1. Medical psychology- introduction Psychology is the scientific study of human or animal mental functions (e.g.

perception, cognition, emotion, personality) and behaviors. The knowledge and methods are used for example in the field of clinical psychology (assessment and treatment of mental health problems), counseling, educational, school psychology, industrial/organizational, sports, developmental, social History of psychology The study of psychology in philosophical context dates back to ancient civilizations of Egypt, Greece, China, India, and Persia (Plato, Aristotle, Hippocrates). Hypnosis (animal magnetism)- Franz Mesmer, the 2nd half of 18th century, medical use of hypnosis- James Braid, scottish surgeon in 1842. Psychology as a science dates back to the end of the 19th century when german psychologist Wilhelm Wundt established psychological laboratory in 1879. He moved psychology from the domain of philosophy and paid attention to relations between physiological and mental processes. Mental processes can be explored by the method of introspection- description and classification of feeling etc. Later (in the half of the 20th century) psychology paid attention to behavior and led to behavior psychology and attention paid to cognitive processes led to development of cognitive psychology. Medical psychology Medical psychology in Europian context means application of psychological principles to the practice of medicine. Other similar definitions is "the study and application of psychological factors related to any and all aspects of physical health, illness, and its treatment at the individual, groups, and systems level". All the professionals should apply knowledge of medical psychology in the care of patients. Medical psychology is focused mainly on: 1. the relationship among the physician, patient and his close relations 2. regulation of acute psychic and psychosomatic states (e.g. anxiety, pain, anger, depression) 3. psychological care of the patients and his close relatives 4. psychotherapy influence 5. physicians self-development and self-understanding.

Medical psychology in U.S. context refers to a growing specialty area of clinical psychological practice in which clinical psychologists, who have undergone specialized education and training at the post-doctoral level, integrate somatic and psychotherapeutic modalities into the management of mental illness, including the prescription of medications in the care and management of patients. Guam (since 1999), New Mexico (2002) and Louisiana (2004) currently authorize medical psychologists to prescribe medications. The specialty of medical psychology has established a specialty board certification, American Board of Medical Psychology and an Academy of Medical Psychology requiring a doctorate degree in psychology and extensive post doctoral training in the specialty and the passage of an oral or written examination. Medical psychologists are trained to treat the behavioral and psychological aspects of physical disorders and to treat mental disorders in primary care centers, hospitals, and nursing homes. In Europe is a psychologist a person who has the degree in psychology (Mgr. or PhDr.). A psychiatrist is a medical doctor who has the degree in medicine and is allowed to prescribe medications. Medical psychology represents one kind of applied psychology. It includes psychological knowledge necessary needed for therapeutico-preventive practice. Medical psychology involves psychology as well as knowledge of normal mans mental reactions during illness (the so-called pathopsychology), psychology of examination, therapy and also psychology of the physician and health-care workers in general. Psychopathology is the main domain of psychiatry (clinical medical science focused on mental disorders, their etiology, pathogenesis, clinical manifestations, diagnostics, therapy, prevention and judgement). Many themes of medical psychology closely relate to psychiatric problems. However, medical psychology is an independent subject of the study and is not an introduction to the study of psychiatry. Only a part of general psychology focused on separate mental processes, function and characteristics (perception, memory, etc) represents and introduction to the study of psychiatry. Psychopathology, which is a part of psychiatry, deals with disorders of mental processes and functions as well as deviations and pathological changes in psychological characteristics such as personality disorders. The relation between psychology and psychopathology is analogous to the one between anatomy and pathological anatomy or physiology and pathological physiology. However, psychopathology closely relates to physiology. The brain is an organ of the mind. Psychological phenomena depend on the functioning of the central nervous system. At present, it is still relatively difficult to gain

physiological knowledge of phenomena studied and defined in psychology and sometimes there is also a subjective part of diagnostics and treatment connected with the individuality of psychologist itself. Two different levels of studying mental processes physiological and psychological are involved. But the acceptance of two different levels has nothing to do with duality in the philosophical sense. The matter in question is that there are mental phenomena which are theoretically, as well as practically important and it is necessary to study them using psychological methods and to define them using psychological terms. For instance, it is possible to study and interpret emotions at the physiological level; there is even anatomical knowledge of them. However, many aspects of emotivity we have to study by psychological methods. In the past, namely under the influence of findings in physiology, there was a tendency to underestimate the importance of psychology, simply speaking, to understand psychology as a temporary science which would be replaced by physiology in the future. Clinical psychology is a branch of medicine applied by psychologists. Clinical psychologists can examine patients using psycho-diagnostic methods and provide psychotherapy. Psychosomatic medicine interdisciplinary branch focused on the physiological and pathological processes through which some mental and social factors can: 1. cause some somatic disorders (so-called psychogenesis) 2. contribute to the origination and development of these disorders (psychosomatic part of diseases) 3. affect the course of the mentioned disorders and diseases. The view of man as a psychosomatic unity also with respect for his environment (including social dimension) is an important part of treatment. Modern medicine with its strict specialization, technicalisation and profit orientation can lead to a more anonymous relationship between the physician and the patient (approach to a man as to a broken machine) and to so called dehumanization of medicine neglecting mans subjectivity, originality and his feelings. We should consider mans subjectivity, psychological, social, environmental and health aspects, individual living style and whole personal history. Communication in the context of medicine

Communication is a form of interaction characterized by mutual interaction, esp. information exchange. Communication with the patient has specific attributes caused by the situation of dependence (more or less), roles (nurse, doctor, patient) and whole context of health care. But it is not just about these specific attributes, an important part of communication in health care is a normal social communication we use in any other areas of life. Communication can be itself the curative factor of treatment- such as in the case of psychotherapy. In most cases we need to communicate properly to form good relationship based on trust and cooperation, giving the patient understanding and support, getting and giving informations needed for the treatment, helping the patient to adopt and cope with bad informations and so on. One of the factor that improve communication and relationship with the patient is good selfknowledge, which we can improve by a special training, introspection or supervision. Basic communicative skills Verbal communication Verbal communication is not just about the meaning of words, important are also other characteristics of voice such as speed, tone, sound, intonation, breaks in speech... . Different situations need to adjust our speech, powerful factor is silence. There are situations when silence can express understanding, respect, helplessness, sometimes also lack of words to react. Tone of voice express emotions. Communication with patient should respect his individuality and intelligence, ability to understand content and words we use (will be different in case of surgeon and tiler), how many details he needs to know. Message should be clear, brief and in appropriate time. Non- verbal communication Non- verbal communication includes all we manifest without speaking and also during speech excluding speech itself. Body speech is more sincere than verbal expression, is more instinctive and less controllable. Non- verbal communication is in the health care very important, the contact is near both emotionally and physically. Facial expressions- important especially in emotional expression. There are three mimic zones in the face- forehead and eyebrow, eyes and lower part- cheek, nose and mouth. Distance- proxemity and body zones Space around us is like a bubble, with different zones in size according to the situation and type of communication. There are individual and cultural differences. We should respect personal space and

zones, inform the patient what he can expect when we do any intervention that breaks his personal zone. Intimate zone, up to 30 centimeters. Zone for very close people such as parents and the child, lovers, husbands, close family members. Communication based in comparison with other zones on touch, smell. If someone strange breaks this zone we feel uncomfortable (e.g. elevator). Personal zone, up to 1,2 m. Communication, when we can reach someone physically, we can observe his mimic, smell. Social zone, up to 3 meters. We can see whole figure (group discussion, business contact) Public zone, more than 3 meters. We can see spacial movement (lecturer, actor)
Non-verbal communication includes facial expressions, eye contact, tone of voice, body posture and motions, and positioning within groups. It may also include the way we wear our clothes or the silence we keep. In person-to-person communications our messages are sent on two levels simultaneously. If the nonverbal cues and the spoken message are incongruous, the flow of communication is hindered. Right or wrong, the receiver of the communication tends to base the intentions of the sender on the non- verbal cues he receives.

Categories and Features

G. W. Porter divides non-verbal communication into four broad categories: Physical. This is the personal type of communication. It includes facial expressions, tone of voice, sense of touch, sense of smell, and body motions. Aesthetic. This is the type of communication that takes place through creative expressions: playing instrumental music, dancing, painting and sculpturing. Signs. This is the mechanical type of communication, which includes the use of signal flags, the 21-gun salute, horns, and sirens. Symbolic. This is the type of communication that makes use of religious, status, or ego-building symbols. Our concern here will be with what Porter has called the physical method of non-verbal communication. Knowledge of non-verbal communication is important managers who serve as leaders of organizational "teams," for at least two reasons: To function effectively as a team leader the manager must interact with the other members successfully. Non-verbal cues, when interpreted correctly, provide him with one means to do so.

The team members project attitudes and feelings through non-verbal communication. Some personal needs such as approval, growth, achievement, and recognition may be met in effective teams. The extent to which these needs are met is closely related to how perceptive the team leader and team members are to non-verbal communication in themselves and in others on the team.

If the team members show a true awareness to non-verbal cues, the organization will have a better chance to succeed, for it will be an open, honest, and confronting unit. Argyle and his associates have been studying the features of nonverbal communication that provide information to managers and their team members. The following summarizes their findings:

Static Features
Distance. Distance. The distance one stands from another frequently conveys a non-verbal message. In some cultures it is a sign of attraction, while in others it may reflect status or the intensity of the exchange. Orientation. People may present themselves in various ways: face-to-face, side-to-side, or even back-to-back. For example, cooperating people are likely to sit side-by-side while competitors frequently face one another. Posture. Obviously one can be lying down, seated, or standing. These are not the elements of posture that convey messages. Are we slouched or erect ? Are our legs crossed or our arms folded ? Such postures convey a degree of formality and the degree of relaxation in the communication exchange. Physical Contact. Shaking hands, touching, holding, embracing, pushing, or patting on the back all convey messages. They reflect an element of intimacy or a feeling of (or lack of) attraction. Dynamic Features Facial Expressions. Facial Expressions. A smile, frown, raised eyebrow, yawn, and sneer all convey information. Facial expressions continually change during interaction and are monitored constantly by the recipient. There is evidence that the meaning of these expressions may be similar across cultures. Gestures. One of the most frequently observed, but least understood, cues is a hand movement. Most people use hand movements regularly when talking. While some gestures (e.g., a clenched fist) have universal meanings, most of the others are individually learned and idiosyncratic. Looking. A major feature of social communication is eye contact. It can convey emotion, signal when to talk or finish, or aversion. The frequency of contact may suggest either interest or boredom. The above list shows that both static features and dynamic features transmit important information from the sender to the receiver.

Tortoriello, Blott, and DeWine have defined non-verbal communication as: ". . . the exchange of messages primarily through non-linguistic means, including: kinesics (body language), facial expressions and eye contact, tactile communication, space and territory, environment, paralanguage (vocal but non-linguistic cues), and the use of silence and time." Let's review these non-linguistic ways of exchanging messages in more detail. Kinesics Lamb believes the best way to access an executive's managerial potential is not to listen to what he has to say, but to observe what he does when he is saying it. He calls this new behavioral science "movement analysis." Some of the movements and gestures he has analyzed follow: Forward and Backward Movements. If you extend a hand straight forward during an interview or tend to lean forward, Lamb considers you to be an "operator"- good for an organization requiring an infusion of energy or dramatic change of course. Vertical Movements. If you tend to draw yourself up to your tallest during the handshake, Lamb considers you to be a "presenter." You are a master at selling yourself or the organization in which you are employed. Side-to-Side Movements. If you take a lot of space while talking by moving your arms about, you are a good informer and good listener. You are best suited for an organization seeking a better sense of direction. Lamb believes there is a relationship between positioning of the body and movements of the limbs and facial expressions. He has observed harmony between the two. On the other hand, if certain gestures are rehearsed, such as those made to impress others, there is a tendency to separate the posture and the movements. The harmony disappears. Studies by Lamb also indicate that communication comes about through our degree of body flexibility. If you begin a movement with considerable force and then decelerate, you are considered a "gentle-touch." By contrast, if you are a "pressurizer," you are firm from beginning to end. The accuracy of Lamb's analyses is not fully known. However, it is important that corporation executives are becoming so sensitive to the importance of non-verbal messages that they are hiring consultants, such as Lamb, to analyze non-verbal communications in their organizations. Facial Expressions Facial expressions usually communicate emotions. The expressions tell the attitudes of the communicator. Researchers have discovered that certain facial areas reveal our emotional state better than others. For example, the eyes tend to reveal happiness or sadness, and even surprise. The lower face also can reveal happiness or surprise; the smile, for example, can communicate friendliness and cooperation. The lower face, brows, and forehead can also reveal anger. Mehrabian believes verbal cues provide 7 percent of the meaning of the message; vocal cues, 38 percent; and facial expressions, 55 percent. This means that, as the receiver of a message, you can rely heavily on the facial expressions of the sender because his expressions are a better indicator of the meaning behind the message than his words. Eye Contact

Eye contact is a direct and powerful form of non-verbal communication. The superior in the organization generally maintains eye contact longer than the subordinate. The direct stare of the sender of the message conveys candor and openness. It elicits a feeling of trust. Downward glances are generally associated with modesty. Eyes rolled upward are associated with fatigue. Tactile Communication Communication through touch is obviously non-verbal. Used properly it can create a more direct message than dozens of words; used improperly it can build barriers and cause mistrust. You can easily invade someone's space through this type of communication. If it is used reciprocally, it indicates solidarity; if not used reciprocally, it tends to indicate differences in status. Touch not only facilitates the sending of the message, but the emotional impact of the message as well. Personal Space Personal space is your "bubble" - the space you place between yourself and others. This invisible boundary becomes apparent only when someone bumps or tries to enter your bubble. How you identify your personal space and use the environment in which you find yourself influences your ability to send or receive messages. How close do you stand to the one with whom you are communicating ? Where do you sit in the room ? How do you position yourself with respect to others at a meeting ? All of these things affect your level of comfort, and the level of comfort of those receiving your message. Goldhaber says there are three basic principles that summarize the use of personal space in an organization: The higher your position (status) in the organization, (a) the more and better space you will have, (b) the better protected your territory will be, and (c) the easier it will be to invade the territory of lower-status personnel. The impact of use of space on the communication process is related directly to the environment in which the space is maintained. Environment How do you arrange the objects in your environment - the desks, chairs, tables, and bookcases? The design of your office, according to researchers, can greatly affect the communications within it. Some managers divide their offices into personal and impersonal areas. This can improve the communication process if the areas are used for the purposes intended. Your pecking-order in the organization is frequently determined by such things as the size of your desk, square feet in your office, number of windows in the office, quality of the carpet, and type of paintings (originals or copies) on the wall. It is obvious that your personal space and environment affect the level of your comfort and your status and facilitate or hinder the communication process. Paralanguage

Is the content of your message contradicted by the attitude with which you are communicating it? Researchers have found that the tone, pitch, quality of voice, and rate of speaking convey emotions that can be accurately judged regardless of the content of the message. The important thing to gain from this is that the voice is important, not just as the conveyor of the message, but as a complement to the message. As a communicator you should be sensitive to the influence of tone, pitch, and quality of your voice on the interpretation of your message by the receiver. Silence and Time Silence can be a positive or negative influence in the communications process. It can provide a link between messages or sever relationships. It can create tension and uneasiness or create a peaceful situation. Silence can also be judgmental by indicating favor or disfavor - agreement or disagreement. For example, suppose a manager finds a couple of his staff members resting. If he believes these staff members are basically lazy, the idleness conveys to him that they are "goofing off" and should be given additional assignments. If he believes these staff members are self-motivated and good workers, the idleness conveys to him that they are taking a well-deserved "break." If he is personally insecure, the idleness conveys to him that they are threatening his authority. Time can be an indicator of status. How long will you give the staff member who wishes to speak to you ? How long will you make him wait to see you ? Do you maintain a schedule? Is your schedule such that your subordinates must arrange their schedules to suit yours ? In a healthy organization, the manager and his subordinates use time to communicate their mutual respect to each other.

