Jan 23

An Introduction to Health & Wellness

Objectives

1. Define the terms health and wellness

Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity [WHO]
Wellness can be defined as an active process of becoming aware of and making choice
toward a more successful existence

2. Discuss the concept of the biopsychosocial model

The biopsychosocial model is a general model or approach that posits that biological,
psychological and social factors all play a significant role in human functioning in the
context of disease or illness [physical (biological integrity of the individual), mental
(subjective sense of well-being), social (role fulfilment), spiritual (issues related to one’s
value system) health]

3. Discuss the concept of optimal health

Optimal health is a state of complete physical, mental and social well-being; being your
best with what you’ve been given.
5 key areas to keep in balance – physical, emotional, social, intellectual, spiritual.

4. Discuss the concept of health determinants and the multifactorial nature of health and
wellness.
Health determinants are any factor in an individual or the environment that helps
determine the state of health of a person. There is a multifactorial nature for both
health and wellness – host factors (basic biology of humans and the organic make up of
an individual), environmental factors (factors external to the human body; physical eg
water, geographic conditions, ergonomics, or biological eg. Microbial agents, toxins,
vectors, or chemical eg pollution, or social, eg family size, occupation, education),
lifestyle factors (choices made at an individual level; 8keys areas, diet &activity, drug
use/alcohol/smoking, sexual behaviour, conflict resolution, road use behaviour,
environmental hygiene, health care seeking behaviour, spirituality), health services
factors (availability, accessibility and acceptability of health and social services).
These factors can either be non-modifiable (eg age, gender, genetic make up) or
modifiable (eg diet, exercise habits, smoking, etc)

**Health promotion is the process of enabling people to increase control over, and to improve
their health.
 Jan 24
Concepts of Health Education & Health Promotion
Objectives

1. Explain health education

Health education is a combination of learning experiences designed to achieve voluntary actions
supportive of health. It forms a part of health promotion, it complements it.
Individuals, families and communities can be taught how to assume responsibility for their
health, which will make effective use of the changes in social conditions.

2. Explain health promotion

The combination of educational, social and environmental supports for actions and conditions of
living conducive to health.

3. Explain the rationale behind multiple approaches to health enhancement

The biopsychosocial model of health (a combination of biological, psychological,
environmental and social) states that the individual is not just a passive victim of
circumstance and that there are brad approaches to health enhancement: Treatment,
Behavioural, Socio-environmental (policies, infrastructure, social services)

Treatment – deals with the problems defined by disease and is concerned about disease
process, physical factors and using medical interventions for solving problems.

Behavioral – Use multiple risk reduction strategies, such as identifying knowledge, attitudes and
risk behaviors, understand the effects of these behaviors on health and plan change. Behavior
change involves communication strategies and building relationships.

Socio-environmental – priority given to condition over which people have little or no control and
is concerned with the underlying determinants of health (develop infrastructure, healthy public
policies, intersectoral partnerships, equitable distribution of resources)

These multiple approaches can improve one’s health status

4. Value the different areas of responsibility for health

 Each member of the health team should take responsibility for promoting well
being.
 The individual should be an active participant
 Family support
 Organizational
 Communities
 National level
 Regional & international bodies
 5. Articulate the role of healthcare professionals.
 Seek to maintain good health status
 Understand the need to individuals served
 Involve the individual
 Understand more than what is told
 Understand that the individual belongs to a family, friends and community, all of
which impact their health and health behaviours

Jan 24
Health & Illness
Notes

 Disorder – a functional abnormality

 Morbidity – a diseased state, disability or poor health due to any cause (or the degree
that the health condition affects the patient) **co-morbidity – at the same time in one
person
 Medical condition – includes all diseases and disorders (injuries and normal health
situations)
 Disease – and abnormal condition that impairs normal function

 Causes of disease:
 Risk factors (things that affect you/your health that are about you or that you
engage in):
o Genetic & Physiological factors
o Age
o Environment
o Lifestyle

 Health determinants (anything that can and will affect your health, eg. lighting in a
room, overcrowding, lack of physical contact with a person, the amount of noise,
etc.)

 Classifications of Diseases
 According to aetiological factors
o Hereditary (defect in genes)
o Congenital (defect in development)
 o Metabolic (abnormality in process of metabolism (eg. G6PD deficiency, RBC has
low oxygen carrying capacity)
o Deficiency (inadequate intake of essential dietary factors)
o Traumatic (injury)
o Allergic (abnormal response of body to chemical or protein substances)
o Neoplastic (uncontrolled growth of cells)
o Idiopathic (unknown cause, self-originated, spontaneous origin)
o Degenerative (degenerative changes in tissues and organs)
o Iatrogenic (treatment of a disease, eg. anaphylaxis – reaction to medicine)

 According to duration of onset

o Acute disease (short, severe, following which person returns to normal
functioning)
o Chronic Illness (slow onset, longer than 6 months, fluctuation between maximal
functioning and serious relapses, characterized by remission [no obvious
symptoms] and exacerbation [pronounced symptoms])

 Other classifications of disease

o Organic (structural/anatomical changes)
o Functional Occupational
o Familial (eg. cancer, hypertension)
o Venereal (eg. HIV/AIDs, gonorrhea)
o Epidemic (large number of individuals in community at the same time)
o Endemic (present and recurs in community, eg malaria one or two in country)
o Pandemic (extremely widespread epidemic disease eg. country/continent)
o Sporadic (occasional cases, eg. polio)

 Illness is a personal or subjective state in which the person feels unhealthy or unwell

 Stage of illness:
1. Symptom experience (experience some symptoms, believe something is wrong. 3
aspects: i. physical – fever, muscle aches, malaise, headaches ii. Cognitive –
perception of having flu iii. Emotional – worry about consequences of illness)
2. Assumption of sick role (accept illness, seek advice)
3. Medical care contact (seek advice to health professionals to validate real illness,
explain symptoms, reassure prediction or outcome)
4. Dependent patient role (accept/reject health professional’s suggestions, becomes
more passive and accepting, may regress to an earlier beharioural stage)

 Effects of illness
o Privacy
o Autonomy
 o Financial burden
o Lifestyle
o Family & significant others

Jan 24
Religion, Culture & Health
Objectives
1. Clearly define pertinent terms
Health – state of complete physical, mental and social well-being
A sociological understanding of health considers structural and social factors instead of
simply biological explanations of health and disease.

Culture – learned, shared and transmitted values, beliefs, norms and life practices of a
particular group that guides the thinking, decisions and actions in patterned ways
Culture shapes out beliefs, attitudes and values and therefore exerting considerable
influence on health and health seeking behaviours (eg. having your own natural remedy
for everything, bush medicine, having access to technology will enable us to use
appropriate over-the-counter drugs for self-treatment)

Religion – a matter of faith-belief anchored in conviction rather than scientific evidence.

It is founded on the idea of the sacred, that which is set apart as extraordinary and
demands submission – religion is not spirituality, it is the context in which your
spirituality is expressed
Spirituality permeates all aspects of patients lives who are devout, affecting their health
care decisions and practices (eg. Jehovah’s witnesses do not accept blood transfusions,
Catholics are averse to fertility treatment, abortion and contraceptives, for Jewish
families, circumcising boys is one of faith and tradition as well as a medical decision)

2. Appropriately explain influential theories relevant to religion & culture in healthcare

****WHAT IS THIISSS????

3. Better appreciate cultural diversity in relation to healthcare

Culture influences health in a number of ways:
o Language (means of connection & transmitting culture; may pose a problem in
translation and meanings assigned to words)
o Body language (certain gestures reflect certain attitudes/beliefs)
o Gender (males tend to stay sick longer before seeking medical attention)
o Gender relations (women tend to be dependent on the man)
o Technology (expand range and explanation of conditions)

Not only thought in the medical profession are involved in health now, also alternative
medicine, disease specific local and international self-help groups
 Must be culturally competent as a medical professional
o Cultural awareness (recognition of cultural beliefs, practices, values, and be
sensitive to these)
o Cultural knowledge (develop a culturally sensitive approach to patient care and
interactions)
o Cultural skills (ability to collect data and perform physical histories that are both
thorough and culturally sensitive)
o Cultural encounter (direct interactions between provider and patient, despite
their different cultural backgrounds; helps provider to refine their approaches to
different groups)
o Make your office culturally comfortable (eg. note what posters you have up,
would they have specific meanings to certain clients, have worldly magazines
available)
o Conduct a self assessment
o Ask questions that will determine your patient’s beliefs and behaviours (eg.
asking how religious a person is)
o Never dismiss or ridicule a patient’s beliefs
o Do what you can to accommodate patient’s families

Jan 25
Approaches to Learning: Behavioral & Social
Notes:
 Learning can be defined as the process leading to relatively permanent or potential
behavioral change.

Behaviorism
 The study of how the process of learning affects our behavior; behaviorists believe that
only observable behaviors are worthy of research since other abstractions such as a
person’s mood or thoughts are too subjective
 BF Skinner thought internal states could affect behavior just as external stimuli &
behavior is ultimately explainable in terms of the principles of instrumental (OPERANT)
conditioning
 Operant conditioning believes that we act a particular way because in past situations,
some behaviors were reinforced, and others were punished.
 Personality traits are viewed as behavioral tendencies produced by a person’s history of
reinforcement.
 Behavioral psychology – interested in how out behavior results from stimuli both in the
environment and within ourselves (the effect of our environment, how we learn new
behaviors and what motivates us to change or remain the same)
Social Learning Theory
 The belief that we learn through our interactions with society.
 Julian Rotter – “behavior potential” – the potential for a person to act in a certain
manner is determined by both how much is expected as a reward for the behavior and
how much the reward is worth to the person.
 Internals – strongly believe they shape their own destinies
 Externals – believe their outcomes are the result of forces outside their control

Social-Cognitive Theory
 Bandura – environment causes behavior, but behavior causes environment as well
(reciprocal determinism)
 Personality as an interaction among 1. Environment 2. Behavior 3. Psychological
processes
 Observational learning (modeling) and self-regulation considered strong suits of human
species

Observational Learning
o Learning can take place without actually exhibiting a change in behavior
o Even though we don’t perform the activity learnt, we maintain an internal and
external belief about the outcome of the activity.
o Bobo Doll Studies

o Steps in Modeling:
1. Attention – to learn anything, you must pay attention; anything that
dampens attention will decrease learning. Influenced by characteristics of the
model.
2. Retention – must be able to remember what you paid attention to so that it
can be reproduced in your own behavior.
3. Reproduction – have to translate the images or descriptions into actual
behavior, must have the ability to do so. Imitation improves with practice.
4. Motivation – must be reason to imitate (eg. positives: past reinforcement,
promised reinforcement/incentives, vicarious reinforcement [seeing and
recalling the model being reinforced] OR the reciprocal negatives of the
above)

Self – Regulation
o Controlling our own behavior has 3 steps:
1. Self-observation – we look at ourselves, our behavior, and keep tabs on it
2. Judgment – compare what we see with a standard/compete with others or
ourselves
 3. Self-response – results of comparison with standard; if positive, give yourself
rewarding self-responses (continuous positive rewarding leads to high self
esteem & failing to meet the standards leads to low self esteem)

o Excessive self-punishment leads to:

- Compensation – superiority complex and delusions of grandeur
- Inactivity – apathy, boredom, depression
- Escape – drugs, television, fantasies, suicide

o Bandura’s recommendations to those who suffer from poor self-concept:

- Self-regulation – KNOW thyself
- Standards – make sure standards are not too high/too low ones are
meaningless
- Self-response – use rewards not punishment

Jan 26
Approaches to Learning: Cognitive
Notes:
1. Definition
Cognitive psyhocology is a discipline focused on studying how people perceieve,
remember, think, problem solve and learn.
Focus is on the main internal psychological processed involved in studying the
environment and making appropriate decisions

2. Precursor to cognitive – Gestalt Theories

Gestalt theories – theory of mind
The operating principle of Gestalt psychology is that the brain is holistic, parallel and
analog with self-organizing tendencies. It stipulates that perception is the product of
complex interactions among various stimuli.
The key principles of Gestalt systems are:
o Emergence objects are perceived as a whole, all at once eg. seeing the image of
the park with the tree and the sniffing dog in the mess of white with black spots)
o Reification (Closure) (the experienced percept contains more explicit spatial
information than the sensory stimulus on which it is based eg. seeing the triagle
between the three pacmen, seeing the sphere, and the lochness monster on the
plan black and white background)
o Multistability (Figure/Ground) (tendency of ambiguous perceptual experiences
to pop back and forth unstably between two or more alternative interpretations
eg two faces vs one vase, different views of the cube)
 o Invariance (simple geometrical objects are recognized independent of rotation,
translation and scale eg. that weird stamp looking thing and the variations of it,
we only remember the pieces of it basically, or remember that they all looked
alike)

Law of Pragnanz – reality is organized or reduced to the simplest form possible. Basis
of other rules (proximity, similarity, closure, symmetry, continuity, common fate)

3. Cognitive Psychology – Brief overview

 Studies mental processes (including how people think, perceive, remember,
learn and problem solve) and how people acquire, process and store
information. The main focus is the main internal psychological processes
involved in studying the environment and making appropriate decisions.
 It investigates internal mental processes: problem solving, memory and
language.
 It uses psychophysical and experimental approaches to understand, diagnose
and solve human and animal problems.
 Individual learns by senses then processes and remembers the information;
passive learning (no motor movement)
 Cognitive psychology contends that solutions to problems take the form of
algorithms (predetermined procedure – for simple tasks) and heuristics (many
algorithms combined – more complex tasks, involve more thinking)

4. Key Concepts of Cognitive Theory

o Schema – knowledge structure; when receiving new information, the new
information is in contrast again the existing cognitive structures. Existing schema
may be combined, extended or altered to accommodate new information.
*some solution may be found through insight (a sudden awareness of
relationships) although this is very rare.
o Meaningful Effects – linking relatively meaningless information with prior
schema make it easier to retain (eg. linking the facts of something you studied
into a story)
o Serial Position Effects – items at the beginning or end of a list are easier to
remember, and items in a list that as distinctly different will be remembered
o Practice Effects – rehearsing improves retention.
*distributed effect: associating rehearsed material with many different contexts
o Transfer Effects – the way material was learnt in the past affects learning new
tasks or material
o Interference Effects - some encoded material interferes with learning of new
material.
o Levels of Processing Effects – the more deeply a word is processed, the easier it
will be to remember
 o State Dependent Effects – the context in which material is learnt makes it easier
to remember the material in a similar context.
o Mnemonic Effects & Method of Loci Organization Effects – categorizing material
to be learnt makes it easier to remember.

