c-1 final exam study guide

8/9/2019 C-1 Final Exam Study Guide

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C1FinalExamStudyGuide,5/12/11

HumanDevelopmentandLearningTheory

1.Foreachofthefollowingdevelopmentaltheories,knowthestages,associated

characteristics,

and

ages:

a.Cognitive(Piaget)

b.Social(Erikson)

c.Moral(Kohlberg)

d.Psychosexual(Freud)

REMEMBER:

Pee 3letterssochildrenshouldgainbladdercontrolshortlyafterage3

Poop 4letterssotheyshouldgainbowelfunctionshortlybeforeage4

Groomingbyage4

COGNITIVE Piaget

(1)Sensorimotor

(Birth

2years)

babylearnsfromsensoryobservation,controlmotorfunctionsmore,andexplore

environment

ObjectPermanence babyunderstandsthatanobjectisstillthere,eveniftheycan'tseeit

Symbolization theycancreatevisualimage

**Theattainmentofobjectpermanencemarksthetransitionfromsensorimotorstagetothe

preoperationalstageofdevelopment**

(2)PreoperationalThought(36yearsold)

childrenusesymbolsandlanguagemore

unable

to

think

logically,

or

understand

consequences

of

actions

Immanentjustice punishmentforbaddeedsisinevitable

Egocentric viewofthemselvesascenterofuniverse

PhenomenalisticCausality onethingcausesanother(thundercauseslightning)

AnimalisticThinking endowphysicaleventsandobjectswithhumancharacteristics

SemioticFunction canuseasymboltostandforsomethingelse

(3)ConcreteOperations(710yearsold)

childrencanoperateandactontheconcrete,real,andperceivableworldofobjectsand

events

developmorals

Operationalthought childrencannowseethingsfromsomeoneelse'sperspective(replaces

egocentricthought)

SyllogisticReasoning logicalconclusionisformedfromtwopremises(ieifyouknowthat

horses

aremammals,andthatallmammalsarewarmblooded,thenhorsesarewarmblooded)

Conservation althoughshapeofobjectmaychange,itisstillthatobject(ieballofclayis

smooshedout,youstillknowitisclay)


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Reversibility understandrelationshipbetweenthings(iewatercanbecomeice,andthen

becomewateragain)

**Youknowyouarestillinpreoperationalstageiftheyhavenotcompletedconservationor

reversibility**

(4)Formal

Operations

(11

years

old

to

end

of

adolescence)

thinkingisabstract(politics,religion,ethics),abilitytoreasondeductively,defineconceptsand

skillsfordealingwithpermutationsandcombinations

HypotheticodeductiveThinking enablespersontomakehypothesisandtestit

DeductiveReasoning generaltospecificreasoning

InductiveReasoning specifictogeneralreasoning

StagesinSocialDevelopment(EricErickson'sStagesofSocialDevelopment)

stressedimportanceofchildhoodeventsandexperienceduringadulthood

Youhavetoworkthougheachofthe8stagesofepigeneticprincipals.Youcaneitherhavea

healthy

ornothealthyoutcome;ifyouhaveanunhealthyoutcomeyoucan'tmoveontothenextphase

oryou

canhaveregression

EpigeneticPrincipal developmentoccursinsequential,definedstages,andthateachstage

mustberesolvedinordertomovetothenextstage

PsychosocialStages

Phase1:Trustvs.Mistrust(Birth 1yearold)

Toget babyreceiveswhatisoffered,andelicitswhatisdesired

infantistakingintheworldthroughitsmouth,earandeyes

development

of

trust

is

from

mother

and

mother

anticipating

its

needs

Phase2:Autonomyvs.ShameandDoubt(13yearsold)

dependentonamountandtypeofcontrolthatparentexertsoverchild(Can'tbetoomuchor

toolittle)

canhaveproblemssuchasOCD,inflexibility,etc

Phase3:Initiativevs.Guilt(35yearsold)

OedipusComplex:competingwithparentofsamesexforaffectionsofoppositegenderparent

childisactive,developingmotorskills,etc

starttohaveadultherorolemodels

canhaveproblemswithconversion,inhibitionorphobias

**Phase

4:

Industry

vs.

Inferiority

(5

11

years

old)**

takingprideinlearningnewskills

sociallyisthemostimportantstage

Phase5:Identityvs.RoleConfusion(1121yearsold)

adolescentispreoccupiedwithquestionofidentity

problemswiththisstagecanresultinrunningaway,criminalbehavior,andsexualrole

confusions

Fidelity faithfulnesstoideologythatprovidesaversionofselfinworld


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Phase6:Intimacyvs.Isolation(2140yearsold)

abilitytohonorcommitmentstoconcreteaffiliationsandpartnerships,evenwhenthat

requires

sacrificeandcompromise

Distantiation readinesstorepudiate,isolateandifnecessarydestroythoseforcesandpersons

whoseessence

seems

dangerous

to

one's

own

Phase7:Generativelyvs.Stagnation(4060yearsold)

concernforestablishingandguidingthenextgeneration

Phase8:Integrityvs.Despair(60death)

acceptingresponsibilityforaperson'sownlife

"Healthychildrenwillnotfearlifeiftheireldershaveenoughintegritytonotfeardeath"

StagesinMoralDomains(Kohlberg)

Kohlbergstudiedchildrenviaaskingtheirreasoningandjudgementinaseriesofstorieswhere

charactersfacemoraldilemmas

youcan'tskipstages

Level1.PreconventionalReasoning(ages410)

goodandbadareinterpretedintermsofexternalrewardsandpunishment

Stage1HeteronomousMorality

Rulesarefixedandabsolute.Moraldecisionsarebasedonfearandavoidanceofpunishment

Example,Idonottakemysistersbikebecausemydadwillbemadatme.