2. Suggestion and placebo effect, burn-out syndrome Suggestion Irrational influencing of mind, used for example during hypnosis or as a part of persuasion the subject. The ability to accept the stimulus is called suggestibility. The effect of suggestive influence depends on: (1) authority of the physician (the bigger, the more suggestive influence)

(2) suggestibility of the person (the ability to accept the stimulus). Some patients, for example, with pithiatic disposition (identic denomination of hysteric or histrionic) are more suggestible. (3) Former experience of the person with successful treatment, closely connected with confidence in advance (4) Acute subjective state of the personthe more he suffers, the more suggestible he is (5) On the regression of the person (when we regress, we loss critical thinking, children are more suggestible). Suggestive influence of the physician can be positive, but also negative as in the case of psychogenous iatropathogenesis. Burnout syndrome Specific emotional fatique typically with long lasting subdepressive mood, irritation, worse concentration on the client, doubts about the work sense and lack of empathy. Prevention of burnout syndrome is to know limits of what we can achiee, to have good personal background (family, friends, hobbies...) and also is important professional atmosphere with positive example of other colleagues with a possibility to consult difficult patients. Placebo The effect of treatment that is not attributable to the mechanics of the treatment itself, but rather to circumstances surrounding it. Placebo can intensify the effect of the drug or can cure by itself. A big role of the placebo effect is probably due to suggestibility, though this is not consistently related to it. Not all the patients respond to a placebo and a small proportion of patients can show reverse placebo effects. The effectiveness of placebo is influenced by the expectation of the patient, which is closely related with the explanation of the physician (rare, exceptional ,expensive drug...). When a new drug is tested it is necessary to compare it with a placebo intervention, lest any demonstrated effect is due to non-specific factors (fouble blind trial). This can be ethical problem because of treatment by non-effective placebo. We also rarely use a placebo for example when a patient insist on using redundant medicantion. This is also ethically controversial because of cheating the patient.

3) Human Development ALSO READ PGS 3-6 PAST NOTES Eriksons Stages of Psychosocial Development Like Piaget, Erik Erikson (1902-1994) maintained that children develop in a predetermined order. Instead of focusing on cognitive development, however, he was interested in how children socialize and how this affects their sense of self. Eriksons Theory of Psychosocial Development has eight distinct stage, each with two possible outcomes. According to the theory, successful completion of each stage results in a healthy personality and successful interactions with others. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time. Trust Versus Mistrust. From ages birth to one year, children begin to learn the ability to trust others based upon the consistency of their caregiver(s). If trust develops successfully, the child gains confidence and security in the world around him and is able to feel secure even when threatened. Unsuccessful completion of this stage can result in an inability to trust, and therefore an sense of fear about the inconsistent world. It may result in anxiety, heightened insecurities, and an over feeling of mistrust in the world around them. Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to assert their independence, by walking away from their mother, picking which toy to play with, and making choices about what they like to wear, to eat, etc. If children in this stage are encouraged and supported in their increased independence, they become more confident and secure in their own ability to survive in the world. If children are criticized, overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in their own abilities. Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves more frequently. They begin to plan activities, make up games, and initiate activities with others. If given this opportunity, children develop a sense of initiative, and feel secure in their ability to lead others and make decisions. Conversely, if this tendency is squelched, either through criticism or control, children develop a sense of guilt. They may feel like a nuisance to others and will therefore remain followers, lacking in self-initiative. Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of pride in their accomplishments. They initiate projects, see them through to completion, and feel good about what they have achieved. During this time, teachers play an increased role in the childs development.

If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his potential. Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood is most important. Children are becoming more independent, and begin to look at the future in terms of career, relationships, families, housing, etc. During this period, they explore possibilities and begin to form their own identity based upon the outcome of their explorations. This sense of who they are can be hindered, which results in a sense of confusion ("I dont know what I want to be when I grow up") about themselves and their role in the world. Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more intimately with others. We explore relationships leading toward longer term commitments with someone other than a family member. Successful completion can lead to comfortable relationships and a sense of commitment, safety, and care within a relationship. Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes depression. Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children, being productive at work, and becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant and feel unproductive. Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow down our productivity, and explore life as a retired person. It is during this time that we contemplate our accomplishments and are able to develop integrity if we see ourselves as leading a successful life. If we see our lives as unproductive, feel guilt about our pasts, or feel that we did not accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression and hopelessness

4 Consciousness sleep, dreaming, sleep disorders, nightmares, night terrors, somnambulism CONSCIOUSNESS: Consciousness, in psychology, a term commonly used to indicate a state of awareness of self and environment. In Freudian psychology, conscious behaviour largely includes cognitive processes of the ego, such as thinking, perception, and planning, as well as some aspects of the superego, such as moral conscience. Some psychologists deny the distinction between conscious and unconscious behaviour; others use the term consciousness to indicate all the activities of an individual that constitute the personality. In recent years, neuropsychologists have begun to investigate the links between consciousness and memory, as well as altered states of consciousness such as the dream state. SLEEP: A natural periodic state of rest for the mind and body, in which the eyes usually close and consciousness is completely or partially lost, so that there is a decrease in bodily movement and responsiveness to external stimuli. During sleep the brain in humans and other mammals undergoes a characteristic cycle of brain-wave activity that includes intervals of dreaming. Sleep is a resting state in which an individual becomes relatively quiescent and relatively unaware of the environment. During sleep, this is in part a period of rest and relaxation, most physiological functions such as body temperature, blood pressure, and rate of breathing and heartbeat decrease. However, sleep is also a time of repair and growth, and some tissues, e.g., epithelium, proliferate more rapidly during sleep. In humans, sleep occurs in cyclical patterns; in each cycle of 11/2 to 2 hr, the sleeper moves through four stages of sleep, from Stage 1 to Stage 4, and back again to Stage 1. In the first stage, lowfrequency, low-amplitude theta waves characterize brain activity. The stage usually lasts only several minutes, before the individual drifts into Stage 2 sleep, and the brain moves into low-frequency, highamplitude waves. Stage 3 signals an increase of low-frequency, high-amplitude delta waves, and at Stage 4 sleep these delta waves account for more than half of all brain wave activity. Rapid-eyemovement (REM) sleep occurs during Stage 1 sleep at the end of each cycle, and people woken up at this time usually report that they have been dreaming. Dream deprivation or sleep deprivation results in detrimental changes in personality, perceptual processes, and intellectual functioning. There is some evidence that emotional and environmental deprivation disrupts the sleep patterns of young children, which in turn inhibits the secretion of growth hormone, normally secreted maximally during sleep. The amount of sleep needed depends on both the individual and the environment: For instance, worrying, critical individuals tend to need both more sleep and more dream sleep than easygoing ones, and stress and worry during the day result in an increase in REM sleep. It has been hypothesized that while deeper stages of sleep are physically restorative, REM sleep is psychically restorative. REM sleep is also believed to integrate new information in the brain and to reactivate the sleeping brain without waking the sleeper. There is evidence that the hypothalamus and thalamus of the brain initiate sleep and that part of the midbrain acts as an arousal system. DREAMING:

A series of images, ideas, emotions, and sensations occurring involuntarily in the mind during certain stages of sleep. Dream is mental activity associated with the rapid-eye-movement (REM) period of sleep. It is commonly made up of a number of visual images, scenes or thoughts expressed in terms of seeing rather than in those of the other senses or in words. Electroencephalograph studies, measuring the electrical activity of the brain during REM sleep, have shown that young adults dream for 11/2 to 2 hours of every 8-hour period of sleep. Infants spend an average of 50% of their sleep in the REM phase (they are believed to dream more often than adults) a figure which decreases steadily with age. During dreams, blood pressure and heart rate increase, and breathing is quickened, but the body is otherwise immobile. Studies have shown that sleepers deprived of dream-sleep are likely to become irritable and lose coordination skills. Unusually frightening dreams are called nightmares, and daydreams are constructed fantasies that occur while the individual is awake. Studies have demonstrated the existence of lucid dreaming, where the individual is aware that he is dreaming and has a degree of control over his dream. Sigmund Freud, in his pioneering work The Interpretation of Dreams (1900, tr. 1913), was one of the first to emphasize dreams as keys to the unconscious. He distinguished the manifest content of dreams the dream as it is recalled by the individualfrom the latent content or the meaning of the dream, which Freud saw in terms of wish fulfillment. C. G. Jung held that dreams function to reveal the unconscious mind, anticipate future events, and give expression to neglected areas of the dreamer's personality. Another theory, which PET scan studies appear to support, suggests that dreams are a result of electrical energy that stimulates memories located in various regions of the brain. SLEEP DISORDERS: Nightmares: A dream arousing feelings of intense fear, horror, and distress. Nightmares are vivid and terrifying nocturnal episodes in which the dreamer is abruptly awakened from sleep. Typically, the dreamer wakes from REM sleep and is able to describe a detailed, associative, often bizarre dream plot. Usually, the dreamer has difficulty returning to sleep. Nightmares are also common. In a two-week prospective study of college students, 47 percent described having at least one nightmare. Results of a general population study of 1,049 persons with insomnia revealed that 18.3 percent had nightmares. In this study, nightmares were more common in women and were associated with increases in nocturnal awakenings, sleep onset insomnia, and daytime memory impairment and anxiety following poor nocturnal sleep. Studies of the general population reveal that 5 to 8 percent of the adult population report a current problem with nightmares. Nightmares affect 20 to 39 percent of children between five and 12 years of age. Contrary to popular belief, frequent nightmares in children do not suggest underlying psychopathology. Nightmares are often described by creative persons who demonstrate "thin boundaries" on psychological tests. Persons with thin boundaries are less likely than others to define the world around them in concrete terms.

They rarely define issues as being black and white, but instead see themselves and the world in shades of grey. Nightmares are also associated with the use of medication, primarily those medications that affect neurotransmitter levels of the central nervous system, such as antidepressants, narcotics or barbiturates. Intense, frightening dreams may occur during the withdrawal of drugs that cause REM sleep rebound, such as ethanol, barbiturates and benzodiazepines. Recurrent Nightmares: Nightmares that occur after the patient has experienced trauma or stress may lead to an interpersonal integration of the event. On the other hand, long-term persistence (the habitual pattern of recurrent nightmares not associated with recent trauma) can cause a decline in daytime functioning without apparent benefit. Behavioural approaches in the treatment of nightmares have been successful and can result in shortand long-term reduction of nightmare frequency in more than 70 percent of patients. Such therapy requires only a few group or individual sessions with a psychologist or in a sleep medicine center. (Source: http://www.aafp.org/afp/20000401/2037.html) Night Terrors: A state of intense fear and agitation, usually occurring in children, that causes the person to wake up screaming with fear and to remain distressed during a period of semi-consciousness. Night terrors are nocturnal episodes of extreme terror and panic that usually occur early in the sleep period. They are similar to other arousal disorders that occur during deep sleep, such as somnambulism (sleepwalking) and confusional arousals. Night terrors are associated with autonomic discharge, confusion and vocalizations, often a "blood-curdling" scream. Persons with night terrors are often difficult to arouse and have limited recall of their dream content. Night terrors can occur in association with the other arousal disorders that are associated with deep sleep. Night terrors are most common in children between four and 12 years of age and affect 1 to 4 percent of the population. Polysomnographic studies in these patients generally show increased arousals from deep sleep. Adults who have night terrors are more likely than children to have psychopathology, mainly substance abuse and affective disorders. As with other parasomnias that affect adults, night terrors are more likely to occur in association with other sleep pathology, such as periodic limb movements and obstructive sleep apnea. (Source: http://www.aafp.org/afp/20000401/2037.html) Treatment of Nightmares and Night Terrors in Children: Nightmares and night terrors in children are usually disturbing to parents and family members; therefore, proper diagnosis and education of family members are important components of management. It is essential to control the environment by removing dangerous objects and providing barriers to prevent escape from a safe sleeping environment. Reassurance and support are often the only therapy required because these disorders rarely, if ever, reflect underlying illness and usually

disappear with maturity. Pharmacologic intervention is not usually indicated; in fact, it should be discouraged because it may contribute to further sleep disruption. Behavioural methods for treatment of frequent nightmares are effective in older children. (Source: http://www.aafp.org/afp/20000401/2037.html) Somnambulism: The act of walking or performing another activity associated with wakefulness while asleep or in a sleep-like state. Also known as noctambulism and sleepwalking. Sleepwalking (also called noctambulism or somnambulism), under the larger category of Parasomnias, is a sleep disorder where the sufferer engages in activities that are normally associated with wakefulness while asleep or in a sleeplike state. Sleepwalking can affect people of any age. It generally occurs when an individual awakes suddenly from Slow Wave Sleep (SWS or sometimes referred to as "deep sleep"), causing the sleepwalking episode. In children and young adults, up to 25% of the night is spent in SWS. However this decreases as the person ages until none can be measured in the geriatric individual. For this reason, children and young adults (or anyone else with high amount of SWS), are more likely to be woken up. And for the same reasons, they are witnessed to have many more episodes than the older individuals. Statistics: o Somewhere between 1% and 17% of U.S. children sleepwalk, and juveniles are seen to be those more prone to the activity. o Some 18% of Americans are prone to the act, roughly 2 in 11 of the US population o One study showed that the highest prevalence of sleepwalking was 16.7% for children of 11 to 12 years of age. o Boys are seen to be more likely to sleepwalk than girls. Activities such as eating, dressing or even driving cars have also been recorded as taking place while the subjects are technically asleep. Contrary to popular belief, most cases of sleepwalking do not consist of walking around (without the conscious knowledge of the subject). Most cases of somnambulism occur when the person is woken up (something or someone disturbs their SWS), the person may sit up, look around and immediately go back to sleep. But these kinds of incidence are rarely noticed or reported unless recorded in a sleep clinic. Sleepwalkers engage in their activities with their eyes open so they can navigate their surroundings, not with their eyes closed and their arms outstretched as parodied in cartoons and Hollywood productions. The victims' eyes may have a glazed or empty appearance and if questioned, the subject will be slow to answer and will be unable to respond in an intelligible manner. While sleepwalking itself does not inherently pose a health concern, accidents may happen as the subject is performing actions without the control of conscious mind. If the walker commits a criminal offence while asleep, the defence of automatism may be available.

A common myth surrounding this disorder is that one should never wake sleepwalkers while they are engaged in the activity. In truth, there is no implicit danger in waking sleepwalkers, though the subjects may be disoriented or embarrassed when awakened. The danger lies not in the fact that something might happen to the sleepwalker, but to the individual doing the waking, as occasionally the sleepwalkers get aggressive when interrupted. Although the majority of the time, nothing happens, it is not unheard of for assaults or even homicide to occur (though the latter is extremely rare). However sleepwalkers are much more likely to endanger themselves than anyone else. When sleepwalkers are a danger to themselves or others, (for example, when climbing up or down steps or trying to use a potentially dangerous tool such as a stove or a knife), steering them away from the danger or even waking them is advisable. It has even been reported that people have fallen out of windows while sleepwalking and died as a result.

RELAXATION Autogenic training

Autogenic training is a relaxation technique developed by the German psychiatrist Johannes Heinrich Schultz and first published in 1932. The technique involves the daily practice of sessions that last around 15 minutes, usually in the morning, at lunch time, and in the evening. During each session, the practitioner will repeat a set of visualisations that induce a state of relaxation. Each session can be practiced in a position chosen amongst a set of recommended postures (for example, lying down, sitting meditation, sitting like a rag doll). The technique can be used to alleviate many stress-induced psychosomatic disorders. Schultz emphasized parallels to techniques in yoga and meditation. It is a method for influencing one's autonomic nervous system. There are many parallels to progressive relaxation. Example of an autogenic training session 1. 2. 3. 4. 5. 6. 7. 8. 9. Sit in the meditative posture and scan the body "my right arm is heavy" "my arms and legs are heavy and warm" (repeat 3 or more times) "my heartbeat is calm and regular" (repeat 3 times) "my solar plexus is warm" (repeat 3 times) "my forehead is cool" "my neck and shoulders are heavy" (repeat 3 times) "I am at peace" (repeat 3 times) Finish by cancelling

Many practitioners will choose not to cancel between the three iterations, in order to maintain deeper relaxation. Quite often, one will ease themselves into the "trance" by counting to ten, and exit by counting backwards from ten. This is another practice taken from progressive relaxation.

Effects of autogenic training

Autogenic Training restores the balance between the activity of the sympathetic (flight or fight) and the parasympathetic (rest and digest) branches of the autonomic nervous system. This has important health benefits, as the parasympathetic activity promotes digestion and bowel movements, lowers the blood pressure, slows the heart rate, and promotes the functions of the immune system.

Contraindications
Autogenic Training is contraindicated for people with heart conditions or psychotic disorders.

