1.

prolonged separation from his mother Reactive attachment disorder of

infancy or early childhood, inhibited and disinhibited type.
(1) Inhibited type: Children are withdrawn and unresponsive.
(2) Disinhibited type: Children approach and attach indiscriminately to strangers as
though the strangers were familiar to them.

2. The principal psychological task of infancy is the formation of an intimate

attachment to the
primary caregiver, usually the mother.
The major theme of the second year of life is to separate from the mother or
primary caregiver,
a process that is complete by about age 3.
A child who cannot do this after age 3 is experiencing separation anxiety disorder
3. The child begins to understand that death is final and fears that his or her parents
will die
and leave at age 6. It is not until about age 9, however, that the child understands
that he or she
also can die.
4. Children develop an understanding of the concept of gender by age 3-4 and
have a sense of the permanency of gender around age 5-6. Development normal for
them to explore world by engaging in activities associated with the opposite gender.

10. The husband of a 28-year-old woman, who gave birth to a healthy infant 2 weeks ago,
reports that he found her shaking the infant to stop it from crying. When the doctor questions
the woman about the incident, she says I did not realize it would be so much work. The patient
also reports that she wakes up at 5 AM every day and cannot fall back asleep and has very little
appetite. The next step in management is for the doctor to
(A) assess the patient for thoughts of suicide
(B) advise the father to hire a caregiver to
assist the mother in caring for the child
(C) set up another appointment for the
following week
(D) prescribe an antidepressant
(E) tell the father that the mother is showing
evidence of the baby blues
10. The answer is A. This woman is showing evidence of a serious post-partum reaction such as
major depression, not simply the baby blues. Because she shows evidence of depression, for
example, early morning awakening, lack of appetite, the next step in management is to assess
her for thoughts of suicide. The child must also be protected. If she is suicidal or likely to harm
the child, inpatient treatment may be indicated. Ultimately, assistance with care of the child may
be helpful, but the next step is to protect the patient and the child. Just setting up another
appointment for the following week or prescribing an antidepressant will not protect either.

17. Transfers toys from one hand to the other.

(A) 03 months
(B) 46 months
(C) 711 months
(D) 1215 months
(E) 1630 months
18. Turns over.
(A) 03 months
(B) 46 months
(C) 711 months
(D) 1215 months
(E) 1630 months
19. Smiles in response to a human face.
(A) 03 months
(B) 46 months
(C) 711 months
(D) 1215 months
(E) 1630 months
20. Responds to own name.
(A) 03 months
(B) 46 months
(C) 711 months
(D) 1215 months
(E) 1630 months
21. Feeds self with a spoon.
(A) 03 months
(B) 46 months
(C) 711 months
(D) 1215 months
(E) 1630 months

School age: 7-11 years best age to perform elective surgery.