Stage2Individualism,Purpose,andExchange

childrenpursuetheirowninterestsbutletothersdothesame.

Theyreasonthatiftheyarenicetoothers,otherswillbenicetotheminreturn.

Example,Foracookie,Iwillpickupmytoys.

Level2.ConventionalReasoning(ages1013)

Individuals

apply

external

standards

(i.e.,

standards

set

by

parents,

government,

etc).

Stage3MutualInterpersonalExpectations,

RelationshipsandInterpersonalConformity

Childrenandadolescentsoftenadopttheirparentsmoralstandardsandattempttoliveupto

social

expectationsandrolesbybeingniceandconforming.

"goodboygoodgirl."

Example,Ikeepmydeskcleanbecausemyteacherlikesit.

Stage4SocialSystemsMorality

focusonmaintaininglawandorderbyfollowingtherules,doingonesduty,andrespecting

authority.

Example,IraisemyhandwhenIhaveaquestionbecausethatisoneoftheclassrules.

Level3.PostconventionalReasoning(adolescencetoadulthood)

thehighestlevelofmoraldevelopment.Individualsrecognizealternativemoralcourses,

exploreoptionsandthendecideonapersonalmoralcode.

Stage5 SocialContractorUtilityandIndividualRights

Rulesoflawareimportantformaintainingasociety,butvalues,rightsandprinciples

transcendthelaw


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Example,Ipaytaxesbecauseitisthelaw.

Stage6UniversalEthicalPrinciples

peoplefollowtheseinternalizedprinciplesofjustice,eveniftheyconflictwithlawsandrules

Example,Ipaytaxesnotbecauseitisthelawbutbecauseitistherightthingtodo.

Stages in Psycho Sexual Development (Freud's Stages of CognitiveDevelopment)- Person is constantly trying to get pleasure from different areas (depending onwhat phase they are in). If they are to move on to the next phase they must haveconflic t resolution or else they can't move onto the next phaseFreud's Phases of Psychosexual Development- id, ego, superego, drives, instinctOral (Birth - 1 year)- child focusing libidinal and aggressive energy toward oral pleasure zones (likessuckling, but trying to control aggressive urges to bite)

Anal (1-3 years old)- need to develop autonomy from caregiver and more bodily control

Phallic (3-5 years old)- focus on play and genitalia- Oedipal complexLatency (5-11 years old)- diminished sexual drive, and focused on social relationsGenital (11 and above)- physiological changes associated with puberty- renewed interest in sex and in the other gender

Developmental Snapshots

Infancy (Birth - 18 months)Birth- Normal baby = 7-7.5 lbs and 19-21 inches long- grows more than any other time in life- completely dependent on caregiversGoals: (1) Secure attachment (2) Regulation of sleep wake cycle (3) Creation offeedingpattern2 Months +- baby smiles and parents respond, which promotes bondingErickson's: Trust vs. Mistrust Stage - inconsistent parents can lead to mistrust in

baby6+ Months- child resolving oral gratification (suckling), but learning to not bite- a child to adequately resolves these conflicts can give and receive from others,trustothers, and experience self reliance. Person who doesn't resolve these stagesmay bedependent, low self esteem, envy and jealousy


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Piaget's Sensorimotor Stage - baby uses motor skills to explore, make sense of theworld,and develop schema

Toddler(18months36months)

motor

skills

develop:

run

and

climb

stairs

abilitytosolveproblemsontheirown

symbolicandmagicalthinkingdevelops

Erikson'sAutonomyvs.Shame&Doubt

exploreenvironmentanddevelopbetteranalsphinctercontrol

Mahler'sRapprochementstage

separationindividuationoccurs

Freud'sAnalPhase

needtoseparateanddevelopautonomyfromparent;greatercontrolofbodymovements

TransitionalObject helpschildrenmaketransitionfromdependenceoncaregiverto

independence;normal

PreoperationalStage

childrenfunctionatprelogicalstate

Prelogical can'tuselogictomakeconclusions

ConservationofMass(Piaget)

childisaskedwhatcupofwaterhasmorewaterinit,eventhoughbothglasses

hasthesameamountofwater.Thechildwillchoosetheglassthatislarger

ImportantBladder&FecalControlMarkers

Preschooler(3years 5years)

growthisslowed

bladdercontrolisgainedby30months(almost3yearsold)

develop

cooperative

play,

and

learn

to

work

with

others

magicalthinking

childdevelopssexualurgestowardsparentofoppositesexandcompeteswithsamesex

parent

moralsenseofrightandwronghasdeveloped

learnaggressiveimpulsescanbeconstructivelyexpressed

Piaget'sPreoperationalStage continues

EricksonsInitiativevs.Guilt

candevelopinitiateandcompetenceifallowedtoexploreenvironmentandinitiate

meaningful

motorandintellectualactivities

Freud'sPhallicPhase curiosityaboutbody(genitalia)functions

OedipalComplex seeksrelationshipwithparentsofsamesex.Eventuallygetsresolved

CastrationAnxiety fearoffathercastratingson(bychild)

Egocentrism everyeventisperceivedtooccurinrelationtothechild

SchoolAge(5years 12years)

growthratesareequaluntilage9,whengirlsgrowfaster


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magicalthinkingfades

canfocusfor45minforschool

seekpraisefromotheradults(teachers,coaches,etc)

moreimportanttogetvalidationfrompeers

seekrolemodelssuchassuperheros

EricksonsIndustry

vs.