Progressive muscle relaxation

Progressive muscle relaxation (or PMR) is a technique for reducing anxiety by alternately tensing and relaxing the muscles. It was developed by American physician Edmund Jacobson in the early 1920s. Jacobson argued that since muscle tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscular tension. PMR entails a physical and mental component. The physical component involves the tensing and relaxing of muscle groups over the legs, abdomen, chest, arms and face. With the eyes closed and in a sequential pattern, a tension in a given muscle group is purposefully done for approximately 10 seconds and then released for 20 seconds before continuing with the next muscle group. The mental component focuses on the difference between the feelings of the tension and relaxation. Because the eyes are closed, one is forced to concentrate on the sensation of tension and relaxation. In patients with anxiety, the mind often wanders with thoughts such as "I don't know if this will work" or "Am I feeling it yet." If such is the case, the patient is told to simply focus on the feelings of the tensed muscle. Because of the feelings of warmth and heaviness are felt in the relaxed muscle after it is tensed, a mental relaxation is felt as a result. With practice, the patient learns how to effectively relax and deter anxiety when it becomes at an unhealthy level where an anxiety attack would otherwise occur. Jacobson trained his patients to voluntarily relax certain muscles in their body in order to reduce anxiety symptoms. He also found that the relaxation procedure is effective against ulcers, insomnia, and hypertension. There are many parallels with autogenic training, which was developed independently. Jacobson's Progressive Relaxation has remained popular with modern physical therapists.

Relaxation method
Progressive relaxation involves alternately tensing and relaxing the muscles. A person using PMR may start by sitting or lying down in a comfortable position. With the eyes closed, the muscles are tensed (10 seconds) and relaxed (20 seconds) sequentially through various parts of the body. The whole PMR session takes approximately 30 minutes. As this is a technique, practice with PMR does make perfect and will usually not work effectively as it should the first couple of times.

Patients with generalized anxiety disorder who first try PMR with anxiety may become frustrated, feel rushed, or feel an increase in anxiety for various reasons such as being afraid to "let your guard down." As with doing anything new, this is to be expected and simply practiced again once or twice a day.

5. Alternate states of consciousness, alexithymia Consciousness is a specific quality which enables experiencing. It is intentional, ie, it is the consciousness of its contents. Consciousness illuminates percepts, fancies, thoughts, emotions, etc. It creates a meaningful space in which mental units are stored. So, it plays an integrative role like the space which integrates the location of the objects. Lucidity is the brightness of consciousness. It is always only one centre with the maximal brightness that is in use; brightness weakens peripherally. The field of vision is the analogue. The centre is moving according to the attention. For eg, now I am thinking of my task tom, now of the fly buzzing in the room, etc. The bright centre of consciousness cannot be divided. Self-awareness, idiognosis Consciousness is always mine, it is part of I. It cannot be anybody elses but mine. You have your consciousness. I immediately know (not using reasoning but an inner sight, intuition) that my idea is mine, but that a chair is not part of I. So, idiognosis determines the boundaries of consciousness and the boundaries of I. Self-reflection represents the ability to focus ones own sight on ones own consciousness introspection. I know that I know. Self-reflection enables infinite regression I know that I know that I know It is the precondition for freedom: owing to self=reflection, a man carried out self-assessment and confronts himself with above-personal values. Some contents are not actually conscious, however, they can be called to mind anytime. For instance, I can think of a giraffe anytime I want. The set of contents available anytime is called preconsciousness. Experience shows that it is not possible to order consciousness to call up some contents which are not in it: personality resists their realization. For instance, a moral man does not allow himself to hate his father.

A set of mental contents outside consciousness and the realization of which is prevented by aversion is called unconsciousness. This set includes such contents which if brought to consciousness would hurt, reduce self-consciousness or threaten. For eg, an awful motive is replaced by a nice one in the consciousness. Unconscious contents enter consciousness in substitute forms, symbolically coded and deformed.

Conscious life (and its interaction with pre-consciousness and unconsciousness) depends on intact brain activity. Hypnosis represents a special form of consciousness. Consciousness narrows during concentrated attention, for instance a passionate reader is in contact with his book to such an extent that he does not see or hear. The book fascinates him. If the narrow consciousness escalates, hypnosis emerges. It is a tube contact with the world: the intimate relationship of the hypnotized individual with the object hypnotizing him is called rapport. If the object is a person, he can deliver a hypnotized human being suggestions which are accepted in this state of high suggestibility in hypnosis.

Extasis is a state of consciousness when a man experiences intensive lucidity, escalation of self-reflection; the boundaries of I disappear, a person experiences himself as being fused with the universe, dissolving in being, etc. There are some people who consider extasis the escalation of consciousness possibilities. It can initiate creativity.

Alexithymia - A condition where a person is unable to describe emotion in words. Frequently, alexithymic individuals are unaware of what their feelings are. It is a disturbance in affective and cognitive function that overlaps diagnostic entities but is common in psychosomatic disorders, addictive disorders, and post traumatic stress disorder. The chief manifestations are difficulty in describing or recognizing ones own emotions, a limited fantasy life and general constriction in the affective life.

Relation patient-physician, their communication Physicians behavior is influenced by expectations due to this role and also by individual experience and image of this role. The role changes in time. Today the physician is considered to be more a specialist. In previous times it indluced more moral aspects and had neaerly a magic power. The relation patient-physician is always asymetrical, the physician is dominant and has responsibility for the patient. This factor is also changing in time. The trad is to make this relation more equal, to enable a patient take part in his treatment and give him more reaponsibility. The dominance of the physician is modified by his personality-dominant therapists see themselves as a leading figure of the therapeutic agreement. Submissive ones can be insecure and can pass some decisions on the patient or colleges. There is no direct relation bewteen insecurity and submissiveness. Some physicians can be insecure and can behave dominantly as a form of their defence mechanism. Dominance and submissiveness are similar terms as directive and non-directive approach. Directive therapists give the patients commands and prohibitions. Nondirective ones leave more initiative on the patient, and they offer more patient advices and information. An important factor in communication is a congruence bewteen verbal and nonverbal expression of the therapeutist. Inconsonance between communicated (verbal) and metacommunicated (other signals which differ from the content of the communication) is called double bond and can make confusion and distrust of the patient. The role of the patient brings changes in patients status. The patient expects apolog for his duties and emotional support. This can be advantages leading for example to chronicity fo the illness or to invalid pension. We call this secondary advantages. Tercial advantages we can see in case of relatives of the patient, for example a mother extend childrens inability to avoid her job. It is expected that a patient wants to recover and will cooperate with the physician. Very often a patient doesnt cooperate, espcially in cases when a patient doesnt feel to be ill or disabled (hypertension). The physician expects that the patient is truthfull and will comply with all needed examinations and acts.

The relation is influenced by both physician and patient personality. The patient transfers his pervious attitudes and evaluations to the therapeutic relationship. The sum of such attitudial repeats is called transference.

The sum of irrational evaluations mediated by personality mechanisms which deform the therapists approach to the patient is called contratrasference. It is desirable that the physician knows himself, his basic manners, social reactions and expectations. This characteristics are probably created during childrhood and can be also present in physician-patient relation. Processes fo transference and contra-transference can complicated the relation.

7) Compliance, Balints groups, Iatropathogenesis ALSO READ Pgs 10,11,12,29 IN PASTUCHAS NOTES Compliance: The degree to which a patient follows a treatment regimen. In studies of patient behavior, only about half of patients who leave a physician's office with a prescription take the drug as directed. The most common reason given for noncompliance is forgetfulness, which may be more appropriately described as denial of illness; having to take a drug is a constant reminder of illness. Children are less likely than adults to follow a treatment plan. In a study of children with streptococcal infections for which a 10-day course of penicillin was prescribed, 56% stopped taking the drug by the 3rd day, 71% by the 6th day, and 82% by the 9th day. Compliance is worse with chronic diseases requiring complex, long-term treatment (eg, juvenile diabetes, asthma). Parents may not clearly understand prescription instructions and, according to studies, forget about half the information given by the physician 15 min later Older persons may take several drugs; the regimen may be complex and hard to remember and to follow, thereby increasing the likelihood of an adverse drug interaction Results of Noncompliance Even the best treatment plan fails without patient compliance. The most obvious result of noncompliance is that the disorder may not be relieved or cured. According to an estimate from the Office of the U.S. Inspector General, noncompliance results in 125,000 deaths from cardiovascular disease each year. If patients took their drugs as directed, up to 23% of nursing home admissions, 10% of hospital admissions, many physician visits, many diagnostic tests, and many unnecessary treatments could be avoided. Noncompliance can worsen the quality of life as well as add to the cost of medical care. For example, missed doses of a glaucoma drug can lead to optic nerve damage and blindness; missed doses of a cardiac drug can lead to arrhythmia and cardiac arrest; missed doses of an antihypertensive can lead to stroke; and failure to take prescribed doses of an antibiotic can cause an infection to flare up again and can lead to the emergence of drug-resistant bacteria. Ways to Improve Compliance Patients are more like to comply if they have a good relationship with their physician, in which they are included in the decision making and the physician shows concern that they comply. Clear prescription instructions and explanations of why the treatment is necessary and what to expect (eg, delayed benefits, general adverse effects) also help ensure compliance. Trust in the physician is crucial. Encouraging patients to ask questions and express their concerns can help them come to terms with the severity of their illness and intelligently weigh the advantages and disadvantages of a treatment regimen. Discussing the unconscious mechanism of denial of illness and how it leads to "forgetting" or otherwise not taking the drug as directed can help patients avoid that pitfall. They should be urged to report any unwanted or unexpected effects to their physician before

adjusting or stopping the treatment on their own. Patients often have good reasons for not following a regimen, and their physician can make an appropriate adjustment after a frank discussion of the problem. Pharmacists and nurses may detect and help solve compliance problems. For example, the pharmacist may note that the patient does not obtain refills or that a prescription is illogical or incorrect. In reviewing prescription directions with the patient, a pharmacist or nurse may uncover a patient's misunderstandings or fears and alleviate them. Communication among all health care practitioners providing care for a patient is important. Support groups for patients with certain disorders can often reinforce treatment plans and provide suggestions for coping with problems.

Balints Groups: The aim was to help the doctors with the psychological aspect of their patients' problems - and their problems with their patients. The focus of the work was on the doctor-patient relationship: what it meant, how it could be used helpfully, why it so often broke down with doctor and patient failing to understand each other. The doctors were invited to present cases from their practices and these would be discussed by the seminar members under the guidance of one or two leaders, who were psychoanalysts. In this way the doctors were able to benefit from the analysts' way of looking at the material although they did not often make analytical interpretations. In the early years the doctors were encouraged to hold "long interviews" before presenting a patient and saw themselves as a offering a kind of formal psychotherapy to certain patients over a limited period. Later on, the Balints became more interested in what went on between doctor and patient in ordinary brief consultations, sometimes over a period of years. The long interview was now described as "a foreign body" in general practice. The emphasis had shifted to understanding the ordinary discourse of general practice rather than trying to turn GPs into psychotherapists for selected patients. Unlike a case discussion group, the Balint group concentrates only on the presented patient and his/her doctor. Furthermore the group does not aim to tell the doctor how to treat or refer the patient; only to look at what has been going on between doctor and patient in the hope of understanding what they mean to each other and what they are doing to each other. In the Balint group members listen to the presenting doctor's story and then discuss the case, trying to concentrate on the doctor patient relationship. In particular they try to be aware of the feelings aroused in them by the patient. This may provide important evidence about the patients own feelings as transmitted by the presenting doctor. There is a tendency, in the group, for the presenting doctor to behave like the patient and for the group to behave like the doctor. The situation in the consulting room is thus dramatically reproduced in the group. This is sometimes called "the parallel process'. Unlike a support group, the Balint group does not consider the doctors' personal difficulties in relation to colleagues, family or personal psychological history. These matters may be touched on but are not usually pursued in depth. As a result of working in a group over a period of time the doctors will ideally learn something useful about themselves and may even undergo what Michael Balint described as "a limited but significant change in personality". But these insights are gained through discussion of the relationships with patients rather than material from the doctor's private life.

8 Indirective empathic conversation, empathy and authenticity Indirective Empathic Conversation: We try to create a friendly and safe atmosphere for the patient; the initiative is more on the patient. We express that we; Understand him/her, That we have a liking for him/her, We accept what he/she says, Display interest and Be Empathetic towards the patient.

This approach is indirective - it means that you proceed from the patients subjectivity and do not use any form of manipulation. You should not emphasize Your authority, Do not give direct advice(s) (only very exceptionally you can give the patient advice). This type of conversation is based on the conviction that the patient is able to solve his/her problems by their own potential and the task of the physician is to create optimum conditions for that. The physician is more than a leader, a company and a support. Empathy: The origin of the word empathy dates back to the 1880s, when German psychologist Theodore Lipps coined the term "einfuhlung" (literally, "in-feeling") to describe the emotional appreciation of another's feelings. Empathy has further been described as the process of understanding a person's subjective experience by vicariously sharing that experience while maintaining an observant stance. Empathy is a balanced curiosity leading to a deeper understanding of another human being; stated another way, empathy is the capacity to understand another person's experience from within that person's frame of reference. Even more simply stated, empathy is the ability to "put oneself in another's shoes". In an essay entitled "Some Thoughts on Empathy," Columbia University psychiatrist Alberta Szalita stated, "I view empathy as one of the important mechanisms through which we bridge the gap between experience and thought." Empathy is a powerful communication skill that is often misunderstood and underused. Initially, empathy was referred to as "bedside manner"; now, however, authors and educators consider empathetic communication a teachable, learnable skill that has tangible benefits for both clinician and patient: Effective empathetic communication enhances the therapeutic effectiveness of the clinician-

patient relationship. Appropriate use of empathy as a communication tool facilitates the clinical interview, increases the efficiency of gathering information, and honours the patient. Practical Empathetic Communication: Making practical use of an otherwise esoteric concept such as empathy requires division of the concept into its simplest elements. As outlined by Frederic Platt, key steps to effective empathy include: Recognizing presence of strong feeling in the clinical setting (i.e., fear, anger, grief, disappointment); Pausing to imagine how the patient might be feeling; stating our perception of the patient's feeling (i.e., "I can imagine that must be ..." or "It sounds like you're upset about ..."); Legitimizing that feeling; Respecting the patient's effort to cope with the predicament; and Offering support and partnership (i.e., "I'm committed to work with you to ..." or "Let's see what we can do together to ..."). Being a psychiatrist or mental health expert is not necessary for using empathetic communication; the only requirement is an awareness of opportunities for empathy as they arise during the interview with a patient. This type of opportunity arises from a patient's emotion (either directly expressed or implied): This emotion creates the opportunity for an empathetic response by the physician. In a study by Wendy Levinson et al, 116 office visits to primary care and surgical physicians were audio-taped and transcribed to look at the frequency of empathy opportunities or "clues." More than half of visits in each setting included one or more clues. In more than half of cases, patients presented these clues not overtly but in more subtle ways. Unfortunately, physicians responded to those clues in only 38% of surgical cases and in only 21% of primary care cases and frequently missed opportunities to adequately acknowledge a patient's feelings. Clues are often hidden in the fabric of discussion about medical problems and thus may be easily missed by physicians who are busy attending to biomedical details of diagnosis and management. In fact, when opportunities for empathy are missed by physicians, patients tend to offer them again, sometimes repeatedly. This phenomenon can lead to longer, more frustrating interviews, return visits, and "doctor shopping" by patients who feel dismissed or alienated. After an opportunity for empathy has been presented, the clinician should consider offering a gesture or statement of empathy. Statements that facilitate empathy have been categorized as queries, clarifications, and responses. Examples of each are as follows: o Queries "Can you tell me more about that?" "What has this been like for you?" "How has all of this made you feel?" o Clarifications "Let me see if I've gotten this right ..." "Tell me more about ..." "I want to make sure I understand what you've said ..."

o Responses "Sounds like you are ..." "I imagine that must be ..." "I can understand that must make you feel ..." Conclusion: Empathy is a powerful, efficient communication tool when used appropriately during a medical interview. Empathy extends understanding of the patient beyond the history and symptoms to include values, ideas, and feelings. Benefits of improved empathetic communication are tangible for both physician and patient. (Source: The Permanente Journal, vol.7, No.4, 2003) Authenticity: Magic occurs for both the practitioner and the patient when professionals approach their interactions with patients from passion and commitment. Meeting people passionate about their profession, who enjoy serving people, is always an uplifting experience. Letting people sincerely know this is what you love to do can turn an individual's distrust into admiration. Authenticity has been called one of the most effective leadership tools, because in an age of cynicism and distrust, it is one of the few things that inspire people to action. What we say doesn't count for much if people don't believe us. The absence of authenticity affects all our relationships and prevents the very connectedness that we all yearn for as human beings. Practitioners want patients to appreciate their training, knowledge, and expertise. Steer clear of appearing arrogant or overconfident, which will distance you from your patient. Do this by using words the patient understands and by presenting options and educating the patient in an unhurried manner. Honour each patient's questions; they provide a critical opportunity for gaining compliance.

