Exam 1

Question 1

What is the difference between maturation and development?

Answer 1

• Maturation refers to a biological process, whilst development refers to a biological and psychological process by which an organism gains increased independence from its environment

Question 1

What are the signs indicating that attachment trauma has occurred that can lead to psychiatric problems?

Answer 1

• Severe chronic physical and/or sexual abuse - Disorganized/disoriented attachment patterns - Anxiety and depression

Question 2

List the stages of change.

Answer 2

• PCPAMR - P: precontemplation - C: contemplation - P: preparation - A: action - M: maintenance - R: relapse (not technically stage, part of process)

Question 2

In terms of Freud’s Structural Model, what do psychological and behavioral symptoms reflect?

Answer 2

• Compromised made by the Ego, harsh injunctions imposed by the Superego, unrecognized and unmet instinctual drives of the Id

Question 3

What are potential obstacles to a helpful pt/doctor relationship?

Answer 3

• Cooperation - Engagement of pt (active vs passive) - Resistance - Relapse - Not knowing direction pt is moving

Question 3

A developing child is very susceptible to shame and humiliation during which of the following stages or sub-phases of Mahler’s developmental process: A. Symbiosis B. Hatching C. Practicing D. Rapprochement E. Object Constancy

Answer 3

C

Question 3

What are transgender categories?

Answer 3

• Transsexual: person who identifies oneself as a member of biological sex opposite to that assigned at birth. Feel that gender identity and true sex don’t match one’s assigned or recognized biological sex. - Androgynous - Bi-gender: move back and forth between distinct feminine and masculine gender roles - Cross-dresser

Question 4

What is cultural humility? What are the basic tenets?

Answer 4

• Defined as an ability to maintain an interpersonal stance that is open to other people and in relation to aspects of cultural identity that are important to other people. - Tenets: lifelong process of self-reflection, self critique; is not mastery of different beliefs/practices; requires developing respectful partnerships with pts through: patient-focused interviewing; exploring similarities / differences bw one’s own and patient’s priorities, goals and capacities and appreciation for different worldviews hewn from lived experience

Question 5

What does too much attachment lead to?

Answer 5

• Loss of autonomy and freedom - Loss of identity - Inability to move on in face of loss - Dependency based relationships that drag others down

Question 6

Piaget’s stage of development correlating with the “latency” phase in Freud’s psychosexual development is: A. sensory motor B. formal operations. C. preoperational thought. D. logical thought. E. concrete operations.

Answer 6

E

Question 7

What are common concerns from infancy to childhood?

Answer 7

• SIDS - Challenging children (intense negative reactions to new situations) - Sleeping difficulties (1-3 yo separation anxiety and over-indulgence; 4-6 years yo nightmares and monsters) - Masturbation - Toilet training (successful at 30 months) - Enuresis (wetting – primary: never sustained dryness; secondary: wetting after sustained dryness) - Encopresis (bowel incontinence, more serious than enuresis) - School phobia - Learning disorders - Bullying - Overeating - Pica (especially 18-24 months) - Autism spectrum disorders - Red flags: setting fires, violent behavior, cruelty to animals

Question 8

According to Freud’s structural model of the mind, internalization and identification are important processes that play a major role in the development of which of the following: A. the Id B. the Ego C. the Superego D. the preconscious level of the mind E. the unconscious level of the mind

Answer 8

C

Question 10

What are the reaction types that are seen in the patient and physician during a clinical encounter?

Answer 10

• Transference: refers to reactions the pt has to the clinician - Countertransference: refers to reactions the clinician has to the pt

Question 11

Identify factors that are likely to influence pt success with change.

Answer 11

• Affirmation (eg. It says a lot that you took the step in coming here today.) - Intention & Commitment (eg. How much do you want to do this?) - Elicit “change talk” (eg. What worries you about your current situation? What would be the good things about losing weight?) - Express optimism (eg. What personal strengths can you use to help you succeed?) - Summarize (link statements together and reinforce material discussed)

Question 11

Describe changes to thoughts around gender for ages 2-6?

Answer 11

• Age 2 to 5: beginning preference for same-sex play - Age 3: know male and female differences are for life - Age 4: certain toys and roles are seen as more appropriate for one sex than the other - Pre-school: still confusion of sex and gender - Age 6: know which sex is better (their own) and which sex is stupid (the opposite)

Question 12

What are the stages of Kohlberg’s Theory of Moral Reasoning? Briefly explain.

Answer 12

• 1.) Level I: Preconventional a.) Stage 1: Heteronomous morality (around preschool): right (vs wrong) is determined by adherence to external rules. Reason for doing right is avoidance of punishment. b.) Stage 2: Instrumental morality (~ age 7-8): right is determined by acting in one’s own interest and allowing others to do the same. Interest in fairness. Reason for doing right is to serve’s one’s own needs, includes awareness that others have separate needs. No longer dependent on external authority to determine right vs wrong. - 2.) Level II: Conventional a.) Stage 3: Good-child morality (~ 10-11): right is determined by living up to expectations, having good motives and being pro-social (rather than individualistic). Reason to do right is to be good person and to care for others. b.) Stage 4: Law-and-order mentality (~ 11/adolescence to early 20s): right is determined by following law and helping society as a whole. Reason to do right is to promote rules of social group as whole. - 3.) Level III: Postconventional (or Principled) a.) Stage 5: Social-contract reasoning (early adulthood): right is determined by upholding universal values and right with awareness that people hold a variety of values and beliefs. Reason to do right is to abide by social contract that promotes everyone’s welfare. b.) Stage 6: Universal principles (ideal than reality): right is determined by following ethical principles that were self-chosen (rather than societal). Principles override law in case of conflict. Reason to do right is a belief in validity of university moral principles.

Question 13

Describe how gratitude helps build resiliency. How can it be boosted?

Answer 13

• Studies have indicated that gratitude is linked to better sleep, decreased anxiety/depression, increased positive emotions optimisim coping skills creativity and interpersonal skills, decreased pain and fatigue - To boost gratitude, create a gratitude journal, perform acts of altruism and kindness, learn to forgive, invest time/energy in friends and family, take care of body, develop strategies for coping with stress and hardships

Question 13

What are attitudes that contribute to resistance during an interview?

Answer 13

• Arguing for change - Assuming expert role - Criticizing, shaming or blaming - Labeling - Being in a hurry - Claiming preeminence (ie. superiority)

Question 14

What is Carol Gilligan’s contribution to the development of morals in women?

Answer 14

• Kohlberg research that led to his theory of moral reasoning was done with only male participants. - Gilligan argued that women tend to reason more out of a morality of care, that girls are socialized to be nurturant, compassionate and non-judgmental and are reluctant to judge right and wrong in absolute terms. - Subsequent research testing Gilligan’s argument has not upheld any strong gender differences in terms of moral reasoning.

Question 15

In terms of identity development, define following: a.) identity diffusion b.) moratorium c.) foreclosure d.) identity achievement

Answer 15

• a.) identity diffusion = no exploration, no commitment - b.) moratorium = exploration, no commitment - c.) foreclosure = no exploration, comittment - d.) identity achievement = exploration and commitment

Question 16

What are the stages of Mahler’s child development theory?