Inferiority

childseeksvalidationfromsucceedinginschool,socialinteractionstodevelopconfidenceand

industry.Otherwise,thechildfeelsinferior

Piaget'sConcreteOperations

developlogicthatisusedtosolveproblems

Freud'sLatencyPhase

diminishedsexualdrive

However,childrenstillmasturbateanddohavesexualurges

Conservation

quantityremainsthesamedespitechangesinappearance

Adolescence(1218yearsold)

developmentofsenseofidentityandselfrelianceandlessdependenceonparentsthatwill

allowtransitiontoadultrolesandresponsibilities

failureofsuccessfullycompletingthesestagesleadstorolediffusion(identityconfusion)

wheretheadolescencedoesn'tknowhisorherroleintheworld

Puberty periodofadolescencethatresultsinsexualmaturation

Adolescence periodfromonsetofpubertytobeginningofadulthood

Telearche breastdevelopmentinfemales

Pubarche pubichairdevelopment

Menarche onsetofmenses

Adrenarche adrenalcortexsecretesandrogens

Piaget'sFormal

Operations

useabstractconcepts,problemsolving

Freud'sGenitalPhase

renewedinterestinpleasurefromexcretoryactivity

Erikson'sIdentityvs.RoleDiffusion(1220years)

developsenseofidentitywithrespecttoselfandsocietywithaclearrole

******************************************************************************

*******

Learning

2.Beabletodeterminewhetherornotadevelopmentaldelayispresent,andwhenthereisa

need

for

intervention.

3.Knowclassicalandoperantconditioningtheories,includingwhicharemosteffectiveforchild

discipline/parenting. Inparticular,befamiliarwiththefollowing:

a.PositivereinforcementbehaviorincreasedbyrewardChildincreaseshisbehavior

towardhisyoungerbrothertogetpraisefromhismother

b.Negativereinforcement behaviorisincreasedbyavoidanceorescape,Child

increaseshisbehaviortowardhisyoungerbrothertoavoidbeingscolded


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c.Punishment behaviordecreasedbysuppression,Childdecreaseshishittingbehavior

afterhisotherscoldshim

d.Extinction behavioreliminatedbynonreinforcement,moreeffectivethan

punishment,behaviormaybeincreasedbeforeitdisappears,Childstopshittingbehavior

whenthebehaviorisignoredbyhismother

e.Unconditioned

stimulus

automatic

response

without

having

to

be

learned

produces

response,odoroffood,injection

Conditionedstimulusproducesresponsefollowinglearning,soundoflunchbell,siteof

thenursethefollowingmonth

f.Unconditionedresponse naturalreflexivebehaviorthatdoesnothavetobelearned

/conditionedresponse,cryinginresponsetoinjection,cryingwhenseeingthenursethe

followingmonth

g.Stimulusgeneralizationnewstimulusthatresemblesconditionedstimulusresultsin

conditionedresponse,firebellmakeyoudrool

h.Discriminationreferstotherecognitionandresponsetodifferencesbetweensimilar

stimuli(tellingthedifferencebetweencowanddog allarefourlegged)

i.Primary/secondaryreinforcers

Reinforcer is anything that maintains a response or increases its strengthPrimary reinforcers are independent of previous learning (e.g., the need for food)Secondary reinforcers are based on previous learning (e.g., getting money for mowingthe lawn).- Interestingly, continuous reinforcement, or reinforcement of every response, leadsto rapid acquisition, but not maintenance, ofbehavior. On the other hand, partialreinforcement, or reinforcing a behavior intermittently, is most effective inmaintaining a behavior (thisresearch comes from gambling - and doesn't refer to punishment)

4.Knowthedefinition,dimensions,andcategoriesoftemperament(e.g.,easy,difficult,and

slowtowarmup).

Types of Children TemperamentsEasy children tend to adapt quickly to change, have predictable eating and sleepingpatterns, and are usually positive.Difficult children have trouble adapting to change, have unpredictable or irregulareating and sleeping patterns, and tend to be more negative


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Slow-to-warm-up children are initially similar to difficult children, but they are able toadapt and improve as they become more comfortable in the social environment- As adolescents, easy children are at lowest risk for psychological problems,diff icult children are at highest risk, and slow-to-warm-up children have amoderately increased risk.

5.Knowthedefinitionandtypesofattachment(e.g.,secure,insecure/avoidant,

insecure/ambivalent),whatinfluencesattachment,andgoodnessoffit.