9. Anger and aggression, Approach to an aggressive patient Aggression describes a hostile attitude or behaviour. Aggression is a relatively stable personality disposition. It maybe genetic. There are 2 forms of aggression: 1. Intrapunitive against the patient himself 2. Extrapunitive against the environment Aggression may be either: 1. Verbal raising of ones voice, screaming, arguing, threatening 2. Destructive behaviour (Physical) hitting the walls, destroying equipment, hitting someone. The risk factors predisposing to aggressive behaviour are: 1. alcohol 2. drugs 3. being male 4. having been aggressive in the past. Aggressive behaviour can be manifested by: feelings of threat and fear feelings of being treated unfairly in subjectively important events disappointment in his expectations or effort that leads to frustration which leads to aggression stress and exhaustion feelings of humility and of being offended Helplessness Feelings of being guilty and attempting to find someone responsible for the situation (often in the case of relatives) strong pain

The most common causes of aggressive behaviour in psychiatry: 1. Acute mania - outwardly the person can be quite pleasant and jovial, but when he is angered, he can become aggressive.

2. Schizophrenia especially the paranoid variety 3. Organic brain syndromes (eg encephalitis, hypoglycemia, head injury, drug withdrawal, dementia, delirium, mental retardation, atherosclerosis in older people, hypoxemia) The hallmark is disorientation, fluctuating level of consciousness, abnormal vital signs 4. Drug and alcohol abuse (eg of amphetamines, pervitine) 5. Personality or behavioural disorders ppl with antisocial or borderline personality disorders can be noisy and aggressive. Inappropriate behaviour can be intensified by little respect and little conversation and also the hostile behaviour of other people. Patients with anti-social personality disorders: 1. display no conscience 2. believe that the rules of normal society do not apply to them 3. get what they want by lying, cheating, stealing, being aggressive 4. can be found in prison (a lot of them) but also are well-dressed ppl of the upper class. It is recommended to: 1. keep distance from the patient both physically (1.5m) and literally 2. never meet with the patient outside of the workplace or work-hours 3. set limits and borders; do not tolerate threats 4. not prescribe benzodiazepines or opiates to this type of patient; look for substitutions 5. never leave the patient in an ambulance alone 6. terminate the relationship if the patient does not obey the rules 7. always have another present in the case of a woman (so that she cant claim sexual harassment) 8. speak slowly; introduce yourself and ask why he is angry; behave kindly and politely 9. not behave aggressively as well. It would only amplify his behaviour. 10. acknowledge his excitement and tell him how it makes you feel. This personal reflection can diminish aggressive behaviour. 11. listen carefully and express that you accept his attitude. Accepting means that you accept him as he is but this does not mean that you agree.

12. take what the patient says seriously and do not value it; try to understand what the patient says or thinks. By questioning, try to orientate in the situation and at the same time express your personal interest. Allow the patient to vent a little. 13. summarise what the patient said and reflect upon it. It should be said what caused his agitation, what happened, what he wants to achieve etc. Most often, there is some reason for agitation but do not argue with him. 14. if it is possible, you should satisfy the patient. If it is possible explain peacefully your view and express understanding towards his disappointment. 15. give enough space for questions and enable the patient to take part in making decisions. 16. never stand directly in front of the patient; always stand a little to the side 17. not look him directly in the eye but rather focus on his chin 18. not sit if the patient is standing 19. not sit in a corner where there is no possibility to escape 20. search person beforehand for weapons 21. in the case of restraints, explain why it should be done and it should be done quickly without harm to the patient. If you decide to use them, do not negotiate this with the patient. Also proper documentation should be completed. Monitor the patient in restraints carefully. Aggressive behaviour on the side of the physician can be induced by: patients who do not comply aggressive patients patients who criticize, complain, slander

The physician may: raise his voice be inconsiderate during examination and treatment punish a patient by not using the indicated medication

10. Approach to difficult types of patients (anxious, antisocial) The patient wiht antisocial personality disorder has no conscience. He believes the rules of civilized society do not apply to him. He will get what he wants, when he wants, however he wants. He will get it by lying, stealing and cheating and in extreme cases even by killing from everyone including his physician. Many noc men are people with antisocial personality disorder but depending on the persons intelligence, social class and other skills, he may be charming, well-dressed and a good talker. These patients may present their problems as a litany of misfortuneseverything is someone elses fault. They are never to blame for anything that has befallen them. Dealing with patients with antisocial personality disorder (1) keep your distance, literally and figuratively (2) never meet with these patients outside regular office hours or in another location. (3) Set limits early in your realtionshop, do not tolerate threats. (4) Be extremely cautious when prescribing benzodiazepines or narcotics. There patients have a high risk of substance abuse. Also they may sell or redirect these drugs (5) Dont leave the patient alone in your office even for a second. (6) If the patient doesnt keep the rules, terminate the relationship. (7) If you are a male physician and examine the female patient have an attendant in the rom as they might blame you from sexual harrasment. Relaxation techniques aim to make patients less anxious and therefore cope better with their treatment. It could be said that relaxation is simply doing nothing. However, doing nothing, it seems, is not as easy as it sounds; the existence of a wealth of relaxation techniques is testimony to this. While relaxation is often used with reference to muscle relaxation, researchers agree that relaxation must have both a mental and physical dimension. Relaxation has been defined as 'a state of consciousness characterized by feelings of peace, and release from tension, anxiety and

fear' (Ryman, 1995). This includes psychological aspects of the experience, such as a pleasant sensation and absence of stressful or uncomfortable thoughts. There are a number of techniques that can be used to induce relaxation but there are common factors underlying them all. Relaxation techniques may be practiced on an individual basis or in groups or classes. The therapist must aim to create a comfortable, non-threatening and friendly environment. The subjects are then taken through a routine that induces ever- deeper relaxation. Physical actions may be undertaken, such as progressive muscle relaxation therapy (PMRT). In this technique the subjects are asked to become aware of the tension in every part of their body, to clench and tense muscles and then to 'let go' and relax them completely. PMRT has been shown to significantly decrease the duration and lower the frequency of nausea and vomiting in breast cancer patients (Molassiotis et al.2002). Alternatively the tensing part of the process may be omitted in passive muscular relaxation (PMR). This may be more appropriate for debilitated or weak patients as attention is focused on particular muscle groups. Another technique is visualization, where the patient may be asked to visualize a warm cloth wiping away all their tension, or to imagine a pleasant scene: a sunny meadow, a warm beach. The therapist then paints a mental picture and subjects are asked to examine the scene, visualize the colors, hear the sounds and feel the air on their skin. Once explored in such detail the scene can be recalled on subsequent occasions and used to help induce relaxation. A meta-analysis of randomised intervention-control studies aimed at improving patients' treatment-related symptoms and emotional adjustment by relaxation training found that relaxation was equally effective for patients undergoing a range of different medical procedures, including chemotherapy, radiotherapy, or bone marrow transplantation (Leubbert et al., 2001). Mean weighted effect sizes were calculated for 12 categories: Treatment-related symptoms (1) pain (2) nausea (3) blood pressure (4) pulse rate Emotional adjustment (1) anxiety (2) depression (3) hostility

(4) tension (5) fatigue (6) confusion (7) vigour (8) overall mood. Significant positive effects were found for the treatment-related symptoms. Relaxation training also had a significant effect on some emotional adjustment variables (depression, anxiety and hostility). In addition, two studies pointed to a significant effect of relaxation on the reduction of tension and amelioration of overall mood (Leubbert et al., 2001). The time that the healthcare professional spent with the patient overall and the scheduling of the intervention were relevant to the outcome; interventions offered independently of treatment proved to be significantly more effective in ameliorating anxiety.

12 Death & Dying Children between and up to 3 years do not discriminate between alive and death. From the ages between 3 to 6 children begin to discriminate between alive and death. They understand death to being as immobile and sleeping. Death is considered to be more reversible state. Children can meet with death in fairy tales, but they consider themselves to be immortal. Children between the ages of 6 and 10 years start to begin to understand that death is something final and inescapable. They understand that death is connected with stop of physiological functions. Even in the case of seriously ill children they do not have fear from death. We can explain that by absence of abstract thinking and also by perceiving parents as very powerful. During puberty is the fear from death connected with creating ones identity and individuality. The idea of death becomes characterised by universality, unrecurrence and finality. The adults connect death with feeling of nothing, not-being, unknown state. Except the idea of final ending, there are often ideas and thought about continuing existence in some different way. (e.g., Christians view in reincarnation and so on) Dying and death is a big stress for the physician, because he/she realises his own mortality and mortality of his close. Another factor is feeling of failing and helplessness. Some physicians perceive this situation as their own insufficiency and have guilty feelings. There are a few typical strategies in case of unconscious fear from death: Minimalising and avoiding contact with dying patients and their close family members. The physician communicates with them less than with other patients and relatives. This is a natural, spontaneous and defence reaction on the situation of dying, but it is not good for the patient. Other strategy is objectivizing/objectifying (not sure if is a word) the situation and behaving to the patient as he/she is a thing/object or not adult person.

 The third strategy is escape to hyperactivity. This means that the physician does many useless things and tries to keep the patient alive, although it is in vain. The basic strategy of how to cope with dying is free and open communication with other members of the team. The process of dying was described and divided into 5 phases by Elizabeth Kubler-Ross in the sixties, they are: 1. The phase of shock, rejection and negation of death. A man is panic-stricken, anxious and has a tendency to neglect this fact. 2. The phase of anger characterised by excitability, usually also by verbal aggressiveness and sometimes envy healthy people. 3. The phase of sedation and process of negotiation. A man accepts the unavoidable end, but tries to delay it as much as possible. He might look for new and miraculous methods and has a tendency to negotiate with death e.g., wish to live until some important event. 4. The phase of depression. The death is coming on. The person is afraid about loneliness, pain and about the destiny of his close. This is a phase of suffering. 5. The phase of conciliation and giving up. A person accepts death and is restful. In opposite case, is in despair or fights. These phases overlap, last different time and can be parallel and as well they do not have to occur. The process of dying is influenced by the approach of his relatives and other people including medical staff. Most of the people wish to de at home, if it is possible we should fulfil this. Basic Recommendations In The Care Of Dying: Close cooperation with relatives, permitting the relatives to visit a patient as often as it is needed. Non-directive approach even with physical contacts, e.g., taking his hand gives him support and feeling of closeness. Enable the patient to speak about everything he considers to be important. Accept his feelings including anxiety, anger, cry, etc. The feeling of having good life is important for a dying person. Respect his wishes. Sometimes they might want to stay alone; sometimes they wish to have close people around them. If a person wishes, enable visit of the priest or if you consider it to be desirable, offer it.

 If it is possible enable relatives to take part in nursery care so they can feel they did all they could Do not prescribe sedative drugs in case it is necessary you disable him to say good bye. Do not avoid communication about death in families, because it can help you to prepare on your death and process of dying.

13. Personality, temperament, character and self-concept Personality is an individual unique and relatively stable pattern of thoughts, feelings and behaviour. Temperament determines general characteristics of psychic dynamics, for eg, power and permanency of feelings, activity or passivity of the individual. Hippocrates proposed 4 major personality types. The psychologist Cloninger hypothesizes that temperament reflects the biological concept of personality. He discriminates 4 dimensions: 1. novelty-seeking 2. harm-avoidance 3. reward dependence 4. persistence 5. Character is a part of personality that develops during early psychosocial development. The character is a unique characteristic of each individual. It is influenced by the temperament but the main factor for character development is the community of other people, especially the family setting during the 1st 4 years of life. Self-concept is created by relation to I-myself perception, evaluation, what I feel and think about me. A part of self-concept is also the ideal of what I would like it to be. The difference between my perception and my ideal me is a source of personality development and growth. If the difference is too big, an individual can be unsatisfied with himself and have feelings of inferiority.

Self-concept develops in early childhood especially on the basis of adults evaluation and later, as well as on the evaluation of our contemporaries. We take over their opinions this process is called internalisation and the contents which we internalize are called introjects.

Self-concept is thus a reflection of what we think about how we are perceived by others.

The dispositional approach is characterized by describing the core characteristics of an individual and interest in how these characteristics differ from one person to the next. Type theories The history of categorization of personality into few types is older than 2 500 years ago when Hippocrates said that personality type was associated with the bodys 4 basic fluids blood, phlegm, yellow bile and black bile: 1. Sanguine type has an excess of blood and is warm, optimistic, hopeful, passionate. 2. Melancholic type has an excess of black bile and is sad, slow, and gloomy. 3. Phlegmatic type has an excess of phlegm and is calm, dull, and hard to rouse to action. 4. Choleric type has an excess of yellow bile and is unstable, explosive and excitable. Somatotype theory, created by William Sheldon, in which he proposed that body shape correlates with specific personality traits. Although that theory was proved to be inaccurate, some of his terms remain: Endomorphs (heavy), Mesomorphs (muscular) and Ectomorphs (thin). Trait theories Trait theorists believe that personality can be identified by unique characteristics that fall along a continuum. Psychological methods that come out from these theories try to find how people differ and measure by how much they differ. Allports trait theories He systemized personality traits into a hierarchy. He divided this hierarchy into 3 groups of traits 1. cardinal traits 1 or 2 fundamental characteristics which can be observed in only a few ppl 2. central traits a small number of traits that are highly characteristic of a given individual for eg, intelligence. 3. secondary traits these traits are less important for describing personality for eg, general interests such as football.

Cattells theory By using a mathematical technique called factor analysis, he identified 16 basic personality dimensions which he called source traits (intelligence, dominancy, imagination, conservativeness, self-sufficiency, sensitivity, emotional stability)

Eysencks theory He proposed that there are 3 personality dimensions: 1. introversion extroversion 2. stability instability 3. normality psychosis

Relatively stable traits are affected by situational pressures. Theories explaining differences in personality and how they came about: Psychoanalytic theories Learning theories human nature is neutral and personality depends on learning experiences and so symptoms can be treated by learning a more adaptive form of behaviour Humanistic theories concentrate on internal feelings and thoughts of the man, who is basically good and has a natural tendency toward self-actualisation. Self-actualisation is the inborn drive to develop all ones talents and capacities. Cognitive theories our personality depends primarily on the way about how we think about the world and interpret things that happen. Biological theories personality is determined by the genetic equipment. Interactionism based on integration of above mentioned theories.

These theories have a big practical issue because they determine treatment from their point of view.

14. Human sexuality Sexual drive is one of the basic instinctsthe base of sexual behavior is inborn. Some part of sexual behavior is modified by environment. It is not clear how much s the role of man and woman innate or culturally conditioned, but it is probably more determined biologically than we considered some time ago. Sexual norm is determined by culture. For example during the 19th century married women who actively enjoyed sexual interxourse were considered abnormal and impure and how society and culture influence perception of sexual behavior can be masturbation or homosexuality. Maleness and femaleness (1) Biological dimensions (a) Chromosomal gender or genetic sex (b) Gonadal and hormonal genderoveries and productin of estrogenstestes and production of androgens (c) Genital sexexternal sex organs (d) Internal accessory organsuterus, vagina, fallopian tubes X the prostate gland, seminal vesicles, vas deferens (2) Psychological and behavioral dimensions (a) Psychosexual identityself-definition and perception of oneself as being male or female (b) Gender rolemale X female behavior (c) Sexual orientationhomosexual, heterosexual, bisexual

(d) Sexual behavior Genital identity disorders (1) Transsexualismtranssexuals feel to be trapped in the body of the wrong gender, their gender identity doesnt match their gonads, genitals, or internal accessory organs. They wish to look like the gender they feel to be, so they may cross dress (which is also characteristic for transvestites, but the motivation is different), they wish to get rid of their genital and obtain opposite genital. (2) Transvestitism is an example of disorder in sexual preferencescross dressing is motivated by obtaining sexual arousal. (3) There were few theories trying to find out the cause of homosexuality, the strongest support is that homosexuals have inborn structural brain differences in the area of hypothalamus that causes homosexuality. Sexual behavior is a behavior which has two general aims. The subjective one is to achieve excitement which relates to the genital apparatus and it reaches its climax in the experience of orgasm. The objective one is the reproduction of the species. This behavior is not learned, an individual finds it in him/herself, so drive represents the base of it. Achieving orgastic bliss is the last aim of the drive. There are also aims which are nearer; their achieving is provided by isolated drives which serve the global sexual function. Curiosity drive is an innate need to saturate onself with sexual stimuli. Impressing is an innate need. Boys show off in front of the girls. Decorating is innate too. Assertion is an innate tendency. Its opposite pole, submissiveness, is represented by the tendency to yield to others. Both of these tendencies are manifested in sexual behavior. Drives for nursing others and being nursed represent a part of sexuality. It is manifested by giving a present to somebody and accepting a present. Usually the innate tendencies are polar, for instance, the need of exhibition and need of intimacy. Sexual excitement is achieved by charging as well as discharging. Therefore, sexual behavior is a complex structure of partial innate tendencies. Some tendencies are put in action using ways modified by culture. For instance, courtesy, f;irting can take place according to strictly given rules. Sometimes, these activities are evidently reformed, i.e. instinctive.

