usually established by age 7
 Can distinguish between right and left
 All 20 primary teeth are lost and when new teeth come in the jaw and facial bones grow
○ Psychosexual Behavior
 Lots of sexual curiosity, but not much action
 If sexually abused, then they often have more overt sexual behavior
○ Sex Differences – girls better at handwriting and balance/agility
 Physical superiority of boys is mostly due to social factors
○ Play/Behavior – rough and tumble play that isn’t focused on winning (professionalization of play is bad)
 Supposed to be developing motor skills here, if too much emphasis on winning then those with poor motor
skills quit trying and those skills never develop
○ Cognitive Development
 Piaget’s Concrete Operational Stage (7-11)
 Conservation of matter, classification, seriation (ability to order), spatial reasoning (can draw map) abilities
improve
 Information Processing – biologically based improvements
 Improvements in attention, ↑ digit span (ability to hold #s in mind)
 Memory – improvement in memory (use memory techniques like rehearsal, organization, elaboration etc)
 Theory of Mind – they form their own perception of reality
 Cognitive Self Regulation – they monitor progress toward a goal and strive for it
 Too much negative feedback can cause them to lose confidence and develop learned helplessness
 Scales for Intelligence - WISC-IV (Wechsler Intelligence Scale), measures reasoning and memory
 Cultural Bias – culture can emphasize certain aspects of ‘intelligence’ (ex. some cultures emphasize fact
knowing, while others emphasize story telling)
 Language Development – big improvements, learn about 20 words a day, can analyze complex words, words
have psychological and physical meaning
○ School
 Signs of a good elementary school
 Small class size (emphasizes individual attention), richly equipped with activities, good curriculum, good
interaction between children and teachers, allow children to evaluate their work and decide how to improve,
school has good relationship with parents
 Children with special needs – you don’t want to mainstream them too early because then they might just give
up
 Gifted Children – show extra creativity, divergent thinking, convergent thinking (ability to arrive at the single
correct answer) and talent
 Need to provide extra instruction for them or advance them so they don’t get bored, but this may result in
social isolation
 US Children – average or below average; instruction not as challenging or focused
 Learn by memorization rather than relating information to prior knowledge (moreso than in other countries)
 Other Countries – have better cultural values attached with academic achievement
 Put more of an emphasis on effort (while US is more focused on success)
 More likely to have moral obligation rather than individual need to succeed in school
○ Emotional and Social Development
 Eriksson Theory – Industry vs Inferiority
 They begin to have a positive, yet realistic self concept, they are prideful in their accomplishments, but do
compare themselves with others which can make them feel worse about them
 School brings out the comparisons to others (this can be good or bad)
 Self Concept – can describe their personality, strengths and weaknesses
 Social comparisons are common
 Self Esteem – have developed self-evaluation in academic, social, athletic and physical competence
 Self esteem is very much based on internal goals as opposed to objective assessment
 Effect of what others say is dependent on how much they buy into it
 Things that contribute to self esteem – culture, gender, parenting, what a person attributes outcomes to
(failure deemed due to luck then self esteem might be preserved)
 Inflated Self Esteem – expectations so high that they can’t live up to them; bullies often have this
 Shame can cause a huge loss in self esteem and anger against those who shame them
 Emotional Development – are self conscious of their emotions
 Emotional Understanding – able to figure out contradictory facial and situational cues (read internal state)
 Have a rise in empathy
 Emotional Regulation
 Problem Centered Coping – appraise the situation as changeable, and decide how to resolve it
 Emotion Centered Coping – control distress when little can be done about the situation
 Moral Development
 Ex. distributive justice (dividing goods) – 5-6yo would do it equally, 6-7yo would do it by merit, 8yo
would take special considerations
 Moral Understanding – not as concrete about ‘truth and lying’ (they can choose to lie instead of tell the truth if
it is better for the situation)
○ Peer Relations
 Peer groups will develop unique values and standards of behavior (group identity)
 Note – bullied kids often have over-controlling parents
 Gender Typing – parents often encourage gender specific activities (and also give boys more independence)
 Gender Behavior
 Girls more flexible in their interests and options because of society
 Gender Typicality – feelings similar to people of same gender
 Gender Contentedness – satisfied about being their gender
 Pressure to conform to gender roles is seen much more in males
 Family Influences – amount of time spent with parent ↓ a lot
 Same sex child starts to spend more time with same sex parent
 If access to one of the parents is limited then siblings will fight over who gets the affection
 If parents show favoritism then sibling rivalry can insue
 Only Children – have ↑ self esteem, better academic achievement, closer relationship with parents but less
accepted in peer group (Chinese encourage interaction between cousins)
○ Resilience – ability to adopt effectively in the face of threats to development
 Promoted by easy temperament, good parenting, good support system (including school and community)
○ Life
 Concept of Illness
 Still look for cause and effect relationships, thus if someone gets lung cancer without smoking then it is
perplexing
 May still believe that bad behavior caused an illness
 They begin to understand body processes and functions
 Reaction to Hospitalization – their main concern is lack of body control
 May think that the world is no longer a safe place
 Knowledge of the situation is helpful in handling anxiety
 Need to reassure them that the illness is temporary
 Perception of Death – they begin to understand the irreversibility of death
 Language Development
○ Language is amazingly complex, yet children learn it quite quickly with little instruction
○ Note – average high school student knows about 160,000 words
○ Language – a shared system for representing concepts through the use of arbitrary symbols and rule-goverened
combinations of those symbols
 Generally considered to be uniquely human
 Receptive & Expressive Language
 Receptive Language – language as it is understood (ex. you understand ‘trust’)
○ Usually first to develop
 Expressive Language – language as it is spoken (ex. trying to describe ‘trust’)
 Components of Language
○ Phonology – the sounds words make
○ Semantics – the meaning of words
○ Morphology – pairing sound with meaning
○ Syntax – using words in sentences
○ Pragmatics – language in social situations (ex. close talker)
○ Language Development
 Infants – focus on listening, phonology & pragmatics
 Discriminate vowel vs consonant sounds at 4 weeks
 Discriminate syllables at 4 months
 Can understand new phenomes not part of their native language up until 12 months
 Phonology – progress from cooing → vocal play (changes in pitch) → babbling → jargon (correct stress,
but no real words) → first words (1 year)
 Pragmatics – 8-12 months they start gestures and vocalizations to regulate others behavior and get attention
 Toddlers (12-36 months) – a huge time for language development
 Receptive language understanding may begin around 8-12 months
 Expressive language my start around 12-16 months; first few words happen slowly, but then it increases
exponentially
 Syntax – word combinations begin around 18-36 months
 Preschoolers (ages 3-6)
 Phonology – vowels are correctly pronounced by age 3
○ Inaccurate mental rules are dropped
 Morphology – start speaking with more good grammar
 Syntax – can do negative sentences, yes/no and who questions, can conjoin independent clauses, etc.