Answer 16

• 1.) Normal symbiosis stage: 1-5 months, begins with initial awareness that there is something other than self, beginning recognition of mother as need satisfying, infant’s sense of mother and me - 2.) Separation-individualization state: 5 – 24 months with 3 sub-phases - 2a.) Hatching (5-10 months): child perceives mother and explores her facial features, begin to focus on world beyond mother (physical differentiation = separation), comparison of mother to others (stranger anxiety), need to make repeated visual and tactile contact with mother to re-establish sense of safety. Fear here is loss of object (mother), which can lead to loss of self, since separation-individualization is not yet resolved. - 2b.) Practicing (10-16 months): self-initiated locomotion is primary focus of attention, curiosity and exploration, sense of omnipotence and invulnerability, also susceptibility to shame and humiliation, development of separation anxiety (if present). - 2c.) Rapprochement (16-24 months): increased sense of separateness and helplessness relative to mother, child moves away from and back to mother seeking reassurance, need for autonomy, but continued need for re-establishing contact/merger with mother, focus on psychological differentiation = individuation, time of ambivalence in child (wants to be close to mother and away and separate from mother), time of frustration for mother. Feature here is loss of object or loss of object’s love if differentiates AND fear of loss of self if merger with object is maintained - 3.) Object constancy stage (24-36 months): establishing whole object relations (rather than parts), capacity to see positive and negative qualities in self and other, view of other and self is more positive than negative, stable/secure sense of self. Results in capacity to tolerate love and hostile feelings toward the same person, value another for their own attributes (rather than just for gratification), objects not exchanged purely on basis whether they are satisfying or not, absent objects are not hated (instead longed for), maintenance of relationship with object regardless of whether one’s needs are satisfied all of the time. Differentiation is complete (sense of self and mother as separate, but in relationship), soothing and comforting functions of mother are internalized, greater tolerance of mothering substitutes.

Question 17

What are examples of questions that could be asked during a pt interview focusing on behavioral change?

Answer 17

• Greeting, building rapport - How did you decide to make an appt to see me today? (if new pt) - What brought you in to see me today? - This is obviously an area of importance to you. Could we talk about this in more detail? - How long have you been concerned about this? When did it start? - What happened that alerted you to the need to do something about this now? - What are some attitudes and beliefs you have about this that affect the way you think about it? - How have you dealt with serious concerns before in your life? - How might this situation put you at risk in some way? - Are you concerned about your own safety? - As we have talked today, you identified some factors that have contributed to the concern you have. Any change is definitely difficult. Would you like to meet again to further discuss this? Would you like the name of people / places that could be helpful with this situation? - End interview appropriately, attuned to nature and setting of encounter. Pay attention to pts affective state.

Question 17

Infancy. a.) What is the age? b.) What is the major / primary psychological task for the infant? What is the factor that allows for developmental tasks to occur? c.) Describe developmental periods that occur during infancy. What are parental tasks?

Answer 17

• A.) Birth to 18 months - B.) Psychological task: to establish a secure attachment to mother (or caregiver) leading to basic trust. Development tasks require neurological development that allow for attachment to occur. - C.) Establishment of symbiotic relationship (less than 5 months): requires that parents are sensitive and attuned and have capacity to: be aware of baby’s signals, accurately interpret baby’s signals, respond appropriately and promptly. Hatching (5-10 months): attention shifts from inside the symbiotic relationship to outside. Result of maturation and increasing pleasure in all stimulation from outside world. Child has periods of withdrawal into self in sleep and calm pondering. Parents must respect child’s need for quiet, must be neither too intrusive or withdrawn. They must help build confidence given emerging abilities and provide environment conducive to development. Threats is in this periods are fear of losing mother parent that leads to protest, despair and detachment. Good attachment in first 6 months followed by prolonged separation leads to child being depressed. Stranger anxiety seen here when child has developed attachment preferences and has made progress with differentiation. Stranger anxiety requires that infant has ability to remember mother’s face, compare it with another face, realize difference and realize mother is not there. Around 7 months, peek-a-boo is important to helping develop infant’s object permanence. Infant has some control over appearance and disappearance of significant figures, which helps decrease anxiety. Serves as a way to practice separation from parent. Practicing (10-16 months): begins with ability to move away from the mother, ends with ability to walk alone. Infant is developing abilities, coordination through crawling, walking and manipulating. Increasingly able to make things happen on own. There is increased separation from mother during this time, but “powers” are shown to parent by infant. Vacilation between autonomy and mastery, and self-doubt and dependency. Grandiosity, pride and willfulness occurs during this period. Peak of separation anxiety occurs here around 14 months, gradually resolves after. Parents need to: build self-esteem, minimize shame and humiliation. They need to encourage and praise efforts, help child become comfortable with trying and failing short. Parental delight and frustration must be managed. Support dependency needs and encourage new achievements. Don’t be so delighted that center of attention becomes delight. Transitional objects seen during this time, which aids in development of self-soothing. Self Awareness (15-18 months): child develops self-awareness.

Question 17

Describe cognitive development in adolescence.

Answer 17

• Capacity for logical, abstract thought: not attained by everyone, particularly not by end of adolescence. Not used consistently by those who attained it, use rule of thumbs more commonly. Can test hypotheses systematically. More interested in idealism and abstract ideas than practicalities. Passionate ideas arise here about changing world, but logistics go out window. This is promoted by western-style education. IQ rises over time, but thought to be result of improved education in how to think logically.

Question 19

What is the transtheoretical model of change?

Answer 19

• It is an integrative, biopsychosocial model to conceptualize the process of intentional behavior change. It uses Stages of Change to integrate the most powerful principles and processes of change from leading theories of counseling and behavior change – developed from 35 years of research. Results of research funded by over $80 million.

Question 20

What are factors that affect pt cooperation?

Answer 20

• Severity of illness and consequences (when high, more cooperation) - Susceptibility to disease (when high, more cooperation) - Capability of pt: are they capable to perform a particular behavior to reduce risk? - Confidence in treatment: if highly confident treatment will reduce risk, they will cooperate

Question 20

What are common errors in the interview that lead to disengagement?

Answer 20

• Inadvertently shaming, embarrassing or humiliating pt - Finding fault with or blaming the pt - A focus on assessment to the exclusion of relationship - Drawing premature conclusions - Assuming a common understanding - Spending too much time in social chit-chat

Question 20

What are the characteristics of a couple whose styles are secure/secure?

Answer 20

• Each partner functions as secure base for other - Partners are empathetic of other’s needs - Can move back and forth between dependent child and comforting adult - Can openly express needs for comfort/contact, and also receive this

Question 21

According to Mahler’s theory, the individuation process is a major focus of which of the following stages or sub-phases: A. Symbiosis B. Hatching C. Practicing D. Rapprochement E. Object Constancy

Answer 21

D

Question 22

Identify strategies that will help increase amount of happiness experience in life:

Answer 22

• Work/leisure experiences - Finding meaning/purpose - Having relationships - Physical health - Community service/helping others

Question 22

Name the core functions of attachment. Explain.

Answer 22

• Protection/survival (establishing safe haven and secure base) - Regulation of physiological arousal and emotional distress - Development of a sense of self (through mirroring) - Foundation for mentalizing (process of making sense of one’s own mind and minds of others)

Question 23

What causes insecure attachment and indiscriminate attachment behavior? What are these predictive of?

Answer 23

• Causes: infants being reared in institutional settings, disrupted affective communication between parent and infant and particularly disorienting/confusing behaviors on part of parent. - These are predictive of later behavioral problems in a child

Question 24

Which of the following BEST describes the role of physicians in relation to facilitating health behavior change in patients? A. Physicians diagnose and treat illness, not behavior. B. Physicians provide information about the impact of health behavior. C. Physicians require compliance with health behavior plans D. Physicians help patients find motivation to change. E. Physicians tell patients what they need to do.

Answer 24

D

Question 24

Each time you ask the patient about a different time of his life, he goes into a detailed discourse that makes you wonder how relevant it all is. He describes in detail and with over-flowing emotion how his father would take time off from his busy schedule to take him fishing and how proud his father was of him no matter what size fish he caught and how hard it was to go back home realizing it would be a long time before they would be close like that again. He also says that it is important to him that his doctor be available to take phone calls when he needs to talk or has a question, and asks you if that is something you do. Given the above description, what attachment style does this patient exhibit?

Answer 24

• Anxious-ambivalent

Question 25

Childhood. a.) What is the age of this period? b.) What are the major tasks of this period? c.) What are the parental tasks or challenges during this period? d.) What are the developmental achievements of this period? e.) What are the cognitive achievements of this period? f.) Explain changes to moral development to this period. g.) What changes that occur to gender identity and sex role development in this period?