Social characteristics
1. Prefers to play with children of the same sex; typically avoids and is critical of
those of the
opposite sex.
2. Has internalized a moral sense of right and wrong (conscience) and
understands how to
follow rules, (e.g., playing fair).
3. School-age children and younger children are typically interviewed and examined by
the
doctor with the mother present.
Cognitive characteristics. The school-age child:
1. Is industrious and organized (e.g., gathers collections of objects).
2. Has the capacity for logical thought and can determine that objects have more than
one
property (e.g., an object can be both red and metal).
3. Understands the concepts of conservation and seriation; both are necessary for
certain
types of learning.
a. Conservation involves the understanding that a quantity of a substance remains the
same regardless of the size of the container or shape it is in (e.g., two containers may
contain the same amount of water even though one is a tall, thin tube and one is a
short, wide bowl).
b. Seriation involves the ability to arrange objects in order with respect to their sizes or
other qualities.
ADOLESCENCE: 1120 YEARS
A. Early adolescence (1114 years of age)
1. Puberty occurs in early adolescence and is marked by:
a. The development of secondary sex characteristics (Table 2.1) and increased
skeletal growth.
b. First menstruation (menarche) in girls, which on average occurs at 1114 years of
age.
c. First ejaculation in boys, which on average occurs at 1215 years of age.
d. Cognitive maturation and formation of the personalityidentification of
themselves.
e. Sex drives, which are expressed through physical activity and masturbation
(daily masturbation
is typic
2. Early adolescents show strong sensitivity to the opinions of peers but are generally
obedient
and unlikely to seriously challenge parental authority.
3. Alterations in expected patterns of development (e.g., acne, obesity, late
breast development
in girls, nipple enlargement in boys [usually temporary but may concern the boy and his
parents]) may lead to psychological difficulties
4. A child with an ill sibling or parent may respond by acting badly at school or home
(use of
the defense mechanism of acting out
Middle adolescence (1517 years of age)
1. Characteristics
a. There is great interest in gender roles, body image, and popularity.
b. Heterosexual crushes (love for an unattainable person such as a rock star) are
common.
c. Homosexual experiences may occur. Although parents may become alarmed, such
practicing is part of typical development.
d. Efforts to develop an identity by adopting current teen fashion in clothing and music,
and preference for spending time with peers over family are typical, but may lead to
conflict with parents.
e. first sexual intercourse occurs on average at 16 years of age
2. Risk-taking behavior
a. Readiness to challenge parental rules and feelings of omnipotence may result in risk
taking behavior (e.g., failure to use condoms, driving too fast, smoking).
b. Education about obvious short-term benefits rather than references to long-term
consequences
of behavior is more likely to decrease teenagers unwanted behavior. For example,
to discourage smoking, telling teenagers that their teeth will stay white if they
do not smoke, or that other teens find smoking disgusting, will be more helpful than
telling them that they will avoid lung cancer in 30 years.
Late adolescence (1820 years of age)
1. Characteristics - morals, ethics, self-control// an identity crisis commonly
developsrole confusioncriminality or an interest in cults
EARLY ADULTHOOD: 2040 YEARS
The adults role in society is defined. + The development of an intimate (e.g.,
close, sexual) relationship with another person occurs.
MIDDLE ADULTHOOD: 4065 YEARS
Many men in their middle 40s or early 50s exhibit a midlife crisis. This may lead to:
a. A change in profession or lifestyle.
b. Infidelity, separation, or divorce.
c. Increased use of alcohol or drugs.
d. Depression.
associated with an awareness of ones own aging and death and severe or
unexpected lifestyle changes (e.g., death of a spouse, loss of a job, serious illness).
Mental retardation
Mildly (IQ of 5069) and moderately (IQ of 3549) mentally retarded children and
adolescents commonly know they are handicapped (see Chapter 8). Because of this,
they may become frustrated and socially withdrawn. They may have poor self-
esteem because it is difficult for them to communicate and compete with peers.

Gerontology, the study of aging, and geriatrics, the care of aging people, have become
important medical fields.
a. Geriatricians typically manage rather than cure the chronic illness of aging such as
hypertension, cancer, and diabetes.
b. A major aim of geriatrics is to keep elderly patients mobile and active. Because
fractures
(e.g., of the hip) are more likely than chronic illness to cause loss of mobility leading to
disability and death in the elderly, preventing falls and prevention and management of
osteoporosis are important foci in management.
c. Prevention and management of osteoporosis includes: Increasing weight bearing
exercise,
and increasing calcium and Vitamin D in the diet. Medications which decrease
bone resorption by blocking osteoclasts, for example, alendronate sodium (Fosamax) or
increase bone formation by stimulating osteoblasts, for example, teriparatide (Forteo)
are also useful.

Changes in the brain

1. decreased brain weight, enlarged ventricles and sulci, and decreased cerebral blood
flow.
2. Amyloid (senile) plaques and neurofibrillary tangles are present in the
normally aging brain
3. decreased availability of neurotransmitters such as norepinephrine, dopamine,
g-aminobutyric acid, and acetylcholine; increased availability of monoamine
oxidase; and decreased responsiveness of neurotransmitter receptors .
4. Intelligence remains approximately the same throughout life

5. Depression is the most common psychiatric disorder in the elderly. Suicide is more
common in the elderly than in the general population.
(1) Factors associated with depression in the elderly include loss of spouse, other family
members, and friends; decreased social status; and decline of health.
(2) Depression may mimic and thus be misdiagnosed as Alzheimer disease .
This misdiagnosed disorder is referred to as pseudodementia because it is associated
with memory loss and cognitive problems (see Chapter 14).
(3) Depression can be managed successfully using supportive psychotherapy in
conjunction with pharmacotherapy or electroconvulsive therapy (see Chapter 15).