 Elementary School (7-11)
 ↑ complexity in all areas
 Semantic – can start to understand multiple meanings and abstract meanings (metaphors)
 Morphology – can add prefix to change meaning or suffix to change grammatical class
 Pragmatics – conversational skills improve (by age 9 they can restart a conversation that was broken down)
○ Storytelling improves – by age 8 all pieces of a narrative can be expressed
○ Language Delays/Disorders
 Language-Specific Problems
 Phonological Disorder – difficulty producing the sounds of speech may be caused by:
○ Oral-Motor Difficulties – difficulty coordinating tongue movements
○ Inaccurate Mental Rules – maybe they believe that consonants at the end of words are optional
 Doesn’t mean they have low IQ
○ Affects 4% of kindergardeners
 Language Learning Difficulties – problems acquiring language despite normal sensory and cognitive
abilities
○ These tend to be delays instead of disorders
○ Affects 7% of kindergardeners, but only about half of those are treated
○ Semantics – slow to acquire the first 50 words, might know a little about the word, but not all of it
○ Morphology/Syntax – poor sentences etc.
○ Pragmatics – may be more passive communicators
○ Literacy – about 50% of these kids will have problems reading
○ Note – a common myth is that children outgrow their language problems (they often occur throughout
life)
 Autism and Developmental Disorders
○ Primary cause may be lack of social interaction
○ Language – small vocabularies, simple conversation forms, limited expression
○ Social Impairment – lack of engagement in social interactions
○ Restricted interests/activities
 Secondary Language Problems
 Hearing Loss/Impairment – language problems not due to cognitive disfunction
○ Phonology is main thing that is impaired, but semantics, morphology and syntax can also be affected
 Mental Retardation – language problems often occur in children with IQ scores below 70
○ Language skills often match mental age better than chronological age
○ Down Syndrome – language performance often below mental age
 Tongue is big and so my have articulation errors
○ Fragile X Syndrome - language performance often near or a little above mental age
 Phonology and fluency are often impaired
○ Williams Syndrome - language performance often same as chronological age
 Mild morphological/syntactical errors
 Possibly severely impaired pragmatic skills
○ Other Communication Problems
 Disfluency/Stuttering – breaks may be due to repetitions of sounds, syllables, or words; prolongation of
sounds; total blockage of airflow
 Voice – any adult voice disorder (disruptions in vocal fold vibration) can occur in kids
 Nodules, polyps, pitch irregularities, asthma related vocal fold problems
○ Language Referrals
 Speech-language pathologists & audiologists specialize in speech, language & hearing disorders. Evaluations
can take 30-120 minutes
 Free for kids over 3 years old through the school
 Treatment focuses on behavioral and cognitive change
 Earlier intervention is best
 Late Life
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Focus on self neglect, learning and memory
Most opt for quality years instead of quantity
Young Old – 65-74
8 Stages of Aging – 50-54, + 5 to 85+
○ Aging – gradual decline of functioning of all the body’s systems
 Body starts aging at age 25!!!
 Not all organ systems deteriorate at the same rate
 SAME – Sleep, Appetite, Memory, Energy (the most troublesome aging changes
 Sleep Disturbance - ↓ sleep time, ↑ sleep latency (time it takes to go to bed), ↑ awakenings, ↑ time in
bed
○ No more REM sleep!
 Appetite - ↓ energy expenditure, ↓ ability to taste and smell
 Memory – instant recall ↓, but memory stays same
○ Mental processing speed declines in our 40s
○ Age 50 sees slower perception and slower recall
○ Abstract reasoning and spatial ability decline
○ Age 70, ↓ ability to concentrate and focus
○ Gains
 Learning continues, vocabulary improves, greater developmental intelligence (think broadly), have
greater factual knowledge, more wisdom
 Better able to relate a problem to something they’ve already experienced
 Energy – illness and medication can contribute to this problem
 Biology
 Life expectancy at 65 – men = 15.7 yrs, women = 20.3 years
 Attitude is best medicine for aging
 4/5 of 65+ have at least 1 chronic illness – hiatus hernia (stomach into diaphragm) and diverticulitis are
most common
 Senility may actually be malnutrition, alcoholism, etc.
 Psychosocial
 Being social helps them and it also helps younger people because they pass on cultural values etc.
 Health is described as good by 75% of people ages 65-75
 Countertransference can be bad for the patient because the doctor may fear old age
 Elderly used to be quite impoverished, but since social security only 10% are impoverished
 Retirement isn’t all good
 Sexual activity – elderly don’t lose interest in sexuality
○ Just as strong in elderly as in older people, but not as much ability or opportunity to express them
○ Intimacy can be physical, psychological, social or spiritual
○ Outercourse – touching, holding, caressing, intimacy substitute for sexual activity
○ Intimacy and meaningful relationships are necessary to feel alive
 Erikson’s Stage – Integrity vs Despair
○ Integrity – result of intimacy?
 Acceptance of ones life and significant people in it, sense of satisfaction
○ Despair – result of narcissism; failure to accept one’s life, fears death
 Long term care – only 5% of those over 65 are in nursing homes
○ 50% widowed women are in nursing homes
 Caregivers – should be cheerful, compassionate and understanding; but have many burdens to carry
○ Advantages – better understanding of one’s parent, gratification, etc.