Answer 25

• A.) Age 5-12, kindergarten to sixth grade - B.) To become capable and competent, consolidate developmental gains, learn a body of knowledge and skill (incl physical) and how to apply them with competence. Develop a core of same-sex peer relationships. Develop a positive self concept. Language development, vocab and expression. Get along with others the same age. Learn gender roles. Develop fundamental skills like reading and writing. Learn habits needed for daily living. Conscience development. Management of personal independence. Friendships based on shared values, loyalty and mutual support vs similar interests. Personal sense of accomplishment. - C.) Let go, be supportive, be neither too involved or under-involved. Meet basic needs. Encourage learning and education. Facilitate development of healthy self-esteem. Nurture peer relationships. Provide harmony / stability and safeness and secureness. Add predictability. Don’t take it personally! - D.) Better able to differentiate between fantasy and reality (shifting out of pre-operational stage). Shifting into stage of concrete operations (need to establish and follow rule, thinking is more logical and organized). Accomplishment becomes important. Begins to look to other adults for praise and guidance. Compare their performance to that of other children. For self-development: able to maintain self-regulation and periods of calmness, conscious control over impulses and verbalizations, attention span increases. Memory ability increases. Concentration gets better. Better control of mental processes. Automatization occurs. - E.) Able to classify objects. Able to consider more than one characteristics of an object at same time. Early problem-solving skills develop. Social cognition: comparing self to others via physical attributes, later emphasis on fairness, generosity and kindness; ego-centrism begins to fade, increased ability to take another’s perspective, emphasis on same-sex peer groups. - F.) Consequences of an act, emphasis on rules, moral judgements are influenced by child’s social interactions and circumstances of a situation. Emotional responses and social judgments influence moral decisions. - G.) Establishment of gender-related behavioral patterns (boy vs girl behaviors). Modesty increases. Some same-sex sexual play is not unusual, but covert – more curious than malevolent. Sense of one’s own sexual orientation may begin to evolve.

Question 26

According to Main, how does one determine an individual’s working mode of attachment?

Answer 26

• The mode of attachment pertaining to an individual is observable in characteristic patterns of their narrative presentations obtained through the Adult Attachment Interview.

Question 27

Why are attachment styles important?

Answer 27

• Provides diagnostic data that have clinical relevance and predictive value - Helps navigate complex and difficult relationship both personally and professionally - Can help: minimize emotional needs of pts, minimize pt reactivity and keep office setting a safe place conducive to pt self-disclosure and healing

Question 28

What is mentalizing? What is its function?

Answer 28

• Mentalizing is the process of making sense of one’s own mind and the minds of others. It serves to promote self-expression and empathy.

Question 29

How does one become grounded?

Answer 29

• Demonstrate commitment to quality care - Be trustworthy and communicate timely - Perform heart-centered listening and truth-telling - Have a lack of denial - Be proactive and perform ongoing decision-making

Question 29

Define engagement.

Answer 29

• process by which doctor and patient initiate and maintain an effective working relationship

Question 30

What are the aspects of the mind according to Freud’s Topographic Model?

Answer 30

• Conscious mind: mind that is fully aware and is governed by secondary process, that is rational, logical and cognitive - Pre-conscious mind: mind that is capable of becoming conscious when attention is focused in its direction - Unconscious mind: mind that is repressed and unaware and is governed by primary process, that is irrational, instinctual, closely linked to emotional states and has symbolic/metapohorical thought (ie. dreams)

Question 31

When asked about what his parents were like, he reports, “They’re great. The best parents anyone could have. We had no problems in our family. Everyone got along great. I never heard a cross word between my parents, and they were always there for me.” When asked how close he was to his mother, he replied unemotionally, “I knew my mom loved me. She died recently. The funeral was really nice and quite a few people came. She didn’t have much time for us kids, though, working as she did. Is this really important?” Given the above description, what attachment style does this patient exhibit?

Answer 31

• Avoidant

Question 32

What are models for classification of gender?

Answer 32

• Dichotomous categories: masculine and feminine - One-dimensional continuum: increasing masculinity toward one end, increasing femininity toward other end - Two-dimensional continuum: low to high femininity on one axis, low to high masculinity on other - Bam Sex Role Inventory

Question 32

Describe the Kinsey scale.

Answer 32

0: exclusively heterosexual attraction and experiences 1: primarily heterosexual, with occasional homosexual attraction and experiences 2: mostly heterosexual, with fairly frequent homosexual attraction and experiences 3: equally attracted to same and opposite sex partners, engage in both sexual experiences 4: mostly homosexual, with fairly frequent heterosexual attraction and experiences 5: primarily homosexual, with occasional heterosexual attraction and experiences 6: exclusively homosexual attraction and experiences

Question 33

How is “mind” developed?

Answer 33

• Children develop their minds from the outside in, not from the inside out. We co-create one another. - Experiences shape the brain connections that create the mind and enable an emerging sense of self in the world. - None of us is a person until we are called forth by the responsiveness of others.

Question 34

What is psychopathology according to Bowlby?

Answer 34

• a succession of experiences that divert direction of pathways away from resilience and competent functioning.

Question 35

What is the function of mentalizing? How do insecure styles alter mentalizing and what occurs when mentalization fails or is problematic?

Answer 35

• Ability to mentalize enables one to consider behavior from multiple perspectives. - Failure to mentalize leaves one stuck in rigid, reaction, repetitive patters of interaction - Problems in mentalizing are prominent in personality disorders.

Question 36

Toddler. a.) What is the age? b.) What is the major / primary psychological task for the infant? What is the factor that allows for developmental tasks to occur? c.) Describe developmental periods that occur during infancy. What are parental tasks?

Answer 36

• a.) 18 months – 3 years - b.) Self-assertion and increased bodily control and self-regulation - c.) Rapprochement (16-24 months): period of increased separation from mother – autonomy. Sense of omnipotence is threatened by real world experiences – parental dependency as source of power is reinforced. Internalization of rules and demands leads to development of superego. Concern about loss of parent’s love. Parental tasks include: supporting dependency needs while encouraging achievements in world; be receptive to child’s moving out and moving back; encourage freedom to will her own action, while also teaching acceptance and respect for parental limits. Threats for toddler include loss of parents’ love and support if their will is increasingly asserted AND idea of loss of self assertion an automy (if I stay merged with you, I keep your love, but I lose myself). Terrible 2s seen here. Child says no is just an assertion of will. Parents must ignore temper tantrums, never give in to manipulative behavior. Parents must not attribute meaning to behavior or take things personally. Habits such as thumb sucking, masturbation and biting can occur here. This should not concern parents.

Question 37

What are the characteristics of a couple whose styles are anxious / avoidant?

Answer 37

• Become trapped in vicious cycles - More anxious partner demands love, more avoidant partner withdraws and / or attacks other for expression of dependency needs - Highly conflicted due to anxious partner’s fear of abandonment and avoidant partner’s fear of intimacy

Question 38

What does too much detachment lead to?

Answer 38

• Loss of connection to the human community - Loneliness - Isolation - Loss of meaning and purpose

Question 38

What are the characteristics of each attachment style for a child or adult following a particular attachment style? What are characteristics of caregivers that lead to each of these styles?

Answer 38

Question 40

Explain each of the central constructs to the TTM?

Answer 40

• Processes of change: a.) Cognitive/emotional: changing way ppl think / feel about health risk behavior in early stages eg. Think about deciding to quit than about quitting b.) Behavioral: change behavioral process to help ppl move through stages of change eg. Taking steps to change to maintaining change - Decisional balance: Pros vs Cons (progress vs regress): keeping balance toward positive/progress, but not at cost of ignoring cons/regress - Stages of change: (PCPAMR mnemonic) Precontemplation, contemplation, preparation, action, maintenance, relapse - Self-efficacy: Confidence in ability for pt to manage specific situation without returning to old behavior. What is the pt’s sense of their ability to accomplish something? - Temptation: Intensity of the urge to engage in a behavior in particular situations?

