Benjamin J. Sadock, Virginia a. Sadock-Kaplan and Sadock's Comprehensive Textbook of Psychiatry 8th Edition-Lippincott Williams & Wilkins (2004)

December 4, 2017 | Author: Rolland Arriza | Category: Cerebral Cortex, Cingulate Cortex, Limbic System, Cerebellum, Neurotransmitter
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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 1 - Neural S ciences > 1.1: Neural S ciences : Introduction and

1.1: Neural S c ienc es : Introduc tion and Overview J ac k A. Grebb M.D. P art of "1 - Neural S ciences " A paradox in the ongoing effort to unders tand the brain is that it is wis e to know everything there is to in the area of neural s ciences, but nothing should be believed. Much like Maurits C . E scher's enigmatic illus tration of a hand drawing itself, it is up to our own brains to discover and diagram how they are put T his paradox should not be s een as nihilis tic, but rather reflecting the tremendous excitement regarding neural sciences in the 21st century, which was us hered in by awarding of the 2000 Nobel P rize in Medicine to three neuros cientists : Arvid C arlss on, P aul G reengard, and K andel. It is the human brain, after all, that is the subs trate for emotions , cognitive abilities, and behaviors that is , everything that humans feel, think, do. E very week, the s cientific journals publish new into the neural sciences, many of which conflict with or least modify previous obs ervations, hypotheses, or theoretical models. Obvious overs implifications from past include the abs olute demarcation between neurological and ps ychiatric dis orders, the absolute categorization of brain regions as devoted to only or emotional activities , and the absolute dogma that 1 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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only release neurotransmitters and dendrites only to neurotrans mitters . Although the sections in this first chapter on neural s ciences do not include everything is to know, they do provide a framework that outlines much of what is currently known. Moreover, each of the sections provides an ins ight into the directions in which that particular field is evolving.

NE UR OA NA TOMY A ND NE UR ODE VE L OP ME NT F unctional neuroanatomy (dis cuss ed in S ection 1.2) is study of interacting and interdependent neurons, glia, groups of neurons and glia (e.g., nuclei), and brain T he three neural systems of most interest in psychiatry the thalamocortical system, the basal ganglia, and the limbic s ys tem. Although previous generations of neuroanatomis ts have ass igned functions, such as sens ation, movement, emotion, cognition, and specific neuroanatomical structures, a general trend in neuroanatomy is to des cribe how networks of brain regions interact to produce what is eventually or obs erved as feelings , thoughts, or behaviors . In as another example of a change to previous dogma, it increasingly becoming accepted that new neurons can form and function in the adult human brain, es pecially regions of the limbic s ys tem, such as the hippocampus. T his area of neural science is covered in S ection 1.3, Development and Neurogenes is , which discus ses embryonic neurogenesis , the migration of neurons, and the outgrowth and formation of neuronal axons and dendrites. T hese developmental proces ses are of to psychiatrists because pathology in neural might later res ult in clinical symptoms , or, conversely, 2 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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clinical pathological states (e.g., excess ive s tres s) affect thes e very same neural development and neurogenes is proces ses in an adverse manner.