Sexual performance is initiated by internal incentives as well as by external stimuli. Therefore, sexual behavior is of an interactive nature. The interactions are strictly tuned, the participating persons, as the rule, do not reflect them consciously. The interaction, sometimes, is not successful if one member of the pair is not sensitive to the stimuli of the other one.

Drive partial tendencies can also represent a part of other than sexual behavior. For instance, a model dresses up in order to earn a lot of money. In this way, the sexual theme and dynamism become a part of completely different motivation structures. On the other hand, the motivation structure which differs from the sexual one becomes a part of sexuality. So sexuality becomes semiotically active in society: it indicates and gives new sense to various types of activity.

Sexuality development starts in childhood, probably at birth. It is manifested as looking for bliss which is not genital yet. Sexual dimorphism is formed, children distinguish between the male and female human world. They identify themselves with their bilogical sex group. They learn to play sexual roles.

Sexual maturity persumes: (1) Acceptance of the sexual role which is stable all the time (2) Genitalization of the sexual bliss, in spite of the fact that extragenital saturations are active too. (3) Ability to interact appropriately i the net of partial sexual performances in a partner relationship.

A partner relationship is determined culturally. Culture offers a great assortment of loves. Sexuality is domesticated in a family. It achieves tame forms. Sexuality is polymorphous and sexual drive is strong. Sexual themes, offers, needs adn frustrations are cumulated in fantasy. Their variety is so great that nobody can be comletely sexually satisfied. Some partial frustration is always exists. This is the reason for extrapartner sexuality. Some people have a lover along with the spouse. Masturbation can appear adn at present artifical satisfaction appears too. Extrapartner sexuality is under a sstrong control of morality, religiosity, etc.

The abandoment of sexuality (asceticism) can represent a great virtue. It can be a source of bliss. Falling for temptations can represent not only distress but also a special bliss. Using fantasy, sexuality can penetrte into every human activity and any activity can become sexually relevant.

The expirtion of sexuality in old age is a myth. Adequate sexual functioning necessitates a working genital apparatus. Sexual behavior changes in dependence on its disorders. The other partial ways of sexual satisfaction work hypercompensationally. For instance, an impotent man takes more intense care of his wife, he is extremely solicitous. On the other hand, he can become dominant and accentuates male force.

The final aim of sexual behavior, orgasm, represents a special psychophysiological state which runs a reformed somatic course as well as a reformed content of experience. It is a sort of derealization, extinction in bliss. The precondition of orgasm is yieldig to a situation, getting rid of reflectivity of consciousness.

Sexual norm is a problem. It is determined by culture. There were some cultures which considered masturbation abnormal and treated it. Other cultures tolerate a great variety of sexual acts. A person and a couple form their norms implicitly in sexual interaction. A mutual agreement is the precondition. In sexual fantasy of socially adequately functioning people there are many conventionally abnormal items assimilated in such a way that harmful sexual behavior is not manifested.

In sexuality of the century, the mass medial models have become important for sexual fantasy. Plenty of TV films and video recordings can offer oversaturating numberof stimuli for sexual fantasy. The assimilation of these models can represent a problem for the developing personality.

16 Post-traumatic Stress Disorder & Reaction, Crisis Intervention An anxiety disorder affecting individuals who have experienced profound emotional trauma, such as torture, rape, military combat, or a natural disaster, characterized by recurrent flashbacks of the traumatic event, nightmares, eating disorders, anxiety, fatigue, forgetfulness, and social withdrawal. Family members of victims also can develop the disorder. PTSD can occur in people of any age, including children and adolescents. More than twice as many women as men experience PTSD following exposure to trauma. Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur with PTSD. PTSD, as such, has been a part of organized psychiatry for only the past twenty years. The concept of PTSD, however, has been well known for over a hundred years under a variety of different names. Certainly, Freud thought that traumatic events in childhood had an effect on an individual's subsequent emotional development. Actually, however, it was his contemporary, Pierre Janet, who wrote most brilliantly and eloquently on traumatic stress. In fact, he was really the first person to describe the full syndrome (group of symptoms) of posttraumatic stress disorder. During World War I, PTSD was called shell shock, and during WW II, it was referred to as combat fatigue. After the Vietnam War, it was often mistakenly called the Post Vietnam Syndrome. Indeed, the understanding and effective treatment of PTSD were actually described in the psychiatric literature well before the Vietnam War. A psychiatrist from Harvard Medical School, Dr. Eric Lindemann at Massachusetts General Hospital in Boston, was the first to report on the systematic management of PTSD. He did this work after the Coconut Grove fire and tragedy in the 1940's.

Posttraumatic stress disorder is defined in terms of the trauma itself and the person's response to the trauma. Trauma occurs when a person has experienced, witnessed, or been confronted with a terrible event that is an actual occurrence. Alternatively, the person may have been threatened with a terrible event, perhaps injury (physical or psychological) or death to themselves or others. Then, the person's response to the event or to the threat involves intense fear, helplessness, and/or horror. It is important to note, however, that having strong reactions to trauma is normal. What's more, there is a range (spectrum) of expected reactions depending on a person's prior exposure to trauma and even on hereditary (genetic) factors. Most importantly, you should understand that there are efficient and effective treatments for PTSD. Reaction to PTSD: Research suggests that a relationship exists between exposure to traumatic events (such as war, crime, or natural disaster), experiencing the symptoms of post-traumatic stress disorder (PTSD), and problems with physical health. Health problems associated with PTSD may involve a variety of bodily systems, including the cardiovascular, neurological, and gastrointestinal systems. PTSD may promote poor health through a complex interaction between biological and psychological mechanisms. Study of these mechanisms is in progress at the National Center for PTSD and at other laboratories around the world. Current thinking is that the experience of trauma brings about neurochemical changes in the brain. These changes may have biological effects on health, such as: o o o o vulnerability to hypertension and atherosclerotic heart disease abnormalities in thyroid and other hormone functions increased susceptibility to infections and immunologic disorders problems with pain perception, pain tolerance, and chronic pain syndromes

Symptoms can include general restlessness, insomnia, aggressiveness, depression, dissociation, emotional detachment, or nightmares. A potential symptom is the memory loss about an aspect of the traumatic event. Amplification of other underlying psychological conditions may also occur. Young children suffering from PTSD will often enact aspects of the trauma through their play, and may often have nightmares that lack any recognizable content. One patho-psychological way of explaining PTSD is by viewing the condition as secondary to deficient emotional or cognitive processing of a trauma (Cordova 2001). This view also helps to explain the three symptom clusters of the disorder (Shalev 2001): Intrusion: Since the person cannot process difficult emotions in a normal way, he/she is plagued by recurrent nightmares, or daytime flashbacks, while he/she realistically reexperiences the trauma. These re-experiences are characterized by high anxiety levels, and make up one part of the PTSD symptom cluster triad called intrusive symptoms. Hyper-arousal: PTSD is also characterized by a state of nervousness with the organism being prepared for "fight or flight". The typical hyperactive startle reaction, characterized by "jumpiness" in connection with high sounds or fast motions, is typical for another part of the

PTSD cluster called hyper-arousal symptoms, and could also be secondary to an incomplete processing. Avoidance: The hyper-arousal and the intrusive symptoms are eventually so distressing that the individual strives to avoid contact with everything, and everyone, even to his/her own thoughts that can arouse memories of the trauma and thus cause the intrusive and hyper-arousal states to go on. He/She isolates him/herself, being detached in his/her feelings with a restricted range of emotional response, and can experience so-called emotional detachment ("numbing"). This avoidance behaviour is the third and most important part of the symptom triad that makes up the PTSD criteria. Diagnosis of PTSD: The diagnosis of PTSD requires that one or more symptoms from each of the following categories be present for at least a month and that symptom or symptoms must seriously interfere with leading a normal life: Reliving the event through upsetting thoughts, nightmares or flashbacks, or having very strong mental and physical reactions if something reminds the person of the event. Avoiding activities, thoughts, feelings or conversations that remind the person of the event; feeling numb to one's surroundings; or being unable to remember details of the event. Having a loss of interest in important activities, feeling all alone, being unable to have normal emotions or feeling that there is nothing to look forward to in the future may also be experienced. Feeling that one can never relax and must be on guard all the time to protect oneself, trouble sleeping, feeling irritable, overreacting when startled, angry outbursts or trouble concentrating. Crisis Intervention: In psychical crisis, an individual looks for help from his/her relatives, friends and acquaintances (laymans help) or he/she looks for help from professionals (Professional help). The main goal of crisis intervention is to prevent crisis coming to a head and possible suicidal action or a disorder of somatic health. Help given to an individual in crisis is focused on the release of emotional tension (abreaction), calming down, and moderation of guilt and shame feelings, searching for ways of solving the stressful life situation and for a way out of the crisis. It is necessary to start with intervention as soon as possible to prevent unfavourable impact of the crisis and its consequences for the individual and his/her environment. During the period of loss of psychological balance, especially during the second phase of the crisis, the individuals suggestibility is increased due to the weakening of mental defence mechanisms and thus making the individual most easily affectable. This finding is very important from the point of view of preventative orientation of crisis intervention. Professional help given to an individual in crisis must be:

o o o o

Quick Sufficiently extensive to cover the whole relevant social field (family, school, work place) General utilising variously combined methods of help (psychopharmacological help) Team an appropriate organisational structure of help is needed because several professionals, as a rule, participate in crisis intervention).

Psychological aids, especially psychotherapeutic interviews between the physician, psychologist or as the case may be, another specialist and an individual in crisis are very useful in coping with the state of psychical crisis. An individual psychotherapy used by the physician or psychologist is the most suitable aid. It is very important for the therapist to also interview the relatives of the individual in crisis because he/she will acquire additional knowledge about the personality of the afflicted individual, character of the life event leading to the crisis state, his/her behaviour in crisis and the development of the crisis state. The therapist will call the relatives attention to the importance of emotional support for coping with the crisis. If needed, he/she tries hard to adjust the relationships of the family and closest social environment to the individual or as the case may be, recommends exempting the individual from some duties in the family for some time. The interview between the therapist and the partner or another relative is fruitful if he/she is ready to cooperate in looking for a solution. If the psychical crisis is caused by a disharmonious relationship in family, for instance by the partners drug addiction or his/her sexual dysfunction, the therapist can advise a visit to a professional counselling center or professional out-patient physician. In the cases when the manifestations of the crisis state are very pronounced and the psychotherapeutic interview is sufficient for coping with them, the therapist will recommend an examination and observation of the patient by the local psychiatrist or his/her admittance to the psychiatry department (for instance, if the suicidal tendencies or the patients agitation are persistent). Professional help is given to individuals in crisis by: Phone contact with specialists (the so-called psychological hot-line) Personal contact (with counselling professionals, local and company physicians, local and company psychiatrists and other specialists at healthcare centers and hospital departments)

17. Fear and anxiety Fear is a feeling connected with some specific object or situation that evokes distress. It is a reaction to the dangerous situation that is known. Fear can be real (understandable to the others) or unreal (inadequate, unreasonable). Anxiety is an uncomfortable feeling and state and its cause is unknown. It is a reaction to some unknown danger. In reality, there is no strict differentiation between anxiety and fear because they influence each other and overlap. Physiological symptoms of anxiety are for eg rapid breathing, dry mouth, increased heart rate, sweating, increased muscle tension. The most frequent anxiety disorders in context of psychiatry disorders are generalized anxiety disorder, panic disorders, phobias obsessive-compulsive disorders and post-traumatic stress disorder. Generalized anxiety disorder is characterized by long-lasting anxiety that is not focused on any particular object or situation. The individual is not able to articulate the specific fear. In panic disorders anxiety is concentrated into specific episodes panic attacks. These attacks are usually characterized by heart palpitations, chest pain, nausea, trembling , shaking, breathing difficulties, dizziness, fears of going crazy, dying, feelings of losing control.

Specific phobias are mental disorders characterized by exaggerated fears of an object or situation. Agoraphobia involves a strong, irrational fear of open spaces but also from small or enclosed places (so called claustrophobia) such as elevators, public transport vehicles, shops and so on. Social phobia is a typical fear of being observed and negatively evaluated by others. Obsessive-compulsive disorder (OCD) is characterized by diffuse anxiety created by obsessive thoughts or compulsive behaviour. An obsession is a persistent preoccupation with an idea or feeling. A compulsion is an irresistible impulse to perform ritualistic behaviours, such as handwashing, counting or putting things in order. Patients feel driven to think about certain things or to carry out some action against their will. They recognize that the behaviour is irrational but cannot control it. When OCD sufferers resist performing compulsive behaviours, they experience a feeling of mounting tension that can only be relieved by yielding to the compulsion. OCD behaviour is extreme in comparison with common behaviour such as control of locked doors or checking the stove burners.

Post-traumatic stress disorder develops after a traumatic event. Typical symptoms after trauma are lasting fear, helplessness, recurrent flashbacks, nightmares, impaired concentration and emotional numbing.

18. Relaxation techniques, imagination, imaginative conditioning Classical conditioning is based on the stimulus which causes unvoluntary, reflex, automatic raction. These methods include: (1) Systematic desensitizationa gradual process of associating a hierarchy of fear-evoking stimuli with deep relaxation. It is based on the opposite actions of the sympathetic and parasympathetic branches of the autonomic nervous system (2) Aversion therapypairs an aversive stimulus with a maladaptive behavior, negative associations compete iwth the pleasurable ones (electric shock, apomorphine therapy of alcoholics) Relaxation techniques aim to make patients less anxious and therefore cope better with their treatment. It could be said that relaxation is simply doing nothing. However, doing nothing, it seems, is not as easy as it sounds; the existence of a wealth of relaxation techniques is testimony to this. While relaxation is often used with reference to muscle relaxation, researchers agree that relaxation must have both a mental and physical dimension. Relaxation has been defined as 'a state of consciousness characterized by feelings of peace, and release from tension, anxiety and fear' (Ryman, 1995). This includes psychological aspects of the experience, such as a pleasant

sensation and absence of stressful or uncomfortable thoughts. There are a number of techniques that can be used to induce relaxation but there are common factors underlying them all. Relaxation techniques may be practiced on an individual basis or in groups or classes. The therapist must aim to create a comfortable, non-threatening and friendly environment. The subjects are then taken through a routine that induces ever- deeper relaxation. Physical actions may be undertaken, such as progressive muscle relaxation therapy (PMRT). In this technique the subjects are asked to become aware of the tension in every part of their body, to clench and tense muscles and then to 'let go' and relax them completely. PMRT has been shown to significantly decrease the duration and lower the frequency of nausea and vomiting in breast cancer patients (Molassiotis et al.2002). Alternatively the tensing part of the process may be omitted in passive muscular relaxation (PMR). This may be more appropriate for debilitated or weak patients as attention is focused on particular muscle groups. Another technique is visualization, where the patient may be asked to visualize a warm cloth wiping away all their tension, or to imagine a pleasant scene: a sunny meadow, a warm beach. The therapist then paints a mental picture and subjects are asked to examine the scene, visualize the colors, hear the sounds and feel the air on their skin. Once explored in such detail the scene can be recalled on subsequent occasions and used to help induce relaxation. A meta-analysis of randomised intervention-control studies aimed at improving patients' treatment-related symptoms and emotional adjustment by relaxation training found that relaxation was equally effective for patients undergoing a range of different medical procedures, including chemotherapy, radiotherapy, or bone marrow transplantation (Leubbert et al., 2001). Mean weighted effect sizes were calculated for 12 categories: Treatment-related symptoms (5) pain (6) nausea (7) blood pressure (8) pulse rate Emotional adjustment (9) anxiety (10) depression (11) hostility (12) tension

