PSHYCHIC STRUCTURES
o Freudian psychology
Id = drives (instincts) present at birth
Sex
Aggression
Ego = mediates between Id and Superego
Superego = conscience
DEFENSE MECHANISMS
o The ways and means with which the ego wards off anxiety and controls instinctive urge and unpleasant affects (emotions)
o Defense mechanisms are unconscious, discrete, dynamic, and irreversible, adaptive and maladaptive
o Suppression is the only defense mechanism which is conscious
o When defense mechanisms become maladaptive we as physicians have to step in
o Projection
Attributing your own wishes, thoughts, or feelings onto someone else
“I’m sure my wife is cheating on me”
Found in schizophrenia
o Denial
To avoid becoming aware of some painful aspect of reality
“I know I do not have cancer”
o Splitting
External objects are divided into all good or all bad
“The morning staff are better than the evening staff
Found in borderline personality
o Blocking
Temporary block in thinking. (Might have an emotional charge against it)
“I cant seem to remember his name”
o Regression (most immature)
Become child like
o Somatization
Psychic derivatives are converted into bodily symptoms
“Just thinking of the exam I get butterflies in my stomach”
o Introjection
Opposite to projection
“The resident physician dresses like the attending”
Not the same as imitating, because that’s conscious
o Displacement
Taking out my anger out on something else, or on someone else.
o Repression
Painful memories that we do not know that we had them. If we however recall/remember that we had them, but we rather want
to forget them = suppression
o Intellectualization
Trying to understand what is wrong.
“It is interesting to note the specific skin lesions which seem to arise as an consequence of my end-stage disease”
o Isolation
Separating how we feel and how we express our emotions
“As she arrive the station to identify the body, she appeared to show no emotion”
o Rationalization
Rational explanations are used to justify unacceptable attitudes, beliefs or behaviors
When you make an excuse for your behavior
o Reaction formation (seen in obsessive compulsive disorder), OBSESSION
Unacceptable impulse transforms into its opposite, resulting in the formation of character traits
“Listen to him tell his family he was not afraid, when I saw him crying”
You want to start a fire, but become a firefighter. Actually putting it out.
Undoing (seen in obsessive compulsive disorder), COMPULSION
Acting out the reverse of the unacceptable behavior
o Acting out
Behavioral or emotional outburst
1
, o Humor
Permit the expression of feelings and thought without personal discomfort
Making a joke about terrible experiences
o Sublimation (the most mature defense mechanism)
The aim or object has been changes from unacceptable to acceptable
You want to start a fire, and work in a Hollywood special effect department
“Jack the ripper becomes a surgeon”
o Suppression
Conscious forgetting
I would rather forget that my dog was run over by a car
THEORIES OF HUMAN DEVELOPMENT
o Erik Eriksson
Believed that human personality was determined by childhood and adult experiences. Infancy to old age
Stages are determined by crises, which are the turning points of the stages
Stage 1 (birth to 1 year) – trust versus mistrust
Stage 2 (1-3 years) – autonomy versus shame and doubt
o Children have a sense of mastery over themselves and their drives
o Cooperative or stubborn
Stage 3 (3-5 years) – initiative versus guilt
Stage 4 (6-11 years) – industry (accomplishment) versus inferiority
Stage 5 (11 years to end of adolescence) – identity versus role diffusion
Stage 6 (21-40 years) – intimacy versus isolation
Stage 7 (40-65 years) – generativity versus stagnation
Stage 8 (>66 years) – integrity versus despair
o Jean Piaget
Believed that intelligence was an extension of biologic adaption and had a logical structures. Consisted on how children and
adolescents think and acquire knowledge.
Stage 1 (birth – 2 years) – sensorimotor
Stage 2 (2-7 years) - preoperational stage
o Children are egocentric
o “Daddy left because of something I did”
o Animation – “bad bicycle you made me fall”
o Death is reversible – “I understand that grandpa is dead, but when is he going take me to the park?”