INTE R NE UR ONA L MOL E C UL A R S IG NA L S T he two methods for communication among neurons glia are molecular (or chemical) and electrical. T he four most widely recognized class es of molecular signals the monoamines , amino acids , peptides, and the more recently dis covered neurotrophic factors. Although it is reasonable to dis cuss each of thes e clas ses done in this textbook, there are a number of common themes relevant to all four clas ses of molecular signals. F irst, new molecular s ignals are being discovered, both within thes e exis ting clas ses (e.g., previous ly amino acid or peptide neurotransmitters), as well as in novel class es of molecular signals (e.g., nitric oxide, monoxide, adenosine, adenosine triphosphate [AT P ]). S econd, there are hundreds of so-called orphan that have been discovered through examining the sequence of the human genome. T hes e proteins have the characteristics of receptor proteins, but the endogenous ligands for them have not been and, in most cas es , chemicals that activate or inhibit receptor function have not yet been s ynthes ized. T hird, general theme among both known and unknown receptors is heterogeneity, s uch that there are multiple subtypes of receptors for a particular neurotrans mitter, such as the α-adrenergic and β-adrenergic receptors norepinephrine. S imilar to heterogeneity in receptors is heterogeneity in the deactivation of neurotransmitter molecules via multiple s ubtypes of deactivating 3 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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(e.g., monoamine oxidas e, peptidas es ) as well as subtypes of trans porter proteins (e.g., reuptake F ourth, any s ingle neuron can releas e multiple different types of molecular signals (e.g., two different peptides a monoamine) and als o have receptors and receptor subtypes for multiple different molecular signals, thus making each individual neuron capable of exquisite integration and modulation of incoming and outgoing signals . T here are s ix class ic monoamine neurotransmitters: serotonin, the three catecholamines (epinephrine, norepinephrine, and dopamine), acetylcholine, and histamine (S ection 1.4). T he monoamine neurotransmitters, although present in only a small percentage of neurons localized in s mall nuclei in the brain, have enormous impact on total brain function because the diffuse projections of axons from these monoaminergic neurons can affect virtually every brain region. In contras t to the monoamine the amino acid neurotrans mitters are widely dis tributed the brain, and it is poss ible to conceptualize the brain reflecting the balance between the excitatory amino glutamate and the inhibitory amino acid γ-aminobutyric acid (G AB A) (S ection 1.5). In P.2 contrast to the relatively s mall number of different monoamine neurotrans mitters and amino acid neurotransmitters, more than 100 different putative neuropeptide neurotrans mitters have been identified (S ection 1.6). T he neurotrophic factors (S ection 1.7) clas s of protein molecular signals that were more 4 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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discovered than the other molecular signals. T hes e proteins are involved in the growth, differentiation, maintenance, and death of neuronal and glial cells and have been demonstrated to be involved in process es as learning, memory, and complex behaviors .

INTR A NE UR ONA L S IG NA L S T he integrative work of an individual neuron is accomplis hed via intraneuronal molecular signaling pathways, the modulation of the balance between external and internal concentrations of ions , and the conversion of these signals within each individual into the s timulation of axon potentials, the trans cription deoxyribonucleic acid (DNA) into ribonucleic acid and the translation of R NA into proteins . W hen a signal binds to its specific cell surface receptor, a of intraneuronal signals is initiated (S ection 1.8). T here multiple interacting s ignaling pathways within each neuron, and these intraneuronal events s hould actually cons idered the es sential s ites of action for drugs rather than merely the cell surface receptors. T hes e complex intraneuronal s ignaling pathways are additional sites of interest for understanding the pathophysiology neurops ychiatric disorders . T he balance between external and internal of ions is achieved by a wide array of ion channels, which are regulated by neurotrans mitters and others by voltage gradients directly (S ection 1.9). Many of the of interes t in psychiatry act directly on ion channels. benzodiazepines act on G AB A type A receptors that chloride ion channels. P hencyclidine (P C P , or angel acts on a subtype of glutamate receptors that are 5 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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ion channels . Nicotine, the active ingredient in tobacco, acts on nicotinic acetylcholine receptors that are and potas sium ion channels. A more recently property of certain neurons and ion channels is the role of pacemaker, or oscillatory, activity in normal maintenance of wakefulness , attention, and mood. Driving the development of the brain as well as the maintenance and regulation of brain function is the proces s of genetic express ion (S ection 1.10). T he proces s of genetics involves the trans cription of DNA R NA and the translation of R NA into a protein. A system of regulation exis ts for transcription and translation, and the newly dis covered molecules and pathways for this regulation are sites of investigation discoveries in the etiology, pathophysiology, and treatment of mental disorders . Alterations in gene expres sion occur both during development and in adulthood and may be the bas is of abnormal and development and of abnormal and normal adaptation stress .