AttachmentAttachment - relationship an infant develops with caregiversTypes of At tachment- there are several types of attachment: (1) Secure attachment, (2)Insecure./Avoidant Attachment,and (3) Insecure/Ambivalent AttachmentSecure attachment - determined by maternal sensitivity and responsivenessInsecure Attachments- the type of insecure attachments is determined by the infants

temperamentGoodness of fit - interaction between parent and child in terms of motivation and styles

of behavior

Death,Dying,andGivingBadNews

1.KnowthestagesofgriefasdescribedbyKublerRoss,aswellascommonmanifestationsof

griefinadultsandchildren.

Stages of Dying (Kubler Ross) ~ all of these are normalDeath arrives bringing grave adjustemnts

1. Denial- People repress conversation, deny physician's verdict- Only when denial becomes dysfunctional that the doctor should confront2. Anger- Health care professionals get little training in dealing with anger- Important to LET IT BE- Anger of patient and loved ones is valid- Do not get defensive, and seek to find out what you can do to meet the needs ofthepatient3. Bargaining

- Gives illusion of control in a situation in which one is powerless- Physicians can accept bargains that do not compromise the patient care4. Depression/grieving- Normal to have depression, but important to make sure it is not clinicaldepression5. 5. Acceptance of Death- few patients reach this point- Usually exhaustion and advancing organic brain dysfunction


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CHILDREN

Longergrief

Abilitytoexperienceintenseemotionlimited

Thinkaboutlossimmediately

Lossofspeech,diffusedistress(youngerthan2)

Dysfunctionin

eating,

sleeping,

bowel,

bladder

(5

yo)

Phobic,hypochondrial,withdrawn(schoolage)

Behaviorproblems(adolescents griefaslongasadults))

2.Knowhowculturalattitudesinfluenceindividualgriefreactionsandhowtoapproach

individualsfromdifferentcultureswhoaredealingwithdeathanddying.

Have to be sensitive to culture; some cultures want doctor to deliver bad news, whileothers want family members to deliver bad news

- Important to use interpreter (if not fluent in native language), even though familymembers maybe bilingual- Most important: Communication skills must be practices, implemented, andobserved with feedback- Important for doctor to respect patient's wishes (autonomy), even if it clashes withdoctor's own beliefs about disclosure- Important to respect patient's right to choose- Nondisclosure occurs most frequently w ith cancer; especially when there is abad outcome expected- Cases illustrate where physician wants to tell patient, but patient family tells doctor to

NOT tell patient because of cultural practices and beliefsFor the case regarding the Chinese male:- Important to allow patient to die in his home country, children to do their duty andprotect elder from bad news, and for resident to be relieved from burden of lying or notdisclosing information about patient to the patient; normal to not tell patient he or sheis dyingFor the case regarding the Georgian male:- Patient may be more likely to commit suicide because of disgrace of not being able totake care of family; normal to not tell patient he or she is dying

3.Identifycharacteristicsofnormalandcomplicated/pathologicalbereavementforadultsand

children.

Normal vs. Complicated BereavementNormal Bereavement- when person can accept the death of a person and let go of memories andexpectations of deceasedpersonComplicated Bereavement- person is unable to fully comprehend or work through the loss


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Problems that Can Arise with Complicated Bereavement(1) Introjection - wholesale enactment of traits of a lost loved one(2) Identification - bereaved persons wear clothing or adopt mannerismsbelonging to theDeceased

4.Knowhowtodeliverbadnewsappropriately,includinghowtodeliverbadnewsto

individualsfromdifferentculturalbackgrounds.MakesureyouknowtheSPIKESprotocol.

Six Stages of SPIKE(1) Setting up the InterviewRehearse what you will say and how you will respond to questionsHelpful guidelines

Arrange for pr ivacyInvolve significant others

Arrange for pr ivacy

Involve significant othersSit down - relaxes patientMake connection with patient - eye contact, touch patient armManage time Constraints - let patient know if you have to be somewhere or that youexpect your pager to beep(2) Assessing the Patients Perception

Ask opened ended questions to see what the patients perception is of the medicalsituation"What have you been told about your medical situation?""What is your understanding of the reasons we did MRI?"You can correct misconceptions

(3) Obtaining the Patients InvitationYou need to ask patient if they want all information about diagnosis or don't wantitIf patient doesn't want to know, offer to answer questions that they may have in future itheychange their mind

Ask the patient, "How would you like me to give you the information about the testresults"(4) Give Knowledge and Information to PatientTell patient in layman's termsDon't be too blunt

Give information in small chunks and assess how they are understanding itDon't say, "There is nothing else we can do for you"(5) Address the Patient's Emotions with Empathetic ResponsesIf necessary ask patient what their emotions are (may not always be clear)MethodObserve for any emotion from patientIdentify emotion from patientIdentify the reason for emotion (usually from bad news)


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After letting patient express feelings, express empathy by making a connectingstatement(6) Strategy and SummaryPatients who have plan for future are less anxious

Ask patient if they are ready to talk about future plans for dying

Ask pat ient to express thei r fears: worried about family, loss of job, pain andsuffering,hardship on othersUnderstand what the goal of the patient is : symptom control, making sure get bestpossibletreatment

CopingStyles,DefenseMechanisms,andPersonality

1.Knowthedefinitionsofthevariousdefensemechanisms,beabletoidentifythemostmature

defensemechanisms,andbeabletorecognizethemanifestationsofdefensemechanisms. We

recommendyou

try

to

come

up

with

examples

of

each

to

help

you

remember

them

better.