 Elder Abuse – occurs in all demographics; maybe at 10%
○ Risk factors – mental illness or drug abuse, history of family violence, isolation of the victim
 Elderspeak – must be eliminated to keep dignity of patient
○ Disrespectful, implies that speaker is in control, cause low self esteem
 Paternalism may be required if patient is too ill to choose freely
○ Justified when it helps patient break the cycle of abuse and dependency
 Self Abuse – refusal to eat, refusal to seek medical attention, neglect of hygiene, isolation
○ Could be due to an emotional disorder or a brain disorder (alzheimer’s)
○ Diogenes Syndrome – when self-neglect is nearly life threatening
 Most are above average IQ, following stressful life event or debilitating physical problems
 46% have 5 year survival rate; difficult to manage
 Reminisence – reliving of memories that are joyful, especially when life becomes too lonely
○ Can even involve talking to oneself, but is ok as long as they still take care of themselves
 Personality – can change with age
○ stress can bring out exaggeration of personality traits
○ could get more active to make sure they get the most out of life
 Benefits – personal freedom, lots of free time, ‘take one day at a time’, acceptance of mortality
 Successful Aging – result of mature responses to changes brought on by aging
○ Chronological age – can’t be changed
○ Biological Age – can be advanced by illness
○ Psychological Age (maturity) – depends on an individual’s coping mechanisms
 Coping Mechanisms
○ Altruism – volunteer
○ Humor, playfulness –
○ Suppression – conscious postponement of expressing one’s unpleasant feelings until right time
○ Anticipation – realistic planning for the future
○ Sublimation – express socially unacceptable impulses in an acceptable manner
 Mini Mental Status Exam
○ Cognition – process of obtaining, organizing and using intellectual knowledge
○ Cognitive Capacity – measure of organic brain function
○ Diminished cognitive capacity may be the cause of many psychological disturbances
 Psychiatric Disorders in Elderly Patients
○ Cognitive Disorders – impairment of memory, language, attention
 Delirium – short term confusion with changes in cognition
 Dementia – severe impairment in cognition, judgment and orientation
 Amnestic Disorders – panic, anxiety, obsessive, PTSD, and stress disorders???
○ Anxiety Disorders – a bunch of them
○ Depression – there are obstacles to recognition of depression in the elderly (depressive symptoms are
often attributed to age and physical illness, physical illness often said to be a ‘good reason to be
depressed’)
○ Suicide – 12% of elderly do this (25% of all suicides)
 Most at risk are widowed males, serious medical illness or with substance abuse problem
 Physician assisted suicide doesn’t really help
○ Somatoform Disorders – somatic symptoms that cannot be explained by physical phenomena
 Hypochondriasis – preoccupation with body organs and functions. May be to fulfill emotional needs
○ Substance Abuse – 20% of nursing home patients have alcohol dependence
 Clinical presentation – confusion, poor hygiene, malnutrition, depression, falls, sudden delirium,
unexplained gastrointestinal problem
○ Psychosis – delusions, hallucinations etc.
 Advantages of working with the elderly – gratification, better understanding of parental figures, personal
satisfaction in continuing to work through ones unfinished business (mend unresolved anger against an
older person or fear of aging or dying
 Diagnosis of Mental & Emotional Illness/Mental Status
○ DSM – Diagnostic and Statistical Manual of Mental Disorders
 Classification system based on description not cause
 Divides mental disorders into categories based on criteria set with defining features
 Individual disorders are based on specific diagnostic criteria
 Does not provide description of treatment
 Describes associated features of the each disorder (onset, incidence, complications, etc.)
 5 Axes
 Axis 1 – clinical disorders and other conditions that may be a focus of clinical attention
 Axis 2 – personality disorder and mental retardation
 Axis 3 – any physical disorder or general medical condition that is present in addition to the mental
disorder
 Axis 4 – psychosocial and environmental factors that significantly contribute to the development or
exacerbation of the current disorders
 Axis 5 – global assessment function (GAF) scale – 100 point scale that allows clinician to judge patient’s
overall level of functioning
○ 61-70 – mild symptoms but generally functioning pretty well
○ 21-30 – behavior is considerably influenced by delusions or hallucinations or inability to function in
almost all areas
 Sample differential diagnosis
○ Axis 1 – major depression single episode, severe without psychotic features
○ Axis 2 – dependent personality disorder
○ Axis 3 – diabetes, coronary artery disease, MI, bypass surgery
○ Axis 4 – recent job loss
○ Axis 5 – GAF 50
 Mental Disorder – ~clinically significant behavioral or psychological syndrome that significantly impacts
functioning
○ ICD – International Classification of Disease and Related Health Problems
 Developed by WHO; not official in the US
 Required for medicare billing
 Less restrictive and only has 3 axes (clinical diagnosis, diablements, contextual factors)
○ Mental Status Examination – do every time
 Appearance – grooming, hygiene, dress, posture, weight, facial expression, etc.
 Speech – physical characteristics of speech; rate, quality, etc.
 Mood and Affect –
 Mood – patient’s predominant emotional state (sad, happy)
 Affect – the expression and expressivity of the patient’s emotions (flat, blunted, etc)
 Thought –
 Process – form of thinking; ‘how’ they think (might reflect impaired reality testing etc.)