(13) fatigue (14) confusion (15) vigour (16) overall mood. Significant positive effects were found for the treatment-related symptoms. Relaxation training also had a significant effect on some emotional adjustment variables (depression, anxiety and hostility). In addition, two studies pointed to a significant effect of relaxation on the reduction of tension and amelioration of overall mood (Leubbert et al., 2001). The time that the healthcare professional spent with the patient overall and the scheduling of the intervention were relevant to the outcome; interventions offered independently of treatment proved to be significantly more effective in ameliorating anxiety. Hypnosis is understood to be a psychological condition in which an individual may be induced to exhibit apparent changes in behavior and thought. Although some individuals experience an increase in suggestibility and subjective feelings of an 'altered state of consciousness', this is not true for everyone. In fact, supposed hypnotic indicators and subjective changes can be achieved without relaxation or a lengthy induction, a fact which increases the controversy around hypnosis. Intense debate surrounds the topic of hypnosis. Some scientists dispute its very existence, while many therapists insist upon its value. One potential source of controversy is the wide variety of theories of hypnosis which have traditionally been split into 'state' and 'non-state' camps. This controversy may be decreasing as the value of both perspectives is increasingly recognized. Modern brain-imaging techniques offer hope for an increased understanding of the nature of hypnosis. The applications of hypnosis vary widely. Currently, two distinct applications of hypnosis include its use in entertainment and health applications. The popular perception of the hypnotic experience is that of the entertainment version. The stage hypnotist uses a variety of methods to relax and focus the subjects eventually making it appear to the audience that the subject is asleep or, popularly termed, in trance. During the performance, the subjects seem to obey the commands of the hypnotist to engage in behaviors they might not normally choose to perform. On the other hand, hypnosis applications in the medical and health-related fields are often experienced very differently. Evidence supports the clinical use of hypnosis for pain control, for weight control, in the treatment of irritable bowel syndrome, and as an adjunct to cognitive

behavioral and other therapies. Hypnosis is not a therapy in-and-of-itself but is effectively used as an adjunct to other therapies; hence "hypnotherapy" is less preferable than the use of hypnosisrelated techniques as part of an integrated psychological package. With a little practice, most people can be hypnotized and can use self-hypnosis. Hypnosis allows us to experience thoughts, fantasies and images as almost real. The hypnotized person knows the experience is not real, however, because he/she doesn't act like it is real. Under hypnosis we may vividly imagine being at the beach but we don't take off our clothes and try to jump into the water. Yet, by experiencing a situation differently, e.g. seeing public speaking as a way of influencing minds, we may act and feel differently (more positive, less scared). The mental scenes can seem very real to us but we know it is all just in our head. It is the same experience as watching a film and feeling we are there, we really get "into it" and become afraid, inspired, sexually aroused, very sad and so on. This imagery is something we do, not something done to us. It used to be thought that the hypnotist gained power over the subject through "animal magnetism." Actually, there can be no hypnotic experience without the subject's agreement and participation. Thus, all hypnosis is in a sense self-hypnosis. Could anyone force you against your will to get deeply emotionally involved in a good book or movie? No. But you can do it by yourself...and feel wonderful. At first, you are likely to believe that an experienced hypnotist could perform impressive feats but you couldn't possibly do much. That is a reflection of the stories you have read and movies you have seen. Research has shown (Fromm, 1975) that some people reach deeper trance states in selfhypnosis than with a hypnotist. They have more vivid, richer imagery. Self-hypnosis costs nothing, is easy to produce, and allows the person to make changes in the procedures so that they work best for him/her. So, again, an old therapy technique may become even more effective in the hands of an informed self-helper (Fisher, 1991). Alman & Lambrou (1991) also provide a selfhypnosis induction method and specific self-instructions for several specific problems, like selfconfidence, pain relief, weight loss, phobia reduction, etc. It is not necessary to be hypnotized in order to have vivid imaginary experiences. Daydreams are vivid. The basic idea of hypnosis and mental imagery is this: if you want to do something, imagine yourself doing it over and over. This is also called goal rehearsal. The idea is father to the act. Books by Lazarus (1977) and Fanning (1988) are filled with examples of visualization (without hypnosis) serving many purposes.

By using hypnosis or mental imagery (without hypnosis) a person can sometimes produce impressive results. Perhaps the most astonishing is the control of pain. Many people (not everybody can) have had dental work, surgery, and babies without pain. One of the easiest experiences to have is relaxation which can counteract fears and stress. If your behavior or someone else's is hard to understand, the key is likely to be uncovering the thoughts and images occurring between perceiving the situation and responding. Example: One paraplegic sees only misery, another plans on going to graduate school. Developing new intervening images and selfsuggestions can change certain behaviors, such as studying and concentration, help control anger and sadness, build self-esteem, reduce bad habits, and so on.

Autogenic, which means "self-regulation or -generation," refers to the way in which your mind can influence your body to balance the self-regulative systems that control circulation, breathing, heart rate, and so on. Autogenic training allows you to control stress by training your autonomic nervous system to become relaxed. It is suggested that you learn progressive relaxation first. Autogenic training will then teach you to respond, in a passive manner, to verbal and visual cues that reduce tension. By focusing on relaxing phrases and images, the training conditions positive, relaxing responses, such as rhythmic breathing and heart rate and a warm, relaxed, heavy feeling throughout the body. Autogenic training is based on the notion of passive concentration: that is, you try to achieve your goal of relaxation by not working actively to do so (as in progressive relaxation). Practice autogenic training twice each day in order to maximize the benefits. Choose times and places that are feasible for an uninterrupted session. Wear comfortable clothes. Sit or be in a position that allows total support for your entire body. When you begin autogenic training, first work on reducing your heart rate and calming your breathing; then you can move on to trying to evoke warm, heavy, relaxed sensations in your limbs and body. As you practice, try to combine phrases with images in order to keep your mind occupied. If thoughts do intrude into your session, just observe them and let them go.

Suicide: ALSO READ PG 36 PAST NOTES Suicide is a complex event. There are biological, psychological, and sociological causes of suicide and suicidal behaviour (e.g., thinking about or attempting suicide). The World Health Organization (WHO) estimated in the year 2000 there were 800,000 people who committed suicide worldwide. Canadas rate is high, with young people especially at risk, and even higher risk among the young in Native communities. Men are four times more likely to kill themselves than women but women make more attempts. The sheer numbers have made suicide prevention one of the three major health targets by the WHO for this decade. Suicide risk is multidetermined. There are so many factors that influence who is at risk and who carries through. The complexity of suicide calls for an equally complex set of solutions. There is no one solution. Psychology has played an important role in helping us to understand, prevent, and help those who are thinking of or who have attempted suicide.

20 Pain, psychosomatic disorders PSYCHOSOMATIC DISORDERS: All illnesses can be considered to be psychosomatic. That is, they inevitably involve the mind's reaction (psyche) to a physical (soma) illness. However, in some illnesses, psychological factors seem to play a particularly important part. They can influence not only the cause of the illness, but can also worsen the symptoms and affect the course of the disorder. It is these illnesses that are termed psychosomatic disorders. Because psychological factors are important in every illness, there is lack of agreement as to what should be considered as a psychosomatic disorder. Many doctors believe that illnesses such as duodenal ulcers, irritable bowel syndrome, bronchial asthma, eczema, psoriasis, high blood pressure and heart attacks are strongly influenced by psychological factors. Sometimes psychological factors can cause ill health without actually causing a disease. As a result of unhappiness, anxiety or stress due to personal problems, physical symptoms may develop. We are all familiar with the headache that develops as a result of stress. Similarly, other physical symptoms can develop. These include nausea, abdominal pain and chest pain, breathlessness, diarrhoea and giddiness and muscle pains. How Does a Psychosomatic Disorder Occur:

Illness can be due to many factors. It can occur as a result of social or environmental factors. It may also happen as a result of genetic or hereditary reasons: a tendency for a certain condition to run in families. Some families also tend to suppress feelings: any emotion then tends to be expressed by physical symptoms. Children can learn this behaviour which may continue to adult life. Some people think that it is our personality that is a major factor in determining which illness we develop. For example, people with what is known as Type A personality tend to be ambitious, impatient, and set themselves high standards. They seem more likely to develop heart attacks. Quiet, introverted individuals, who tend to conceal their feelings and fears and to suppress emotions, may be more likely to develop cancers. Pain as a Psychosomatic Disorder: According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), somatoform disorders are characterized by "the occurrence of one or more physical complaints for which appropriate medical evaluation reveals no explanatory physical pathology or pathophysiologic mechanism, or, when pathology is present, the physical complaints or resulting impairment are grossly in excess of what would be expected from the physical findings." Pain disorder is 1 of the somatoform disorders (Physical symptoms that seem as if they are part of a general medical condition, however no general medical condition, other mental disorder, or substance is present. In this case psychological conflicts may becoming translated into physical problems or complaints. With the number one complaint being of some type of physical symptom, it is no wonder this disorder is often discovered in a general medical setting). The main clinical feature of this disorder (i.e. somatoform) is pain, which cannot be fully attributed to a known medical disorder, in at least 1 anatomic site. The pain causes clinically significant distress, impairment, or both in social, academic, occupational, or other areas of functioning. Psychological factors are judged to play an important role in the onset, severity, exacerbation, or maintenance of the pain. The pain is not produced intentionally and is not under the patient's voluntary control. A somatoform disorder cannot be better accounted for by a mood, anxiety, or psychotic disorder. Pain disorder can be divided into 2 categories: Pain disorder associated with psychological factors and no identifiable general medical condition: Psychological factors play a major role in the onset, severity, exacerbation, or maintenance of the pain. Pain disorder associated with psychological factors and a general medical condition: Both the psychological factors and the general medical condition have important roles in the onset, severity, exacerbation, or maintenance of the pain. (Sources: http://www.emedicine.com/ped/topic1706.htm; http://www.mentalhelp.net/psyhelp/chap5/chap5v.htm#d)

21. Nosophobia, hypochondria, simulation, dissimulation Nosophobia (previously syphlophobia, today carcinophobia or AIDS-phobia) refers to severe psychic derangements which involve hypochondriac delusion. The patient unreasonably and unremittingly believes that he has a particular illness. In med psychology, we consider patients to be nosophobic when they have great fear of a disease and act unreasonably not to get the disease. Eg, they consider fruit and vegetable unclean even when washed, unreasonably care about what to eat, how to dress according to the weather etc. A particular group of people are those who try to avoid med examination, are afraid of syringes and stomatological treatment. These are not identical to nosophobic patients. They are not afraid of diseases but rather of treatment. Nosophobic patients reject injections because of their fear of infection and not of pain.

Hypochondriac reaction is that reaction when a patient with some problems is too afraid whether his illness is not an even more severe condition and whether the results of the tests are correct. He insists that his tests be repeated and uses vitamins excessively.

Scotoma is when the patient does not see the severity of his problems because he is afraid of a severe illness. Usually the patient can be persuaded to yield treatment. When scotoma is longlasting and the patient is not treated adequately, psychic derangement is involved and consultation with a psychiatrist is indicated.

Dissimulation is conscious concealing of problems by the patient. Eg, the patient fears for his position at work, fears that the diagnosis of the doctor will become known. Dissimulation is conscious and is not a psychic defect. Patients often dissimulate on entrance examinations (For eg, to get the job, they conceal their epilepsy which involves several restrictions such as not working on heights.)

There are people who like to be examined and treated, have an affinity to the medical environement and welcome interest in health care. They repeatedly use small, insignificant problems to visit the doctor and discuss their health and possible examinations. These people are called Pathophilic (Nosophilic) individuals.

Simulation (aggravation or exaggeration of problems) is conscious while purpose superposition is unconscious. Purpose superposition occurs when a patient wants to get something or to avoid something (eg to avoid working, get pension, avoid jail, explain failure, get treatment etc.) It occurs under the influence of emotion (fear or desire to achieve something) in suggestible people. Since suggestibility presumes mitigation of criticism, patients are likely to have vivid emotionality or less developed intellectual abilities.

Purpose reaction, in contrast to superposition, occurs in healthy patients, for eg, a patient suddenly ceases walking, talking, writing, reacting, behaves as if in a coma etc. Purpose reaction is a psychic dysfunction and so is the more severe purpose superposition. Temporary purpose superposition can be treated quite easily and is not considered a psychic disease.

Conscious simulation (aggravation) and unconscious purpose reaction (superposition) must be distinguished. In the latter, a real disease is present, ie, psychic derangement which must be treated. It is even important to get the dysfunction under control quickly because there is a risk of fixation which would entail long-term reatment.

The differential diagnosis between conscious production and unconscious reaction can be very hard to establish. In both cases, the picture of derangement corresponds closely to someone who genuinely has it.

The distinction can be quickly and successfully made when the patient, thinking he is not being observed, stops simulating. Purpose reaction persists when the patient is alone. The patient does not realise the actual origin of the disease and is not able to walk, talk etc. Since we deal with suggestible individuals and the reaction has a purpose, the disorder is emphasized in the presence of a doctor and a greater audience while the manifestations are less marked when the patient is alone.

In conscious aggravation and simulation the doctor should also be interested in the cause. From the medical point of view, it is unimportant when the patient simulates in the presence of the medical counselor when he wants to make a big clean up or wants to finish building his house. The doctor must be interested when a young man, graduated from high school does not want to work and is willing to live without money, in poor social conditions. He is an abnormal individual (psychopath) who needs to be psychotherapeutically guided. Sometimes, it may even be a slowly developing psychic disease (schizophrenia) where intensive psychiatric treatment is indicated.

22. Psychological problems of the out-patient care and hospitalization In order to provide the therapeutic effect of the environment in which the medical care takes place it is extraordinarily important to stick to the following two main principles: (1) Give the patients in the health-care environment as many positive stimuli and situations as possible (2) Eliminate troublesome and psychologically stressing effects Psychological problems of the out-patient care The number of patients examined and cured in doctors offices is greater than the number of patients cure in hospitals and asylums. Physicians in the out-patient departments are usually the first ones who come into contact with the patients. Since in the hospitals and health-care centers other health-care specialists work along with the physicians, the physicians are professionally, organizationally and legally responsible for the entire team. They are concerned with the effort of all health-care specialists to provide the appropriate atmosphere in the doctors office as well as in other departments of the hospital or health-center.

Out-patient physicians must try to provide the appropriate work organization (adhere to office hours, make rational use of office hours, make appointments with patients, etc). Empathic behaviour of a physician, out-patient nurse, laboratory technician and other health-care specialists in the out-patient departments results in an atmosphere full of understanding, trust and optimism which helps the patients to overcome the fear of examination as well as having a positive effect on their state of health. Good organization of work in the out-patient department protects the patient from unnecessarily long waiting in the waiting-room and prolonged contact with other patients whose discussions and advices can psychotraumatically affect the patient. It is necessary to create the appropriate conditions for the discussion with and examination of the patient in the doctors office. It means that they must be undisturbed and intimacy must be preserved (for instance, to conduct the somatic examination of the patient in the examining room or, at least, in a separated part of the doctors office). The physician also takes advantage of the discussion with the patient for psychotherapeutic reasons. He/she tries to calm the patient, support his/her appropriate attitude toward the disease and win him/her over for the cooperation in the treatment. The physician finds a suitable way to inform the patient about the examination result, explains to the patient how to take medicines, how to observe the regimen and diet principles, or about the necessity of other examinations. The physician must always verify how the patient took the information about the disease, whether he/she is able to cope with it appropriately. Psychological problems f hospitalization The idea of the hospital and hospitalization is usually associated with the fear of the seriousness of the disease. However, hospitalization enables a complex examination of the patient in a short time and offers universal medical care. Many patients realize this fact perfectly. In any care, however, the stay in a hospital represents profound intervention in the patients life. The stay in a hospital can affect the patient psychotraumatically. It brings a number of changes and unwanted situations to which the patient must adapt. In the moment of hospitalization, the patient is taken away from his/her family, group of friends and acquaintances. The patient undergoes a psychological isolation associated with the loss of emotional support. The patient finds him/herself in an unfamiliar environment, among unknown people to whom he/she must adjust, at least to some degree. Hospital frustrates the patients needs. Namely in case of an acute disease, hospital brings a sudden and radical change of the hitherto way of life. It limits the patients movement or completely disables him/her, makes a patient unable to continue with his/her interests, it represents change in the eating habits and often a total loss of privacy. Low aesthetic attractiveness of the environment in which the patient is forced to live for some usually unknown length of time can also have an unfavourable effect. The hospital environment, except in the case when the health-care specialists pay sufficient attention to the daily regimen, brings only few positive stimuli for the distraction of the patient. The patient has a lot of time to think about his/her health state. The presence of seriously ill or dying patients in the ward can also psychotraumatically affect the patient. Some patients tend to identify themselves with the seriously ill ones which multiplies their fear of death. The mutual interaction between patients in wards can also cause negative feelings. The task of a physician and other health-care specialists at the department and hospital is to reduce the effect of negative factors associated with the patients hospitalization to a minimum.