Stage 3 (7-11 years) – concrete operations
o Egocentric is replaced by operational thoughts. They can see things in other’s perspective
Stage 4 (11 to the end of adolescence) – formal operations
o Ability to think abstractly, reason deductively, and define concepts
o Sigmund Freud (psychosexual development)
Sigmund Freud believed that children were influenced by sexual drives. He noted that infants were capable of sexual activities from
birth, the first of which were nonsexual.
Stage 1 (birth to 18 months) – oral stage
Mouth is the main site of gratification – biting, chewing, sucking
Stage 2 (1-3 years) – anal stage
The anus and surrounding areas is the main site of gratification.
The child fights for control
Primarily involved in bowel functions and bladder control. If experiences harsh toilet training, the child may become
“anally fixated” (obsessive-compulsive personality disorder). A fixation is an arrested stage of development.
Stage 3 (3-5 years) – phallic stage
The genital area is the main site of gratification
Penis envy and fear of castration are evident during this stage
Increase in genital masturbation with fantasies involving the opposite-sex parent = “oedipal complex”
Stage 4 (5-13 years) – latency stage
Formation of superego
Resolution of oedipal complex
Sublimation of sexual energy into energetic learning and play activities
Stage 5 – genital stage
Capacity of true intimacy
2
, CHILDHOOD DISORDERS
o Mental retardation (more in boys)
IQ < 70, and social adaptive functioning deficits, onset before 18 years of age
o Autistic disorders
Qualitative impairment in social interaction, communication, imaginative activities, and interests
May be due to encephalitis, maternal rubella, PKU…
o ADHD
Inattention, hyperactivity, and impulsivity that interfere with social or academic function
Symptoms last for at least 6 months, and onset occur before 7 years of age
Are present in multiple settings, such as school, home, and work
Family history (parents)
Treatment
Psychostimulants: Increase norepinephrine and dopamine = methylphenidate (>6yrs), dextroamphetamine (>3yrs),
atomoxetine
o Conduct disorder
Pre-teen or teen, boys
Persistent violations in four areas
Aggression (family, animals)
Property destruction
Deceitfulness or theft
Break rules
Family history (parents)
>18 years these kids are labeled antisocial personality disorder
Differential diagnosis
Oppositional defiant disorder
Treatment
Changing the environment
Behavioral modification (exposing to prison life, boot camps…)
Parental involvement/support
Community support
Medications only in children who are very aggressive and hostile = atypical antipsychotics
o Oppositional defiant disorder (problem with authority figures)
Pre-teen or teen, equal boys and girls
Obey rules
Persistent pattern of negativistic, hostile, and defiant behaviors toward adults. Including arguments, temper outbursts,
vindictiveness, and deliberate annoyance
Differential diagnosis
Conduct disorders
Treatment
Educating parents
o Childhood enuresis
>5 years of age
Reason: Underlying stressor at home
Family history
Behavioral treatment
o Childhood anxiety
Stranger anxiety – 8 months to 2 years of age
Separation anxiety – 1 to 3 years of age
Phobias – 3 to 6 years of age (dark, monsters – stomachache, headache)
o Tourette disorder
Childhood onset of multiple motor and vocal tics
Theory = too much norepinephrine and dopamine treatment with antipsychotics (risperidone)
Coprolalia (10% of cases) = inappropriate swearing
Most common associated findings = ADHD and OCD
MOOD DISORDERS
o Major depressive disorder
Symptoms > 2 weeks, and deterioration of you level of functioning
Must have depressed mood, or anhedonia (absence of pleasure)
Presenting symptoms (sleep, weight, appetite)
Depressed mood most of the day
Anhedonia mot of the day
Insomnia or hypersomnia
Significant weight loss or weight gain
Increased appetite or decreased appetite
Diminished ability to concentrate
Psychomotor agitation or retardation
Fatigue or loss of energy
Feeling of worthlessness or guilt
Recurrent thoughts about death (suicidal ideation). 10-15% will actually commit suicide.