 Content – ‘what’ they think (ideas, beliefs, obsessions)
 Perceptual Disturbances
 Hallucinations – false sensory perception not associated with real external stimuli
 Illusions – misperception or misinterpretation of real external sensory stimuli
 Depersonalization – disturbed perception of self
 Derealization – ‘things don’t feel right’
 Sensorium and Recognition –
 alertness/level of consciousness
 orientation (know time and place)
 Memory – test memory for different time periods (immediate (seconds to minutes), recent (minutes to
days), recent past memory (months), remote (distant past)
 Attention – ability to focus perception on an outside or inside stimulus
 Concentration – sustained attention to an internal thought process
 Capcity to read or write
 Visuospatial ability
 Abstract thinking
 Knowledge and intelligence
 Impulse Control –
 Judgment and Insight
 Judgment – ability to assess a situation correctly and to act appropriately within that situation
 Insight – ability of the person to understand the true cause or meaning of a situation
○ Awareness ← slight awareness ← awareness, but faulty causality (wife causes them to drink) ←
intellectual insight (says they are going to AA) ← true emotional insight (infrequent, they know why
they want to drink)
 Reliability –
○ How to Assess Mental Status
 Observation – appearance, speech, mood & affect, thought, sensorium and cognition
 Questioning – perceptual disturbances, orientation
 Tests – Sensorium and Recognition
 Memory
○ Immediate retention and recall – digit span
○ Recent Memory – word recall, day’s events
○ Recent Past Memory – current events of last few months
○ Remote Memory – verifiable information about personal and general past events
 Concentration - Serial Subtrations, reverse spelling, changing sets (if they can’t read)
 Reading and writing – read sentence and follow directions
 Visuospatial ability – copy figure etc
 Abstract thinking – interpret proverbs, explain similarities of two words
 Fund of knowledge and Intelligence – computations, vocabulary, facts
 Anxiety Disorders
○ Anxiety – diffuse, unpleasant sense of apprehension
 Usually presents as – muscle tension, sweating, palpitations, tightness in chest, stomach upset, restlessness
○ Fear – response to a threa that is known, external and definite
○ Behavioral Theories of Anxiety
 Learning Theory – anxiety is a conditioned response to environmental stimuli
 Results from copying parents’s behaviors
 Cognitive Theory – person overestimates degree of danger and/or underestimates ability to cope
 Physiological
 Neurotransmitters messed up – catecholamines ↑↑, GABA ↓↓
 Brainstem (sympathetic), Limbic (emotional), hippocampus, prefrontal cortex (conscious behavioral
therapy works here)
 Dysregulation of the hypothalamic-pituitary-adrenal axis (HPA) and over-activity of alarm circuits
 Genetic Predisposition
○ Panic Attack – must 1. be abrupt onset, 2. peak within 10 minutes and 3. have 4 of these symptoms:
 Palpitations, sweating, trembling, shortness of breath, choking, chest pain, chills, hot flashes, dizzy, derealization, de-personalization, fear of losing control, fear of dying, paresthesis
○ Agoraphobia – avoidance of situations where they might feel trapped (crowds, closed in spaces)
 May refuse to leave house (maybe with a person)
○ Categories
 Panic Disorder
 Criteria
○ Repeated and unexpected panic attacks
○ > 1 months of worry about the next attack (because the first one scared them so much
○ Not due to substances or another illness
○ If with agoraphobia, then called panic disorder with agoraphobia
 Stipulations
○ Onset before age 40
○ No loss of consciousness or bodily functions
○ Attacks may come on during sleep
 Therapy
○ Medication – tricyclics, SSRIs, benzodiazepines (addictive, only use short term)
○ Behavioral Therapy – for the long run; deep breathing, muscle relaxation, cognitive behavioral therapy
 Phobias
 Criteria
○ An irrational, persistent, excessive fear of objects, places or situations resulting in conscious avoidance
of the feared object or situation
○ Person realizes that the fear is excessive, but still can’t manage it
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○ Elicits severe distress or impairs function
 Etiology
○ Genetic factors
○ Different phobias may act on different systems (thus different meds can work on them) - adrenergic
theory (performance phobias), dopaminergic theory (social phobia), blood-injury phobia (strong
vasovagal reflex, ↑ sympathetic activity followed by parasympathetic dominance that causes feignting)
 Specific Phobia – phobia of horses; more common
○ Treatment
 Exposure Therapy – gradual exposure to feared object
○ Also teaches relaxation and breath control to prevent escalation of symptoms
 Cognitive Restructuring – deal with thoughts about the feared object
 Meds – including SSRIs
 Social Phobia – fear of social or performance situations
○ Treament – cognitive/behavioral therapy; social skills training; meds
Acute Stress Disorder
 Characteristics
○ Person exposed to a traumatic event and symptoms occur from 2 days to 4 weeks
○ Person reacted with intense fear, horror or helplessness and now experiences distress or impairment
○ Must have at least 3 of these symptoms: numbing, detachment, de-realization, de-personalization,
amnesia (of critical aspects of event), lessened awareness
○ Event re-experienced over and over
○ Reminders of event are avoided (this causes impaired function)
○ Increased arousal
 Treatment
○ Crisis intervention (provide ways to deal with event, not relive it)
○ Prevention of prolonged stress response (breathing, CBT, relaxation)
○ Short term benzos
PTSD
 Characteristics
○ Re-experience traumatic event via dreams and thoughts
○ Avoidance or numbing
○ Hyperarousal (high startle response, irritable, can’t concentrate etc.)
○ >1 month
○ Person has significant distress or impairment
○ Note – can occur years after event (maybe person stopped drinking and now experiences it)
 Vulnerability – age, proximity, childhood trauma, inadequate support system, external locus of control
 Treatment
○ Psychodynamic Therapy
○ Behavior Therapy – exposure, thought stopping, relaxation therapy
○ Group/family therapy – teach family how to deal with PTSD
○ Eye Movement Desensitization Therapy – watch moving object and think about trauma → desensitize
Generalized Anxiety Therapy
 Criteria
○ Excessive anxity and worry > 6 months
○ 3+ symptoms: reslessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance
○ Causes significant distress or impairment
 Could also be – caffeine overuse, stimulant abuse, drug/alcohol withdrawl etc
 Treatment – best if both psychotherapy and meds
○ Psychotherapy - CBT, relaxation, supportive, psychodynamic
○ Meds – buspirone (non-benzo antianxiety), benzo, tricyclics, beta blockers (to slow heart rate)
Obsessive Compulsive Disorder
 Facts
○ Onset often around 20
○ Affects males and females equally
○ Waxes and wanes (stress tends to bring it out)
○ Lifetime prevalence – 2.5%
○ They often feel ashamed of their OCD and realize it is ridiculous
 Criteria
○ Obsessions – unwanted, persistent thoughts, impulses or images; intrusive and sensless
 Attempts to ignore, suppress, neutralize don’t work (that is where compulsions come in)
 Recognizes obsessions are product of own mind
○ Compulsions – repetitive mental acts in respose to obsessions
 Aimed at reducing distress or preventing dreaded event
 Recognizes behavior is excessive or unreasonable; person fights these urges
○ OCD – obsessions or compulsions A. cause marked distress, B. are time consuming, C. impact function
 Treatment
○ Education – tell them this is treatable
○ Meds – SSRIs, tricyclics
○ Psychotherapy – supportive; family (make sure they don’t assist and that they refuse obsessive