Question 40

What are losses that are disenfranchised and under-recognized?

Answer 40

• Relationship loss - Perinatal loss - Infertility - Loss of homeland/culture - Loss of physicial abilities

Question 41

John comes home from work. He enters the house without saying he’s home. Mary, preparing dinner in the kitchen and hearing him enter, says, “Is that you John?” He answers, “Yup,” and goes to the BR to change clothes. After changing clothes, he sits down, turns on the TV and watches the news. Mary calls him for dinner, and they eat with her asking questions about his day, and him responding with short and non-descriptive replies. She asks if he notices she fixed his favorite dish for dinner. He says, “Now that you mention it, yes. Thanks.” She says she really wanted to please him since she loves him so much and she’d do anything for him. She then says, “Let’s go to a movie tonight and sit in the rear of the theatre so we can cuddle.” He says, “I’d rather stay home and read. You can go with a friend if you like, I don’t mind.” Mary says, “John, seeing the movie is not the point. I want to be with you! Why don’t you ever want to spend time with me? You come home and plop in front of the TV and show no interest in me or my day. I don’t think you love me anymore. Maybe you have someone else in your life that’s more important than me. You do seem a lot happier around that new secretary of yours than you do at home.” John responds, “That’s ridiculous, I spend a lot more time at home with you than I do with her. I love you a lot; I told you that yesterday, or was it last week? I just need some space at times. Go to the movie with your friend; I’ll be fine.” Mary responds, “OK, OK. I’ll stay home with you and we can sit together on the couch and I can run my fingers through your hair while you read.” John responds, “Why do you have to hang on me all the time. You need to get a life of your own! Go to the movie. I’m going to bed!” Given the above description, what combination of attachment styles does this couple exhibit?

Answer 41

• Anxious-ambivalent/avoidant

Question 43

In what stage(s) are pts most receptive to information / education about condition and treatment?

Answer 43

• preparation and action stages

Question 44

What are characteristics that symbiotic attachment has failed?

Answer 44

• inability to keep rules, lack of guilt experience, indiscriminate friendliness, inappropriate craving for attention, inability to make lasting relationships, affectionless

Question 45

What are the 3 stages of adolescence? Include age and basic characteristics.

Answer 45

• Early adolescence: age 10-13 (middle school). Marked by quest for autonomy from family. Period of testing authority (first done in toddler stage, this is second). Mood swings and emotional lability are seen. Intense friendships with same-sex peers are common. Feelings of opposite-sex attraction may being, but often are not yet acted upon. As bodies being to change, comparisons made with others. Body issues common, anxiety about body issues common. Thinking concrete, limited understanding of consequences. Little impulse control, strong desire for quick gratification, and high levels risk taking. Vocational goals unrealistic. - Middle adolescence: age 14-17 (high school). Less interest in parents and more time with peers may lead to conflicts. Typically have friends of both sexes (new in comparison to early, where only same sex). Conformity with peer group is of central important – can be problematic for children with chronic health concerns who become non-compliant with meds etc. Relationships often experimental and exploitive. Attractiveness to peers is major concern. Capacity to reason abstractly can begin to develop. Sense of omnipotence and immortality, leads to continuance of risk taking. Creativity and intellectual ability increases, vocational hopes become more realistic. - Late adolescence: age 17-21 (college, military or beginning career). Relationships with parent renegotiated and typically improve. Values begin to mirror that of the family. Peer values are less important, and confidence in self increases. Relationships become more mutual and health. Body image is realistic. Abstract reasoning established. Interests more stable. Capacity to delay gratification improves.

Question 47

Define progression, regression and fixation in terms applicable to Freud’s Psychosexual Model.

Answer 47

• Progression: normal movement from one stage to another - Regression: the move from a more mature state to an earlier / primitive state - Fixation: a point of stuckness caused by some failure or disruption in the development process (results in regression)

Question 48

What is motivational interviewing?

Answer 48

• It is a method to engage pts as collaborators in health behavior changes and facilitate pt motivation for change. Does not provide pts with solutions or problem-solving until they make a decision to change. Relies upon shared decision-making.

Question 50

What are key dimensions of helpful doctor/pt relationships? What are potential obstacles?

Answer 50

• Pt cooperation: depending on perceived severity of illness and consequences, pt will be more of less likely to cooperate. Cooperation increases if pt is capable of performing a behavior to reduce risk of increased severity of illness and if they are confident treatment being given will reduce risk. - Help pt make the issue their own, allow them to be actively engaged - Court resistance - Know that relapse is part of the change process - Develop sense of the direction the pt is moving and how to work with that, not against

Question 52

What are some areas to typical areas of difficulty during a motivational interview?

Answer 52

• Appropriate engagement - Not asking about precipitating event - Not asking permission to go deeper - Working with both sides of ambivalence - Rolling with resistance - Recognizing examples of self-efficacy - Developing discrepancy - Evaluating risk - Summarizing - Appropriately ending the interview

Question 53

Which of the following techniques is MOST likely to facilitate engagement? A. An interrogatory interview style in the opening minutes of the interview B. Initially allowing the patient to do most of the talking C. Using closed-ended questions D. Beginning the encounter by telling the patient about the importance of annual examinations E. Ensuring that the patient understands the doctor’s agenda

Answer 53

B

Question 54

Define sexual identity.

Answer 54

• Understanding of oneself as heterosexual, homosexual or bisexual.

Question 56

A middle-aged woman is being treated for emphysema. She starts to cry and says she has been under a lot of stress lately. She states, “I know I should quit smoking, but I can’t.” Her physician nods and says, “You would like to quit smoking but you feel you can’t because you are under a lot of stress.” The physician’s response is an example of which of the following interview techniques? A. An evocative question B. Empathetic reflection C. Reframing D. Double-sided reflection E. Repeating

Answer 56

B

Question 56

Describe brain development in adolescence.

Answer 56

• Brain 90% of adult size by 5 - Cerebral cortex and frontal lobes immature through early adulthood - Prefrontal cortex responsible for regulating thoughts, feelings and actions, capacity to inhibit impulse. White matter increases through early adulthood, gray matter during early puberty then decrease in late adolescence through synaptic pruning. - Limbic system: where emotions are experienced. Undergoes myelination and pruning to lesser degree. Sensation seeking, novelty seeking and risk taking associated with this development. May increase ability to procreate and learn new tasks, but also increases danger. Risk taking declines by early adulthood. - In males, these processes take longer.

Question 57

What identity developmental process do LGBTQ people undergo? What are the stages? When does each resolve and what are roles of healthcare providers?

Answer 57

• LGBTQ individuals undergo an extra developmental process - Need for entering this process results from: stigma (homophobia and heterosexism), isolation, lack of support - Stages: a.) Awareness stage: becoming conscious of same-sex attractions and or inclinations, accompanied by feelings of badness. Resolution of stage: acknowledgement and acceptance of same-sex attractions. Healthcare provider role: struggling, conflicted, confused pt should be referred to supportive psychotherapist with specialized LGBTQ populations b.) Acknowledgement stage: moving from acknowledgement to self to acknowledgement to others, includes coming out. Resolution: increased self-acceptance characterized by successful self-disclosure and skillful coping. Healthcare provider role: referral to specialized therapist, coming out support group. c.) Exploration stage: awkwardness and intensity in relationship, experimental with range of sub-culture, possible relapse into maladaptive coping. Resolution: increased capacity for intimacy and stability, reduced intensity and frequency of shame-based responses. Healthcare provider role: counsel regarding safer sex practices, therapist if signs of internalized homophobia and maladaptive coping, connect with GSA in school or LGBTQ centers d.) Intimacy stage: increasing stability, satisfying friendships and romantic relationships, sound decision-making around disclosure, effective coping e.) Integration stage: energy directed into new areas of life, awareness of integration as ongoing process, balancing sexual orientation/gender identity and other culture identities

Question 59

What are mental structures and what are the components to Freud’s Structural Model?