5. Bad Learning – A-B-C-D-E

Problems are caused by the way we think about/perceieve events in our lives
We develop negative schema from negative events (self defeating/irrational thoughts)
which lead to emotional and behavioural disorders

A – activating events
B – beliefs/schema
C – consequences
**most people think that A leads to C when in actuality B leads to C

Undoing bad learning:

Cognitive restructuring
D – Disputing faulty belief systems
E- Effectively challenging them and developing new ones

6. Misperception

Jan 26
Determinants of Health & Health Promotion
Objectives
1. Describe how complex factors influencing health status can be factored into health
promotion responses to health problems

2. Give consideration to issues beyond the patient and his/her presenting problem while
providing medical care.

Jan 27
Perception
Notes:
 Perception is the process by which organisms interpret and organize sensation to
produce a meaningful experience of the world. One’s ultimate experience of the world,
typically involving further processing of sensory input
 Sensation refers to the immediate, relatively unprocessed result of stimulation of
sensory receptors (5 senses). Process by which our senses gather information and send
it to the brain.
 Perception and sensation are impossible to separate
 Our senses tend to be overwhelmed with many stimuli at once, and we must focus our
attention on certain things while at the same time ignoring the flood of information
entering our senses. We are making a determination as to what is important and what is
background noise [concept called signal detection]
 Sensory adaptation – process of becoming less sensitive to unchanging stimulus (if it
doesn’t change, who do we need to constantly sense it)
 Absolute Threshold – point where something becomes noticeable to our senses
 Difference Threshold – the amount of change needed for us to recognize that a change
has occurred
 The way we perceive our environment is what makes us different from other animals
and different from each other.

 Gestalt Concepts of perception – we tend to group elements of our environment

together in order to make sense; FOUR natural groupings: 1. Similarity 2. Proximity 3.
Continuity 4. Closure

 Perceptual constancy – keep us from being fooled by our senses

1. Size constancy – out ability to see objects as maintaining the same size even when
our distance from them makes them appear larger or smaller
2. Shape constancy – allows us to perceive the shape of an object even when the angle
from which we view it appears to distort its shape.
3. Brightness constancy – refers to our ability to recognize that color remains the same
regardless of how it looks under different levels of light.
 Gestalt Psychology – Theory of Mind – the operational principle of the brain is holistic,
parallel and analog, with self-organizing tendencies
 The Gestalt principle made manifest in:
1. Emergence – objects perceived as a whole, all at once (ink dots of the dog in shade)
2. Reification – experienced percept contains more explicit spatial information than the
sensory stimulus on which it is based (seeing the triangle between the Pac men)
3. Multi-stability – tendency of ambiguous perceptual experiences to pop back and
forth unstably between two or more alternative interpretation (cube & two
faces/vase)
4. Invariance – simple geometrical objects are recognized independent of rotation,
translation and scale (all seeing little stamps)

 Law of Pragnanz – fundamental principle of perceptual segregation proposed by Gestalt

psychologists: “during visual perception, the best, simplest and most stable shape of any
possibilities will be perceived” (law of proximity, similarity and closure follow this law)
  Laws of Pragnanz:
1. Closure – if something is missing in an otherwise complete figure, we tend to add it
2. Similarity – the mind groups similar elements into collective entities or totalities
3. Proximity – things that are close together are seen as belonging together
4. Symmetry – symmetrical images are perceived collectively.
 Perception in reading – Word superiority effect – when a person must decide whether
the last of a string of letters flashed quickly on the screen is a particular one; recognition
is faster when the word is meaningful; people process letters more effectively in the
context of words than nonwords.

Ways to undo what has been done to us/How to look at things in a new way
 Changing long-held beliefs – takes a quantum leap, and is facilitated by five principles:
1. Willingness – must be motivated enough to look at things in a new way
2. Guidance – helps to have someone who has already seen the viewpoint to assist as a
guide
3. Flexibility – must attempt different strategies; not doing the same thing over and
over, but using different methods
4. Time – changing ones viewpoint will require time
5. – must look at the old issue and look at similar issues so as not to revert to the old
view point

Jan 30
Symptoms & Signs in Psychiatry
Notes:
 Signs – OBJECTIVE findings elicited by clinician
 Symptoms – SUBJECTIVE experiences reported by patient
 Syndrome - group of signs & symptoms
 Major Disorders:
o Psychotic disorder (eg. schizophrenia)
o Mood disorders (eg. depression & bipolar disorder)
o Anxiety disorders
 Emotion – complex feeling state and involves AFFECT (observed expression of emotion)
and MOOD (pervasive emotion; subjectively experienced and reported by patient)
 Perception – process by which sensory stimuli brought to awareness
 Disorders in perception:
o Hallucination
 Perception + stimulus
 False sensory perception occurring in the absence of specific stimulus
 Types:
  Hearing – i. Auditory (most common) ii. Voices - threatening,
obscene, accusatory, insulting, conversing, commenting,
commanding. The voices can be addressing the person directly
(second person hallucination) or talking to one another – “he” and
“she” (third person hallucination
 Sight – visual (common)
 Touch – i. Tactile (haptic; touched, pricked, strangled) ii. Somatic
 Smell – olfactory
 Taste – gustatory
 Hypnogogic (occurs while falling asleep) and hypnopompic (occurs while
awakening) are not pathological

o Illusion
 Perception: misperception of stimulus
 Good example: mirage – heat on the road can make it look like there is a
puddle

 Disorders in Thought
o Stream of thought
 Pressure of thought – thought is rapid (occurs in mania)
 Poverty of thought – thought is slow, limited (occurs in schizophrenia)
 Thought block – stream of thought is interrupted (occurs in
schizophrenia)
o Form of thought (thought form)
 Perseveration – repetition of the same thought (dementia)
 Flight of ideas – thoughts and speech move quickly from one topic to
another (logical sequence of ideas preserved; mania in bipolar disorder)
 Loosening of association – disorganized speech, ideas shift from one
subject to another, logical sequence of ideas not preserved. Speech is
illogical and muddled (schizophrenia)
o Content of thought (thought content)/Delusions
 Fixed (not amenable to reasoning), false belief, inappropriate to social-
cultural background
 Types:
 Delusions of persecution (think people are plotting against them,
planting cameras, watching them)
 Delusions of jealousy
 Delusions of guilt
 Delusions of grandeur
 Somatic delusions (feel things crawling on you)
 Religious delusions (belief that she has an immaculate pregnancy)
 Delusions of reference (believe people are always talking about
you, watching what you do, etc)
 Delusions of being controlled (by an outside force)
  Psychotic Disorders have positive and negative symptoms
o Positive symptoms (respond positively to medication)
 Hallucinations
 Delusions
 Disorganized symptoms (disorganized speech [loosening of association],
disorganized behavior)
o Negative symptoms
 Brief psychotic disorder (ONE DAY – ONE MONTH)
 Schizophreniform disorder (ONE MONTH – SIX MONTHS)
 Schizophrenia (MORE THAN 6 MONTHS)
 Schizoaffective (schizophrenia + mood symptoms)
 Psychotic disorder due to a general medical condition (eg. a tumour)
 Substance induced psychotic disorder (eg. by marijuana)

Jan 30
Motivation
Notes:
 Motivation is what gets you going, keeps you going and determines where you are
trying to go
 Theories:
o Physiological
 Biological drives of humans: hunger, thirst, need to maintain 98.6degree
body temperature.
 Factors which affect hunger – bodily factors (eg. Rumbling stomach &
brain tends to favor tastes of food that contains nutrients we lack),
factors in the brain, environmental factors (media plays on this, eg fast
food companies). The stomach stretching sends impulses to our brain via
the vagus nerve to reduce levels of hunger
 Food in the intestine stimulates the release of cholecystokinin (CCK) – this
hormone is important in indicating that you are full; if you don’t have this
hormone, you don’t feel full.
 Insulin induces feelings of hunger
 Stimulating ventromedial hypothalamus inhibits eating, destroying it
induces eating
 Sexual drive is both physiological and social (procreate & pleasure)
  Sex hormones controlled by pituitary and hypothalamus – testosterone
important in both males and females
 Sexual drives tend to be affected by psychological factors (eg. Socio-
cultural, media, gender roles)

o Instinct
 (McDougall) You are born with the capacity – instinct is a complex
inherited behavior pattern characteristic of a species
 Says humans are guided by a variety of instincts including aggression,
curiosity, friendliness, protection on what we hold valuable
 This lost scientific credibility because it could not be proven and could not
be used to explain why not all instincts were evident in all persons – eg.
Not all females want to have babies, not all older persons are protective
of all children (possibly they were lost in their socialization, however
there is no way to prove this)
 (Freud) theories on personality based on instincts that motivate sex and
aggression Eros (life instinct) and Thanatos (death instinct)
 (John B. Watson) he believed human behavior was dependent on
learning – we are a blank slate and everything is learnt.

o Drive-Reduction
 (Clark Hull) the lack of a need causes the drive for that need to be fulfilled
– thirst motivates drinking, sex drive motivates sexual relations
 Does not explain all human motivation, eg people may be hungry, but
don’t eat, in order to lose weight
 Incentives – substances which satisfy a need/reduce a drive, drive =
internal push, incentive = internal pull, eg. Thirst DRIVE pushes u to
quench thirst, but favourite drink INCENTIVE pulls you to your choice of
drink

o Humanistic
 (Maslow) humans are driven to achieve their maximum potential
 Maslow’s Heirarchy of Needs: physiological  safety  belonging/love
 esteem  self actualization; we move from first to last but cannot
move without having satisfied the needs at the previous level.
 Lincoln and Roosevelt are considered self-actualized, however CRITICISM:
there are exceptions, like Ghandi, who bypass lower order needs in
search of higher order ones, eg. Ne would go hungry for self actualization

o Optimum Arousal
 (Yerkes-Dodson) best performance is achieved under conditions of
moderate arousal rather than too high or too low.
  Eg. Signing your name can be easy, if you are in a high state of arousal, eg
excited, you will not sign it well.
 Too low can be boredom so you don’t want to do the task – demotivating
 Too high you are too excited to effectively do the task – discouraging

o Cognitive
 Ability to consciously control your behavior using memory, attention,
problem-solving to motivate self.
 Intrinsic – self-determination, challenge, effort (our personal reasons)
 Extrinsic – external incentive (Outside reasons, eg. becoming a doctor for
money, to make our parents proud, etc)

Jan 30
Understanding Behaviour Change
Notes:
 In order to break the cycle of illness and disease, you must understand the cycle, know
the risk factors (modifiable and non-modifiable) and make a decision to break the cycle.
 Behavior change is an important determinant of health, as it is a modifiable risk factor
which can be assessed and used as a part of individual health care. Some medical
procedures or interventions are not effective without actions on the part of the
beneficiaries.
 For change to be effective, the individual must want to change, not be forced. Getting
others to change requires skills in listening, communicating and persuading and
recognizing that incremental change can encourage greater change.
 Factors Influencing individual behavior change – 1. predisposing (intrapersonal
characteristics) 2. reinforcing (interpersonal factors, eg. relationships) 3. Enabling factors
(circumstances)
 To manage change you must first identify the behavior, asses the barrier to change,
personalize the risks, take steps to remove barriers, involve individual in planning
change, recognize that change takes from and support, then follow-up on it.