Every health-care specialist with whom the patient comes into contact after entering the hospital (information officer, out-patient nurse, admitting physician, etc) plays an important role in the reduction of the patients fears and anxiety. On the basis of their behaviour, the patient often creates an impression of the health-care specialists work and the hospital itself in which he/she is going to be treated. To a considerable degree it depends on him/her whether the patient develops trust in the specialists in this health-care center or not. The health-care specialists have to realize that the patients trust in them can be challenged if the admitting of the patient to the department lasts too long, if the patient sees unwillingness of the admitting staff, if he/she listens to a discussion about where to place him/her since everything is overcrowded, etc. After admitting the patient to the department it is the nurse that should take care of him/her. She should help the patient to change into the hospital gown, take his/her personal things which will not be needed during hospitalization and put them into a locker, take the patient to bed, help him/her to the roommate patients. Her duty is also to acquaint the patient with the daily regiment (i.e., at what time in the morning wake up call, when do the physicians have rounds, what is the time for medicines and meals, visiting, etc). Due to the necessary information offered, the anxiety of the unfamiliar environment is, to some degree, reduced and the patient adapts to it more easily. The attending physician supervised by the head of the department or by the chief of the clinic takes care for the patient. The physician should always see to it that during the examination of the patient all other persons or disturbing effects of the surrounding environment are excluded. After a thorough medical examination the physician determines the plan of additional examinations and therapeutic procedure. He/she informs the patient about the result of the examination, the necessity for additional examinations and treatment which he/she will undergo. He/she acquaints the patients in detail with the daily regimen which the physician individually adjusts to the health state of the patient. He/she makes sure that the patient understood the information correctly, not allowing for iatrogenization. During hospitalization, subordinate health-care specialists take care of the patient according to the physicians instructions and the patients complicated psychological problems and realize that every disease provokes a psychological reaction. This can differ and every health-care specialist, especially the physician, must recognize it. During daily rounds, the physician shows interest in the patients subjective troubles and observes the course of the disease. The physicians rounds represent a very important psychological process. First of all, during rounds, it is necessary to speak with the patient and not about the patient, as it is often done. Everything concerning the patient should be discussed before or after the rounds. Otherwise, the patient is psychotraumatized when he/she misinterprets the words heard. The entire work at the department should be organized so that the time of giving medicines, meals, cleaning, rounds, etc. is always the same. If everything works according to the plan, the patient puts greater trust in the health-care center. He/she has the feeling that the daily regimen is well tested and believes that the stay in hospital will be of help.

23) Substance Related Disorder Common Characteristics The two disorders in this category refer to either the abuse or dependence on a substance. A substance can be anything that is ingested in order to produce a high, alter one's senses, or otherwise affect functioning. The most common substance thought of in this category is alcohol although other drugs, such as cocaine, marijuana, heroin, ecstasy, special-K, and crack, are also included. Probably the most abused substances, caffeine and nicotine, are also included although rarely thought of in this manner by the layman. Substance Abuse:

Etiology: There is evidence that genetic factors play a role in both dependence and abuse. Other theories involve the use of substances as a means to cover up or get relief from other problems (e.g., psychosis, relationship issues, stress), which makes the dependence or abuse more of a symptom than a disorder in itself. Symptoms: A pattern of substance use leading to significant impairment in functioning. One of the following must be present within a 12 month period: (1) recurrent use resulting in a failure to fulfill major obligations at work, school, or home; (2) recurrent use in situations which are physically hazardous (e.g., driving while intoxicated); (3) legal problems resulting from recurrent use; or (4) continued use despite significant social or interpersonal problems caused by the substance use. The symptoms do not meet the criteria for substance dependence as abuse is a part of this disorder. Treatment: Research suggests that no treatment method is superior, but that social support is very important. An openness to accept the abuse is also paramount in successfully treating the illness. Organizations such as AA and NA have had better than average success in reducing relapse. Prognosis: Variable. Both substance abuse and dependence is difficult to treat and often involves a cycle of abstinence from the substance and substance use. Substance dependence: Etiology: There is evidence that genetic factors play a role in both dependence and abuse. Other theories involve the use of substances as a means to cover up or get relief from other problems (e.g., psychosis, relationship issues, stress), which makes the dependence or abuse more of a symptom than a disorder in itself. Symptoms: Substance use history which includes the following: (1) substance abuse (see below); (2) continuation of use despite related problems; (3) increase in tolerance (more of the drug is needed to achieve the same effect); and (4) withdrawal symptoms. Treatment: Detoxification treatment may need to be administered due to the dangerousness of some withdrawal symptoms. Research suggests that no treatment method is superior, but that social support is very important. Organizations such as AA and NA have had better than average success in reducing relapse. Prognosis: Variable. Both substance abuse and dependence is difficult to treat and often involves a cycle of abstinence from the substance and substance use.

24 PSYCHODIAGNOSTIC METHODS Psychodiagnostics is an applied psychological discipline aimed at as much accurate and objective investigation or measuring of individuals psychological characteristics as possible. Psychometrics is its auxillary discipline. It represents the application of mathematico-statistical methods in the creation and use of psychological examination procedures. Unlike medicine, psychological diagnostics is focused not only on investigating abnormalities but also on investigating individual personality specificities and various causal relationships in mental development. It means that it is not limited only to the description of the characteristics of the person studied (inappropriate adaptation, aggressiveness, anxiety, etc.) but it also concerns the analysis of its causes (for instance, the role of an unsuitable family environment, stressful situations or other life events).

To achieve diagnostically important information psychodiagnostic methods special psychological examination procedures leading to gaining knowledge about the person examined, i.e. psychological diagnosis are utilised. Principally, there are two main types of psychodiagostic methods: Clinical Ones (non-standard): They are not strictly ruled and they are not statistically based; however, they are flexible and it is possible to adapt them to the individuality of the person examined. Test Ones (standard): With application of psychodiagostic (psychological) tests. There is not a hard line between these two approaches. The optimal psychodiagnostic examination combines clinical and test methods (the psychologist should always be intentional in studying the patient, his/her behaviour during administration of the test methods). CLINICAL METHODS: Non-standard approaches that are not psychometrically based are classified within this category. From among these methods, interview and observation which belong to the basic methods of psychology are the ones most frequently used. Clinical psychodiagnostic methods, although they seem to be layman or unscientific, represent a constituent part of every psychodiagnostic examination. It is in the context of the information gained using these approaches we can interpret findings of more exact test methods, and, many times, knowledge gained by clinical methods enables us to choose subsequent approaches, especially test diagnostic procedures (e.g., we decide to use a particular test on the basis of the clinical impression of the interview and observation).

TEST METHODS: In 1980, the American psychologist James Mckeen Cattell used for the first time the term mental test for a set of psychological exams measuring individual differences. In psychology, the term test means a standardised experimental situation, i.e. a standardised examination procedure in which, using the same stimuli material under the same conditions in all individuals examined; we provoke a diagnostically valuable phenomenon. We register these phenomena and process them in a strictly determined way, so it is possible to compare the results achieved from various individuals. The standardisation represents a fundamental condition that every psychodiagnostic test must fulfil. It starts with establishing the standard samples of stimuli. This sample of the stimuli future test- is administered to a representative sample of the population (the future test is tested by the examination of a great number of people). The test norms necessary for the assessment of the results (enable us to

compare the individuals results with the standard values of a given population) are developed on the basis of a mathematico-statistical processing of the results achieved by the examination. Psychodiagnostic tests must also fulfil some other methodologico-psychometric demands. The most important ones are: o Reliability: Consistency of the measurement regardless what he test measures; the results independence of the incidental effects (i.e. the test yields the same results when used repeatedly) o Validity: Gives a guarantee that the test really measures what it should measure (the matter in question is a correlation between the test result and the external criterion which reflects the practical usefulness of the test). o Discriminating Power: The capability of the test to discriminate between even small differences or changes. It is possible to classify psychodiagnostic tests according to various criteria. In clinical practice, it is most suitable to classify them according to their function (aim of the examinations, i.e. what the tests measure) into: 1) Achievement Tests: Intelligence tests, tests of mental functions and abilities. 2) Personality Tests: Projective methods, personality questionnaires. Achievement Tests: These are methods in which the individuals achievement or result indicates the level of his/her abilities. Intelligence Tests The Stanford-Binet Intelligence Scale was the first widely used test. It consists of such tasks as copying geometric designs, identifying similarities and repeating sequence of numbers. Test consists of a set of various ages level items and subject must complete one age level before advancing to the next. Test scores are expressed as a comparison of a single persons score to a national sample of similar aged people. Ravens Progressive Matrices Test consists of geometrical designs (matrices) arranged according to a certain principle. The subject should find the principle of arrangements and select the right matrix in accordance with this principle. Wechsler Adult Intelligence Scale contains 5 or 6 verbal subtests and 5 performance subtests. The verbal subtests are focused on general information, practical reasoning, arithmetic reasoning, generalisation, concentration of attention and creation of concepts. The performance subtests contains abilities to grasp a social situation and

differentiate between fundamental details of a whole, visual analysis and synthesis, psychomotor rate, visual-motor coordination and practical abilities. From the results of these subtests we obtain not only total, verbal and performance IQ score, but also intellectual structure which helps us to differentiate between oligophrenia, dementia and educational deprivation. The Wechsler Memory Scale tells us about memory abilities and the result is so called memory quotient (MQ). From the comparison of IQ with MQ we can identify the memory level and memory disorders based on organic brain lesions. The Army Alpha Test was the first group test of intelligence and was used for testing recruits in the U.S. Army during World War I. The Bourdon Test is a test of attention. The subject tries to discriminate different symbols in a sheet of paper in 30 or 40 rows. The time is limited and we interpret quantity (i.e. how fast is the subject) and quality (the number of errors). The Numerical Square is another test of attention the subject search as quickly as possible for randomly arranged digits from 1 to 25.

Personality Tests Minnesota Multiphasic Personality Inventory (MMPI) is the most widely used multitrait test. It consists of about 550 items with possible responses: true, false, cannot say. The result is a score on 10 clinical scales hypochondriasis, depression, hysteria, psychopathic deviancy, masculinity/femininity, paranoia, psychastenia, schizophrenia, mania and social introversion. The MMPI was developed during the 1930s and now we use its revised version MMPI2. The Sixteen Personality Factors questionnaire (16PF) is another often used questionnaire and was constructed by the author of 16th personality traits Raymond Catell. Projective Methods use ambiguous, unstructured stimuli. The subject projects himself into the ambiguous stimuli and thus reveals his personality. The advantage is that the person cannot give false answers; disadvantage is that responses are often difficult to interpret. Examples of projective methods are; The Rorschach Test and The Thematic Apperception Test. Drawing Methods drawing of figures, tree, family, vicious family into animals..

For good personality assessment we use combination of projective methods and personality questionnaires.

25. Intelligence, intelligence test, mental retardation The Stanford-Binet Intelligence Scale was the 1st widely used test. It consists of such tasks as copying geometric designs, identifying similarities and repeating sequences of numbers. The test consists of a set of various age-level items and the subject must complete one age level before advancing to the next. Test scores are expressed as a comparison of a single persons score to a national sample of similarly aged people.

Ravens Progressive Matrices test consists of geometrical designs (matrices) arranged according to a certain principle. The subject should find the principle of arrangement and select the right matrix in accordance with this principle.

Wechsler Adult Intelligence Scale contains 5 or 6 verbal subtests. The verbal subtests are focused on general information, practical reasoning, arithmetic reasoning, generalization, concentration of attention and creation of concepts. The performance subtests contains abilities to grasp a social situation and differentiate between fundamental details of a whole, visual analysis and synthesis, psychomotor rate, visual-motor coordination and practical abilities. From the results of these subtests we obtain not only total, verbal and performance IQ score but also intellectual structure which helps us to differentiate among oligophrenia, dementia and educational deprivation.

The Wechsler Memory Scale gives info about memory abilities and the result is the so called memory quotient (MQ). From the comparison of IQ with MQ, the memory level and memory disorders can be identified based on organic brain lesions.

The Army Alpha Test was the 1st group test of intelligence and was used for testing recruits in the US army during World War 1. The Bourdon test is a test of attention. The subject tries to discern different symbols on a sheet of paper in 30 or 40 rows. The time is limited and we interpret quantity (ie, how fast the subject is) and quality (the number of errors).

The Numerical Square is another test of attention. The subject searches as quickly as possible and points out digits in succession on a matrix with randomly arranged digits. A series of 25 matrices (the digit arrangement differs in each of them) administered in a quick succession with a simultaneous measuring of solving time is the most widely used one.

The above mentioned tests of attention register the concentration of attention in particular but also vigilance, tenacity of attention as well as accuracy of perception and the psychomotor rate.

Mental retardation IQ tests can be used for assessment of mental ability. If a person has a score of 70 or less on an IQ test, that person can be considered to be mentally retarded. If the score is greater than 140, then that person is said to be mentally gifted.

Degrees of mental retardation Mild IQ score is 50-70. They are able to become self-sufficient, may secure full-time jobs in unskilled occupations. They reach the mental level of a 12 year old child. They compose about 70% of mental retardations. Moderate IQ score is 35-49. They are able to perform simple unskilled tasks but are psychomotorically retarded and although it is difficult to learn basic hygienic habits, it is possible. They reach the mental level of a 6 year old child. They often suffer from epilepsy, neurology and psychiatry symptoms. 15-20% of mental retardations. Severe IQ score is 20-34. They are able to learn only basic hygienic habits and may learn a few sensible words. They need continual supervision. They react differently in comparison with the healthy child, for eg, affective disorders, behavioral disorders, hyperactivity, aggression, self-harming, automatic and stereotype movements. 5% of mental retardations. Profound IQ is below 20 and they are not able to recognize close people, do not communicate, dont maintain hygiene. They have somatic disorders, epilepsy and neurological disorders. Less than 5% of mental retardations.

26. Psychoanalysis The father of psychoanalytic theory is Sigmund Freud. Psychoanalysis tries to bring unconscious conflicts into consciousness, the patient comes to understand the reasons for his behavior. Once this realization occurs, the conflicts can be resolved and the patient can develop more adaptive behavior patterns.

 Levels of consciousness (1) Conscious is a part of mind open to easy inspection. It consists of all thoughts, feelings, and actions of which we are actively aware at the moment. (2) Preconsciousmental activities which are not part of our current thoughts but which can be brough to mind if needed. (3) Unconsciousthoughts, motives, impulses or desires that lie beyond a persons normal awareness, but which can be made available through psychoanalysis. Personality structureis composed of three basic structuresthe id, ego, and superego. (1) IDis the source of instinctual energy. It functions according to so called pleasurable principle, which is the immediate and uninhibited seeking of pleasurable and avoidance of discomfort. The id operates without any consideration for logic or reality. (2) Egois the rational part of the psyche that deals with reality and attempts to control the impulses of the id. It operates on the reality principleit has the ability to understand and deal with objects an dcircumstances in the external environment. (3) Superegois a set of ethical standards or rules for behavior. It separates from the ego when the child lears the rules and values of the parents and society. The superego constantly strives for perfection and is as unrealistic as the id. (4) The ego plays a regulating role between needs of the id and superego. Psychosexual stages of developmentexperiences during early childhood are important predictors of later adult personality (1) Oral stage 0-1 year of age, erogenous zone is mouth (2) Anal stage 1-3 years of age, erogenous zone is anus (3) Phallic stage 3-6 years of age, erogenous zone is genitals (4) Latency stage 6-12 years of age, no erogenous zone (5) Genital stage 12-adult, erogenous zone are genitals Major techniques of psychoanalysis are: (1) Free associationthe patient is told to say whatever comes to mind, during this process is temporarily removed the consicous censorshop and unconscious thoughts are important clues in the therapy. To encourage free association use freudian analysis seettings where the patient reclines on a couch or sits in a comfortable chair while the analyst sits out of sight, often saying little or nothing during the sessions.