Answer 59

• Mental structures are constructs that have particular functions in the mental life of the individual and are not easily changed - Id: operates at unconscious level, functions according to pleasure principle seeking immediate gratification and is not concerned with reality or social etiquette, functions by primary process (like unconscious mind of topographic model), source of instinctual drive (sexual: drive toward and object perceived as desirable and aggressive: drive away from object perceived as dangerous) - Ego: operates at conscious and unconscious levels, developes out of Id, mediator of Id impulses, mediator of Superego injunctions, mediator of demands/limits imposed by reality, functions by secondary process/reality principle, main function is to find socially acceptable way to gratify the instinctual drives, if demands of Id are not sufficiently address the Id can disrupt Ego function, source of Ego defenses - Superego: referred to as conscience, composed of internalized morals-values-behavioral injunctions-prohibitions, internalization and indentification play major roles in its development, contains the ego ideal (what does an ideal person look like that we would like to look like), can be harsh and punitive (guilt)

Question 60

Describe each of the attachment styles on the spectrum of anxiety, avoidance/attachment axes.

Answer 60

1.) secure: low anxiety, low avoidance, high attachment 2.) anxious-ambivalent: high anxiety, low avoidance, high attachment 3.) avoidant: low anxiety, high avoidance, low attachment 4.) disorganized: high anxiety, high avoidance, low attachment

Question 61

What are the 4 basic attachment styles and what fosters their formation?

Answer 61

1.) Secure 2.) Anxious-ambivalent aka Ambivalent-insecure* 3.) Avoidant aka Avoidant-insecure* 4.) Disorganized aka Disorganized-insecure or disoriented* *all known as insecure

Question 61

What are issues surrounding sex assignment surgery?

Answer 61

• Debate in medical/larger community on whether or not surgery should occur in infancy or later, or whether should occur at all. - Advocates state it reduces potential stigma - Opponents state lack of choice and informed consent by child, results in loss of sexual sensation for some

Question 62

What are issues in mental health care with transgender people?

Answer 62

• Addressing confusion/questions on gender identity - Addressing inner conflict/emotional distress on gender identity - Addressing effects of trauma due to social prejudice, discrimination and violence - Addressing steps/stages of coming out - Controversy over mental health eval and therapy before reassignment therapy - Controversy over gender identity diagnostic disorder

Question 63

Explain Jean Phinney’s stages of ethinic identity development.

Answer 63

• Unexamined ethnic identity: preference for cultural values of majority - Ethnic identity search: interest in personal implication of ethnicity and search for information about group - Ethnic identity achievement: self-confidence in identity and positive self-concept, fostered by cultural traditions being upheld in home

Question 64

In what children does failure of symbiotic attachment typically occur?

Answer 64

• Those who are adopted or have been institutionalized for first 2-3 years of life.

Question 64

What are major red flags during the childhood phase?

Answer 64

• Setting fires, violent behavior and cruelty to animals. Indicates serious problem for which the parents and child need to see professional expertise.

Question 64

Define biological sex.

Answer 64

• Based on physical / visible characteristics, reproductive functions and genetics. Usually viewed as 2 discrete categories: male & female. - Exception to this is intersex individuals, previously known as hermaphrodites.

Question 66

According to Mahler’s theory, separation is a process that begins during which of the following stages or sub-phases: A. Symbiosis B. Hatching C. Practicing D. Rapprochement E. Object Constancy

Answer 66

B

Question 67

Discuss adolescent emotional health concerns to pay attention to.

Answer 67

• Internalization of problems, particularly in girls - Marked increase in depression and anxiety, particularly in girls - Risk for eating disorders increases, particularly in girls - Externalizing problems, common in boys - Delinquent behavior increases markedly between early and middle adolescence (10-17) - Increase in property destruction, fighting and drug use

Question 67

What is the definition of transgender identity?

Answer 67

• Transgender is a gender or umbrella term describing people whose gender identity is not congruent with the usual gender role for their assigned sex. Eg. Biological sex is female, but gender identity is masculine. Importantly, sexual orientation is not in definition, so they can be any.

Question 69

What are determinants of the attachment hierarchy?

Answer 69

• Time spent - Quality of care - Adult’s emotional investment - Emotional responsiveness of adult - Repeated presence across time

Question 70

What are the stages of Freud’s Psychosexual Developmental Stages? Explain.

Answer 70

• Oral stage (birth to 1 year) Mouth is area of focus (means of exploring, sucking and feeding provide sources of pleasure), period of total dependence on mother (secure foundation provided for subsequent development), fixation here leads to: lack of ability to delay gratification, clinging/dependent behavior in relationships, sense of other not caring or not being warm or nuturing enough, lack of ability to self-soothe, lack a sense of psychic or physical safety, being demanding and fearful - Anal stage (1 to 3 years) Anal area and feces are focus of attention and source of pleasure, sphincter control develops and creates sense of master/control and autonomy: child learns s/he can produce or withhold, period of conflict with parents around issues of obedience and control, fixation here leads to: control/lack of control, assertion/submission, obedience/defiance, giving/withholding - Phallic-Oedipal stage (3-5 years) Penis or clitoris is area of focus (mastubatory exploration and pleasure, boys are proud of penises and are afraid of losing them, girls wonder why they don’t have one), oedipal / electra conflicts: child notices parental relationship is exclusive, dilemma results when child loves and hates the same parent: boys want to possess mother and eliminate father (oedipal), girl wants to possess father and eliminate mother (electra), fixation here leads to: triangulation (attention focused on third person), repetitive relationship with unavailable partners of opposite sex, seeing relationships in terms of conquests - Latency (school age): not formal stage Sexual interests are dormant, psychic energy and attention is directed to activities of play, school and friendships - Genital (early adolescence (10?) throughout adulthood) Genitals are focus of attention and pleasure, sexual stimulation and satisfaction is sought through relations with other, mature sexual interests develop with aim to form mature sexual relationships

Question 72

Explain concept of cumulative loss?

Answer 72

• Cumulative loss are losses that are not fully integrated and accumulate in reservoirs that can erupt with there are loss(es) of current attachment figures or anniversaries of loss.

Question 73

While taking a psychosocial history with a new patient, he responds to your questions in a direct and confident manner and is able to describe the positive and negative influences key figures had on his life. He tears up as he reports the recent death of his mother, indicates he misses her a lot, and that he appreciates you taking the time to ask him about important people in his life. Given the above description, what attachment style does this patient exhibit?

Answer 73

• Secure

Question 74

What are techniques/advice to deal with non-compliance?

Answer 74

• look for reasons behind the pts non-compliance - view non-compliance as symptom required exploration into cause - Ask: What can this pt teach me that I need to know? Or How do I build a relationship with an angry person or a person who won’t tell me very much? - Elicit feedback from pt on their perceived ability to achieve a goal - Anticipate certain degree of non-cooperation in all pts (plan for it) - Support/empathy - Keep care inexpensive and simple

Question 76

What is the function of reorganization? When does it occur? Who does it occur in? What are ways in which reorganization occurs?

Answer 76

• Reorganization is designed to maintain the attention and involvement of the caregiver. - Occurs between 18 months and 6 years old in many disorganized infants or children - Ways to reorganize include: child seeks to control through punitive hostile or humiliating behaviors OR through solicitous, directing and caregiving behaviors – child starts acting like parent.

Question 77

Define behavioral medicine and its contribution to practice of medicine.

Answer 77

• interdisciplinary field concerned with development and integration of behavioral, psychosocial and biomedical science knowledge/techniques relevant to understanding health and illness and application of this to prevention, diagnosis, treatment and rehab

Question 78

What is a transitional object?