3
o Freudian psychology
Id = drives (instincts) present at birth
Sex
Aggression
Ego = mediates between Id and Superego
Superego = conscience
DEFENSE MECHANISMS
o The ways and means with which the ego wards off anxiety and controls instinctive urge and unpleasant affects (emotions)
o Defense mechanisms are unconscious, discrete, dynamic, and irreversible, adaptive and maladaptive
o Suppression is the only defense mechanism which is conscious
o When defense mechanisms become maladaptive we as physicians have to step in
o Projection
Attributing your own wishes, thoughts, or feelings onto someone else
“I’m sure my wife is cheating on me”
Found in schizophrenia
o Denial
To avoid becoming aware of some painful aspect of reality
“I know I do not have cancer”
o Splitting
External objects are divided into all good or all bad
“The morning staff are better than the evening staff
Found in borderline personality
o Blocking
Temporary block in thinking. (Might have an emotional charge against it)
“I cant seem to remember his name”
o Regression (most immature)
Become child like
o Somatization
Psychic derivatives are converted into bodily symptoms
“Just thinking of the exam I get butterflies in my stomach”
o Introjection
Opposite to projection
“The resident physician dresses like the attending”
Not the same as imitating, because that’s conscious
o Displacement
Taking out my anger out on something else, or on someone else.
o Repression
Painful memories that we do not know that we had them. If we however recall/remember that we had them, but we rather want
to forget them = suppression
o Intellectualization
Trying to understand what is wrong.
“It is interesting to note the specific skin lesions which seem to arise as an consequence of my end-stage disease”
o Isolation
Separating how we feel and how we express our emotions
“As she arrive the station to identify the body, she appeared to show no emotion”
o Rationalization
Rational explanations are used to justify unacceptable attitudes, beliefs or behaviors
When you make an excuse for your behavior
o Reaction formation (seen in obsessive compulsive disorder), OBSESSION
Unacceptable impulse transforms into its opposite, resulting in the formation of character traits
“Listen to him tell his family he was not afraid, when I saw him crying”
You want to start a fire, but become a firefighter. Actually putting it out.
Undoing (seen in obsessive compulsive disorder), COMPULSION
Acting out the reverse of the unacceptable behavior
o Acting out
Behavioral or emotional outburst
1
, o Humor
Permit the expression of feelings and thought without personal discomfort
Making a joke about terrible experiences
o Sublimation (the most mature defense mechanism)
The aim or object has been changes from unacceptable to acceptable
You want to start a fire, and work in a Hollywood special effect department
“Jack the ripper becomes a surgeon”
o Suppression
Conscious forgetting
I would rather forget that my dog was run over by a car
THEORIES OF HUMAN DEVELOPMENT
o Erik Eriksson
Believed that human personality was determined by childhood and adult experiences. Infancy to old age
Stages are determined by crises, which are the turning points of the stages
Stage 1 (birth to 1 year) – trust versus mistrust
Stage 2 (1-3 years) – autonomy versus shame and doubt
o Children have a sense of mastery over themselves and their drives
o Cooperative or stubborn
Stage 3 (3-5 years) – initiative versus guilt
Stage 4 (6-11 years) – industry (accomplishment) versus inferiority
Stage 5 (11 years to end of adolescence) – identity versus role diffusion
Stage 6 (21-40 years) – intimacy versus isolation
Stage 7 (40-65 years) – generativity versus stagnation
Stage 8 (>66 years) – integrity versus despair
o Jean Piaget
Believed that intelligence was an extension of biologic adaption and had a logical structures. Consisted on how children and
adolescents think and acquire knowledge.
Stage 1 (birth – 2 years) – sensorimotor
Stage 2 (2-7 years) - preoperational stage
o Children are egocentric
o “Daddy left because of something I did”
o Animation – “bad bicycle you made me fall”
o Death is reversible – “I understand that grandpa is dead, but when is he going take me to the park?”