questions); behavior (exposure and response prevention)
 Obsessive-Compulsive Personality Disorder – on Axis II
○ Perfectionism; preoccupation with details, order etc; insist others do it like them; excessive devotion to
work to the exclusion of leisure activities and friendships; indecisivencess; over conscientiousness; lack
of generosity in giving time, money or gifts…
 Substance Induced Anxiety Disorder
 Anxiety, panic attacks, obsessions or compulsions related to substance abuse
 Symptoms develop within 1 month of substance abuse or withdrawl
 Anxiety Disorder due to Medical Conditions
 Anxiety, panic attacks, obsessions or compulsions as a direct result of a general medical condition
 Symptoms cause significant impairment
 Mood Disorders
○ Specific objectives
 Compare the diagnoses of major depressive disorder, bipolar I and bipolar II using criteria
 Diagram a typical major depressive episode in terms of symptom severity, treatment response, relapse and
symptom remission across time
○ Lifetime prevalence of mood disorders
 Major depressive disorder and dysthymic affect more females
 Bipolar spectrum disorders are much less common and affect the sexes equally
 Seasonal effect on mood greater in women
 Stress causing depression, atypical symptoms of depression and suicide attempts more common in women
 More common for men to complete suicide
○ Major Depressive Episode
 Criteria
 A - Must have depressed mood/loss of interest + 4 other SIGECAPS symptoms in 2 week period
○ Sleep – insomnia or hypersomnia
○ Interest – depressed mood, loss of interest or pleasure
○ Guilt – feelings of worthlessness or guilt
○ Energy – fatigue
○ Concentration – diminished ability to think or make decisions
○ Appetite – weight change (loss)
○ Psychomotor – psychomotor retardation or agitation
○ Suicidality – preoccupation with death
 B – symptoms do not meet criteria for mixed episode (bipolar trumps everything)
 C – symptoms cause clinically significant distress or impairment
 D – symptoms not due to direct physiological effects of substance
 E – symptoms not better accounted for by bereavement >2 months
○ Manic Episode
 Criteria
 A – distinct period of abnormally and persistently elevated mood lasting >1 week
 B – during period, has 3+ symptoms
○ Inflated self-esteem or grandiosity
○ Decreased need for sleep
○ More talkative than usual or pressure to keep talking
○ Flight of ideas or subjective experience that thoughts or racing
○ Distractibility
○ Increase in goal-directed behavior
○ Excessive involvement in pleasurable activities with high potential consequences
 C – symptoms do not meet criteria for mixed episode?
 D – symptoms cause marked impairment in functioning (may cause hospitalization)
 E – symptoms not due to direct physiological effects of substance (including SSRIs)
○ Hypomanic Episode
 Criteria
 Same criteria as manic episode, except does not include symptom D
○ Criteria for diagnosis of Mood disorders
 Major Depressive Disorder - 1+ major depressive episodes
 Bipolar I Disorder – 1+ manic or mixed episodes
 Usually accompanied by major depressive episodes, but not always
 Bipolar II Disorder - 1+ major depressive episodes AND <1 hypomanic episode
○ Major Depressive Disorder
 Depression worsens morbidity and mortality after MI, CHF
 Worsens mortality in nursing homes
 Worsens outcomes in cancer, diabetes, AIDS and chronic disease
 Common presenting symptoms – tired all time, blah, headache, sexual dysfunction, GI complaints
 Can be different across ethnic groups too
 Physiology
 Stress can exacerbate all of this
 ↓ Neurotransmitters (norepinephrine, serotonin, dopamine) → all sorts of weird stuff → ↓ BDNF →→
↓ neuronal growth and maintenance (↓ cell size, ↓ hippocampal volume, ↑ vulnerability to
neurotoxins)
 Limbic dysregulation; HPA axis dysregulation
 Brain Atrophy – larger third ventricle, hippocampal atrophy, smaller frontal lobe, cerebellum, caudate, etc.
 What ↓ in specific neurotransmitters does
○ Dopamine - ↓ ability to experience pleasure, ↓ motivation, apathy, ↓ attention, cognitive slowing
○ Norepinephrine – lethargy, decreased alertness, anxiety, depression
○ Serotonin – obsessive compulsive symptoms, anxiety, depression
○ Source – essential psychopharmacology 2nd edition, Cambridge university press, 2000
 Pathways
○ Dopamine pathways - tuberoinfundibular
pathway, nigrostriatal pathway, mesolimbic,
mesocortical
○ Corticostriatal projections
○ Norepinephrine pathways – frontal 1 & 2,
limbic, cerebellum, brainstem and beyond
 Most depression is never diagnosed and if
treated it is often inadequate dose or too short
 Treatment
 Electroconvulsive therapy is actually a good
treatment and evokes a rapid response
 Psychotherapy – best for lesser severity, non-chronic, non-psychotic depression
 Medication – best for more severe, chronic, recurrent, psychotic, melancholic, previous + response to meds
○ Antidepressant therapy has been shown to actually ↑ BDNF and thus neuronal growth and cell size
 Remission is the goal of treatment in major depressive disorder
 Note – risk of recurrence ↑ significantly after 1 episode and goes up to 90% likelihood after 4 episodes
 Indications for Maintenance Phase Therapy – three episodes or two episodes + risk factor
 Course and Prognosis
 Major Depressive Disorder
○ Untreated major depressive episode can last 6-13 months
○ As disorder progresses, episodes may become more frequent, longer, and more severe
○ Over 20 year period, average number of episodes is 5-6
○ Most return to normal between episodes, but some might not
 Bipolar I Disorder
○ Untreated manic episodes can last 3 months
○ >90% with 1 episode will have another
○ 10-20% never get a major depressive episode
○ ↑ number of lifetime episodes
○ Episodes become ↑ frequent as individual ages
○ Most return to normal between episodes, but some might not
○ Dysthymic Disorder
 Criteria
 A – depressed mood most of the day, more days than not for 2+ years
 B – presence of 2+ of these symptoms
○ Poor appetite or overeating
○ Insomnia or hypersomnia
○ Low energy or fatigue
○ Low self-esteem
○ Poor concentration or difficulty making decisions
○ Feelings of hopelessness
 C – never without symptoms in A and B for > 2 months at a time
 D – not better accounted for by major depressive disorder for the first two years, but after 1st two years the
two can overlap
 E – never had a manic episode
 F – doesn’t occur exclusively during a psychotic disorder
 G – symptoms not due to direct physiological effects of a substance
 H – symptoms cause significant distress or impairment
 6% lifetime prevalence, adult women more affected then men
 Course and Prognosis - usually early and insidious onset
 Treatment – combination of pharmacotherapy and CBT
○ Cyclothymic Disorder
 Criteria
 A – numerous periods with hypomanic symptoms and numerous periods with depressive symptoms that do
not meet criteria for major depressive episode
 B – never without symptoms for > 2 months in 2 year period
 Rest of the criteria are basically same as dysthymic disorder
 Course and prognosis – early and insidious onset; has higher risk of developing bipolar I or II
 Treatment – mood stabilizers
 Mood and Anxiety Disorders in Children and Adolescents
○ Anxiety Disorders in Childhood and Adolescence
 Developmental Course of Normal fear and anxiety
 Loud noises – infants
 Fear of strangers – 8 months
 Separation anxiety – 1-3 years
 Super ego anxiety/guilt – 4-6 years
 Performance anxiety – increases during grade school
 Etiology – children of adults with anxiety disorders are more likely to have them
 Mothers of children with anxiety disorders have higher rates of anxiety disorders
 Stressful life events correlate with anxiety disorders?