Managing:-
1. Predisposing factors – discuss current behavior, their perception about the change,
why change is necessary, specific actions to be taken and possible alternatives, how
to perform the action
 2. Reinforcing factors – determine significant others, get permission to involve them,
get their commitment and provide information
3. Enabling factors – know social support system & health team, be prepared to
facilitate change as far as possible and focus on getting individual to take personal
responsibility

 Stages of change theory:

People are at varying stages in their readiness to adopt a new health behavior. Knowing
what stage the person is at helps to determine what intervention is necessary and when
the change occurs. Pre contemplation  contemplation  preparation  action 
maintenance  termination

 Health belief model – people are more likely to comply with a recommended health
behavior if they perceive themselves vulnerable to a condition they consider to be
severe, if they perceive the effects of non compliance to be severe, if the benefits
outweigh the cost of engaging in the behavior, if the barriers to doing the action are
manageable and if there is self efficacy for performing the behavior before starting the
behavior
 Health providers action: assess risk perception, identify risk behavior, emphasize risks
and benefits of changing, provide opens, secure commitment

Jan 31
The Family Globally
Notes:
 Family – social institution that unites individuals into cooperative groups that oversee
the bearing and rearing of children
 Family of choice – people without legal or blood ties that define themselves as a family
 Extended family – married couple + one of more of their married children and their
children in the same house/linking of more than one nuclear family (parent/child bond)
 Nuclear family – prevailing form of the family – basic unit from which more complex
forms are compounded
 Blended family – has children from a previous marriage of one or both spouses (step
family)
 Marriage patterns:
 Monogamous - one man + one woman; dominant in western society
 Polygamous – spouse has more than one partner; illegal in Jamaica; polygyny
(one man, multiple wives; eg Muslims), polyandry (on woman, multiple
husbands; eg. Tibet, Todas of India, Marquesan Islanders)
  Endogamy – marriage between people of the same social category
 Marriage between people of different social categories
 Registered partnership for gay & lesbian couples gives their relationship
equivalent rights as heterosexual marriages except for the rights of adoption or a
church marriage
 Functions of the family:
 Socialization
 Sexual function/regulation of sexual activity (maintains property rights)
 Social placement/reproductive function (provide social placement for children)
 Economic/emotional security
 Stages of Family Life Cycle:
1. Leaving home
2. Joining of Families via Marriage (The New Couple)
3. Families with Young Children
4. Families with Adolescents
5. Launching Children & Moving On
6. Families in Later Life

 Family is important to compliance and convalescent care

 Impact of illness on the family:
 Role change
 Role dissonance (all roles become affected)
 Financial, social and psychological resources are stretched
 Precipitates stress, anxiety, anger, denial, shame, guilt, uncertainty,
 When the child is ill, it can be emotionally draining on the family, and the child could
have feelings of resentment, may regress, or exhibit bad behavior
 When the breadwinner is ill, there is a decreased income and a reallocation of role and
its issues (other people have to provide income)
 Chronic illnesses in a family member can affect the developmental goals of another
member
 All family members adapt differently to illnesses
 Untimely events and chronic illnesses can disrupt the usual sense of continuity and
rhythm of the life cycle

Jan 31
Intelligence
Notes:
 Represents a general label for a group of processes that are inferred from more
observable behaviours
 A combination of the ability to learn, pose problems and solve problems
 Theories of intelligence:
o Francis Galton – SENSES - considered intelligence to be higher functioning of low
level cognitive skills, such as more energy and higher sensitivity to the physical
environment (he did not formulate it, he just documented it)
o Alferd Binet – EXECUTIVE FUNCTIONING – considered intelligence to involve high
level cognitive functioning, such as, judgement, comprehension and reasoning
 Factor Theories – use factor analysis to identify common factors among groups of test.
Administer test to large samples, if scores are similar then the same abilities are being
tested, provides guidelines about the intellectual abilities that make up intelligence.
o Spearman’s Two Factor Theory
 Neogenesis – ability to deduce relations (entirely innate)
 The G Factor – apprehension of experience (ability to perceive and
understand the problem); deduction of relations (eg. lawyer is to client as
doctor is to…)
 Deduction of correlates (the ability to apply a rule from one case to
another)
 Criticisms: an association between two things does not mean that one
caused the other. Innate intelligence does not account for learning
o Thurstone’s Seven Factor Theory
 Multiple factor model of intelligence
 Intelligence is made of specific and separate abilities:
i. Verbal ability (vocabulary)
ii. Word fluency
iii. Numerical ability (mathematical reasoning)
iv. Spatial ability (eg. dance, architecture)
v. Perceptual ability
vi. Inductive reasoning
vii. Memory
o Cattell’s Theory
 Crystallized Intelligence ( ability to use skills, knowledge and experience
you have, increases throughout lifespan, reflection of learning
experiences) and
 Fluid Intelligence (Knowledge you have; increases in childhood and
adolescence; not influenced by culture; independent of acquired
knowledge, how to use logic to solve problems, technical problem
solving)
 Persons with higher fluid intelligence will developed larger crystallized
intelligence
o Sternberg’s Triarchic Theory
 Consists of three sub-theories:
  Componential Sub-Theory – deals with cognitive processes, verbal
ability & deductive reasoning. Similar to crystallized intelligence. 6
components needed to solve a problem: eg. A is to B as C is to D
1. Encoding the terms of the problem 2. Inference (discovering
rule relating A to B) 3. Mapping (discovering the rule relating A to
C) 4. Application (deciding what the fourth term should be) 5.
Justification (considering the accuracy) 6. Preparation (response,
speed of completion)
 Contextual Sub-Theory – street smarts; socio-cultural context
 Experiential Sub-Theory – mediation between contextual and
componential; how effectively we adapt to situations
 Criticisms: how the sub-theories relate is unclear; aspects of personality
rather than intelligence?
o Gardener’s Multiple Intelligences
 An ability or set of abilities that permits an individual to solve problems
or fashion products that are of consequence in a particular cultural
setting.
 3 basic principles: 1. Intelligence is not a single unitary thing 2. Each
intelligence is independent of all others 3. These intelligences interact
 Gardener’s nine intelligences:
i. Linguistic
ii. Logical
iii. Musical
iv. Spatial (eg. sculptors, surgeons)
v. Interpersonal (eg. politicians, religious leaders)
vi. Intrapersonal (accurate model of oneself)
vii. Bodily
viii. Nature
ix. Leadership
 Criticisms: are all these aspects of intelligence? He did not explain how
we attain, maintain or achieve these different intelligences, generally
people who score high in one area score high in others, they are not
independent of each other.

 Determinants of intelligence:
o Nature vs Nurture – twin studies who high correlation but higher when reaered
together than apart
o Relationship between personality (introvert/extrovert) and intelligence
o Gender & intelligence
o Family environment
o Culture & ethnicity – cultures vary in the way they define intelligence
o Experience/Exposure – because of the opportunities you are afforded, eg. being
black in the USA affects your opportunities
  Assessment of Intelligence
o Francis Galton believed that intelligence could be inherited leads the selective
breeding  EUGENICS
o Alfred Binet felt that intelligence should be measured by tasks that required
reasoning and problem-solving abilities (not perceptual and motor skills like
Galton felt).
 He created a scale which measuring changes in intelligence, that if a slow
child of a certain age showed lower scores than those expected, that he
was performing at a level of a younger normal child.
 By this scale, the higher the child achieved, the higher the child’s MENTAL
AGE (MA)
 Then he compares one’s mental age (MA) with the chronological age (CA)
o Stanford-Binet Intelligence Scale
 Revision of Binet’s
 Adopted an Index of Intelligence/the Intelligence Quotient (IQ) –
expressed intelligence as a ration of MA/CA * 100
 Revised further to agree with the current view of intelligence, as a
composite of different abilities: verbal reasoning, abstract/visual
reasoning, quantitative reasoning, short-term memory
o The Wechsler Intelligence Scales
 Widely used, reliable and valid for adults, children and preschool
individuals
 WAIS-IV (17 – 74 years)
WISC-IV (6 – 16 years, 11months)
WPPSI-III (3-6years)
 Divided into Verbal comprehension, perceptual reasoning, working
memory, processing speed.
 Provides separate scores for each subset as well as in IQ score, giving
view of strengths and weaknesses

Feb 1
The Caribbean Family
Notes:
 Caribbean family pattern has been seen as a “social problem” [Moyne
Commission of 1938/39]
 Considered highly unstable, low marriage rate, high illegitimacy rate
 Mostly single headed households but has a variation of conjugal forms
 Men are marginalized
 Households tend to have matrifocality (but are patriarchial)
 Conjugal unions are non-legal, temporary, and there are outside children
 Polygyny from out African cultural heritage is evident
 Matrifocality comes from the plantation system
 Matrifocality supposedly attributed to African heritage, slave system,
poverty, community disorganization and socioeconomic circumstances
 Women gives the most emotional support, domestic chores and possibly
allocates the finances of the house, this contributes to her being the focus
 Matrifocality has been described as an adaptive mechanism occurring as
women deliberately chose certain survival strategies in order to cope with
inadequate and uncertain male support in circumstances of poverty,
unemployment and male migration.
 Reasons for matrifocality: economic activities, process of modernization
(economic development and policies), migration
 Matrifocality is supposedly a feature of the subculture of poverty, but this is
debatable eg. What kind of poverty, there is absolute poverty, cannot even
provide food, and there is relative poverty, in comparison to others you are
poor.
 Some women see boundaries over what the father ought to do and ought
not to do with his children because the mother is supposed to be the
nurturer, so she gets jealous.
 Mothers are held in high esteem, eg. When mothers intrude on their son’s
marriage, cooking for him, ironing their clothes, etc. this pushes the wife’s
responsibilities and role to the side. This is why “your mom” comebacks are
so offensive.
 Reasons for matrifocality – females tend to live longer, age of marriage
(women tend to marry older men), low remarriage rates of widows,
increasing divorce rates.
 Conjugal unions: married, common law (cohabiting for 5+ years entitles you
to half of your partner’s property), single mother/father, Christian families
(patriarchal), faithful concubinage (woman lives with man to satisfy his
sexual needs), compassionate union (cohabiting less than 3years),
disintegrate families (household with women, children and grandchildren)
 Casual relationships: extra-residential visiting unions (women tend to have
children to successive partners when attempting to cement the union)
  Threat to family continuity:
 Shrinking of economic base of families (high unemployment rates of
men and high labour force participation of women)
 Inefficiency of the Educational system (poor children reach school
tired, hungry, lacking sleep)
 Inappropriate societal images/role models (pressures from society)
 Young mothers put the lives of their children at risk and often have to
discontinue their education
 Family violence(corporal punishment, violence in media, at home, school &
community) has a negative impact on the psychology of the child

Feb 1
Memory
Notes:
 Memory is the ability to recall information that was acquired previously
 Three types of memory: 1. Sensory 2. Short term / working memory 3. Long term
(Atkinson-Shriffin Theory)
 Three stages of memory:
o Encoding – environmental information is translated into and stored as
meaningful entity
o Storage – when stored information is maintained over time
o Retrieval – when an attempt is made to pull information previously encoded and
stored in memory
 Left hemisphere of the brain is activated in encoding, and right is activated in retrieval.
 Sensory Store - Information from environment comes here first. Three main
characteristics:
i. Information is captured by the sense organs
ii. Information in this area is transient (few seconds)
iii. Information attended to in this store is transferred to the next store (short-term)
o From vision = iconic memory
o From sound = echoic memory
o Experiments which tested iconic memory: 1. Partial-report experiment [proved
that people were able to see more than they can report, but then quickly forgot
it, and that iconic memory fades away after a period by about one third of a
second] 2. Temporal-integration experiment [proved that the image of the
display appeared to persist longer than the display itself]
 o Both experiments tested the concept of “span of apprehension”. This is the
number of immediately recallable items that one can remember after being
briefly presented with them.
 Short Term Store – five characteristics:
i. The individual is conscious of this information
ii. Information is readily accessible
iii. It will be forgotten over a period of 20seconds
iv. Rehearsal of the information can prevent forgetting it
v. The information can be processed in different ways (eg. elaboration) and hence
be transported to the last store
o This is information which is ATTENDED TO
o It is called working memory and has found to be more complex than just storing
information
o Involves encoding, storage and retrieval
o In order to encode we must attend to it (give it attention)
o Our working memory will only contain what we have selected
o Encoding forms: phonological code (use of sounds), visual code (use of pictures),
semantic code (use of some meaningful association)
o Eidetic imagery/photographic memory is more prominent with children and is
reduced with age – very rare
o Right hemisphere for visual encoding; left hemisphere for phonological encoding
o Working memory has a finite capacity  7+/-2 items
o When connections are made to long-term memory, the multiple items are
chunked/grouped together
o We forget because memory decays overtime and because old information is
replaced by new ones (finite capacity)
o Working memory is used to solve a problem, language processes, serves as a
work space for mental computations
o To transfer working memory to long-term memory, use rehearsal [maintenance
– active efforts to hold information in working memory; elaborative – efforts to
encode information in long-term memory]

 Long-Term Store – large repository of information than an individual maintains. Three

characteristics:
i. Information enters it via elaborate processes from short-term store
ii. Its size is unlimited
iii. Information in long term can be replaced in short-term, manipulated and used to
carry out tasks
o Phonological, visual, gustatory and olfactory cues used
o Add meaningful connections to the verbal information – strengthen how the
information is retained
o Elaborate on facts, the more deeply they are elaborated, the better the resulting
memory
 o Means of encoding information: Organizing [proper arrangement of information]
; context [may be external, eg area, or internal, eg. feelings]
o Retrieval – problems with this usually from failure to access, not actual loss of
the information
o If different items are associated with the same cue, and an attempt is made to
access that cue to retrieve one of the items, the target item, the other items may
become active and interfere with the recovery of the target – INTERFERENCE
 Retroactive interference – using the same cue to recall old information,
when it had been used for a recent one (eg. Clarke has changed his
phone number, you learnt it, now you need to remember the old one,
you will have problems because the cue is still “Clarke’s phone number”
but the new number interferes with you ability to recall the old one)
 Proactive interference – using a cue associated with old information to
code for recently changed or new information (eg. you used to park in
spot A, but now that has changed to spot B, the cue you still use is “my
parking space” but the old location is interfering with your ability to
remember the new location)
o Emotions may affect retrieval of long term memory information – rehearsal,
flashbulb memories (vivid and recollection of an emotionally charged event),
retrieval interference anxiety (nervousness on seeing the first exam question
prevents recognition of the information, and seeing the 2nd question worsens the
lapse), context effects (can only remember things in the same mood you learnt
them), repression (severely traumatic events blocked to prevent anxiety from
occurring)