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2.Knowthedefinitionofcopinganddifferenttypesofcopingskills. Beabletoprovide

examplesofeach:

a.Conscious/unconscious

b.Healthy/unhealthy

c.Cognitive/behavioral

Coping responses to stress


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- one particular coping st rategy may be effective in one situation, but it doesn'tmeanit's effective in all situations

A coping response to stress can be:(1) Cognitive and or Behavioral in nature

Cognitive- change the way that you think about the situationExamples of Cognitive Coping Strategies:- Changing the way you think- Humor

Cognitive reframing - looking at the positive side Perspective taking - understanding someone else's perspective Generating a plan of action to solve a problemBehavioral - techniques you can physically do to mediate the effects of stressExamples of Behavioral Coping Strategies:- Mediate- Progressive muscle relaxation

- Going or walk- "Blowing off steam taking one's anger outslamming a door hard, but this canactually increase anger and aggression- Listening to soothing musicDefense Mechanisms - largely unconscious reactions that protect a person fromunpleasant emotions such as anxiety, guilt, threats to self-esteem, aggression, dejection(depression)- You can have some conscious awareness about using defense mechanisms- defense mechanisms are not necessarily considered abnormal or pathologic, itdepends on how they are used and can be thought of in terms ofthe degree of maturityExamples of Defense Mechanisms Strategies:- Humor- Altruism- Denial(2) Conscious or Unconscious level(3) Healthy/adaptive or unhealthy/maladaptive- Examples of healthy/adaptive responses include: physical exercise, seekingsupport (benefiting), meditation

Examples of unhealthy/maladaptive responses inc lude: self-indulgence(overeating, drugs, alcohol, excessive spending), aggression, striking out at others,giving up, and blaming yourself; but these are not absolute(overeating, drugs, alcohol, excessive spending), aggression, striking out at others,giving up, and blaming yourself; but these are not absoluteThere are some situations in which giving up is a good thing: such as giving up in anonconstructive relationship

3.Knowthecharacteristicsofdifferentpersonalitytraits,andrecognizehowthesetraitsare

manifestedinthephysicianpatientrelationship.


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PatientEducation,Compliance,andChange

1.Knowthetenetsofthetranstheoreticalmodel,including:

a.the

stages

of

change

b.basicprinciplesofmotivationalinterviewing

c.techniquesforhelpingpatientsineachstageofbehaviorchange

2.Usingtheprinciplesofthetranstheoreticalmodelandmotivationalinterviewing,determine

appropriatephysicianresponsestopatientsinvariousstagesofchange. Thismeansthatyou


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willneedtoanalyzethephysicianresponsesbasedontheunderlyingconceptrepresentedby

eachresponse,NOTonthewaytheresponsesounds.

MOTIVATIONALINTEVIEWING

Expressingempathy

Developingdiscrepancy

Rollwithresistance

Supportselfefficacy

3.Knowthefactorsassociatedwithtreatmentcompliance,aswellasthefactorsassociated

withtreatmentnoncompliance.


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4.Knowwhatinformationshouldbesharedwheneducatingpatients,aswellashowto

effectivelyprovidepatienteducation.

Givept

multiple

forms

of

info

Usesimplelanguage

Startwiththemostimportantinfo,likediagnosis

Talkaboutmedications

Followup

HumanSexuality

1.Knowthephasesofthenormalsexualresponsecycle,includingtheappropriateorderof

events

and

the

mechanism

of

action

for

each

phase.


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2.Knowthevarioussexualdisorders,including:

a.Hypoactivesexualdesire

b.Sexualaversiondisorder

c.Femalesexualarousaldisorder

d.Male

erectile

disorder

e.Orgasmicdisorder

f.Prematureejaculation

g.Vaginismus

h.Dyspareunia

Sexual Dysfunct ion in Men**most common causes are combo: somatic and psychological elements, withpossible primary andsecondary etiologies**- **Most common erectile dysfunction psychological causes: anxiety, guilt, anger

towards sexual partner **Premature Ejaculation - ejaculation that occurs before it is desire, without reasonablecontrol over timingof ejaculation- **plauteau phase** of sexual response cycle is short or absent- might be related to diminished serotonergic neurotransmission and 5-HT2C or 5-HT1AreceptordisturbancesSpectatoring - male is performing, and not being emotionally involved, so can'tejaculateInhibited ejaculation - can be: psychological, biological (spinal cord injury, MS, severe

diabetes, drugsthat inhibit adrenergic innervation, etc)Sexual Dysfunction in Women- **men are more likely to seek help for sexual dysfunction than women**Orgasmic disorder: occurs in both men and women; can't have an orgasm, and can belifelong oracquired; Lifelong: has never had an orgasm; Acquired: is currently unable to achieveorgasm despiteadequate stimulationFemale Sexual arousal disorder: inability to maintain vaginal lubrication until sex act iscompleted

despite adequate physical stimulationDyspareunia - pain during sexual intercourse; can be due to psychological orphysiological reasonssuch as: PID, insufficient lubrication, thinning of vagina during menopause, scarringfromepisiotomies,etcVaginismus - involuntary contraction of pubococcygeus muscles surround outer 1/3 ofvagina; easily