 Separation Anxiety Disorders
 Criteria
○ Developmentally inappropriate and excessive anxiety concerning a separation from home or from those
whom the individual is attached. Must have 3 symptoms:
 Recurrent, excessive stress when separated or anticipation of separation
 Persistent and excessive worry about losing attachment figure
 Persistent worry that they will get lost etc. from attachment figure
 Persistent reluctance to go to school etc. because of fear of separation
 Etiology – genetic; environmental (overprotecting parenting style can affect)
○ Temperament affects it – shy kids are more vulnerable
○ If have it as children, often have it as adults
 Epidemiology – affects boys and girls equally
○ Peak age is 7-9 years; 3-4%
 Differential Diagnosis – depression, truancy, GAD
 Treatment – return to school; education; individual and family therapy; school; medication (only for critical
cases)
 Generalized Anxiety Disorder
 ‘did not know how to stop worry and felt it was beyond control’
 Criteria
○ Excessive anxiety most days
○ Unable to control worry
 Normal Manifestations – restlessness, fatigue, difficulty concentrating, irritability, muscle tension,
problems falling asleep
 Manifestations in kids – worry about future events, concern about past events, concern about competence,
physical complaints (aches etc.), perfectionistic, need continued reassurance, inability to relax
○ Often can’t express their emotions as well as others
 Comorbid Diagnosis – major depression, specific phobia
 Epidemiology – 2-5%, onset – 8-11
 Treatment –
○ Behavioral therapy – relaxation, CBT, have them make sense of their worries
○ Family therapy –
○ Play therapy – often for little kids (maybe have child draw the family)
 Other Anxiety Disorders
 OCD – just as common in kids as in adults
○ Often occurs with another psychological disorder
 Simple/Social Phobia  Panic Disorder –
 Selective Mutisum – silent, whisper or single-syllable words during stressful situation, but talkative
outside of stressful situation
○ Facts – onset 5-6, rare, treat with SSRI, good prognosis
○ Criteria
 Duration – at least 1 month
 Failure to speak is not due to lack of speaking skills or communication disorder
○ Mood Disorders in Childhood and Adolescence
 Major Depressive Episode
 Criteria
○ 5+ symptoms, daily for > 2 weeks
 Depressed, irritable mood – could manifest itself as aggressive behavior
 Diminished interest or loss of pleasure
 Weight/appetite change, sleep problems, psychomotor agitation or retardation, loss of energy or
fatigue, worthlessness or guilt, concentration, indicisiveness, suicidal ideation
 Might do fine with peers
 Dysthymia
 Criteria
○ Depressed/irritable mood for at least two years
○ Never without symptoms for more than two months at a time
○ At least 2 of the following symptoms: ↓ appetite, sleep problems, fatigue, poor self esteem, ↓
concentration, hopelessness
 Easier to diagnose a kid with this because the criteria are less stringent
 Adjustment Disorder with Depressed Mood
 Criteria
○ Starts within 3 months of onset of stressor
○ Ends within 6 months of termination of stressor
○ More than expected distress or significant impairment in social or academic functioning
 Manic Episode
 Criteria
○ A distinct period of abnormally and persistently elevated, expansive or irritable mood lasting a least 1
week
○ Severe functional impairment
○ At least 3 of the following: inflated self-esteem or grandiosity, decreased need for sleep, talkative or
pressured speech, flight of ideas or racing thoughts, distractibility, psychomotor agitation or ↑ activities,
excessive involvement in pleasurable activities
 Hypomania – the same as manic episode, but does not severely impair functioning and only lasts for 4
days
○ Different ways mood disorders manifest throughout development
 All Ages – depressed mood, diminished concentration, insomnia, suicidal ideation
 Younger Ages – depressed appearance, low self-esteem, somatic complaints
 Older Ages – anhedonia (loss of interest), diurnal variation, hopelessness, psychomotor retardation, delusions
○ How to make a diagnosis
 Psychiatric interview – patient, family and others
 Standardized assessments – various self-report and clinician rating forms
 Lab work – regarding medication?
○ Treatment – meds and therapy
 Behavioral Assessment
○ Types of assessment methods
 Direct structured observation of behavior vs. tests
 Individual vs. group tests
 Tests of maximum vs. typical performance
 Psychometric (personality test) vs. impressionistic (psychoanalysis, often perspective of therapist is included)
 Psychometric – high task definition, limited choice response, scores, limited interpretation, high validity
○ Reliability
 Test-Retest Reliability – repeatability, stability
 Internal Consistency Reliability – same things within the test give same result
 Inter-Rater Reliability – observer agreement
○ Factors affecting reliability – test length (more items the better), examinees (more the better), item
difficulty (should be just right), item clarity
○ Validity – usefulness, meaningfulness
 Content Validity – test adequately samples the content domain of interest
 Face Validity – the test looks like it samples what it says it does
 Criterion-Related Validity – correlation between the test and a criterion used to validate the test
 Construct Validity – extent it measures the theoretical construct it is supposed to
 Convergent Validity – when test comes to same conclusion as similar tests?
 Discriminant Validity – when test comes to different conclusion from different tests
○ Referencing
 Normative Referencing – compare results of the test to performance of a group
 Criterion Referencing – compare results of the test to a criteria/standard
 Impressionistic – low task definition, open ended, low validity, etc.