 Interpretationa psychoanalysts explanation of the significance of the patients free associations. Dream imterpretatinmanifest content of dreams.; latent content (expressed in dream symbols) Resistancethe tendency to block or prevent the free expression of unconscious material (pauses in coversation, changing of topics, coming late...) Transferencethe patient transfer onto his relationship with the therapist emotions experienced in the past. The analyst interprets them as evidenc eof unresolved attachments or conflicts in childhood or previous relationships. This is the topic in the analysis and helps gain insight into past and current relationships. Countertransference

28 Cognitive Behaviour Therapy. Cognitive therapy or cognitive behavior therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder. It involves recognizing unhelpful patterns of thinking and reacting, then modifying or replacing these with more realistic or helpful ones. Its practitioners hold that typically clinical depression is associated

with (although not necessarily caused by) negatively biased thinking and irrational thoughts. Cognitive therapy is often used in conjunction with mood stabilizing medications to treat bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS. According to the U.S.-based National Association of Cognitive-Behavioral Therapists: o "There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy." Cognitive Behaviour Therapy (CBT) is based on the idea that how we think (cognition), how we feel (emotion), and how we act (behaviour) all interacts together. Specifically, our thoughts determine our feelings and our behaviour. Therefore negative thoughts can cause us distress and result in problems. One example could be someone who, after making a mistake, thinks "I'm useless and can't do anything right." This impacts negatively on their mood and makes them feel depressed; then they worsen the problem by reacting to avoid activities. As a result they reduce their chance of successful experience, which reinforces their original thought of being "useless". In therapy the latter example could be identified as a self-fulfilling prophecy or "problem cycle", and the efforts of the therapist and client would be to work together to change this. This is done by addressing the way the client thinks in response to similar situations and by helping them think more flexibly, along with reducing their avoidance of activities. If as a result they escape the negative thought pattern, they will already feel less depressed. They may hopefully also then become more active, succeed more, and further reduce their depression. With thoughts stipulated as being the cause of emotions rather than vice-versa, cognitive therapists reverse the causal order more generally used by psychotherapists. Therefore the therapy is to identify those irrational or maladaptive thoughts that lead to negative emotion and identify what it is about them that is irrational or just not helpful; this is done in an effort to reject the distorted thoughts and replace them with more realistic alternative thoughts. Cognitive therapy is not an overnight process. Even after a patient has learned to recognise when and where his thought processes are going awry, it can take months of concerted effort to replace an irrational thought with a more reasonable one. With patience and a good therapist, however, cognitive therapy can be a valuable tool in recovery. While similar views of emotion have existed for millennia, cognitive therapy was developed in its present form by Albert Ellis and Aaron T. Beck in the 1950s and 1960s. It rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today. Cognitive behavioural group therapy (CBGT) is a similar approach in treating mental illnesses. In this case, clients participate in a group and recognize they are not alone in suffering from their problems. Based on the protocol by Richard Heimberg.

A sub-field of cognitive behavior therapy used to treat Obsessive Compulsive Disorder makes use of classical conditioning through extinction (a type of conditioning) and habituation. CBT has also been successfully applied to the treatment of Generalized Anxiety Disorder, health anxiety, Social phobia, and Panic Disorder. In recent years, CBT to treat symptoms of schizophrenia, such as delusions and hallucinations, has been developed in the UK by Douglas Turkington and David Kingdon. CBT has a good evidence base in terms of its effectiveness in reducing symptoms and preventing relapse, and has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD, bulimia nervosa, and depression.

29. Other psychotherapy approaches (logotherapy, transpersonal psychology, extensicalist, interpersonal, integrative) Psychotherapy is a set of techniques intended to improve mental health, emotional or behavioral issues of individuals, family members or a whole family's interactional climate. Mental health

problems can have both psychological, social and somatic dimensions. These issues often make it hard for people to manage their lives and achieve their goals. Psychotherapy is aimed at these problems, and attempts to solve or help people themselves to solve them via a number of different approaches and techniques. The term counseling is often used interchangeably with psychotherapy. It was originally adopted by Carl Rogers to distinguish his work from the more medically oriented psychotherapy but the difference has become blurred. Its use today tends to imply a less interventionist approach based on listening skills which draw out the subject rather than confronting or challenging them. In this article the term can be taken to be the same as psychotherapy. Logotherapy - Developed by neurologist and psychiatrist Viktor Frankl, Logotherapy is considered the "third Viennese school of psychotherapy" after Freud's psychoanalysis and Adler's individual psychology. It is a type of Existential Analysis that focuses on a "will to meaning" as opposed to Adler's Nietzschian doctrine of "will to power" or Freud's of "will to pleasure". The following list of tenets represents Frankl's basic beliefs regarding the philosophy of Logotherapy:

Life has meaning under all circumstances even the most miserable ones. Our main motivation for living is our will to find meaning in life. We have freedom to find meaning in what we do, and what we experience, or at least in the stand we take when faced with a situation of unchangeable suffering.

A short introduction to this system is introduced in Frankl's most famous book, "Man's Search for Meaning", in which he outlines how his theories helped him to survive his Holocaust experience. The human spirit is referred to in several of the assumptions of Logotherapy, but it should be noted that the use of the term spirit is not "spiritual" or "religious." In Frankl's view, the spirit is the will of the human being. The emphasis, therefore, is on the search for meaning, not the search for God nor any other supernatural existential being. Frankl also noted the barriers to humanity's quest for meaning in life. He warns against "...affluence, hedonism, [and] materialism..." in the search for meaning. Transpersonal psychology - Transpersonal psychology is a school of psychology that studies the transcendent or spiritual dimensions of humanity. Among these factors we find such issues as selfdevelopment, peak experiences, mystical experiences and the possibility of development beyond

traditional ego-boundaries. Thus the interest in human experiences which apparently are 'transpersonal,'or 'trans-egoic'. A short definition is concerned with the study of humanitys highest potential, and with the recognition, understanding, and realization of unitive, spiritual, and transcendent states of consciousness. The field is considered by proponents to be the "fourth force"' in the field of psychology, the three other fields being psychoanalysis, behaviorism, and Humanistic psychology. According to transpersonal theory these other schools of psychology have failed to give weight to transpersonal or "transegoic" elements of human existence, such as religious conversion, altered states of consciousness and spirituality, in their academic reflection. Thus, transpersonal psychology strives to combine insights from modern psychology with insights from the world's contemplative traditions, both East and West. The transpersonal and spiritual dimensions of the psyche have traditionally not been a focus of interest for Western psychology, which has mainly focused on the prepersonal and personal aspects of the human psyche. Existential psychotherapy - Concerned mainly with the individual's ability to preserve a sense of meaning and purpose throughout the lifespan in the face of immutable biological limitations of a mortal existence (ie ageing, death, ultimate aloneness, having sole responsibility for our actions, choices and freedom). Therapeutic stance is a combination of the psychoanalytic school (eg defences versus unconscious death anxiety) and the humanistic model. Major contributors to the field (eg Irvin Yalom) have attempted to create a therapy sensitive to common 'life crises' springing from the essential bleakness of human self awareness, previously accessible through the complex writings of existential philosophers (eg Jean-Paul Sartre, Friedrich Nietzsche). Interpersonal Psychotherapy - Family psychotherapy (therapy) is a professional and conscious attempt and method to study, understand and cure disorders of the interactional whole of a family and its individual members as family members. The aim of family therapy is that the interactional patterns which prevent individual growth will change. This is achieved especially emphasizing and trying to find the hidden positive resources in familys interactional whole. In Family therapy the therapist or a family therapy team meets in the session those family members willing to participate in discussion about the topic they have or some of family members has defined as a disorder or problem. The number of sessions depends on the disorder, but the average is 5-20 sessions. The basic theory of

family therapy is derived mainly from object relations theory, cognitive psychotherapy, systems theory and narrative approaches. According to the main theoretical perspectives, family therapy can be classifies as follows: Psychodynamic; structural; behavioural or cognitive; strategic; reflective and narrative models. The main indications of family therapy are as follows: 1. Serious psychic disorders (e.g. schizophrenia, addictions and eating disorders); 2. Interactional and transitional crises in a familys life cycle (e.g. different separation and individuation crises or divorce crises); 3. As a support of all other psychotherapies and other psychological and psychiatric therapies (even medication). Integrative Psychotherapy - Integrative psychotherapy involves the fusion of different schools of psychotherapy. Initially, Sigmund Freud developed a talking cure called psychoanalysis; then he wrote about his therapy and popularized psychoanalysis. After Freud, many different disciplines splintered off. Some of the more common therapies include: psychoanalytic psychotherapy, counselling, cocounselling, analysis, transactional analysis, cognitive behavioural therapy, gestalt therapy, body psychotherapy, psychodynamic psychotherapy, family systems therapy, person centred counselling, and existential therapy. Over two hundred different acknowledged theories of psychotherapy are practiced. A new therapy is born in several stages. After being trained in an existing school of psychotherapy, the therapist begins to practice. Then, after follow up training in other schools, the therapist may combine the different theories as a basis of a new practice. Then, some practitioners write about their new approach and label this approach with a new name. This overall pattern has been observed in numerous new therapies and is certain to form many future therapies. A pragmatic or a theoretical approach can be taken when fusing schools of psychotherapy. Pragmatic practitioners blend a few strands of theory from a few schools as well as various techniques; such practitioners are sometimes called eclectic psychotherapists and are primarily concerned with what works. Alternatively, other therapists consider themselves to be more theoretically grounded as they blend their theories; they are called integrated psychotherapists and are not only concerned with what works, but why it works. For example an eclectic therapist might experience a change in their client after administering a particular technique and be satisfied with a positive result. In contrast, an integrative therapist is curious about the why and how of the change as well. A theoretical emphasis is important; for example, the client may only have been trying to please the therapist and was adapting to the therapist rather than becoming more fully empowered in themselves.

30. Psychotherapeutic methods Humanistic psychology arise during 1960s as opposition against behavior approach. It tries to help people in their normal growth and realizing their own potential. Humanist therapists assume that the human nature is positive and each person is unique.

Carl Rogers developed a therapy that emphasizes the clients natural tendency to become healthy and productive. His approach is also called client-centered therapy. This therapy also encourages exploration of thoughts and feelings in order to obtain insight into the causes for behaviors. The focus is on encouraging healthy emotional experiences.

Three important principles of communication are empathy, unconditional positive regard and genuineness. (1) Empathy is a sensitive understanding and sharing of another persons inner experience (2) Unconditional positive regard means the nonjudgmental attitude and genuine caring that the therapist should express toward the client. When people receive unconditional caring from others, they better value themselves. (3) Genuineness (authenticity or congruence), is being aware of ones true inner thoughts and feelings and being able to share them honestly with others. Genuine people are not artificial; they are not playing a role. Rogerian therapy is based on the belief that when a therapist is authentic, clients develop a feeling of trust in themselves and are then able to know and express themselves honestly, too.

Abreaction is a simple and short-term mechanism. A passionate, unchecked and uninhibited emotion losses its intensity after some time. A person who overcomes the emotion experiences relief: it is analogous to the relief following an abscess treatment. Short-term euphoria can appear after abreaction. The physician should not inhibit the patients emotionally charged expressions if he/she wants to intentionally release abreaction. For instance, if a patient is in despair, let him/her vent it.

Catharsisclearing follows abreaction, but it differs from it by the fact that a man also experiences cognitive rebirth and attitude or opinion changes. For example a mother who loses a child abreact a strong emotion in her grief affection; moreover, in the relief caused by the evacuation, it becomes clear to her that there are other important values in her life. People also sponatneously provoke abreactive and cathartic experiences. Abreaction and catharsis are often more effective if the individual knows that there is somebody who is ready to listen and understand him/her. Misunderstanding, shouting and ridiculing can mobilize inhibitions which prevent abreaction. It results in the accumulation of emotion. Pharmacological suppression of emotion does not make abreaction and catharsis possible; thus its effect in questionable. Catharsis and abreaction are often effective for a short time.

Emotional distancingdistress is immediately urgent and this urgency absorbs an individual. High mental tension in distress deteriorates cognitive performance. If man is able to step outside himself using autoreflexion (a specifically human characteristic of consciousness), i.e. to inspect oneself as someone else, he/she reflects also his emotion, steps back from it. Stepping outside oneself decreases the urgency of emotion, deactualizes it, decreases its tension and immediate urgency. In this way it can improve cognitive performance. The means of stepping outside oneself are autoirony, ridiculing oneself. gallows humor decrease distress when a tragic situation is viewed as ridiculous.

Insight is a change of self-image, cognitive restructuring in which an individual accepts as his own the explanation of his troubles in terms of the therapists professional interpretation or of the interpretation based on another source. Interpretation is a theoretical explanation, insight is its acceptance, interiorization. Thus it differs from formal knowledge. It is difficult to achieve insight as a mans self-image is protected by personality mechanisms like rationalization, scotomization, projection, etc. Man resists interpretation. Insight is usually achieved slowly, by gradual overcoming of resistance. It is possible to achieve the insight, often simultaneously with emotional distancing. Both mechanisms can be mutually conditioned. The degree of interpretation adequacy which represents a source of insight is a serious theoretical problem. Since the therapist does not have patent for reason, he can be mistaken and he can offer false interpretation to the patient. If false interpretation enables emotional distancing it could be therapeuticaly effective. Therapecutic effectiveness does not prove the correctness of interpretation.

Obtaining relevant information is a simplified insight. We do not speak about insight to extensive personality problems but to one narrowly defined problem. For instance, a patient can be anxious about disastrous consequences of masturbation. The physicians information about the innocuousness of masturbation can cause a patient immediate relief. Interiorization of information is a precondition for therapeutic effectiveness, i.e. man must adopt it. Information without interiorization is only a formal knowledge, it is not therapeutically effective.

Suggestion is irrational influencing of mind. Stimuli pressure someone elses mind to accept them directly, without distancing, without reflexion. This pressure is called suggestiveness, and the ability to accept the stimulus is suggestibility. Communicative aids as well as their metacommunicative accompaniment produce suggestiveness. It is possible to influence suggestively. Phyiscal functions, for instance, it is possible to relieve pain cenesthopathy and

fatigue. Suggestive effect of indifferent interventions is called larval suggestion. Mental functions are possible to alleviate anxiety, evoke experiencing of well-being. Suggestion can modify the patients attitudes, increase the quality of therapeutic relationship, decrease the desire for alcohol. Suggestive influence is incongruous with achieving insight, because it is applied outside of the recipients cogitive differentiated functioning. Paradoxical mechanism is to a certain degree the opposite of suggestive one. Tendency to argue, negativism and refractoriness just like suggestibility are typical for the mind. Paradoxical mechanism processes the stimulus in an opposite way to its formal presentation. For example, with the instruction in the evening you must under no circumstances fall asleep the evident evening sleepiness appears. The precondition for using paradoxical mechanism in therapy is represented by individually high refractoriness. Mechanism of conditioned reflex, learning, discent. It is a aset of mechanisms close ot the physiological level of organism functioning. Psychotherapeutically effective are (1) Instrumental conditioningit is based on the reward and punishment principle-according to which the rewarded reactions are fixed and punished ones extinct. (2) Social conditioningapplies the discent principle in social situations, for instance, within a group activity. (3) Training (learning)is a mechanism. It is possible to learn social sterotpes the performance of which is inhibited because of social inability or social activity which is wrongly performed by a persion. Erotic and sexual interactions are learned. (4) Special trainingforms utilize the principle of reciprocal inhibition. Function innervation inhibits the opposite function. According to the principle of reciprocal inhibition the reciprocal inhibitor, represented by anxiety antagonist, inhibits the anxious response to anxioqunous stimulus. (5) Training of emotional and muscle relaxations decreases anxiety and physical symptoms associated with it. Relaxation can be a starting point for desensitization, it can be utilized in coping iwth pre-sleep tension. (6) Conditioning in phantasty, imaginative conditioning takes place intrapsychologically. It is mediated by imaginative ability. (7) Imitation is a type of learning. It is often combined with identification. Imitation of real or fictive ideals is used therapeutically and instructionally.

Emotional supportis a massively effective mechanism, especially its protective effects are evident. Psychopathogenic factors operating simultaneously with social support are usually less effective than in the case without emotional support. Emotional support is manifested asan awareness of man that he has somebody or something he can lean on emotionally. Emotional support can be gained: from other persion by a direct action, from other person indirectly, using another value. Failur of emotional support can massively increase the effectiveness of pathogenic stimuli, sometimes catastrophically.