E NDOC R INOL OG Y, A ND C HR ONOB IOL OG Y In addition to the central nervous system (C NS ), the body contains two other systems that have a complex, internal communicative network: the endocrine system and the immune s ys tem. Mostly becaus e of the of the involved molecular s ignals , it is now known that these three systems are integrated with each other, has given birth to the sciences of ps ychoneuroendocrinology (S ection 1.11) and ps ychoneuroimmunology (S ection 1.12). T he 6 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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between the neuroendocrine s ys tem and C NS can easily be s een in the ps ychiatric s ymptoms that can accompany some hormonal disorders (e.g., depres sion C us hing's s yndrome) and also in the identification of disorders of neuroendocrine regulation as potential markers for state or trait variables in ps ychiatric S imilarly, the immune s ys tem is linked with both the and endocrine system through s hared molecular T he other property s hared by the C NS , endocrine and immune s ys tem is that they undergo regular with time. T he s tudy of these changes with time and disorders of time regulation are included in the field of chronobiology (S ection 1.13).

B R A IN IMA G ING C urrent technology allows brain imaging to detect and display electrical brain activity and physical brain as well as functional brain activity. Hans B erger firs t recorded the human electroencephalogram (E E G ) in and s ubs equent advances in this area have resulted in as sess ment of evoked potentials (vis ual, auditory, somatos ens ory, and cognitive), as well as quantitative, computerized as sess ments of topographic E E G s ignals (S ection 1.14). In addition to the standard X -ray techniques, including computed tomography (C T ), a of brain imaging techniques relies on nuclear magnetic res onance imaging (MR I) to as ses s both the structure function of the brain (S ection 1.15). T hes e techniques externally induced manipulations in the magnetic fields nuclei to image brain s tructure (sMR I) and brain (fMR I and magnetic res onance spectroscopy [MR S ]). other major technique for brain imaging uses very amounts of radioactive compounds introduced into the 7 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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brain and then vis ualized by the use of specific imaging cameras (S ection 1.16). T he two major techniques of type are positron emiss ion tomography (P E T ) and photon emis sion C T (S P E C T ). T hese techniques are particularly well suited for the s tudy of receptors, and metabolis m. T hes e techniques can and visualize brain function during increasingly s horter time periods, allowing res earchers to as k s pecific about brain regions and neural networks and their relations hips to emotional, cognitive, and behavioral states and activities .

G E NE TIC S S ince the las t edition of this textbook, the human, the mous e, and other animal genomes have been and, in a s ense, the ans wers are now there, but the questions must be asked with regard to the genetic of mental disorders . B y studying the genetics of both populations and individuals, investigators are to break the code regarding the etiology of mental disorders (S ections 1.17 and 1.18). Increasingly, inves tigators conceptualize mos t complex neurops ychiatric disorders as res ulting from the interaction of multiple s us ceptibility genes rather than a single caus al gene or a small number of causal genes. eventual identification of the key genes, however, potentially allow an entirely different approach to the diagnosis, prevention, and treatment of mental by us ing targeted genetic and pharmacological approaches. One of the key experimental approaches this path of unders tanding human ps ychopathology is us e of transgenic animal models of behavior (S ection T he mous e genome is remarkably s imilar to the human 8 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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genome, and investigators are now able to make manipulations in the mous e genome to produce transgenic mous e models that may evidence behavior treatment res ponses that are relevant to unders tanding and treating human disorders .