○ Very individualistic, often has lower inter-rater reliability
○ Personality Assessment Instruments
 Psychometric
 Minnesota Multiphasic Personality Inventory-2 (MMPI-2) – items originally chosen on criterion basis
○ Consists of yes-no questions
○ Has validity scales – L (figures out if they lie), F (response validity, if this is high then lots of stuff was
answered in an unusual way), K (figures out if they responded in the socially desirable way)
○ Results – they get a score for various diseases
 V-Pattern with first three could be somataform disorder??
 Office Screening Tests
○ Beck Depression or Anxiety Inventories – questions on scale of 0-3
 Projective/Impressionistic
 Rorschach Test – from klexographie
○ psychometric scoring and interpretation is actually possible using Exner system!!
 Thematic Apperception Test (TAT) – context-specific stimuli, but like Rorschach
○ Intelligence Testing
 Intelligence – ability to adjust or adapt to the environment, the ability to learn, or the ability to perform
abstract thinking
 Differet tests for different age groups
 Stanford-Binet – 2 years to ~20
 McCarthy – 2-8
 Bayley – 1 month to 42 months
 Wechsler Adult (WAIS) – 16-90
Weschler Children (WISC) – 6-16
○ Cognitive areas measured in WAIS
 Verbal Comprehension – vocab, similarities, information (dependent on culture)
 Working Memory – arithmetic, digit span
 Perceptual Reasoning – block design, matrix reasoning (patterns), visual puzzles
 Processing Speed – digit-symbol-coding, symbol search
○ Cognitive areas measured in WISC
 Verbal Comprehension – vocab, similarities, comprehension
 Working Memory – sequencing, digit span
 Perceptual Reasoning – block design, matrix reasoning, picture concepts
 Processing Speed – digit-symbol-coding, symbol search
○ Scores – each area’s score is turned into an index and given a score, then full IQ score is calculated
 Based on Gaussian curve with 1 standard deviation – 68% of people between 85-115
 +30 or -30 is in 2%
○ Neuropsychological Testing – evaluation of brain function through systematic analysis of behavior using
standardized psychological assessment procedures
 Abilities Assessed
 Motor – strength, speed, coordination
 Sensory-Perceptual – visual, auditory, tactile, olfactory
 Spatial Abilities – visuospatial perception, constructional praxis
 Language – written and oral
 Intellectual Functioning – ‘crystallized’ and ‘fluid’ skills
 Attention
 Memory – immediate, delayed, remote, recognition
 Emotional Functioning – recent behavioral patterns, long-term personality functioning
 Uses
 Give functional description – what someone is able to do
 Provide diagnosis, life situation counseling, predict disease course, evaluate effects of treatment/rehab, etc.
 Random note – alzheimer’s disease and frontotemporal dementia have unique cognitive profiles
○ Behavioral-Medical Assessment
 Tests - MMPI-II, Milton Behavioral Health Inventory, Jenkins Activity Survey, Psychosocial Pain Inventory,
Sickness Impact Profile
 Specialized Applications – learning disability, marital pre-counseling, family pre-counseling, rehab eval,
vocational interest and ability eval, research etc.
○ Note – psychological tests are very valid compared to medical tests
○ How to make a psychological assessment referral
 Do – ask a question, be specific, put request in context of clinical information
 Don’t – list test names
 Psychotherapeutic Interventions in Adults
○ Healing Agent – a person trained in a socially sanctioned method of healing
○ Healing Relationship – relationship between healing agent and sufferer
○ Traditions in Healing
 Religiomagical – mobilize supernatural healing forces (shamen)
 Rhetorical – use of words to form attidutes or action (motivational speakers)
 Naturalistic – empirically derived healing (doctors?)
○ Psychotherapy started by Mesmer?
○ Note – Pavlov (classical conditioning), Skinner (operant conditioning)
○ What Psychotherapy Does
 Combats demoralization – loss of control over internal state
 Changes how patients perceive events (assumptive world)
 Improve patients coping (change thoughts) and adaptation (change behavior)
 Reduces symptoms
○ Who receives Psychotherapy – Jerome Frank’s Categories
 Psychotic – those with severe disorders (schizo, bipolar)
 Neurotic – anxious or depressed (mild to moderate)
 Shaken – external stressors have affected their ability to cope
 Misbehaving – mild criminals or addicts; treatment response is much lower
 Discontented - no diagnosable disorder, no sense of purpose, use it like religion
○ Group therapy is especially good for helping the ‘misbehaving’ group
 Can get ‘vicarious care’ by seeing others get better
○ Family therapy is often used when patient is a child
○ Shared Components of Psychotherapy
 Emotionally charged confiding relationship with a helping person
 A healing setting
 A rationale that provides an explanation for patient’s symptoms and how to resolve them
 A ritual or procedure that requires participation of both patient and therapist and is believed by both to be the
means of restoring the patient’s health
○ How to test effectiveness of psychotherapy – single case studies, case series, controlled clinical trials, empirically
supported treatments, meta-analysis
○ Is it effective?
 Patients benefit more from therapy than waiting list controls (where the placebo is that they will get treatment)
 For moderate depression and OCD therapy is equal to or superior to meds
 Behavior therapies are superior than open ended exploratory approaches (where they just talk)
○ Types of Psychotherapy
 Psychodynamic Psychotherapy
 Goal – understanding conflict area and defense mechanisms used
○ More ‘here and now’ things talked about
○ May be expressive or supportive
 Who should get this – good ego strength (can tolerate negative feelings), personality disorders, some major
depression and schizo during remission (if treated with meds too)
 Techniques – face to face (sitting up), free association, expressive, therapist is not highly active but does
interpret and clarify, provide some supportive techniques
○ Medication also used
 Duration – months to years
 Cognitive/Behavioral Psychotherapy
 Goal – identify and alter cognitive distortions
 Selection – unipolar or bipolar nonpsychotic depressed, anxious, substance abuse, personality disorders,
eating disorders
 Techniques – behavioral assignments (get them to do stuff), reading material (education), they are taught to
recognize negatively biased automatic thoughts, therapist identifies schemas, beliefs, attitudes etc.