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treated with education, counseling, behavioral exercises that involve insertion of largerdilators intovagina; many patients have a history of dyspareunia**the majority of unconsummated marriages results from vaginismus**Sexual Aversion: aversion to sexual activities which can result from many things such

panic disorders,sexual phobias, sexual victimization, rape, etc; treatment with anxiolytic (anti anxiety)medication &brief psychotherapyHypoactive Sexual Desire Disorders- can effect both male and female- can stem from OCD, and anhedonia (symptom of depression - can't experiencepleasure fromactivities that you previously found pleasurable), diabetes, no longer attracted topartner, powerstruggles, etc

**Anxiety d isorders, mood, and substance abuse must be treated before orconcomitant withtreatment for hypoactive sexual desire**

3.Knowthevariousparaphilias,including:

a.Exhibitionism

b.Fetishism

c.Frotteurism

d.Pedophilia

e.Sexualmasochism

f.Sexualsadism

g.Voyeurism

h.Paraphiliasnototherwisespecified


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4.Recognizetherangeofnormalsexualfunctioningintermsofsexualorientationandbehavior

throughoutthelifecycle.

Normal Variations in Sexual behavior- It is normal for both males and females to have nocturnal arousals, but it is morenoticeablein men- It is normal for sexual function to diminish with age:- Male sexual function peak in 20's; refractory period increases in 30's (Teens: 20-30min; 3 hours-3


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days in 70 year old men)- women sexual function peak in 30's or 40's, and decline in 50's (menopause)- Masturbation in both males and females is normal, and includes the use of sexual toysas beingnormal

- Having sexual fantasies (which usually begins in teens), is normal, but decreases withmiddle age

5.Identifytheriskfactorsassociatedwithsexualorientationandbehavior(forexample,

sexuallytransmittedinfections,tobaccouse,etc),includingrecommendationsforscreeningand

preventativepractices.

Male Homosexuals- Men who have sex with men are at high risk for:

- HIV, particularly black and Hispanic men, and younger gay men- STDs indicates high risk for sexual practices and can help spread HIV- Gonorrhea & gonococcal urethritis - with chlamydial infection- Syphilis - large increase in infections, particularly in homosexual men- HSV-2 (Herpes)- infection with HSV might facilitate spread of HIV- HPV - might increase anal cancer risk; homosexual men have higher rates of analcancer- Higher rate of anal cancer- Hepatitis A & Hepatitis B - most homosexual men are not immunized for these- Psychosocial Disorders - homosexual men have higher rates of depression, anxiety,mood disorders,

suicide, eating disorders, alcohol, substance abuse and smokingScreening GuidelinesThere are not an official set that is universally accepted, so this just includes all of them- physicians should ask patients about their sexual history in a nonjudgmental way, andchanges in sexualpractices- homosexual men should be assessed for risk for HIV infection- CDC recommends more frequent STD screening for high risk homosexual men(multiple partners, useillicit drugs)- Vaccinations for Hepatitis A & B

- Rectal screening- Serological tests for Herpes-2 (HSV-2)- PAP smears- screen for psychosocial problemsFemale Lesbians**Never assume that lesbians have never been actively sexual with men**- lesbians are less likely to get STD testing than heterosexual women- lesbians should stil l be screened for violence in relationships


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- women who had same sex attraction were significantly more likely to have suicidaltendency, engage inself harm vs. heterosexual women- risk for ovarian cancer is higher in lesbians because they are likely to have lowparity, low

exogenous hormone use, smoking, higher BMI (factors that increase risk for ovariancancer), but nostudies have been performed to determine ACTUAL risk of ovarian cancer in lesbiansvs. heterosexualwomen- smoking is higher in lesbian populations- Lesbians are more likely to have high BMI, waist to hip ratio- Lesbians are more likely to engage in regular exercise**No proven increase in risk of cardiovascular disease among lesbians andbisexual women**- risk of breast cancer is debated and unknown

- alcohol use being higher in lesbians vs. heterosexuals is debated- Rates of drug use in lesbians vs. heterosexuals is debatedSTDs transmitted between women: Herpes, HPV, TrichomoniasisTheoretically t ransmitted between women: Chlamydia, Gonorrhea, syphilis, HepatitisB, HIV, bacterialvaginosis

AlcoholUseandMisuse

1. Knowthediagnosticcriteriaforalcoholabuseanddependence. Youshouldknowthe

symptomsforeachdisorderandthenumberofsymptomsrequiredtoestablisha

diagnosis. Youshouldalsobeabletodistinguishbetweenthetwodisorders.


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2.Knowthedefinitionofatrisk,moderate,andbingedrinking. Toclarifythequestionin

classregardingbingedrinking,usethefollowingdefinition: drinkingenoughalcoholtobring


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thebloodalcoholto>0.08gram%,whichusuallycorrespondsto>5drinks(formen)or>4

drinks(forwomen)in~2hours.

ALCOHOL

Use Abuse Dependence Binge drinking At risk

Moderatedrinking

Decreased

CHD,reduction in

all cause

mortality,MI

Maladaptivepattern of use

with on e or

more criteriaover a one-

year period

Leads tosignificant

impairment or

distress

Progressive chronicdisease

Genetic disease and

other factors

Consumingenough

alcohol to

get 0.08over 2h

5 for M 4 for W

W: no more

than 1 a day M: no more

than 2 a day 3-4 drinks

per week

1 +

OSLDRepeated

alcohol,inability to fill

obligations

Repeatedalcohol with

dangerous

activityDrinking

despite legal

problemsDrinking

despite social

or

interpersonalproblems

3/7 in last 12 months

TWIP CDo Toleranceo Withdrawal, dry

drunko Impaired control

over drinking,larger amounts

o Preoccupationo Continued use

despite adverse

consequences

o Can't cut downo Activities given up

o Distortion in

thinking, denial


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3.KnowtheFRAMESmodelforbriefintervention,includinghowtoapplytheconceptstoa

clinicalscenario.