Physicians response to death

1. The major responsibility of the physician is to give support to the dying patient
and the patients family.
2. Generally, physicians make the patient completely aware of the diagnosis and
prognosis. However, a physician should follow the patients lead as to how much he or she
wants to know about the condition. With the patients permission, the physician may tell
the family the diagnosis and other details of the illness (see Chapter 23).
3. Physicians often feel a sense of failure at not preventing the death of a patient. They
may deal with this sense by becoming emotionally detached from the patient in order
to deal with his or her imminent death. Such detachment can preclude helping the patient
and family through this important transition.
Memory Systems and Associated Neuroanatomy

A. Drug-assisted interview
1. Administration of a sedative, such as amobarbital sodium (the Amytal interview),
prior
to the clinical interview may be useful in determining whether organic pathology is
responsible for symptomatology in patients who exhibit certain psychiatric disorders or
are malingering (see Chapter 14).
2. Sedatives can relax patients with conditions such as dissociative disorders,
conversion
disorder (see Chapter 14), and other disorders involving high levels of anxiety and mute
psychotic states (see Chapter 11). This will allow patients to express themselves
coherently
during the interview.
B. Sodium lactate administration. Intravenous (IV) administration of sodium lactate
can provoke
panic attacks (see Chapter 13) in susceptible patients and can thus help to
identify individuals
with panic disorder. Inhalation of carbon dioxide can produce the same effect.
.
Topographic theory of the mind. In the topographic theory, the mind contains three
levels: The
unconscious, preconscious, and conscious.
1. The unconscious mind contains repressed thoughts and feelings that are not
available to
the conscious mind, and uses primary process thinking.
a. Primary process is a type of thinking associated with primitive drives, wish
fulfillment,
and pleasure seeking, and has no logic or concept of time. Primary process thinking is
seen in young children and psychotic adults.
b. Dreams represent gratification of unconscious instinctive impulses and wish fulfillment.
2. The preconscious mind contains memories that, while not immediately available, can
be
accessed easily.
3. The conscious mind contains thoughts that a person is currently aware of. It operates
in
close conjunction with the preconscious mind but does not have access to the unconscious
mind. The conscious mind uses secondary process thinking (logical, mature, timeoriented)
and can delay gratification.

HABITUATION AND SENSITIZATION

A. habituation (also called desensitization), repeated stimulation results in a decreased
response (e.g., a child who receives weekly allergy injections cries less and less with each
injection).
B. In sensitization, repeated stimulation results in an increased response (e.g., a child
who is
afraid of spiders feels more anxiety each time he encounters a spider).
CLASSICAL CONDITIONING
A. Principles. In classical conditioning, a natural or reflexive response (behavior) is
elicited by
a learned stimulus (a cue from an internal or external event). This type of learning is
called
associative learning
B. Elements of classical conditioning
1. An unconditioned stimulus is something that automatically, without having to be
learned,
produces a response (e.g., the odor of food).
2. An unconditioned response is a natural, reflexive behavior that does not have to be
learned
(e.g., salivation in response to the odor)
3. A conditioned stimulus is something that produces a response following learning
(e.g., the
sound of the lunch bell).
4. A conditioned response is a behavior that is learned by an association made
between a
conditioned stimulus and an unconditioned stimulus (e.g., salivation in response to the
lunch bell).