 Explicit memory – conscious recollection of events that occur in a particular place &
time (eg. remember sweet 16 party)
 Implicit memory – unconscious recollection of various types of information related to
skills (eg. riding a bike)
 Hippocampus – long-term memory
 Prefrontal lobes – short term memory
 First two years of life cannot be remembered by anyone because the hippocampus fully
developed by the second year after birth, not information could not be consolidated

Feb 1
Promoting Health in Medical Practice
Objectives:
1. Explain the variety of methods available for promoting behavior change/reinforcing
positive health behaviours
Health communication strategies – use different communication channels:
o Intrapersonal (one – to – one)
Time consuming, reaches less people, multiple methods (face to face, use of
computers, telephone), contracting, use reflective listening
Reflective listening – interpreting what a patient says and summarizing it in a
short statement to keep him thinking and talking about change (diffuses
resistance, understand patients perspective and show you are listening,
emphasize positive statements about behavior). Repetition.
o Interpersonal (small group)
o Organizational/community
o Mass media

Health Engineering Strategies – include activities that seek to change the structure or
types of services or system of care to promote health
o Have persons assigned to focus on specific educational inputs (eg. nutritionists,
counselors, etc)
o Change things about people to influence awareness (eg. posters, videos,
pamphlets, removal of ashtrays)
o Healthier and cheaper food available

Community service strategies

o Outreach programmes to:
- Remove barriers to obtaining services
- Benefit persons who do not use the health services
- Include screening for diabetes, cancer, blood pressure etc.
- Provide follow-up/referrals
- Explain or demonstrate alternatives in treatment

Behavior modification activities

o Place emphasis on a specific behavior to increase or decrease the action
o Focus on events that are antecedent or subsequent to the behavior to be
modified (patients keep records of the behavior, ask specific questions about
events and feelings associated with the behavior, recommend changes based on
the feedback)

Incentive & Disincentives

o Used in workplace health programmes.
o Social reinforcers (attention/recognition, praise/verbal reinforcements,
encouragement, publicity, contracting)
o Material reinforcers (tokens, certifications, pins/buttons, cost sharing eg.
reduced fees for engaging in some activities)
o Health insurance
 Support Groups – providing opportunities for persons with similar experiences to come
together and chare experiences and provide encouragement

STAGES OF CHANGE THEORY????

2. Select appropriate educational approaches based on needs and available responses

CASE BY CASE

Feb 2
Principles of Disease Prevention
Objectives:
Principles of Prevention
1. To define primary, secondary and tertiary level of prevention
 Primary prevention is the prevention of the initiation process or development of
the condition eg. Cancer or its precursor (doing pap smears, discouraging
smoking). This can be done if one or more of the causes of the condition is
known and can be eliminated.
 Secondary prevention is the prevention of progression of a disease to a fatal
outcome by means of early detection followed by definitive treatment.
Screening is a component of early detection and an aspect of secondary
prevention. This can only be achieved is there is a stage that can be cured. The
aim of this is to prevent a fatal outcome; should reduce mortality from the
condition.
 Tertiary prevention aims to preserve and enhance remaining function following
injury or partial loss of function from accident or injury. It also encompasses the
treatment and rehabilitation of older persons who will inevitably develop one or
more disabling medical conditions and the main idea is to maximize the abilities
of the elderly to increase their independence.

2. To describe the role of prevention in the management of health related conditions

 For effective primary prevention, you have to know the cause and some measure
which can be taken to prevent exposure to this cause.
 You must asses evidence found to determine if it is valid because if you accept
information which happens to be flawed, there may be policies made by
legislation based on this (eg. No smoking in buildings) which may unfairly/wrong
deprive people of their freedoms (eg. Quarantining certain people, etc)
 Preventative measures should reduce the mortality rate for that condition
  The 60+ population is increasing with more improvement in medicine and
healthcare

3. To link preventative measures with some disease conditions

 Primary prevention of lung cancer by promoting medical research that smoking
causes it.
 Secondary: Doing regular pap smears to catch cervical cancer early
 Tertiary: rehabilitation or early intervention to allow elderly to have as much
independence as possible, eg. Swimming, going to the gym, focusing on available
skills.

Approaches to Prevention of Diseases

1. To describe some historical landmarks related to improvements in health
i. The sanitary revolution
ii. Improved standards of personal hygiene
o Both results in reduction of diarrhoeal diseases in the industrial nations
o Improved living conditions (better housing + nutritional status + education)
produced better infant mortality rates
iii. Immunizing agents
iv. Antibiotics
v. Eradication of some communicable conditions (eg. Small pox)

2. To explain the relationship between public health and well-being

To promote, preserve and restore health by:
i. Safe environment
ii. Enhanced immunity
iii. Healthy lifestyle choices
iv. Good nutrition
o Health promotion is the process of enabling people to increase control over and
improve their health
o Public health refers to the health of the population
o The better public health, the better person’s well being

3. To highlight the physician’s role in preventative medicine

 The physician is to be well-informed and be able to critically assess evidence and
inform patients of the causes of certain disease so that they are able to take
primary preventative measures. They should try to promote healthy lifestyles.
 The physician should have the ability to make the diagnosis and assess where on
the continuum of natural history of disease you are going to place it, which will
determine how you are going to prevent it from progressing. They should inform
patients of the early signs which could indicate that something is wrong; this will
allow the physician to catch the condition in its early stages.
  In tertiary prevention, physicians main goal should be to maximize the abilities of
the elderly by focusing on the available skills, preserving/enhancing these skills in
a rehabilitative nature.

Feb 2
Violence Prevention Strategies
Notes:
 Public Health Approach
o Strategy steps:
i. Define the model
ii. Identify the risk and protective factors
iii. Develop test prevention strategies
iv. Assure widespread adoption

 Recommended strategies
o Violence has always been present, but it does not have to be accepted as an
inevitable part of the human condition [UN]
1. Developing safe, stable and nurturing relationships between kids, their
parents and caregivers
2. Developing life skills in children and adolescents [provide children with
academic and social skills at an early age; eg. BCH’s C.A.M.P.]
3. Reducing the availability and harmful use of alcohol
4. Reducing access to guns, knives and pesticides
5. Promoting gender equality to prevent violence against women
6. Changing cultural and social norms that support violence
 Community rehabilitation 10 point plan:
i. Mediation meetings (peace training in dispute resolution)
ii. Conseling
iii. Inter/intra-community cultural & sports competitions
iv. Health fairs
v. Residential retreats & leadership conferences
vi. Therapeutic field trips
vii. Parenting & homework classes with structured supervised
after school activities
viii. Income-generating projects & job placement
ix. School retention programmes
x. Peace councils
7. Victim identification, care & support programmes

 CHECK slide 38/40 on what works and what doesn’t work!!!!

  Interpersonal violence is strongly associated with macro level social factors:
o Unemployment
o Income inequality
o Rapid social change
o Access to education

Feb 3
Personality Development
Notes:
 Developmental psychology – concerned with changes in cognitive, motivational, psycho-
physiological and social functioning that occur throughout the human life span.
 Human personality – the reasonably stable patterns of emotions, motives and behaviors
that distinguish one person from another
 Human Development Index (HDI) measures health, education and incomes.

Theories of personality development:

 Trait approach to personality
 Type
 Temperament
 Psychoanalytic theory of personality
 Learning/behaviorism

 Humanistic-existential perspective
Least scientific/testable theory.
Everyone is unique, deriving and viewing the world from different perspectives. You are
as you choose to be.
Focuses on how external stimulus affects one’s behavior.
One’s life is determined by one’s choices and is not predetermined by fate.
Ones personality can be manipulated by others who place conditions on one’s worth,
negatively altering one’s self-esteem.
High self esteem is centric as being true to one’s self.

 Social-cognitive theory
Two aspects of human nature determine behavior: internal & external (Reciprocal
determinants)
Learning can take place without exhibiting a change in behavior, and knowledge of
future possibilities can influence our present behaviours.
 Observational learning (Bandura)
Learning can occur outside the boundaries of pleasure and pain. People learn a lot by
just watching others which may not be demonstrated in their own behavior.

 Implicit/cross cultural theory

 Developmental psychology
o Prenatal (before birth; germinal [conception – 2weeks; dividing mass of cells],
embryonic [week 3 – 8; organ system differentiation], fetal [week 9 – birth;
formed human grows] NOT the same as trimesters)
o infancy, toddler,
o Early childhood (start of preschool, broaden horizon, habituation of impulses,
images and fantasy)
2 – 7 years. Piaget’s: symbolic functioning centration, intuitive though,
egocentrism, inability to conserve
Creativity, responsibility, self esteem, discipline
o Childhood
o Adolescence (puberty to assumption of adult responsibilities)
Secondary sex characteristics, formal operational thinking-piaget [abstract
thinking, math concepts, classification of ideas, logical thought, ability to
hypothesize, egocentrism (lack of informed experiences)], sexuality [forming a
sexual identity; little or no information is given by primary care givers on
becoming a sexual being. Information/signals from societal norms are
confusing], self consciousness [mildly paranoid; want to fit in with society, want
independence from guardians, what defines me? Known and assumed values],
moral reasoning (Kholberg) [Level 1 – preconventional; stage 1 – obedience &
punishment; stage 2 – individualism & exchange || Level 2 – conventional; stage
3 – good interpersonal relationship; stage 4 : maintaining, social and emotional
development
o Early adulthood, middle age, old age, death
 Psychosexual Development (Freud)
Oral phase, anal phase, phallic phase, latency, genital phase

 Freud’s structural theory of personality

The structure of the mind which determines our personality
o Id – instincts to survive
o Ego – makes decisions inside you. Suppress a lot of things. Eg Id says you need to
eat to survive, super ego says skinny is sexy, ego makes the decision to not eat
o Superego – makes decisions from outside of you; influence of the society
Freud thinks that it is unnatural to be at ease, and that it is natural to go to a therapist
and get yourself “fixed”
Two people’s conscious responses to the same stimulus may be different because of
their unconscious mind
 Psychodynamic Perspective
Personality is characterized by a dynamic struggle. Drives such as sex, aggression and
the need for pleasure come into conflict with laws, social rules and moral codes. The
conflict in childhood and personality is formed by the age of FIVE
Repression – ejection of anxiety-provoking ideas from awareness.
Primitive drives seek expression, internalized values keep them in check. The conflict
can precipitate outburst and psychological problems.

 Carl Jung & the Myers-Briggs

One of the earliest trait theories. States that traits are inborn, and these genetically
inborn traits are called temperaments.
There is a connection between close people at an unconscious level e.g. when you just
call someone because you feel to and realize something is wrong. Your unconscious (the
related one) was disturbed.
o Introversion - a tendency to prefer the world inside oneself
o Extraversion – the tendency to look to the outside world, especially people, for one’s
pleasures.
o Sensing – these types of people get their information about life from their senses.
Tend to be realistic, down to earth people, but they tend to see everything in
simplistic, concrete, black or white terms
o Intuiting – these people tend to get their information from intuition. They tend to be
a little out of touch with the more solid aspects of reality. They see the big picture
rather than details. Often artistic and philosophical.
o Thinking – these people make their decisions based on thinking – reasoning, logic,
step by step problem solving. Works very well for physical problems but can leave
something to be desired when dealing with something as complex as people.
o Feeling – these people tend to make their decisions based on their feelings. Does not
work with practical problems but works well with people.
o Judging – tend to be more like Freud’s anal-retentive types – neat, orderly,
hardworking, always on time, scheduling things carefully.
o Perceiving

 Operant conditioning – or instrumental conditioning, is the use of consequences to

modify the occurrence and type of behavior. Deal with the modification of voluntary
behavior through use of consequences.

 Two dimensions of personality: - Eysenck’s

o Introversion/Extraversion
o Neuroticism/emotional stability
This dimension of Eysenck’s trait theory is related to moodiness versus even-
temperedness. Neuroticism refers to an individual’s tendency to become upset
 or emotional, while stability refers to the tendency to remain emotionally
constant.

 Personality Types – Five Factor Model – McCrae and Costa

o Neuroticism
Emotional instability, stress, unrealistic ideas.
Anxiety - apprehensive, fearful
Angry hostility - tendency to experience anger, frustration and bitterness
Depression – tendency to experience depressive affect, sadness, guilt, loneliness
Self conscious – sensitivity to ridicule, jokes vs. undisturbed by other’s comments
Impulsiveness – inability to control cravings or urges
Vulnerability – unable to cope with stress, panicky

o Extraversion
Interpersonal interaction: level on which one enjoys the company of others
Warmth, gregariousness (preference of company of others), assertiveness,
activity (sense of energy), excitement seeking, positive emotions

o Openness
Proactive seeking and appreciation of experience for its own sake. Exploration of
the unfamiliar
Fantasy, aesthetics, feelings, action, ideas, values

o Agreeableness
Degree of being in the presence of others
Trust, straightforwardness, altruism (actively concerned for others versus
reluctance to get involved), compliance, modesty, tender mindedness (moved by
others needs)

o Conscientiousness
Degree of organization
Competence, order, dutifulness, achievement striving, self-discipline,
deliberation.