Brief interventionrestricted to 4 or less sessions, each session lasting from a fewminutes1 hour, and is designed to be conducted by health professionals who do not

specialize in addictions treatment**brief intervention for alcohol problems is more effective than no intervention,and as often as effective as more extensive intervention**- brief intervention can help non-alcohol dependent patients reduced theirdrinkingFRAMES: Feedback, Responsibility, Advise, Many of Strategies, Empathy, and SelfEfficacyFeedback- tell patient the impact of drinking on their life i.e. hypertension, etc.- share medical consequences of their drink ingResponsibility of the Patient

- emphasize patient responsibility and choice for reducing drinking, no one can makeyou change or make you decide to change. What you do about your drinking it up toyou

Advice to Change- professionals could give patient explicit advice to reduce or stop drinkingMenu of Ways to Reduce Drinking- giving patients a variety of strategies to choose from: pacing, avoiding drinkingsituations, learning to cope with problems that may lead to excessive drinkingEmpathetic Counseling Style- using empathy instead of confrontational approach helped reduce patient drinkingmore

Self-Efficacy or Optimism the Patient- encourage patient to rely on their own resources to bring about change, motivationenhancing techniques

Establishing A Drinking Goal- patient more likely to change thinking behavior when they are involved in the goalsettingFollow-Up- follow-up on patient progress and can be in the form of telephone calls, repeated officevisits, or repeat

physical examinations, lab testsTiming- actual behavior changes based on studies of smoking cessation

**patients are more likely to make behavioral changes when they perceive thatthey have a problemand when they feel that they can change it**


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4.Befamiliarwiththevariousscreeningtoolsrelatedtoalcoholuse,includingtheappropriate

scoring,interpretation,andrecommendedpopulationforeachinstrument(CAGE,AUDIT,

MAST,TACE). Youshouldalsoknowthepurposeofascreeningtool,includingthedefinitions

ofsensitivityandspecificity. YouareNOTexpectedtomemorizethesensitivitiesand

specificitiesofeachscreeninginstrument,butyouSHOULDknowwhichpopulationsaremost

appropriatefor

their

use.

Screening- if LIKELY have a disorder

Screening tools Results

Primary care with limited time On any single occasion during the past 3 months,

have you had more than 5 drinks containingalcohol?

Identifies pt at risk

Annually

CAGE One yes- suggested alcohol problem

More than one yes- strong indicationthat problem exists

AUDIT- alcohol use disorders identification test Use when + CAGE or suspicion

10 questions

8+ harmful, hazardous drinking Useful

o NOT dependent ppl with

problemo Women,minorities,

adolescence,youngadultso NOTgoodforelderly

MAST- Michigan Alcoholism Screening Test

25 questions

6+ problem drinker

Usefulfor

alcohol

dependence

T-ACE 4 questions

Pregnant womenPre-pregnancy risk drinkingmore

than 2 drinks per drinking day

5.Recognizethesigns/symptomsofanimpairedphysician,andidentifystepstotakeifyou

suspectaphysicianisimpaired. Youshouldalsoknowtheprevalenceof,therisksofsuicide

associatedwith,

and

the

prognosis

for

impaired

physicians.

CulturalIssuesinHealthcare

1.KnowhowtocommunicatewithindividualswhohavelimitedEnglishproficiency(e.g.,who

shouldserveasaninterpreter,howtocommunicatewithaninterpreter,etc.)


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2.Beabletoanswerquestionsaboutthemainteachingpointsofthefilm,HoldYourBreath.

Theseinclude: properuseofinterpreterservices,understandinghowanindividualsbelief

systemimpactshis/hermedicalcare,effectivelyintegratingmedicaltreatmentwithan

individualsspiritualpractices,managingfamilyrequeststohideinformationfromapatient,

etc.

Abuse,Neglect,andPartnerViolence

1.Forchildabuse/neglect,knowthefollowing:

a.Signs/symptoms

b.Riskfactors(forvictimsandperpetrators)

c.Epidemiology(e.g.,prevalence,mostcommontype,ageatgreatestriskforfatal

injuries,leadingcauseofchildabusefatalities,etc.)

d.Reportingrequirements

e.Assessment/interventionstrategies

Risk factors Epidemiology Signs Management Reporting

Maternal

smoking More than 2

sibling Low infant wt Low income

Unmarried

Unrelatedadults at home Child disability

Whenalso

spouseabuse

aswell

Maternal

depression

Child


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Risk factors Epidemiology Signs Management Reporting

GENERAL

Increased by ptaggression

Low caregiver

self-esteem Living with

caregivers Caregiver older

Caregiver is a

spouse CAREGIVER

Abuse NOT

increased withstress and anger

Financial and

emotional

dependence ofthe caregiver on

the pt Family violence Abuser

characteristics

are better

predictors ofviolence than

victim attributes Most common:

person they live

with Physical abuse:

male caregiver

VICTIM Lack of person

they can confide

Financial- livingalone, no one to

turn to No sex-

differences Physical, mental

ans functional

ability (ADL)

Underreported

Pt refuse intervention

Prehospital care

personnel- unique to

identify abuse Barriers: fear of

offending pts, victimsblame themselves, fear

of losing caregivers Institutional- same

o Residents mustreceive a written

description oflegal rights andmust be able to

file complaints

with theirombudsmen

Falls

Dehydration

Common

sense...