Stage 3 (7-11 years) – concrete operations
o Egocentric is replaced by operational thoughts. They can see things in other’s perspective
Stage 4 (11 to the end of adolescence) – formal operations
o Ability to think abstractly, reason deductively, and define concepts
o Sigmund Freud (psychosexual development)
Sigmund Freud believed that children were influenced by sexual drives. He noted that infants were capable of sexual activities from
birth, the first of which were nonsexual.
Stage 1 (birth to 18 months) – oral stage
Mouth is the main site of gratification – biting, chewing, sucking
Stage 2 (1-3 years) – anal stage
The anus and surrounding areas is the main site of gratification.
The child fights for control
Primarily involved in bowel functions and bladder control. If experiences harsh toilet training, the child may become
“anally fixated” (obsessive-compulsive personality disorder). A fixation is an arrested stage of development.
Stage 3 (3-5 years) – phallic stage
The genital area is the main site of gratification
Penis envy and fear of castration are evident during this stage
Increase in genital masturbation with fantasies involving the opposite-sex parent = “oedipal complex”
Stage 4 (5-13 years) – latency stage
Formation of superego
Resolution of oedipal complex
Sublimation of sexual energy into energetic learning and play activities
Stage 5 – genital stage
Capacity of true intimacy
2
, CHILDHOOD DISORDERS
o Mental retardation (more in boys)
IQ < 70, and social adaptive functioning deficits, onset before 18 years of age
o Autistic disorders
Qualitative impairment in social interaction, communication, imaginative activities, and interests
May be due to encephalitis, maternal rubella, PKU…
o ADHD
Inattention, hyperactivity, and impulsivity that interfere with social or academic function
Symptoms last for at least 6 months, and onset occur before 7 years of age
Are present in multiple settings, such as school, home, and work
Family history (parents)
Treatment
Psychostimulants: Increase norepinephrine and dopamine = methylphenidate (>6yrs), dextroamphetamine (>3yrs),
atomoxetine
o Conduct disorder
Pre-teen or teen, boys
Persistent violations in four areas
Aggression (family, animals)
Property destruction
Deceitfulness or theft
Break rules
Family history (parents)
>18 years these kids are labeled antisocial personality disorder
Differential diagnosis
Oppositional defiant disorder
Treatment
Changing the environment
Behavioral modification (exposing to prison life, boot camps…)
Parental involvement/support
Community support
Medications only in children who are very aggressive and hostile = atypical antipsychotics
o Oppositional defiant disorder (problem with authority figures)
Pre-teen or teen, equal boys and girls
Obey rules
Persistent pattern of negativistic, hostile, and defiant behaviors toward adults. Including arguments, temper outbursts,
vindictiveness, and deliberate annoyance
Differential diagnosis
Conduct disorders
Treatment
Educating parents
o Childhood enuresis
>5 years of age
Reason: Underlying stressor at home
Family history
Behavioral treatment
o Childhood anxiety
Stranger anxiety – 8 months to 2 years of age
Separation anxiety – 1 to 3 years of age
Phobias – 3 to 6 years of age (dark, monsters – stomachache, headache)
o Tourette disorder
Childhood onset of multiple motor and vocal tics
Theory = too much norepinephrine and dopamine treatment with antipsychotics (risperidone)
Coprolalia (10% of cases) = inappropriate swearing
Most common associated findings = ADHD and OCD
MOOD DISORDERS
o Major depressive disorder
Symptoms > 2 weeks, and deterioration of you level of functioning
Must have depressed mood, or anhedonia (absence of pleasure)
Presenting symptoms (sleep, weight, appetite)
Depressed mood most of the day
Anhedonia mot of the day
Insomnia or hypersomnia
Significant weight loss or weight gain
Increased appetite or decreased appetite
Diminished ability to concentrate
Psychomotor agitation or retardation
Fatigue or loss of energy
Feeling of worthlessness or guilt
Recurrent thoughts about death (suicidal ideation). 10-15% will actually commit suicide.
3