D. Aversive conditioning. An unwanted behavior (e.g., setting fires) is paired with a

painful
or aversive stimulus (e.g., a painful electric shock). An association is created between the
unwanted behavior (fire-setting) and the aversive stimulus (pain) and the fire-setting
ceases.
E. Learned helplessness
1. An animal receives a series of painful electric shocks from which it is unable to
escape.
2. By classical conditioning, the animal learns that there is an association between an
aversive
stimulus (e.g., painful electric shock) and the inability to escape.
3. Subsequently, the animal makes no attempt to escape when shocked or when faced
with
any new aversive stimulus; instead, the animal becomes hopeless and apathetic.
4. Learned helplessness in animals may be a model system for depression (often
characterized
by hopelessness and apathy) in humans.
5. Antidepressant treatment increases escape attempts in animal models.
F. Imprinting is the tendency of organisms to make an association with and then follow
the first
thing they see after birth or hatching (in birds).r of food).

C. Response acquisition, extinction, and stimulus generalization

1. In acquisition, the conditioned response (e.g., salivation in response to the lunch bell)
is
learned.
2. In extinction, the conditioned response decreases if the conditioned stimulus (e.g., the
sound of the lunch bell) is never again paired with the unconditioned stimulus (e.g., the
odor of food).
2. In stimulus generalization, a new stimulus (e.g., a church bell) that resembles a
conditioned

OPERANT CONDITIONING
1. Behavior is determined by its consequences for the individual. The consequence
(reinforcement
or punishment) occurs immediately following a behavior.
2. In operant conditioning, a behavior that is not part of the individuals natural
repertoire can
be learned through reinforcement.
1. The likelihood that a behavior will occur is increased by positive or negative
reinforcement
and decreased by punishment or extinction (Table 7.1).

a. Types of reinforcement include:

(1) Positive reinforcement (reward) is the introduction of a positive stimulus that
results
in an increase in the rate of behavior.
(2) Negative reinforcement (escape) is the removal of an aversive stimulus that also
results in an increase in the rate of behavior.
b. Punishment is the introduction of an aversive stimulus aimed at reducing the rate of
an
unwanted behavior.
2. Extinction in operant conditioning is the gradual disappearance of a learned behavior
when reinforcement (reward) is withheld.
a. The pattern, or schedule, of reinforcement affects how quickly a behavior is
learned and
how quickly a behavior becomes extinguished when it is not rewarded (Table 7.2).

1. Shaping involves rewarding closer and closer approximations of the wanted behavior
until the correct behavior is achieved (e.g., a child learning to write is praised when she
makes a letter, even though it is not formed perfectly).
2. Modeling is a type of observational learning (e.g., an individual behaves in a manner
similar
to that of someone she admires).

10. A father scolds his child when she hits the dog. The child stops hitting the dog. This
change in the child behavior is most likely to be a result of
(A) punishment
(B) negative reinforcement
(C) positive reinforcement
(D) shaping
(E) classical conditioning
(F) extinction
(G) sensitization
(H) habituation
11. Although a father spanks his child when she hits the dog, the child continues to hit the
dog. This childs hitting behavior is most likely to be a result of
(A) punishment
(B) negative reinforcement
(C) positive reinforcement
(D) shaping
(E) classical conditioning
(F) extinction
(G) sensitization
(H) habituation
12. A patient with diabetes increases her time spent exercising in order to reduce the
number of insulin injections she must receive. The increased exercising behavior is most
likely to be a result of
(A) punishment
(B) negative reinforcement
(C) positive reinforcement
(D) shaping
(E) classical conditioning
(F) extinction
(G) sensitization
(H) habituation
10. The answer is A. Because the behavior (hitting the dog) decreased, the scolding
that
this child received is probably punishment. Both negative and positive reinforcement
increase behavior. Shaping involves rewarding closer and closer approximations of the
wanted behavior until the correct behavior is achieved. In classical conditioning, a natural
or reflexive response (behavior) is elicited by a learned stimulus (a cue from an
internal or external event). (See also answers to Questions 1116).
11. The answer is C. Because the behavior (hitting the dog) is increased, the scolding
that
this child received is probably positive reinforcement. Both negative and positive
reinforcement
increase behavior. The reward or reinforcement for this hitting behavior is
most likely to be increased attention from the father. Punishment decreases behavior.
12. The answer is B. Because the behavior (exercise) is increased to avoid something
negative
(insulin injections), this is an example of negative reinforcement.