Interview

together andseparately

Avoid

confrontation

Empathy,understandin

g

Physical

exam

Preservation

offamily

Assure

safetyofpts

Homevisits

Not

requiredStates

must have

a centralagency to

coordinate abuse

complaint

s


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Physical- olderwho cannot do

ADL Neglect- no one

to turn for help,

poor health,living alone

Verbal,physical- living

with someone

3.Forintimatepartnerviolence,knowthefollowing:

a.Signs/symptoms

b.Riskfactors(forvictimsandperpetrators)

c.Epidemiology(e.g.,prevalence,timeofgreatestrisktothevictim,etc.)

d.Screeningrecommendations


Risk factors Epidemiology Sings Management Reporting

All races,SES, religion

Victim:

female,young,

unmarried,

low income,

uninsured,childhood

maltreatant,

pregnancy

1/4 Americanwomen will be

physically

assaulted/aped bypartner

Increased

gynecologic, GI,

CNS,musculoskeletal,

cardiac

complaints

Morelikelyto

accessoutpatient

primarycare,specialtycare,ED,

mentalhealth,

substanceabuse

services

$4bln/year

Headache,dizziness, chest

pain, palpitations,

back pain, nausea,indigestion,

stomach pain,

diarrhea,

constipation,pelvic pain,

dysreupenia,

insomnia,depression,

anxiety, PTSD,

suicidalidealization

Routinescreening

New pt

AnnuallyStart with

general

statement,

then directly

Validate her

experience

Assess safetyOffer

resources

Moststates do

not

requireunless

injury

with knife

or gun


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DifficultPatients,Transference,Countertransference,andProfessionalBoundaries

1. Knowthedefinitionsoftransferenceandcountertransference. Beabletorecognizeexamplesofeach.

Transference ptisremindedofsomeonefromthepastwhenadoctorwalksinthe

room

Countertransference doctorexperiencesit

2.Knowthedefinitionofempathy,andbeabletorecognizeappropriateexpressionsof

empathyinthedoctorpatientrelationship.

3.Know

the

common

manifestations

of

difficult

patients

and

describe

appropriate

interventionsandstrategiesforworkingwiththeseindividuals,includingpatientswhoare:

a.Angry

b.Seductive

c.Noncompliant

d.Complainingaboutotherphysicians

e.Inpain

f.Mentallyill

g.Hospitalized

See

the

attachment

4.Recognizeappropriateboundariesforthedoctorpatientrelationship,anddescribe

appropriateresponsestopotentialboundarycrossings/violations. Payspecialattentiontothe

following:

a.Sexualboundaries

b.Dualrelationships

c.Giftsandservices

d.Selfdisclosure(includingreligion/prayingwithpatients)

e.Physicalexamination

f.Physicalcontact

Maintaining Professional & Ethical Boundaries- It is important to define and maintain professional boundaries- Definit ion of if a violation of a boundary has occurred is if **harm to a patienthas occurred****Clear communication is the most important way to maintain boundaries**Sexual Relationships- Sexual relationships between physicians & patients is always a boundary violation


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- Usually preceded by nonsexual boundary violations, so it is important to be attentive tononsexual boundaryissues so that it doesn't develop into sexual ones- Do not engage in a sexual relationship with a patient- If a patient is a FORMER patient, it is more difficult to assess whether or not it is okay.

For example, ifthe one time patient was in the ER, and you saved his/her life, then it is unethical toengage in sexualrelations because the patient may idealize, and be dependent on the physicianDual Relationships- Avoid treating friends and family members because it can undermine the physiciansability to focusobjectively on t reating the patient-**Prior ity of doctors is to do what's best for the patient**Gifts & Services- In the past, it was normal to barter with physicians for services; it is not as common

now- Be careful if a patient offers to barter with services such as babysitting, doingpaperwork, etc for aphysician. Kindly decline the patients offer.- Gift giving may be an unconscious bribe by the patient, and often there is a secret orexplicit expectation ofsome reward or acknowledgement involved in performing services are bestowing aguest; the same can applyto doctorsSelf Disclosure- The physician should not talk about his or her personal life, as it may make thephysician seem needy to the patient or it can use the patient to satisfy the doctorsown needs for comfort or sympathyThe Physical Examination- Always have a chaperone in the room with the physician & patient, especially if thedoctor is conductinga pelvic exam, or if the patient has a history of sexual abuse, anxiety or psychiatricdisorder, litigious patient,or any new patientPhysical Contact- Shaking hands of patients is generally accepted as appropriate- Hugging and kissing is not as accepted, and should not be engaged in becausethe patient may have a prior sexual abuse history or may misconstrue the doctor'sintention- Physicians from other countries who may have different local customs about touchingpatients are notabsolved of the physician responsibility of not violating the patient (ie kissing on cheek,etc)

c-1 final exam study guide

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