Answer 78

• It is an object to which a child forms an attachment and aids in development of capacity to self-sooth. It is under the child’s direct control. It represents child/mother. Used for comfort, especially in absence of primary attachment figures. Is used for calming prior to sleep and / or after periods of distress. Loss of this leads to crisis.

Question 80

What are signs/suggestions of pt non-cooperation?

Answer 80

• dependency - manipulativeness - angry, demanding - withdrawn - fearful - depressed - help-rejecting

Question 81

Describe relationship between temperament and attachment.

Answer 81

• Temperament refers to constitutionally based individual differences in emotional, motor and attentional reactivity and self-regulation. - A difficult child is more affected by a mother’s responsiveness than a positive child is. - A difficult temperament plus ineffective parenting leads to future difficulties, ie. someone who is destructive and antisocial.

Question 83

What are primary predictors of depression in adults? How should you screen your pts for depression?

Answer 83

• Heredity - Severe situational stress - Early attachment trauma resulting from loss, abuse or neglect

Question 84

Explain the 4 classifications of the Bem Sex Role Inventory for gender classification.

Answer 84

• Sex-typed: males with high masculinity, low femininity; females with high femininity, low masculinity - Cross sex-typed: males with high femininity, low masculinity; females with high masculinity, low femininity - Androgynous: females and males with both high masculinity and high femininity - Undifferentiated: females and males with both low femininity and low masculinity

Question 85

When you ask the patient to describe his mother, he looks away, lowers his head, and stares into space. In a few seconds he responds, “What did you say? Oh, yes, my mother. She was OK. She let me get a dog once, but I didn’t know how to take care of it, so we had to get rid of it. I think I was 4 at the time. I liked to hold him tight, but he didn’t behave and would wiggle and jump out of my arms and I would get mad at him and chase him around the house. I think he loved me, but when I chased him he’d bark. My mother would laugh, but then she got angry and told me I had to get rid of him. I think his name was Spot, or maybe it was Boy, I can’t remember things that long ago.” Given the above description, what attachment style does this patient exhibit?

Answer 85

• Disorganized

Question 87

What are effects of attachment loss?

Answer 87

• Anxiety, despair, depression

Question 88

What are the stages of Piaget’s Theory of Cognitive Development? Briefly explain.

Answer 88

• Sensorimotor (birth to age 2): infants learn to coordinate their sensory input with their motor output. - Preoperational (age 2-6): ability to mentally represent things in world that are not currently present (imaginative play) and object permanence is mastered (things are still there when you can’t see them). Ability to use symbols to represent reality (playing with dolls). Egocentricism (what happens is because of them). Theory of mind (distinguishing own viewpoint from that of others). Confused about causation, confusion of appearance and reality. - Concrete operational (age 6-12): ability to use logic to mentally manipulate objects and perform actions (addition/subtraction). Objects and events under consideration need to have been experienced directly (unable to perform pure abstract thinking). Can consider more than one attribute of an object at a time. Development of conservation (water from large to small container contains same amt of water). Decline of egocentricism. Parents should take intent into account and punish proportionately; play rule-based games. - Formal operational (age 12-19): development of capacity for abstract thought and formal-deductive reasoning. Solve problems systematically and thoroughly. Interest in abstract ideas and process of thinking itself. Reason is based on abstract principles. Interest in unversal ethical principles (applied rigidly regardless of mitigating factors). This is encouraged in Western-style schools. 30-40% of well-educated Americans reach this by their early 20s. Not always used.

Question 89

Define sexual orientation. What are typical classifications of sexual orientation? What other models exist? Explain.

Answer 89

• Pattern of emotional, romantic, sexual and spiritual attraction to males, females, both, or neither. - Typical classification: Heterosexual, homosexual, bisexual or asexual. - Other models: - A.) discrete, dichotomous categories: heterosexual and homosexual - B.) single continuum model (Kinsey scale): based on attraction, fantasy and behavior – placed on scale that provides varying degrees of heterosexuality, homosexuality - C.) dual continuum model (DeCecco): based on same sex (low-high) and opposite sex (low-high). Dimensions rate for emotional, affectional and physical attraction as well. - D.) multivariate model (Klein): 7 variables rated 0-6 from exclusively heterosexual to homosexual – variables: sexual behavior, emotional attraction, sexual fantasies, sexual attraction, social preference, lifestyle/world/community, self-identification

Question 90

What are issues in medical care for transsexual people?

Answer 90

• Gender reassignment therapy (outdated term = sex change): including HRT, major surgery, minor surgery - Health insurance (policies and discrimination) - Transphobia - Treatment of children who strongly identify as transsexual (supportive vs psychotherapy (to alter gender identity) approaches)

Question 91

Pre-school. a.) What is the age? b.) What is the major / primary psychological task for the infant? What is the factor that allows for developmental tasks to occur? c.) Describe developmental periods that occur during infancy. What are parental tasks?

Answer 91

• a.) 3-5 years old - b.) initiative vs guilt - c.) Pleasure vs pride, guilt, conscience and sex role identities are developing in this period. Parents should encourage talking about feelings and thoughts when expressed. They should respect the child’s needs, listen and take child’s perspective seriously, help child distinguish and sort things out and foster curiosity and exploration and verbal sharing of experience. By age 3

Question 93

What are the basic elements/principles of motivational interviewing?

Answer 93

• Express empathy (not sympathy) - Develop discrepancy (enables pt to see where they are and where they want to be) - Avoid argumentation (collaborate) - Roll with resistance (invite new perspectives, pt must find answers and solutions, pts objection or minimization does not require response) - Support self-efficacy (pt must believe in possibility of change)

Question 94

What is Bowlby’s Hypothesis on attachment styles?

Answer 94

• Behavioral patterns of seeking care and expressing emotions form as a function of mother’s response to child - Patterns that become preferred are those that provide felt security: repeated patterns are internalized and become working models / attachment styles

Question 95

What are the key elements of a pt interview focusing on behavioral change?

Answer 95

• Facilitate engagement with pt - Demonstrate empathy when building rapport - Explore context for encounter - Explore presenting problem / concern - Seek permission to talk more in depth about this concern - Explore history of the problem - Ask about precipitating event(s) - Explore ambivalence, attitudes, beliefs and resistances to change - Explore pt’s strengths, resources and affirm self-efficacy - Develop discrepancy - Assess intrinsic motivation and readiness to change using TTM - Evaluate safety and welfare of pt and others - Summarize - Negotiate a plan for change and/or follow-up - Offer recommendations and/or referrals as deemed appropriate - End the interview (16)

Question 96

A 61-year-old man sees his physician because he is having trouble sleeping. He states, “I am having a hard time since my wife died three weeks ago. We were married for 40 years, and I can’t get used to her not being here. Nights are the worst. It takes me a couple of hours to fall asleep.” Which of the following responses by the physician would be the MOST empathic? A. “Have you thought about starting a new hobby? Staying busy helps.” B. “I know how you feel. My mother died when I was a kid, and it was really hard for me.” C. “I’ll give you a prescription that will help you get to sleep and sleep well through the night.” D. “It sounds like you miss your wife very much. Losing her has had an enormous impact on your life.” E. “You still have many good years to look forward to. You’ll feel better soon.”

Answer 96

D

Question 97

Describe the role of the parent in creating a symbiotic relationship during infancy. What are the results of this parenting?

Answer 97

• Sensitive and attuned parent is key and requires: be aware of baby’s signals, accurately interpret baby’s signals, respond appropriately and promptly. - Results of following these tasks: infants cry less, develop a wider repertoire of communication and are more obedient to commands of the mother.

Question 98

What are the stages of Erikson’s Psychosocial Stages of Development? Provide characteristics of each stage.