Feb 3
Emotion
Notes:
 Emotion is a feeling of affect that has 3 components: physiological arousal, conscious
experience, behavioral expression
 Motivation and emotion spurs us into action
 Emotions function to help organism respond to perceived important events and to help
convey our intentions to others
 Autonomic nervous system plays a vital role in the arousing and calming of the body, to
improve the likelihood of survival:
o Sympathetic nervous system – involved in body’s arousal (fight or flight
response)
 Increases blood flow to the brain
 Dilates pupils
 Faster breathing rate
 Faster heartbeat
 Increases skin perspiration
 Decreases digestive activity
 Increases adrenal gland activity (stress hormones released)
o Parasympathetic nervous system – calms the body
 Decreases blood flow to the brain
 Constricts pupils
 Slower breathing rate
 Slower heartbeat
 Decreases skin perspiration
 Increases digestive activity
 Decreases adrenal gland activity (stress hormones inhibited)
 Anger causes the largest increase in both heart rate and temperature changes
 Disgust decreases both heart rate and temperature
 Galvanic skin response – measuring increases in skins electrical conductivity when sweat
gland activity increases
 Polygraph is a machine that monitors physiological changes thought to be influenced by
emotional states used by examiners to determine when someone is lying – measures
changes in heart rate, breathing and electrodermal response.
 Theories of emotion linked to physiological processes:
o James-Lange Theory
 Emotion results from physiological states triggered by stimuli in the
environment. Emotions occur AFTER physiological reactions.
 Argument against: ANS responses are too diffuse and slow to account for
rapid differentiated emotional responses
o Cannon-Bard Theory
 Emotion and physiological states occur simultaneously

 Amygdala receives neurons from all of the sense

 In danger, the amygdala is activated and immediately sends out messages to bodily
organs that respond in ways to prevent harm
 There is a direct pathway from the thalamus to the amygdala or an indirect pathway
from the thalamus through the sensory cortex to the amygdala
 The amygdala is linked with emotional memories (it hardly ever forgets)
 The amygdala is in a better position to influence the cerebral cortex than the other way
around because it sends more connections to the cerebral cortex than it gets back – this
explains why it is hard to control our emotions and why once fear is learnt it is hard to
erase.

 Cognitive Theories of emotion – premise that emotion always has a cognitive

component, and that feelings are due to thinking.
o Two-Factor Theory
 Emotion is determined by two main factors, physiological arousal and
cognitive labeling (what you think to do)
o The Primacy Debate
 Cognition or emotion
 Some believe that cognitive activity is a preconditioned emotion; we
cognitively appraise ourselves and our circumstances (values, goals,
commitments, beliefs, expectations)
 Happy because they have a deep religious commitment, fearful because
they expect to fail an exam
 Counter argument: emotions are primary and our thoughts are as a result
of them
o Facial Feedback Hypothesis
 Facial expressions can influence emotions as well as reflect them
 Eg. we feel happy when we smile & sad when we frown, so if you force
yourself to smile you will feel better.
 Facial muscles send signals to the brain which help individuals to
recognize the emotion they are experiencing
 Display rules – socio-cultural standards that determine when, where and
how emotions are to be expressed

 Classifying emotions:
o Robert Plutchik
 Emotions have 4 dimensions: positive/negative, primary/mixed, polar
opposites, vary in intensity.

o Two-Dimensional Approach
 Two broad dimensions of classifying emotional experiences: positive
affectivity & negative affectivity

 Catharsis – release of anger or aggressive energy by directly or vicariously engaging in

anger or aggression.
o Catharsis Hypothesis
  By heaving angrily or watching other behave angrily reduces subsequent
anger
 Counter argument: research has shown that acting angrily does not have
any long term power to reduce anger

 Happiness boils down to the frequency of positive emotions and the infrequency of
negative emotions
 Age, gender and money are not considered ways to happiness because you can find
happiness without these, they are not a necessity

Feb 6
Symptoms & Signs in Psychiatry: Psychotic & Non-Psychotic Disorders
Notes:
Anxiety Disorders
 Characterized by anxiety symptoms:
o Skin: sweating, hot flushes, chills, paresthesias (sense of numbness), tingling
sensation
o CNS – dizziness, unsteady, lightheadedness
o Psychological – fear of going crazy, fear of losing control, fear of dying,
depersonalization (you no longer recognize/are cognizant of one’s self, you no
longer feel the same, when you speak you don’t feel as though it is you),
derealization (loss of reality of what is around you)
o Respiratory – choking sensation, chest pain/discomfort, shortness of breath
o Cardiovascular System – palpitations, pounding heart
o Gastrointestinal Tract – nausea, abdominal stress
o Musculoskeletal - tension
***note!! That some of these are also symptoms of other problems, eg. asthma.
 Disorders:
o Panic disorder – sudden onset, sporadic (recurrent), short lived; persistent
worry/concern, agoraphobia (this is the fear of open spaces, but in this case,
they have a fear of going out in public because they fear embarrassing
themselves), substance abuse (self-treatment and become dependent)

o Phobia – associated with a stimulus (object, situation)

 o OCD – obsessions (thoughts which lead to anxiety) and compulsions (behaviours
which decrease the anxiety)

o Generalized Anxiety Disorder – excessive anxiety/worry about a number of

events or activities for more days than not for more than 6months; worry
difficult to control

o Post Traumatic Stress Disorder – associated with TRAUMA (Trauma, Re-

experience trauma, Avoidance, Memory activated, Arousal increased –hyper
vigilance, emotional outburst, sleep disturbances, exaggerated startle response)

Cognitive Disorders
 Disorders:
o Delirium – changes in consciousness & cognition (memory, orientation,
language), perceptual disturbances (hallucinations & delusions), acute onset,
fluctuating course.
 Acute – onset
 Fluctuation - course
 Attention – decreased concentration
 Consciousness – decreased leve
 Thoughts - disorganized

o Dementia (Vascular – problems in blood flow to the brain, eg. someonetimes

persons with hypertension/Alzheimer’s Disease – impact compounds in the brain
which are necessary for functioning) – frequently linked to old age but it is not
normal, late onset more common (65+years old). There is medication which will
slow down its progression but none to treat the symptoms yet.
 Memory impairment – short term first
 Language disturbances – aphasic speech (makes no sense)
 Apraxia – inability to carry out motor function activity despite intact
motor function)
 Agnosia – failure to recognize objects despite intact sensory function
 Problems with executive functioning (SOAP – Sequencing, Organizing,
Abstracting, Planning)

o Amnestic – problems with information recall and formation of new memories.

Disoriented with respect to time and space. Lack insight into their loss of
memory. Undergo a personality change (may appear apathetic of bland).
Confabulate (fill in memory gaps with false information that they believe/have
deduced to be true – NOT intentional lying)
 Causes: head trauma, chronic alcohol use (Wernicke-Korsakoff
Encephalopathy – brain disorder due to thiamine deficiency, use of
alcohol affects absorption)
  Endocrinopathies
 Wilson’s disease (inherited disorder where there is excess copper
through liver and organ systems)

Feb 6
Domestic Violence of the Household
Objectives:
1. Be able to recite some definitions of domestic violence
 Any spousal altercation or interfamilial conflicts of sufficient nature to justify law
enforcement intervention: usually cited as spousal abuse.
 Domestic violence includes violence perpetrated by intimate partners and other
family members

2. Be able to fully explain relations considered to be ‘domestic’

 Legally/previously married persons
 Persons who reside/resided together
 Persons related through marriage or blood to the 2nd degree
 Persons who share a child in common (biological parents)
 Substantial dating or engagement relationship
 Biological parents/stepparents
 Gay & lesbian families
 Families of choice-*

3. Be able to describe different types of abuses occurring in domestic situations

 Physical abuse – use of force or threat of force that may result in bodily injury,
physical pain or impairment includes selective abortion & female infanticide.
 Psychological/Emotional abuse – includes behaviours intended to intimidate and
persecute. Intentional infliction of anguish and pain or distress designed to
control the victim
 Economic abuse – denial of funds, refusal to contribute financially, denial of food
and basic needs, controlling of access to healthcare, employment, etc.
 Neglect – failure/refusal to provide care or services for a person when there is an
obligation to do so resulting in harm due to the action/inaction
 Sexual abuse – coerced sex through threats, intimidation and physical force,
forcing unwanted sex or sex with others, sexual contact with a person incapable
of giving sexual consent
4. Be able to elaborate on some causes and consequences of domestic violence.
Causes:
Cultural:
 Gender socialization
 Appropriate sex roles & expectations
 Belief in inherent superiority of males
 Values that give men propriety/ownership right over females
 Notion that family is in the private sphere (therefore outside intervention should
not occur) and under male control
 Customs of marriage
 Acceptability of violence as a mean of resolving conflict
Economic:
 Economic dependence on one partner
 Limited access to cash and credit
 Limited access to employment
 Limited access to education and training for women
 Discriminatory laws regarding inheritance, property rights issues, use of
communal lands and maintenance after divorce or widowhood.
Legal:
 Lesser legal status of women, either by written law and or practice
 Laws regarding divorce, child custody, maintenance after divorce and
widowhood
 Legal definitions of rape and domestic abuse
 Insensitive treatment of women and girls by police and judiciary
**Matrimonial causes act, Domestic Violence Act, Offenses Against the Person Act –
Jamaican judicial instruments to protect persons against gender-based violence.
Consequences:
 Human development goals undermined
 Health consequences
o Injuries
o Unwanted pregnancies
o Gynaecological problems
o STI’s
o Miscarriage
o Self-injurious behaviours (substance use and unprotected sex)
o Depression
o Fear
o Anxiety
o Low self esteem
o Sexual dysfunction
o Eating problems
o OCD
 o PTSD
o Suicide
o Homicide
o Maternal mortality
o HIV/AIDS

Feb 7
Domestic Violence: Impact on Children
Objectives:
1. Be able to define who is considered a child
Child – a person under the age of 18years.

2. Be able to view some statistics relevant to the impact of domestic violence on children
 3 – 10million children annually, witness acts of domestic violence
 50% of female victims of DV have children less than 12yrs in the home
 Children of battered mothers are 6 – 15 times more likely to be abused
 In 30 – 60% of families with physical violence, other violence/maltreatment is
also present

3. Be able to elaborate on the impact of domestic violence on children from pre-school to

adolescence
 Children who are abused/who witness abuse have problems with, their weight,
sleeping, eating, academic performance, developing close relationships, trying to
run away, suicidal tendencies/attempts.
 Pre-birth – selective abortions, effects of battering during pregnancy on birth
outcomes
 Infancy – female infanticide, physical, sexual, psychological
 Adolescence & young adulthood – dating & courtship violence (eg. Date rape),
economically coerced sex (sugar daddies), incest, rape, sexual harassment,
forced prostitution & pornography, human trafficking, forced pregnancy, abuse
of females/males with disabilities.
 Impact on preschoolers – withdrawn/subdued, anxiety/clinging behaviours, may
regress, low self esteem
 Impact on school-age children – aggression, somatic complaints (eg. Stomach
ache, headache), poor academic performance, behavior problems
 Impact on adolescents – aggression, expressed rage/shame, running away,
experience loss of impulse control, PTSD
 Children who witness DV are more likely to incorporate violence into their adult
lives and relationships
 4. Be introduced to the function of health professionals in situations where children are
victim of domestic violence.
 Ask your patients if they are being abused
 Ask if they feel safe
 Ask if they are hurting and need help
 Refer them to someone or an agency that can help
 Universal screening – RADAR – Routinely screen women/children for abuse, Ask
direct questions, Document your findings, Assess safety of patient/child,
Referrals/resources/reporting
 It is mandatory to report if one have a reason to SUSPECT (there need not be
proof) that a child has been of is in danger of maltreatment, or otherwise in need
of care ad protection.