C OMP L E X HUMA N B E HA VIOR S T his textbook contains many chapters describing and abnormal complex human behaviors . T hree of such complex P.3 behaviors are sleep (S ection 1.20), appetite (S ection and s ubs tance abus e and dependence (S ection 1.22). the beginning of this s ection, it was mentioned that it is neces sary to know everything and believe nothing and also to be wary of overs implifications from past models the brain and behavior. S leep, appetite, and substance abuse are all examples of thes e less ons , as all three now conceptualized as involving complex systems the brain responding to bodily functions outside of the C NS and changing in res ponse to external influences of biological, psychological, and s ocial

FUTUR E DIR E C TIONS R es earchers in neural s cience will continue to the s equencing of the human genome and advances in brain imaging techniques, as well as other advances in experimental neuroscience. Although the ultimate goal all these efforts is to prevent the development of disorders , the immediate goals are to alter dis ease progres sion and promote recovery. T he pace of 9 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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in neural s cience is, unfortunately, well matched by the complexity of the brain. Nevertheles s, neuroscientis ts finding ways to challenge their own beliefs in the light new data, and it may indeed be one of the readers of textbook that breaks through the current relative ignorance and leads psychiatry into a new paradigm for unders tanding mental illness in the 21s t century.

S UG G E S TE D C R OS S Neurops ychiatry and behavioral neurology are in C hapter 2; the neuropsychological and psychiatric as pects of AIDS are discuss ed in S ection 2.8; the neurochemical, viral, and immunological studies of schizophrenia are discus sed in S ection 12.4; the biochemical as pects of mood disorders are discus sed S ection 13.3; biological therapies are discus sed in 31; and Alzheimer's disease is discus sed in S ection T he future of ps ychiatry is discus sed in S ection 55.3.

R E F E R E NC E S *B urke W : G enomics as a probe for dis eas e biology. E ngl J Me d. 2003;349:969. *Dolan R J : E motion, cognition, and behavior. 2002;298:1191. G ingrich J A, ed. G enetically altered mice in the neurops ychiatry. C NS S pe ctrums . 2003;8:551. McK hann G M: Neurology: then, now, and in the Arch Neurol. 2002;59:1369. 10 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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*R utter M: T he interplay of nature, nurture, and developmental influences . Arch G e n P s ychiatry. 2002;59:996. *S nyder S H: F orty years of neurotrans mitters . A personal account. Arch G e n P s ychiatry. *Zonta M, Angulo MC , G obbo S , R osengarten B , Hos smann K -A, P oss an T , C armignoto G : Neuronas trocyte signaling is central to the dynamic control brain microcirculation. Nat N euros ci. 2003;6:43.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 2 - Neurops ychiatry and B eha vioral Neurology > 2.1: Approach to the P a tient

2.1: Neurops yc hiatric Approac h to the Patient Fred Ovs iew M.D. P art of "2 - Neurops ychiatry and B ehavioral Neurology"