 Duration – time limited to 15-25 sessions
 Supportive Psychotherapy
 Goal – maintain or re-estabilsh one’s best level of functioning
 Selection – often the ‘shaken’ category that just need some support and the crazies
○ Healthy individuals exposed to stressful life circumstances (adjustment disorder)
○ Individuals with serious illness, ego deficits, schizo, psychotic major depressive, individuals with
medical illness
 Techniques – available, predictable therapist, limited transference, intellectualization, cognitive coping,
therapist is a guide, mentor, coach but is not probing, discuss alternative behaviors and skills
○ Meds often used
○ Supportive techniques – suggestion, reinforcement, advice, teaching, reality testing, reassurance etc.
 Duration – days to years
 Behavioral Therapy
 Goal – eliminate involuntary disruptive behavior patterns and substitute appropriate behaviors
 Selection – habit modification, phobias, headaches, hypertension, sexual dysfunction etc.
 Techniques – systemic desensitization, implosion therapy and flooding??, aversive therapy, biofeedback
 Duration – usually time limited
 Interventions in Children and Adolescents
○ Psychoparmacology
 Doesn’t necessarily depend on weight
 Children are more vulnerable to the behavioral side effects of meds (tics, agitation, etc.)
 80% of child prescriptions are give off label (need literature support)
 Meds can have unusual side effects in children (depakote – hepatotoxicity)
 Compliance and Informed consent are tough because it is basically the parents that do it
 Placebo response is often ↑ (so is nocebo effect) in children
 Make sure to do baseline assessment before starting treatment (physiological, mental, etc.)
○ Ritalin - Methylphenidate
 Significant increases in ADHD treatment in last 20 years (almost doubles every 4-7 years)
 Ritalin is treatment for 90% of those
 Perscriptions wax and wane depending on current news hysteria
 3x differences between states, 10x differences between zip codes
 More often prescribed in urban areas
 More often prescribed in public schools and less affluent familes
 Why increase?
 More inclusive criteria in DSM-IV; more girls are being diagnosed with ADD (which is harder to spot);
treatment now continues for longer duration; greater public and professional acceptance
 Reimbursement shift towards meds and not psychotherapy
 Unrealistic expectations of medications
 Longer duration of treatment with fewer drug holidays
 More frequent doses; larger doses
 3-6% of children have ADHD (largest population is 8-9 year olds)
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Only 12% of ADHD children received stimulants
ADHD children off meds had similar levels of symptoms as those on meds?
Non-ADHD children on stimulants had higher levels of symptoms than unmedicated children
“Concern about dramatic levels of overprescribing was not supported”
Meds with or without behavioral therapy are superior treatment than just therapy or community care
Ritalin should not be used on children under 5 (preschool)
 Side effects greater in children under 5 and could cause growth retardation
 Ritalin and Substance Abuse
 Early use of Ritalin does not cause increase in substance abuse
 Unmedicated ADHD has 6x risk of substance abuse, medication for ADHD ↓ that by 85%
 No evidence for Ritalin abuse/dependence
 Side Effects – sleep disorders, ↓ appetite, irritability, depression, psychotic features, overactivity and
impulsivity, no personality (side effect of the specific drug, just switch drug)
 Note – if children don’t get sleep, they often become more hyperactive
 Important to communicate with teachers and school directly about child’s performance
 Other mood stabilizing drugs like SSRIs, neuroleptics can be added
 Wellbutrin is often used as a second line treatment for ADHD
○ Antidepressants
 Used for many things
 FDA now has a warning that some antidepressants (Paxil) can ↑ rate of suicidal behavior in children to age
24
 Untreated depression is still the greatest risk
 Data on real cause and effect relationship between antidepressants and suicide is still debated
 Effexor – more frequent side effects, not found superior to placebo (in MDD or axiety disorder), not
recommended for children
 Bipolar Disorder in Children
 Diagnosed with ↑ frequency, (due to recognition of earlier onset and broadening of bipolar spectrum)
 Symptoms/features – rapid cycling (even within the day), unremitting, irritability, insidious onset,
pronounced irritability instead of euphoria, more psychotic symptoms, increased comorbidity (ADHD)
○ More often treatment resistant (because those that get it young often have bad case)
 Drugs – lithium, anticonvulsants, neuroleptics, benzodiazepines, antidepressants (can cause mania)
 Saftey Concerns – certain drugs can have very significant complications, toxicity, organ failure, obesity
(depakote and polycystic ovary disease)
 Neuroleptics can have very serious side effects
○ Interventions in Children and Adolescents
 Early intervention can alter the course of a disorder and reduce the amount of suffering
 Types of Adolescent Therapy
 Play Therapy
○ Incorporates many of the cognitive-behavioral techniques, but in the framework of play
○ May be quite useful in cases of trauma, abuse, attachment, etc.
○ Very little intervention from the therapist
 Behavior Therapy – draws on a full range of empirical evidence (evidence strongly supports this)
○ Identify what is wrong (person, problem, circumstance all or none) and apply treatment on parent or
child, in school, home office etc
 Basically it is very tailored to specific situation
 Cognitive Therapy – try to identify negative thoughts and change them into rational ones
○ Works in adults, doesn’t work as well in children
○ Smarter children do better with this
○ Works better in children if behavioral element is added in
 Exposure and Response Prevention – treatment choice for OCD
○ Ease them into stopping their OCD tendencies
 Parent Training
 Time Tested
○ Attending (pay attention to kid when they do something good), ignoring (ignore when bad), praise, give
clear commands and follow through on them, use time out (use properly and as last resort)
 Positive Parenting – believes child is basically good and will do the right thing if they understand
consequences
○ Basically removes punishment
 Collaborative Problem Solving – arrive at solution to problem mutually (both sides win)
○ Especially useful for children that are extremely difficult (temperament, ↓ executive skills, ↓ social
skills, ↓ language processing skills etc.).
○ Emphasis on antecedents rather than consequences (proactive rather than reactive)
○ Emphasis on situational specificity
○ Goal is to teach kids skills like flexibility of thinking, tolerance of frustration, ability to adapt
 Cognitive Therapy for Depressed Teens
 A.C.T. – activities, calm and confident, talents
 THINK – think positive, help from a friend, identify the silver lining, no replaying bad thoughts, keep
thinking-don’t give up
 Comic Strip Stories –
 Social Stories – mainly for kids on autism spectrum. It helps them be less literal and practice pretending