Feb 8
Child Abuse 1
Objectives:
1. Be able to define who a child is
 Any human being under 18years old is the general consensus
 Around independence time, it was 21years

2. Be able to articulate laws in Jamaica pertinent to who is considered a child

 The Children Adoption Act – under 18years
 The Children Guardianship and Custody Act – person under 18years but does not
include a person who is married

 Law Reform (the Age of Majority) – 16 years can receive medical counsel without
parental consent
 The Juvenile’s Act – “child” = anyone under 14 years; “juvenile” = person under 17
years; “young person” = person aged 14 – 17years

3. Be able to explain ways a child is often abused

 Physical abuse and ill-treatment
 Emotional abuse
 Sexual abuse
 Physical neglect
 Trafficking/child selling
 Child labour – employment of children under 13 years that INTERFERES with
school

4. Be able to elaborate an adolescent abuse

  Adolescence approx. 8 – 15years old
 Causes of adolescent abuse & neglect:
o Disruptions in family functioning
o Isolation from support system
o Changing social relations
o Conflicts inherent in the developmental stages of adolescents and adults
(both adolescents and parents are going through developmental changes
of their own, which can directly clash with the other)
 Reasons adolescents endure abuse:
o Our society tends to accept overly strict/abusive disciplining of
adolescents
o Adolescents face guilt submissiveness and family protectiveness
o They may still be emotionally and psychologically dependent upon their
parents, thus causing them to be submissive
 Indicators of abuse
o Physical (unexplained bruises, fractures, lacerations, unattended medical
problems, lack of supervision/functional abandonment, force ripe,
venereal disease, pregnancy)
o Behaviour (provocative behavior, exaggerated response to being
touched, assaultive, report injury or being scared of parents, acting out,
truancy, drop out of school, delinquency, substance misuse, peer to peer
relations, withdrawn)

5. Be able to expound on factors which contribute to child abuse.

 State of parents (ill health physically & psychologically, depressed, substance
abuse problems, martially instable)
 Step parents vs. biological parents
 Unpredictable feeding and sleeping patterns (may irritate parents)
 A crisis (may be inconvenient)
 A special child (child with ill health or some kind of disability)
 Gender of a child
 Behavior & appearance of child (characteristics that make the child difficult to
care for)
 Chance events affecting mother-child relationship (eg. child looking like his/her
father she hates)
 Disruption in attachment (no time spent together)
 Mismatch of child and expectation of parents (eg. child not reading as soon as
expected, crying too much, etc)
 Age of child (some parents are only good with a certain age group)

** children may not always tell the truth, but they are not always lying either; listen to their
stories.
 Feb 9
Human Life Cycle: Infancy
Notes:
Infancy (0 – 2 years)
Physical:
 Apgar scale – measure of physical condition
o First form of physical measure given twice (immediately birth and 5mins after)
o Measure 5 things: heart rate, infants efforts to breathe, muscle tone, skin color,
reflex
o Maximum score you can get is 10; most babies will get 9 or 10 by the second
reading. Scores less than 5 are problematic
 Primitive reflexes – indication that the CNS is working well
o Eg. Grasping reflex, Babinski flex (toes fan out with stroke), Moro reflex (if a baby
hears a loud noise, they will throw their arm, turn their head, and pull their arm
in), swimming reflex
o These will disappear within the first year
 Motor Development
o Fastest development occurs within the first year of a person’s life
o Physical development occurs from head to toe (why they can lift their head up
before they can roll over) and near body to far body (move arms before being
able to grasp a pencil)
o Things that can affect development – nutrition, low birth rate, opportunity to
walk
o Milestones:
 Most babies will walk by 10 – 12months

Cognitive
 Piaget’s Sensory-Motor Intelligence (first stage of cognitive development)
o Children understand their world through their senses, not reasoning
 Changes which occur around 9months:
o Object Permanence – important because: 1. It tells us that infants have now
maintained images in their minds 2. They are beginning to develop an awareness
of time so they can anticipate events in the near future 3. It facilitates a sense of
security and the starting of separation anxiety 4. Helps the child to develop their
first real awareness of self concept (infants begin to gradually realize that they
are not just a continuation of mommy, they are a separate entity)
o Imitating – helps them to understand their world and relate to others and
facilitates language development in children – they mimic and imitate the words
that they hear
 o Language Development – language is an innate maturational process.
 Milestones:
 Tend to babble at 5months
 First word by 9months
 At 1 year they should be saying one word at a time
 At 2 years they should be saying two words put together
 There is receptive and expressive language, receptive develops before
expressive, this is why babies can understand something before they can
actually express their response.
 The environment can affect the rate at which language develops eg. use
responsive conversation, speak to the child, ask if they want things.

Psychosocial
 Social attachment – 5 week old infant is generally a very social creature, smiling at
everyone; 4months they begin to show preference in people; 8months this coincides
with their development of separation anxiety – this preference explains stranger
anxiety; by 2years the stranger anxiety should be deminishing
 (Erikson) “Trust vs. mistrust” & “Autonomy vs. shame & doubt”
o 1 year – infant’s major task is learning to trust others. In their first year, babies
are dependent on someone for all their needs. If someone is not there, this will
negatively affect their trust development. If a child does not develop trust, they
will develop mistrust.
o Erikson believed that you must achieve one level to move on to the next social
task
o 2years – child must develop autonomy, power of control over self. In 2nd year of
life, toilet training occurs, explains the struggle, say “no” a lot just to show
control, and firm boundaries must be set with the child. If the parent does not
allow the child to develop autonomy, the child will state doubting self because
every time they try, they are shut down
 Temperamental styles:
o Average – regular sleep & eating cycles, smiley, etc
o Slow to warm up – will fuss if there is a change in routine, generally ok, just fussy
o Difficult – colicky, screaming, crying a lot, no sleep or eating cycles – these
infants are prove to develop and express aggressiveness ONLY because of how
we respond to the
 “Goodness of fit” – fit been a parents expectations, attitudes and responses and the
child’s temperament eg. if their personalities “clash” ; easy-going parent but loud &
active child.

Pre-School (3 – 5 years)
Physical
 Healthy period of development (children now tend to be healthier because of vaccines
and their systems are developing, eg. circulatory, respiratory, etc)
  Accidents are the leading cause of death
 Environment must be child proof (for their safety) and child friendly (so that you do not
have to restrict their actions)
 Causes of poor physical development – be aware of shakey/uncoordinated movements,
eg. awkward climbing/riding a tricycle, etc – may indicate neurological deficits

Cognitive
 Pre-operational thinking
o Egocentrism – pre-schoolers really believe that the world revolves around them,
confuse their views with those of others “what I think, you think”. They blame
themselves for sexual abuse, parents divorce, getting sick, etc. like they cause it,
they are being punished for doing something wrong.
o Reversibility – they think you can just reverse something and fix it eg. wanting to
“just” go back to Disney world, going to a funeral and experiencing the entire
thing but still asking when they will come home
o Centration – child will focus on ONE aspect of a situation and everything else will
get lost; they can be easily misled
o Animism – give life to inanimate objects, eg. talk to teddy bear, the imaginary
friend at this age is normal

Psycho-Social
 (Erikson) Major task: learning to take the initiative in doing things eg. playing,
interacting, self help etc. (vs. self-doubt)
o Overprotective parents can inhibit this
o If these skills are not developed, then they lack social skills as an adult.
o If they do not develop this, they will develop self-doubt, this affects self-esteem,
etc.
o Influenced by family, teachers, peers, etc.
 Gender development – three aspects:
o Gender identity – belief of which sex they are
o Gender preference – attitudes towards which sex they wish to be, learn this
based on what they see, their models
o Gender constancy – they understand that who they are because of their sex is
biologically determined and permanent
 Development of conscience
 Feb 10
Child Abuse 2
Notes:
 Many factors involved in investigating alleged abuse: ability to describe the abuse,
feelings & demeanor, medical & psychological evidence, psychological symptoms
consistent with the report.
 Children might be frightened by the process because it may involve strangers, may
potentially be taken away from home, strong emotions of family members, may disrupt
the child’s overall life (may cause child to recent report)
 Children with disabilities are less likely believed when they report abuse
 Encourage an abused child to express their feelings and heal through play, then master
the effects related to the abuse
 Treatment can be individually, in groups or in a family therapy setting.
 Therapist should be comfortable with children and adolescents and be willing to
tolerate unusual positions, getting messy, hearing swear words, have a lively
imagination, communicate through play.
 Therapist must have emotional resilience; practitioners who were themselves abused
may have difficulty if it was not appropriately resolved
 Must consider gender of practitioner in terms of child comfort as well as cultural
acceptability.

Feb 13
Common Child Health Problems & Preventative Strategies
Objectives:
1. Define prevention in the context of paediatrics
o Primary – to preserve health by removing precipitating cause or determinants; to
decrease the incidence of disease and injury (eg. active & passive immunization
against disease, health education and counseling) (reduce new cases)
o Secondary – to detect and correct illness as early as possible; to decrease the
prevalence of disease and disability; to screen before disease is manifested by
signs or symptoms (eg. PAPA smear, blood lipid profile, early case finding of
asymptomatic disease) (reduce current cases)
o Tertiary – rehabilitation; restore to its highest function; minimize negative
effects; prevent disease related-complications (eg. physiotherapy & occupational
therapy for children with cerebral palsy) (reduce complications, intensity and
severity)

2. Outline the common causes of illness in children

o Newborn (first 28days of life) – prematurity, jaundice, respiratory distress,
congenital anomalies, infection
 o Infant (0 – 1) – diarrheal illness, respiratory illness, nutritional problems, injuries
o Child – poisoning, accidents & injuries, infections, nutritional problems
o Adolescent – accidents & injuries, STI/HIV, teenage pregnancy, depression
(suicide), substance abuse

3. Understand the public health approach to prevention of illness

o Provide a safe environment (appropriate dispose of waste & sewage, control
vectors, provide safe water and housing)
o Enhance immunity (immunization)
o Promote a healthy lifestyle (inform about diet to avoid obesity, accidental
poisoning preventing, avoid passive smoking, dental care, seat belts, window
guards, remove guns to secure location; ongoing behavior modification for
teens, surveillance and STI testing)
o Maintain good nutrition (breastfeeding; prevent nutritional deficiencies &
obesity)
o Have well born children (antenatal care (antenatal screening – HIV/HBV,
ultrasound & newborn screening – sickle cell disease & thyroid disease), avoid
exposure to toxins)
o Provide healthcare prudently (history, regular examinations, developmental
assessment, school performance, screen for abuse)

4. Identify key strategies of prevention in paediatrics.

o Promote (primary)
o Preserve (secondary)
o Restore health (tertiary)
o Any combined means

Feb 13
Management Issues: Methods of Treatment
Objectives:
 Management is a holistic biopsychosocial approach
 Involves family, community, workplace, school and recreational

 Physical treatments
o Antipsychotics, antidepressants, electroconvulsive therapy, mood stabilizers and
minor tranquilizers
o Patient may be admitted in hospital, an outpatient in clinics or treated in the
community
o Antipsychotics – reduce delusions and hallucinations and have a
sedating/calming effect. Two types: 1. Typicals (older type) 2. Atypicals (newer
type)
 Typicals – phenothiazines (eg. chlorpromazine), butyrophenones (eg.
haloperidol), thioxanthines (eg. clopixol), diphanylbutylpiperidine (eg.
pimozide), substituted benzamides (eg. amilsulpride) [last two not
commonly used]
 Atypicals – clozapine (clozaril) [can be life threatening, not commonly
used for everyone], olanzapine (zyprexa) [commonly used], quetiapine
(seroquel), risperidone (risperdol), zisprasidone (geodon), aripripazole
(abilify)
Mechanism of action – potent dopamine receptor blockers. Also block
cholinergic, adrenergic and histaminergic receptors. Atypicals also block
serotonin receptors and some atypical block dopamine receptors in the
limbic system only.
Mode of administration – orally, sublingually, intramuscularly, intravenously,
long acting preparation (eg. oil based)
Side Effects: NEUROMUSCULAR [acute dystonias, Parkinsonism, akathesia,
tremors, tardive dyskenesia. These side effects can be minimized by using
anticholinergic agents, but these come with their own side effects: weight
gain, sexual abnormalities/impotence, anticholinergics [dry mouth, blurred
vision/confusion, constipation/urinary retention]
Some antidepressants are used to treat premature ejaculation problems
o Antidepressants
 Tricyclics (eg. amitryptiline, imipramine)
 Monoamine oxidase inhibitors (MAOI) [cannot have wine, cheese or
smoked meats with an MAOI]
 New reversible MAOI (eg. moclobemide)
 Selective serotonin reuptake inhibitors - SSRI (eg. fluoxetine, paroxetine)
[MOST IMPORTANT: advantages and disadvantages, not lethal in
overdose, generics are made which makes it relatively inexpensive, takes
2 weeks to work]
 Selective serotonin and noradrenalin reuptake inhibitors (SNRI) (eg.
venlafaxine, duloxetine)
 Noradrenaline selective reuptake inhibitor (NaSSA) eg. reboxetine
 Atypical antidepressants (eg. trazadone, nefazadone)
 St. John’s Wort (hypericum) MAOI
Mechanism of action: most block the reuptake of serotonin and
noepinephrine into the presynaptic neuron. SSRI blocks reuptake of
serotonin only. MAOI prevents breakdown of serotonin at the synapse.
 Mode of administration: orally – takes 2 weeks for symptoms to start to
abate, full effect in 6 weeks. Anorexia and insomnia symptoms go away
faster
Side effects: nausea, weight loss/gain, insomnia, sexual side
effects/delayed ejaculation, cardiac arrhythmias, increased suicidal
thoughts [BLACKBOX WARNING – GOES ON UNTIL AGE 24!! BBW24],
hypertension, headache, agitation, withdrawal symptoms if not tapered
down before cessation
o Mood Stabilizers
 Used mainly in the treatment of bipolar disorder and aggression and to
augment the efficacy of antipsychotics and antidepressants. Most
commonly used one is lithium, but anticonvulsants are also in this
category.
 Anticonvulsants – sodium valproate (eg. epilim), gabapentine (topamax),
carbamazepine (tegretol)
 Mode of administration – orally. However the THERAPEUTIC level and
the TOXIC level are very close.
 Mechanism of action – sodium and potassium and GABA inhibitory
systems
 Side effects – nausea, fine tremor, weight gain, polydipsia/polyurea,
thyroid abnormalities, blood dyscrasias/rash

o Mood tranquilizers
 Most important class is the benzodiazepines eg. alprazolam, xanax
 Useful for anxiety, insomnia, muscle relaxation, anticonvulsant activity,
treatment of phobias
 Highly addictive/severe withdrawal states
 Mode of admistration – mainly oral, can be IV (must be given slowly and
carefully), intramuscularly, rectally
 Mechanism of action – potentiation of the inhibitory effects of gamma
aminobutyric acid (GABA)
 Side effects – drowsiness/sedation, ataxia/respiratory depression,
aggression, withdrawal symptoms

o Electroconvulsive therapy
 Still used as a physical treatment and has an advantage of being used in
serious situations eg. severe depression, mania, high risk of suicide,
refractory illnesses, patient not eating or drinking, severe mental illness
in pregnancy (all drugs are teratogenic except lactogenin which is given
for nausea)
 Contradictions to ECT – none absolute, airway and spinal problems

 Psychological treatments – supportive therapies, psychotherapies, psychoanalysis

o Based on verbal communication between the patient and the doctor.
 o Aims to help adjust to life, improve mental state, relieve psychological stress
o Specific therapies: psychoanalysis, cognitive behavior therapy, psychodynamic
behavior therapy, supportive psychotherapy, counseling, group therapy, family
therapy, milieu therapy, transactional analysis

 Social treatments – rehabilitation, community care

o Involves the network of contacts and heal professional cadre available to the
patient – baby sitting aspect. Case management or asserted management
o Rehabilitation:
 Important part of treatment
 Including occupational therapy, counseling both as an input and output
 Social workers play a part here:
o Investigate the patients living situation
o Finances
o Family unit/supportive or not
o Assist in skills training
o Try to involve/educate the family, friends & employers
 Rehabilitation may take the form of day hospital, group homes,
medication groups, community care.
 Community care: consists of a psychiatric nurse and trained psychiatric
aides. Psychiatrist is part of the team.
 Group homes: different levels, supervised, partially supervised,
unsupervised (can go to work), staffed with nurses, doctors, aides,
counseling, rehabilitative activities offered.