INTR ODUC TION Neurops ychiatry is the ps ychiatric s ubs pecialty that with the psychological and behavioral manifestations of brain dis eas e. Neurops ychiatry is closely allied with the neurological s ubs pecialty that interes ts itself in ps ychological phenomena in patients with brain namely cognitive and behavioral neurology. T he care patients with identifiable, acquired brain dis eas e—such those with epileps y, movement disorders , and brain injury—requires the phys ician to have a base and a familiarity with ass ess ment and treatment methods not usually required for patients with primary ps ychiatric disorders. P atients with organic mental syndromes are common in clinical practice and often difficult to manage for the generalist or for the general ps ychiatris t in consultation with s pecialis ts in other In addition to expert management of patients with mental disorders , from its clinical vantage point, neurops ychiatry can offer a dis tinctive pers pective on idiopathic psychiatric disorders . Moreover, neurops ychiatry draws on a knowledge bas e in the 12 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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cognitive neuros ciences that has the potential to sharpen, and modernize ass ess ment and nosology in general ps ychiatry. T his chapter provides information about as ses sment by history, examination, and paraclinical investigations in neurops ychiatry and des cribes neuropsychiatric ps ychopathology from three pers pectives : anatomy, symptom or s yndrome, and disease. C overage from vantage point is panoramic in the hope that the three perspectives , by triangulation, produce an image of neurops ychiatris t thinks when ass ess ing a patient—the cerebral s ubs trate of behavior, the plausible of dis eas e process es, the clinical phenomena, and elucidation at the bedside. S ome of the points made in description of clinical techniques are illustrated in vignettes in the final s ection of the chapter that focus as sess ment is sues. T he seemingly obvious view that neuropsychiatry is the offspring of ps ychiatry and neurology is his torically mistaken. P s ychiatry differentiated itself as a medical specialty in the early part of the 19th century and neurology somewhat later. Ample evidence s hows that early asylum phys icians, the precursors of cons idered their patients to have brain dis eas es and, moreover, that a large proportion of their patients organic disease, even as it could be identified with the tools of that time. G eneral pares is of the insane (neuros yphilis, as it was later discovered to be), mental retardation, and the complications of alcohol abuse were all common in the 19th-century asylum. On this evidence, one might s ay that general ps ychiatry, was understood for the larger part of the 20th century, 13 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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derived from an earlier neurops ychiatry. E arly neurology, on the other hand, took little part in care of patients with major ps ychiatric disorders, at those requiring hospitalization; but what would later become outpatient ps ychiatry—the care of patients milder mood and anxiety disorders not requiring management, for example—fell into the province of the early neurologis ts. T he theories by virtue of which they unders tood their patients have, fortunately, been cons igned to the dus tbin of his tory. T he mains tream of Anglo-American neurology was ill equipped to give ris e a s cientific neurops ychiatry, and it was not until (as a convenient and meaningful landmark) Norman in 1965 awakened interest in the continental tradition of behavioral neurology avant la le ttre that the of J ohn Hughlings J ackson, Ludwig Lichtheim, Hugo Liepmann, K arl W ernicke, and others could provide impetus for the development of a clinical specialty devoted to scientific understanding of the cerebral mental and behavioral disorder. T o say that neuropsychiatry is devoted to the care of patients with brain dis eas e is not to depreciate the role ps ychological and social factors in the unders tanding of the genes is of s ymptoms or in the formulation of interventions to ass is t patients. T o the contrary, with brain disease are often inordinately reactive to or dependent on influences from the outside world, the social world. Neurops ychiatric case formulation into account both the vulnerability and the setting. T o extent that patients s uffer from brain-based in proces sing information from their environment, their need for as sistance in dealing with ins trumental and 14 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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interpersonal tas ks increas es . Much of the brain, after devoted to process ing social information and devising ways of meeting internal needs in a s ocial context. T he neurops ychiatris t requires a detailed ass ess ment of the patient's functional deficits and the contexts in which arise. T o say that the neuropsychiatris t regards deficits , or for that matter intact behavior, as the manifes tation of based proces ses is not to imply that idiopathic disorders occur in people with normal brains nor that general ps ychiatris ts are unaware of the cerebral origin these disorders . T o the contrary, the evidence for abnormal brain structure and function in the major ps ychiatric disorders is unmis takable, and general ps ychiatris ts often as sert the neurobiological nature of these illnes ses. However, evidence for s uch as sertions often not demonstrable in the individual cas e, all laboratory inves tigations characteris tically falling within the broad range of normal. Moreover, the abnormalities P.324 in question are believed to be, at least in large part and least in mos t illness es , genetic in nature and developmental in pathogenes is . T he recognition and unders tanding of the mental cons equences of acquired diseases of the brain—which form the bulk of the neurops ychiatris t's concern—are likely to require tools from those required by the general ps ychiatris t treating idiopathic disorders . Although a bright line between the two situations is not poss ible, and many neuropsychiatrists maintain a lively interest in 15 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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disorders as schizophrenia and autis m, the dis tinction supports the continued use of the term organic to refer these acquired disorders with pathology identifiable at bedside and by the clinical laboratory, as much as want to see the term interred. T o define neuropsychiatry by how the clinician thinks, however, may be less telling than to define it by what clinician does . Neurops ychiatris ts perform phys ical examinations, not just a focus ed screen for signs , s uch as is within the ambit of mos t general ps ychiatris ts, but a broad as sess ment of cerebral us ing the tools available. Neuropsychiatrists not only neuroimaging and electroencephalographic studies but also review them pers onally, not just to “rule out disease” but to see which organic disease is pres ent where.