Answer 98

• 1.) Trust vs mistrust (birth to age 1) Are others trustworthy to provide for one’s basic needs, is world safe for exploration/play/relaxation or unpredictable and threatening? Infant not fed, comforted or kept warm learns that others are not to be trusted. If others are seen as untrustworthy, then individual won’t follow advice, seek help, let their guard down or have emotionally intimate connections. - 2.) Autonomy vs shame/doubt (age 1-3) Associated with terrible twos. Capacity to say no signals developing sense of self, sense of free will, awareness of ability to control the environment. Independence and self-assertion increase. Infant gains sense of being competent to solve problems and accomplish tasks. Ideally, parents structure environment to foster master and avoid excessive control. - 3.) Initiative vs guilt (age 3-5) Learning to declare autonomy and individuality in ways that begin to conform to societal expectations. Enjoy joining peers and adults in carrying out activities and making things. Begin to see self as member of community to can conbtribute to activities and goals. Emulate a significant person in child’s life or be part of particular group. Sex-role identity develops. - 4.) Industry vs inferiority (age 5-11) Challenge to establish sense of competence. Increase in comparison of self to others. Development of self-esteem, promoted by parental acception and affection, setting and enforcing limits that are clear and respecting individuality and independence. - 5.) Identity vs role confusion (age 11-21) Starts during adolescent. Question of Who Am I? Period of trying a variety of roles and identities. Requires both exploration and commitment to achieve successfully. Need to develop a stable sense of self across varied roles and in varied settings. Difficult period with high baseline rates of emotional distress. - 6.) Intimacy vs isolation (age 21-40) Need to find and commit to spouse. More broadly, ability to develop deep, lasting and emotionally intimate relationships. - 7.) Generativity vs stagnation (age 40-60) Choice to raise the next generation. Capacity to contribute meaningfully in world of work. - 8.) Integrity vs despair (age 60-death) Reviewing one’s life with need to make sense of one’s own story and find meaning in it.

Question 100

What is mirroring? What is its function? How can it be accomplished during child development and in therapy?

Answer 100

• Mirroring refers to “feeling felt” in order to develop a sense of self. - It develops a sense of self in the person performing the mirroring. - Parent must be open to receiving signals from the child and respond in attuned way. Child needs to find him/herself in gaze of caregiver in order to know him/herself. Child perceives image of him/herself in caregiver’s response and internalizes it. - As therapist, give pt a different view of themselves than what they were experiencing before. Provide feedback that is affirming so that pt may internalize it.

Question 100

What are the characteristics found during Main’s interview that correspond to the basic attachment styles?

Answer 100

Question 102

Describe empathy and its role in the doctor-patient relationship.

Answer 102

• Empathy is a means to understand the subjective world and experience of another person. - Effective practice of medicine hinges on connecting the subjective experience of patients with the evaluation of the objective data set before the physician - To relate empathetically, doctors must be well grounded to something other than the patient.

Question 103

What are Richard Troiden’s stages of sexual minority identity development? Explain.

Answer 103

a.) sensitization: feeling different b.) self-recognition: identity confusion c.) identity assumption d.) commitment: identity integration

Question 105

Define health

Answer 105

• Health is not absence of disease, but process by which individuals maintain: a.) sense of life comprehensible, manageable and meaningful - Ability to function in face of changes within themselves and their relationship with their environment

Question 106

Define gender, gender identity, gender role and gender expression.

Answer 106

• Gender is a social construct of culturally-based expectations typically based on one’s biological sex - Gender identity is one’s core self-concept of his/her gender - Gender role includes appearance, clothing, speech, manner, interests, play and occupations - Gender expression is how one chooses to outwardly manifest one’s gender identity

Question 107

What are the parental tasks during the adolescent phase?

Answer 107

• Gentle question to help adolescents think critically stimulates moral development. - Warm, supportive parenting increases capacity to regulate feelings – opposed to high level of emotional negativity which increase negative emotions and aggression in teens - Ideal is authoritative, not controlling or permissive - Set clear standards - Firm, but not coercive - Consistent discipline - Explain basis for decisions - Allow real discussion of issues where conflict seen - Monitor behavior without overprotectiveness - Foster warm family environment - Provide information and help social skill development - Respond flexibly as children develop

Question 109

What are areas to consider when evaluating disrupted attachment?

Answer 109

• Age of child at time of disruption - Quality of early relationship with mother, or primary parent figure(s) - Presence of other attachment bonds (substitutes and quality of this bond)

Question 110

A 70-year-old woman has had three face-lifts and never leaves the house without makeup. She forbids her grandchildren to address her as “grandmother” and lies about her age. According to Erikson, she is having difficulty mastering which stage of development? A. Integrity vs Despair B. Egocentric C. Generativity vs stagnation D. Narcissistic E. Pragmatic Development

Answer 110

A

Question 111

What are key areas of health risk for the childhood group?

Answer 111

• Chronic medical conditions - Injuries - Learning/attention problems - Anxiety related issues

Question 112

What is the difference between disease and illness?

Answer 112

• Disease is a disruption in normal biological function, is objective and has a focus on curing - Illness is a sense of dis-ease, is subjective (feeling sick) and reflected in mood, affect and behavior; focus here is on healing

Question 113

What do internalized working models of relating reflect for a clinician?

Answer 113

• Child’s internal representations of relationships - Quality of caregiver-child interactions - Child’s expectation of caregiver’s responsiveness to attachment needs - Child’s attempt to regulate affect and keep her/himself safe - Child’s capacity to mentalize

Question 114

Define attachment.

Answer 114

• Attachment is defined as a relatively enduring emotional bond with another person (or object) that forms in response to exposure, interaction and familiarity.

Question 115

What are common behavioral concerns for the childhood group? How to assess behavioral issues/”disorders”?

Answer 115

• functioning at school and at home - normally this period is period of latency per Freud and therefore calmness, pay attention to emotional disturbances - for developmental task successes, look at school achievements - look at age and see if appropriate, behavior may be stress induced, behavior may reflect parent-child conflict, can be result of maturational changes, lack of information, misinterpretation, behavior of child can reflect emotional state of a parent

Question 116

What are the basic characteristics of attachment bonds? What behaviors are indicative of attachment?

Answer 116

• Bonds are: Person-specific (not interchangeable), Persistent, Emotionally significant - Behaviors seen: proximity-seeking and separation protest (crying, checking etc.)

Question 117

What is the purpose of studying development?

Answer 117

• Provides objective framework to assess when development is delayed in consequential ways, provides information to guide appropriate expectations and activities, helps understand what a given individual may be working on and why they’re doing what they’re doing and deepens understanding of a given individual’s experience at a given time.

Question 118

Mrs. Jones has been coming to your family medicine practice for the past four years. She has a 20 month-old son, and has recently given birth to an infant daughter. She reports that she and her husband planned their second child so that their son would be old enough to spend time by himself while she cared for the new baby. She is concerned that while her son is happy playing by himself for short periods of time, he also searches her out after a while and wants her undivided attention. If she gives him attention, he seems interested in playing by himself again, but if she is busy with the baby, he continues to “bother” her until she responds to his request. She tells you she can’t figure out what her son wants, and she finds herself “frustrated” with him. 1. Based upon this description of her son’s behavior, what would you tell Mrs. Jones about his behavior? A. Her son has regressed to the symbiotic stage of development, which is normal when a new child enters the family. B. Her son’s behavior suggests he is in the practicing stage of development, and she needs to encourage him to do more things on his own. C. Her frustration with a child at this stage of development is not normal, and you would suggest she see a counselor. D. Her son’s behavior appears to be normal for a child his age. E. She should not give him the attention he is seeking, since that would reward his dependent behavior. 2. Based on the case information above, this young child’s behavior is representative of: A. the hatching sub-phase described by Mahler B. the practicing sub-phase described by Mahler C. the rapprochement sub-phase described by Mahler D. Freud’s Oedipal stage of psychosexual development E. the psychodynamic process of regression

Answer 118

1. D 2. C

Question 119

What are issues in mental health services with LGBTQ individuals that should be addressed?