Feb 16
Human Life Cycle: Pre-Adolescence
Notes:
Middle years (6 – 11)
Physical
 Growth spurt – growth tends to be quite slow in this period, until the end of it, in which
a growth spurt will signal the onset of puberty. Growth rate tends to be influenced by
your nutrition, socio-economic status and genetics
  Nutritional status & obesity – almost 20% of children in this age range are obese. An
increasing number of children are developing diabetes. Low self-esteem tends to be
associated with obesity in children and carries on into adulthood

Cognitive
 Concrete operational thinking (Piaget) – can reason through logically but tend to focus
on real, tangible events, no real abstract thinking.
o Seriation – ability to retain items of information in sequence in your short term
memory and reverse them, a child under 4 cannot do this. Facilitates the
learning of timetables.
o Classification – ability to understand that information can be group in concepts
or ideas. Understanding similarities and differences.
 Learning via:
o Trial and error
o Logical construction – deliberately actively exert an effort to understand their
world (eg. seeing what limits they can push their parents to)
o Observational learning – role model and observe
o Direct instruction – when you teach them something directly
 Cognitive variation – when you formally test children, their levels fall on a spectrum
(extremely low functioning to superior learning abilities). The bell curve indicates that
the majority of individuals fall in the average. A child’s school achievement is based on
genetics as well as the environment they were raised in, but the cognitive test is NOT
based on what you learnt at school.

Psychosocial
 “Industry vs inferiority” (sense of competence)
Children are naturally performance oriented. Failure to feel like one is achieving will
lead to feelings of inferiority.
 Peer relationships – making friends; helps with their social development and helps
them to overcome egocentrism.
 Changing face of medicine – practice of medicine changing to reflect public health
threats and concerns; medical practitioners are being increasingly call on to manage
behavior because of the increasing violence in society.
 Common behavioural concerns
o Behavioral problems can be caused by biological, psychological (improper
role modeling) or social (environmental stressors) factors
o Increasing number of children who are attempting suicide
o Behaviours are developmentally contextual; they can be appropriate at one
stage of development, but if present at later stages it is not ok. Eg. temper
tantrums in 2 – 3 yr olds are normal, but no longer normal at 5. Types of
tantrums: breath holding spells, throw self on floor an kick, slam doors. Eg.
inability to sleep alone at 12 eg. restless behavior
o 4 characteristics that determine how parenting styles:
 i. Degree of strictness
ii. How willing are they to listen to their child
iii. The pressure that they exert on the child to achieve
iv. How nurturing they are as a parent
o Parenting styles (Diana Baumrind):
1. Authoritarian – high on the strict scale, high on implementing rules and
control, high in demanding excellence and achievement, low in nurturing,
low in communicating and listening. Focus on imposing their will by
asserting their power and authority. Children are distrustful and unhappy
as their sense of autonomy has been constantly thwarted.
2. Permissive – low on being strict/imposing rules and control, low on
placing demand on their child for excellence, high in nurturing and high in
listening to and communicating with child. Children last self-reliance, do
not know how to respect boundary settings and rules.
3. Authoritative – high on being strict, high in making demands for achieving
excellence, high in willingness to listen and high in nurturing. Children
appear responsible.
4. Neglectful – they impose no rules or control, no demands on the child,
not nurturing, not around to listen or communicate. Children tend to
seek nurturing from several sources because they do not get it from
home.

Feb 17
Human Life Cycle: Adolescence
Notes:
Adolescence (12 - …)
Physical
 Primary & secondary sex characteristics
 Obsessive concerns about body image – need for privacy. Obsessive concerns eg
anorexia nervosa. Needs to be a decrease in the number of males using steroids.
 Nutritional status – biggest group with nutritional problems
 Hormonal changes and emotional development – evidence suggests that hormone
development may explain the rapid mood swings we see in adolescents.

Cognitive
 Piaget’s theory – final stage : Formal Operational Thinking
The adolescent’s reasoning, thinking, problem solving etc. resembles that of adults.
They can engage in abstract thinking, not just focus on the actual.
As compared to the middle years:
i. Adolescents can emphasize the possible and not just the real
ii. They can use scientific reasoning to systematically solve problems
iii. Adolescent is better at combining ideas and holding several ideas in mind at once
  Argumentative – expected because they not make astute inferences and look beyond
the real, so they will question
 Unfocused – undisciplined and unfocused because they are more likely to speculate and
experiment, so they focus their energies on that concept and then they switch to
something else.
 Idealistic – adolescents can become overly impressed with their ability to reason
abstractly so they do not realize the practical limits of their logic. They will question the
mistakes that their parents made when raising them
 Egocentric – tend to be preoccupied with the reactions of other to them. Constantly feel
judged criticized and can become highly sensitive to criticism
 Personal fable – individual believes that their experiences are unique eg. when a
relationship has ended it was so special, can drink a lot and still drive, can have sex
unprotected and not get HIV
 Social cognition – eg. what’s right and wrong with the world.

Psychosocial
 Erikson’s “identity formation vs. role confusion”
Establishing ones identity. Identity formation is the main crux during the adolescent
period. Selectively keeping and integrating certain aspects of earlier childhood while
discarding others in order to define self. Identity formation is not static, it keeps
evolving. Individuals need to have the opportunity to experiment with different roles
(western developmentalists) to decide on a role they are comfortable with. When you
decide, you will achieve a sense of satisfaction, etc. if you are unable to achieve this,
commitment to values etc. you will keep changing your beliefs and roles etc.
Four main stages:
i. Differentiation – occurs in the earlier phase; characterized by the young
adolescent questioning and rejecting their parents’ advice. Adolescent may
appear to withdraw from family
ii. Practice & experimentation – after some reflecting, they adolescent begins to
feel that he knows it all, denies any need for caution or advice, actively
challenges parents and experiments with things in this phase. There is a
separation from parents and increased commitment to friends.
iii. Rapprochement – adolescent who has achieved a degree of separation from
parents may begin to feel anxious and they attempt to get back in connection
with parents, not a constant thing – one minute miss independent, next minute
she needs reassurance. Tends to be a struggling phase for both parent and
adolescent.
iv. Consolidation – they develop a sense of independence, autonomy and
individuality.

 James Marcia - Identity statuses

Not static, not hierarchical, can be achieved in one area but searching in others:
i. Identity achievement (rare)
 ii. Foreclosure
iii. Identity diffusion
iv. Moratorium

Health/behavioural risks – caused by hormonal change, search for identity and formal
operational thinking style (need to experiment)
Risks: experimenting with drugs, sexual and reproductive issues (STDs, teen pregnancy),
destructive behavior (crime & violence), impulsive acting out (suicide, mood/eating disorder)

Depression in adolescents is both an illness (5%) and a symptom (5 – 10%)

Risk factors: family history of psychiatric history (age of onset important), history of
environmental trauma (eg. losing a mother before 11 years old), chronic illness, certain
medications.

Feb 17
Substance Abuse
Objectives:
1. Definition of addiction
o Addiction – the state of being enslaved to a habit or practice that it is
psychologically or physically habit-forming, to such an extent that its cessation
causes severe trauma.
o DRUG abuse – use of a substance with such frequency that it impairs your
physical, social and occupational functioning.
o Drug addiction and Drug habituation now called DRUG DEPENDENCE
o Syndrome of dependence – use of drugs assumes a much high priority than
other behavior that once had a higher value
o Based on MOTIVATED BEHAVIOUR MODEL – addiction results when biological
mechanisms and environmental conditioning combine to produce a new “drive”
or hunger to use drugs without the normal checks and balances that keep
natural drives under control (balance i.e. – I do not: feel hungry, walk into a
restaurant, steal the closest person’s food. I get hungry, go to a restaurant and
request a quick meal). This UNNATURAL DRIVE becomes the most important.

2. Addiction as a biobehavioral disorder

3. Triangulation model of addiction

4. Substance use disorders

Things the drug causes:
o Substance intoxication
o Substance withdrawl
o Psychotic disorder
o Mood disorder
o Sexual dysfunction
o Sleep disorder

5. Substance induced disorders

Things you will do for the drug
o Substance abuse & substance dependence = substance misuse
o Chronic relapsing disorder (relapse is often the rule not the exception)

6. Risk and protective factors in addiction

o RISK FACTORS - Greater potential for drug use:
- Availability
- Ineffective parenting
- Unstable home environment
- Poor burturing in childhood
- Poor social coping skills
- Affiliation with deviant groups
- Drug trafficking

o PROTECTIVE FACTORS – reduced potential for drug use:

- Strong family bond
- Schools
- Religious organizations
- Parental monitoring of children
 - Knowledge of conventional norms about drug use (eg. our belief that weed is
ok is making it worse)
- Awareness of personal and community hazards of drug use

The presence of risk factors and absence of protective factors in adolescents lead to
increased EXPOSURE OPPORTUNITY to substances of abuse
Early initiation of alcohol, tobacco and illicit drug use among adolescents is a strong
predictor of subsequent drug dependence.

IMPACT OF RISKS AND PROTECTIVE FACTORS

- Function of stage of psychological and social development of an individual
- Exposure, initial drug use, regular use and subsequently dependence

7. Exposure opportunity to substances of abuse

o Alcohol/cigarette users are more likely than nonusers to have an opportunity to
try marijuana (x 3)
o Alcohol/cigarette users are more likely to use marijuana with a marijuana
exposure opportunity (x 7 )
o Opportunity to use cocaine is associated with prior marijuana smoking (x1.9 with
A/T, x4.6 with marijuana, x7.6 with A/T and marijuana)
o Users of marijuana are more likely to use cocaine with cocaine exposure
opportunity (x 15)

Sequence of events: exposure  use  abuse  craving/compulsion/impaired

control  Dependence

Your brain function decreases on drugs in a matter of minutes and takes months to
return to normal functioning when coming off the drug.

Consequences of repeated drug use – change in brain structure and function,

neuroadaptive changes, new memory connections, distortion of cognitive and
emotional functioning (compulsion to use drugs, drug use the sole motivational
priority)

TRANSTHEORETICAL MODEL OF INTENTIONAL BEHAVIOUR CHANGE

1. Precontemplation – not ready to change eg. “I do not intend to quit in the next 6
months “
2. Contemplation – thinking about change eg. “I intend to quit in the next 6 months”
3. Preparation – getting ready to change eg. “I intend to quit in the next 30 days”
4. Action – making the change eg. “I quit less than 6months ago”
5. Maintenance – sustaining the change eg. “I quit more than 6 months ago”
6. Relapse/recycling – slipping back and reentering the cycle
7. Termination – leaving the cycle
Substance abuse prevention is HIV prevention

Feb 20
Evaluation Methods in Psychiatry
Notes:
 Final evaluation of the psychiatric patient must include: psychiatric history, informant
history, mental status exam and physical examination. This will lead to a differential
diagnosis, plan of investigation and a plan of management
 History must include: patient’s name, age, address, marital status, religion, occupation,
circumstances of referral.
 Patients complaint in his/her own words
 Information to gather on the history of the illness – duration, precipitating factors, effect
on interpersonal relationships, ability to function on all levels, details of all treatment for
this illness previously.
 Family history information: status of parents relationship, information on siblings such
as where the patient falls and their relationship, occupations and achievements of
siblings, family history of mental illness and suicide, substance use and forensic history.
 Personal history information: details of patients mothers pregnancy, developmental
delay/birth trauma, childhood illness, separation, school
information/academics/relationships at school, occupational history (job loss, etc),
sexual orientation/difficulties
 Details of relationships/marriage
 Women : menstrual cycle, contraception, termination, miscarriages
 Children: how many and circumstances of birth, childhood physical and verbal abuse or
rape
 Past psychiatric history: previous diagnosis, prior admissions, day hospitals or clinic
visits, medication history and types of medicines, compliance with medications or if not
reasons why, side effects of previous medications
 Past medical/psychiatric history: relationship to current illness, head trauma/head
injury, seizures, recent infections (eg. STIs), endocrine illnesses, chronic
illnesses/medication for chronic illnesses, vitamin deficiencies.
 Drug history: patients choice of drug, who started, quantity/quality/amount spent,
longest time without use/withdrawal effects, trouble/arrest/jail/negligence, every tried
to get help/rehab
 Pre-morbid personality – speaks to the patients character before the illness: were they
always happy/fun/loving, sad/angry/full of life, spontaneous, loner/life of the party,
note the change from this state when the patient is ill

MENTAL STATUS EXAMINATION (MSE)

 This is the equivalent of the physical examination in a medical/surgical patient in a
psychiatric patient
 The findings are not static and you must say date & time it was done
 Limitations of MSE: cultural background, educational level, religious beliefs, level of
mental illness (too severe will provide false results)

Components of MSE [MUST KNOW THIS!!!!]

 Appearance, attitude/motoric behavior, speech, mood, affect, thought form/process,
thought content, perception, insight, judgment, cognition, orientation, memory (short &
long term), attention & concentration, abstraction, general fund of knowledge,
intelligence test

o Appearance – appropriate, well groomed, good health, attention to hygiene,

gives clues as to the actual mental illness (diagnosis), manic (bright mismatched
colours), heavy makeup/lipstick [Depressed/schizophrenic - disorganized dress,
no attention to detail, not ironed, smelly, dirty clothing]
o Attitude & behavior [towards YOU] – psychomotor agitation/retardation,
demeanour, manner, rapport, eye contact, degree of cooperation, abnormal
movements (tics, chorea, tremor), striking physical features, mannerisms (body
language, goal directed behavior)
o Speech – coherence, rationality, rate/flight of ideas, quantity [a lot – pressured
speech; little – poverty of speech], preservation [repeat words, topics],
neologisms [creation of new words]
o Mood [what the patient tells you] – commonest symptom of mood disorder,
refers to the SUBJECTIVE MANIFESTATION of emotion as experienced by the
patient, must be reported in the patient’s own words, is it congruent with
thoughts and actions?
Abnormal mood states: depression, elation, euphoria (unconcerned
contentment), anxiety, anger
o Affect [what you observe about the patient] – observed external OBJECTIVE
MANIFESTATION of patient’s mood, most often transient, mood more stable.
Note congruence with mood.
Abnormal affect: blunt, labile, suspicious, perplexed, flat,
o Thought form – refers to the way thoughts/ideas are “strung” together, there is
an abnormality when connections between statements are hard to follow
Abnormalities: loosening of association (no connection between each sentence
spoken), tangential (one statement leads to an idea that has a connection to the
initial statement but the patient never returns to his original point – in
schizophrenia). Circumstantial (one statement leads to an idea that has a
connection to the initial statement and then may more ideas some into the
picture but the patient DOES return to the original point and finishes the ideal in
a logical fashion – seen in schizophrenia). Flight of ideas (from one idea to
another in rapid succession, there may be a connection between ideas or not –
 seen in mania), thought block (the sudden disappearance of thoughts, patients
mind just goes blank)
o Thought content – refers to the types of ideas/thoughts in the patients mind eg.
obsessional ideas, suicidal ideation, homicidal ideation, thought ideation,
thought withdrawal, thought broadcast, thoughts of passivity (thought
interference), depersonalization (unpleasant feeling of subjective change,
patient reports feeling detached, unreal, empty inside, unable to feel emotion)
Déjà vu (feelings of having experienced the situation already but you have never)
Jamais vu (you are in a place, you have seen this and known this, but you feel like
you have never experienced it)
Delusion – a fixed false belief not in keeping with the patients culture, it cannot
be shaken even with proof, and patient has no insight (types: delusions of
persecution/paranoia, delusions of grandeur, erotomanic, somatic delusions)
o Abnormalities of perception – encompasses hallucinations and illusions,
Hallucination (sensory perception in the absence of an external stimulus, can be
true [sensory perception coming in from the outside, heard through ears, hear it
and will look in the direction of the sound] or pseudo [sensory perception from
within, ie hearing voices inside the head])
Types of hallucinations: auditory (most common), visual, gustatory, tactile
(usually in substance abuse), olfactory (significant, usually imply there is an
organic pathology like a tumour in the area)
Illusions – distortions of perception of an external stimulus where the patient has
no insight eg. interpreting a curtain rod as a snake, looking at a curtain with an
abtract pattern and seeing a person etc. a mirage is an illusion
o Insight – the patient is aware that something is wrong and that his/her beliefs
are false, wants to get help for this.
o Judgment – the ability to make a logical and sound decision in the best interest
of self and others, can be assessed by asking the patient questions such as “what
would you do is you saw a child crossing the road into the path of an incoming
car?”
o Cognitive assessment – encompasses orientation, memory (long & short),
attention & concentration [eg. ask the person to spell “world” backwards”],
abstraction [eg. ask them a cliché “if you live in a glass house, don’t throw
stones”], general knowledge/intelligence level
o Physical examination – should focus on any area where the MSE raised suspicion
and areas where medical conditions are linked to psychiatric conditions eg.
thyroid disease, auto immune disease (SLE), vitamin B12 deficient, STDs (syphilis
can cause madness, presence of psychosis is used to move patients with HIV to a
diagnosis of AIDS)

 In evaluating the psychiatric patient, the history together with the mental status &
physical examinations should serve to make an informed differential diagnosis.
 DSM IV TR (text revision) MULTIAXIAL CLASSIFICATION
 Multiaxial classification is not a part of the mental status evaluation but you use the
mental status evaluation to arrive at your multiaxial classification.
o Axis I – primary psychiatric diagnosis (what is the patient suffering from?
Developmental disorders, major disorders, eg. schizophrenia, depression)
o Axis II – personality disorder or mental retardation
o Axis III – medical/surgical conditions
o Axis IV – factors impacting on axis I (eg. employment, good family support, etc.
anything that can make their situation better/worse)
o Axis V – Global Assessment Functioning (patients usually score 21 – 30 on GAF)

Feb 24
Human Life Cycle: Elderly
Notes:

Feb 24
Stress and Coping
Notes:
 You must understand stress management in medical school because of the volume of
work, competency and self-esteem issues, and patient issues (ones they can’t help, ones
who will die)
 Stress = pressure – adaptability (Dato)
 Stress – non specific response of the body to any demand made on it (Selye)
 Vulnerability to stress depends on your personality, behavioural skills & coping
repertoire, physical condition & mental state, degree of ongoing life stress and mental
capacity
 Stress signals:
o Physical (frequent headaches, upset stomach, appetite change, palpitations
and/or chest pains, insomnia, frequent infections eg. cold, fatigue, drug use)
o Mental (difficulty concentrating, forgetfulness, confusion, boredom, spacing out)
o Emotional (unrealistic fear, the blues, irritability, frequent and irrational
outbursts of anger, frequent withdrawal from friends, feeling hopeless)
o Spiritual (loss of faith, doubting God, feeling empty, unwillingness to forgive,
looking for magic, apathy)
 Stress management strategies: cognitive, interpersonal, spiritual, physical
 o Cognitive stress management strategies:
Problem solving, prioritizing, setting realistic goals, time management skills,
changing perspective, serenity prayer principle, use humour, appropriate use of
diversions.
o Interpersonal stress management strategies
Communication, assertiveness, building relationships, conflict resolution skills,
anger management skills, learning to say “no”, asking for help
o Spiritual stress management strategies
Being clear about values, commitment, meditation, faith, prayer
o Physical stress management strategies
Exercise, eating healthy, getting sufficient rest, relaxation techniques (deep
breathing, visualization)

 Performance under stress:

1. Focus on the process, not the outcome 2. Be aware of the stress/performance curve
and your own optimal level of stress 3. Learn and practice coping skills 4. Reframe
evaluative situations 5. Keep and use your sense of humour 6. Maintain your
perspective 7. Remember that mistakes are part of learning 8. Separate your self-
worth from your performance.

***NOT ON THIS:
- Human Life Cycle: Adult 2 [Feb 21]
- Human Life Cycle: Elderly [Feb 24]

***Feb 20
Young Adult and Middle Years of the Human Life Cycle
Notes:
 Erik Erikson – Developmental psychologist & psychoanalyst
o Postulated 8 stages of human development; Widow added a 9th

Erikson’s Stages of Psychosocial Development

1. Hopes: Trust vs. Mistrust
Infants: birth to 12-18 months

2. Will: Autonomy vs. Shame & Doubt

Toddlers: 18mth – 3years

3. Purpose: Initiative vs. Guilt

Preschool: 3 – 5years
4. Competence: Industry vs. Inferiority
Childhood: 5 – 13years
5. Identity vs Role confusion
Adolescence: 13 – 21years

6. Love: Intimacy vs Isolation

Young Adult: 21 – 40years

7. Care: Generativity vs Stagnation

Middle adulthood: 41 – 65years

8. Wisdom: Ego Integrity vs Despair

Seniors: 65+years

 Young adult years (20 – 40) considerations

o Healthiest time of life, peak time for biological function and physical
performance
o Women reach their peak fertility in their early 20’s
o Mortality rates very low. Men more likely to die from car accidents and suicide
than women.
o Health problems: sexual health. AIDS has significantly reduced.pregnancy issues.
Cancers less common in older adults (except testicular, cervical and Hodgkin’s
lymphoma)
o Psychological development: transition from a stage of role confusion in
adolescence to becoming an independent person. Eagerness to merge identities
with others – coupling. Ready for intimacy, capacity for commitment, ability to
face the fear of ego loss in situations which call for self abandonment. Ultimate
goal to develop interdependence when one person is fully able to enter a
relationship with another person. Transition to a new family system. Re aligning
your relationships to include your spouse.
o Parenting

 MIDDLE YEARS
o Ego development outcome: generativity vs. self absorption or stagnation
o Basic strengths: production and care
o Significant task is to perpetuate culture and transmit values of the culture
through the family. Strength comes through care of others and production of
something that contributes to the betterment of society.
o Period of change (children leaving, relationships may change, faced with major
life changes, mid-life crisis, struggle with finding new meanings and purposes)
o Health issues: time when energy levels and health may decline, persons may be
diagnosed with chronic illnesses which may limit activities. Hypertension,
diabetes mellitus, weight problems, menopause, arthritis, coronary heart
disease, depression, stress related illnesses, osteoporosis, cancers
 Menopause
o Change of life
o Climacteric
o The silent passage
o MENOPAUSE & ANDROPAUSE – both hormone deficiency syndromes
(menopause – deficiency of oestrogen; andropause – deficiency of testosterone)
– symptoms relieved by hormone therapy
 Differences:
 Menopause – relatively sudden, cessation of periods, loss of
fertility
 Andropause – gradual, no equivalent to cessation of period,
fertility maintained
o Age: 45 – 55 years
o Hallmark – no periods for 12 consecutive months
o Types: premature, natural, induced
o Symptoms: early consequences [hot flashes & night sweats, mood disorders,
sleep disturbances, hair loss, hair growth, fomentations, aches & pains, changes
in libido, fatigue], medium term consequences [urogenital changes: vaginal
dryness – dysparunia, reduced libio, urinary urgency, stress incontinence], long
term consequences [increased risk of cardiovascular disease, adverse changes in
lipid metabolism, increased risk of developing opsteoporosis]
 Osteoporosis – decreased bone density, fractures, deformity, loss of
independence, up to 20% of hip fracture patients die within 1year due to
related complications
 Andropause – change is very gradual, earliest symptoms – erectile
dysfunction, decline in libido, decline in muscle mass and strength,
increase in body fat, decrease in bone mass
 Management – healthy lifestyle, psychological support, hormone
therapy, herbal/complimentary therapy
 Psychological symptoms – anxiety, mood swings, depression, irritability,
midlife crisis, direct cause and effect relationship between these
symptoms and oestrogen is hard to establish

 Depression: empty nest syndrome, exposing underlying weakness in a marriage, loss of

employment, dissatisfaction with achievements in life, care of elderly parents, limited
finances
o Management of symptoms: healthy lifestyle, psychological support, hormone
therapy (oestrogen – women who have had a hysterectomy; oestrogen &
progesterone – women who have an intact uterus)

 Central tasks of the middle years:

o Express love through more than sexual contacts
 o Maintain healthy life patterns
o Help growing and grown up children to be responsible adults
o Relinquish central roles in the lives of grown children
o Accept children’s mates and friends
o Develop a sense of unity with mate
o Create a comfortable home
o Be proud of accomplishments of self and mate/spouse
o Reverse roles with aging parents
o Achieve mature, civic and social responsibility
o Adjust to physical changes of middle age
o Use leisure time creatively

 The middles years are:

o A time for renewal/reinventing one’s self
o A time to launch a new business of convert a hobby into a business
o Can be a time for discovering a dormant talent
o Having more time for one’s self to exercise
o Reducing stress in one’s life
o Time for reflection
o Time of increased confidence
o Launching of adult children
o Developing an adult relationship with children
o Focus on reprioritizing your life
o Forgiving those who have wronged you
o Assessing beliefs about life and death

 Summary
o Avoid unhealthy habits eg. smoking
o Stress reduction
o Exercise including weight bearing ones
o Healthy diet including all food groups
o Maintaining an appropriate weight for height
o Growing spiritually as we age