Answer 119

• Address confusion / questions re: sexual orientation. Help clarify and come to own conclusion - Address inner conflict/emotional distress re: sexual orientation - Address effects of trauma and minority stress d/t social prejudice, discrimination and violence - Address stages of coming out - Address frequent spiritual and religious struggles - Therapists/healthcare providers must assess and reduce/eliminate own residual homophobia, assess and correct for heterosexist biases, consider whether or not disclosure of own sexual orientation is valid and appropriate

Question 120

Describe the key features of the transtheoretical mode of change?

Answer 120

• Change is a process, not an event - Pt moves gradually from being uninterested to consider change to decided on change to preparing to make a change - People typically cycle through the stages of changes - Movement through stages can be facilitated by intervening in particular ways

Question 121

What are the core interviewing skills used during motivational interviews?

Answer 121

• Open-ended questions (followed by reflection) - Affirming by other and self (acknowledge positive) - Reframing (in positive light) - Summarizing

Question 122

What is the physical development that takes place in adolescence?

Answer 122

• This is period of puberty. - Girls: breast budding at age 8-12, menarche typically last step before completion, ovulatory cycles may not begin until 2-3 years after menarche with full fertility by 2 years post-menarche ~ 14-15 yo. - Boys: 2 years later than females. Testicular enlargement is first indication. Growth spurt occurs, followed by spurt in strength. Average time for completion 2-5 years. Full sexual maturity by 17-18.

Question 123

What are helpful physician questions and behaviors appropriate to each stage of change?

Answer 123

1.) Precontemplation: - build relationship, express concern, no scare tactics, education in small bits – “teachable moments,” validate lack of readiness, facilitate self-exploration, establish pro v cons, roll with resistance, express concern, personalize risk factors - Q: How would you know if your…was a problem for you? - Q: If you were to decide to change, what do you imagine might be some advantages? 2.) Contemplation: - lift up pts assessment of pro v cons, raise consciousness, restate both sides of ambivalence, pose advice gently, elicit reasons for change, build and affirm self-efficacy, determine barriers / resistances - Q: What obstacles do you see that might hinder you in addressing this concern? - Q: What are some of the reasons you may not have been concerned about this before? - Q: How have you dealt with serious concerns before in your life? - Q: What are some personal resources that could be of help to you, should you decide to deal with this matter? 3.) Preparation: - encourage pts efforts, encourage small steps and define them with pt, ask about strategies pt will use in risk situations, ask about setting a change date - Q: What are some strategies you have in place should X arise? - Q: What do you think should be done first? 4.) Action: - reinforce the decision, build and facility increased self-efficacy, delight in small successes, view problems as helpful information, ask what else is needed for success - Q: Do you remember accomplishing X? - Q: What else do you think you could do to help continue X? 5.) Maintenance: - continue reinforcement and support, explore internal rewards and benefits from change, identify risks for relapse and helpful strategies to manage them, identify temptations - Q: This has been working really well for you. How do you feel? - Q: What are the biggest benefits to you after doing X? - Q: What temptations do you have while doing X? 6.) Relapse: (not technically stage, part of process) - learn from temporary success and use to re-engage pt in change process, remind pt change is a process and most ppl recycle, reframe relapse and don’t use failure – say successful for a while, identify and evaluate triggers, reassess motivation and obstacles, counter demoralization - Q: What was the most difficult thing for you during X? - Q: You were successful for X period of time, what are some of the obstacles in your way? - Q: Most people move back and forth through this process of change, what are some of the reasons you were successful for a while and reasons you weren’t?

Question 125

What are the central constructs that should be addressed in the transtheoretical model of change?

Answer 125

• Processes of change - Decisional balance - Stages of change - Self-efficacy - Temptation

Question 126

What are key findings of Main’s Adult Attachment interview?

Answer 126

• An individual’s working model of attachment is observable in characteristic patterns based on their narrative presentations - Interview asks participants to describe childhood attachment relationships and experiences. 1 year old child of these parents are observed according to Strange Situation Procedure. - The way an adult talked about early attachment experiences correlated with attachment styles identified by Ainsworth, ie. secure, anxious-ambivalent, avoidant, disorganized. - Children of AAI mothers after assessment had same style of attachment as parent. - Adult security is reflected in ability to talk about past attachment experiences in a coherent and collaborative way. - Mother’s who are aware/reflective of their own attachment processes are more likely to be sensitive to child’s attachment needs. - Attachment styles of parents tend to be passed on to their children unless there are significant other influences/variables.

Question 127

How do attachment styles affect mate selection?

Answer 127

• We tend to unconsciously seek out those who resonate with our early attachment figures and patterns of relating however unsatisfactory they may have been.

Question 128

What are ways to facilitate pt engagement?

Answer 128

• Use open-ended questions - Use evocative questions, which elicit self-motivation statements from pt (eg. If you were to change, what would be the best results you can imagine?) - Reflectively listening (repeating, rephrasing, empathic, reframing, double-sided reflection (both sides of ambivalence explored))

Question 129

Explain relationships seen in adolescents.

Answer 129

• High school students spend twice as much time with friends as with parents - Older adolescents value reciprocity, commitment and equality - Healthy friendships need to balance intimacy and autonomy - Girls’ friendships tend to be closer and more intense - Boys’ friendships tend to be more competitive, which can increase closeness if competition is friendly - Cliques: 5-7 good friends, source of emotional security, leader, mixed gender by middle adolescence - Crowds: larger group of friends and acquaintances, perceived stereotypically (jocks, nerds), provide opportunities to meet new people and develop new relationships - Friends selected based on similarity in personality, values and activities - Friends more alike over time as they socialize one another - Deviancy training seen - Sexual activity is significant transition: first intercourse is 17, slightly older in females - Boys report more positive feelings about sex than girls - Pregnancy in 7% of all US teens - Conflict with parents peak in early adolescence

Question 130

What is the key to a your reactions when dealing with a pt?

Answer 130

• The goal is NOT “no emotional reactivity”. Do not shut off emotions. Monitor expression of emotions and be aware, recognize and analyze in order to use the information provided by the patient to better understand them and facilitate treatment.

Question 131

Explain briefly what each of the stages of change are. Provide timeframe to change.

Answer 131

• P: precontemplation: not really thinking about change (cons high, pros low) – not likely to change for 6 months - C: contemplation: recognizes problem and considering change “some day” (pros = cons) – likely to change in 6 months - P: preparation: ready, but some ambivalence may remain (pros > cons) – will take action within 1 month - A: action: real behavioral changes are occurring (pros >>> cons) – change in place is less than 6 months - M: maintenance: gains are consolidated, long and ongoing – change has been achieved for greater than 6 months - R: relapse: return to an earlier behavior (can occur during any time in the process) – not technically stage, but part of process

Question 132

Describe the scope of non-cooperation.

Answer 132

• pts fail to keep bw 10-20% of appts made - pts fail to fill 30% of rxs written - pts on long-term meds for chronic dz take rx meds about 50% of time

Question 133

Which of the following is NOTcharacteristic of the Transtheoretical Model of Change Stage of Precontemplation? A. Cons of changing outweigh pros of changing B. Pros of changing outweigh cons of changing C. May be unaware of negative consequences of unhealthy behavior(s) D. May be demoralized because of repeated past failures in changing behavior E.Lack confidence about ability to take action

Answer 133

B

Question 134

How do abusive caregivers disrupt the function of attachments?

Answer 134

• Heighten attachment needs, but provide minimal safe have and secure base functions - Hinder development of self-regulatory capacities - Erode self-esteem and self-efficacy

Question 135

What ways do disorganized infants change their attachment behaviors?

Answer 135

• Child undergoes reorganization process to change their attachment behaviors into controlling ones that are directed at parent. - Ways: child seeks to control through punitive hostile or humiliating behaviors OR through solicitous, directing and caregiving behaviors – child starts acting like parent.