NE UR OA NA TOMIC A L B A S IS OF NE UR OP S YC HIA TR IC T he neurops ychiatric brain is more complex than the general ps ychiatric brain. T he latter is a s oup of neurotransmitters, perhaps in “chemical imbalance” (as patients are wont to say), with cons iderable pharmacological, but little anatomical, specificity. Although the benefits of ps ychopharmacological intervention are indis putable, the locus of these effects rarely of concern to clinicians . A neuropsychiatric relies on greater differentiation among brain circuits systems . T he chapter cons iders s everal major brain systems of key importance to neurops ychiatric case formulation.

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L ateralization T he two hemispheres differentially s ubs erve many functions , although in many instances, both participate in naturally occurring behavior, albeit contributing differently to the complex outcome. B rain as ymmetries arise early in vertebrate evolution, and two hemispheres display regional lateral as ymmetries size and differentially innervate viscera and peripheral endocrine tis sues. F or example, the pars opercularis of third frontal gyrus (B roca's area) and the planum temporale (infolded cortex in the pos terior portion of sylvian fis sure) are typically larger on the left, with dendritic branching of the neurons therein (for sake, “left” and “right” here refer to the situation in the average dextral patient). T hes e cortical regions are the substrate of language process ing. Ins ular cortex of right hemisphere regulates cardiac sympathetic drive of the left hemis phere, parasympathetic drive. In cons equence, left hemisphere s troke involving ins ula produces more cardiac destabilization and morbidity right, and lateralization of s eizure dis charges may have implications for autonomic function and unexplained sudden death in patients with epilepsy. Lateral in limbic (hypothalamic and amygdalar) regulation of sexual function als o have clinical implications; for polycys tic ovary syndrome in females may be more commonly ass ociated with left-sided limbic epileps y. Hemispheric s ide of les ion als o affects the cons equences of brain injury. Whether a s ingle tag can accurately contras t the proces sing “styles ” of the hemispheres —“local versus global” or “linear versus context dependent,” for 17 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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example—acros s multiple functions is doubtful. left lateralization of language and right lateralization of visuospatial function are widely recognized, lateral specialization in the prefrontal regions is less obvious of clinical significance. F rontal lobe degeneration the right, more than the left, frontal lobe is particularly as sociated with disinhibition. T raumatic injury to the hemis phere is more ass ociated with depres sion and anxiety, to the left with anger and hos tility. W omen and sinis trals tend to s how less lateralization of language perhaps of other functions ), s o that left hemisphere are les s likely to produce severe impairment. Of cons iderable importance for neurops ychiatric is the ques tion of lateralization of emotional An array of evidence s upports the notion of differential emotional valences in the two hemispheres . On this account, the left hemis phere is specialized for pos itive emotions , the right for negative emotions. T hus left hemis phere destructive les ions are as sociated with pathological crying and right hemisphere ones with pathological laughing; contrariwise, left hemisphere discharging les ions produce gelastic (laughing) and right hemisphere ones , dacrystic (crying) epilepsy. this context, the reported ass ociation of left anterior with depress ion makes s ense. However, much evidence favors as signing a prepotent in emotional process ing in general to the right hemis phere. P atients with right hemisphere damage appear to be more impaired at perceiving emotion regardless of the valence or input medium. Lesions of right hemisphere are ass ociated with impairments in proces sing emotion in speech, a defect known as 18 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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apros odia. P atients may lack the capacity to modulate prosody, so as to encode emotional information into speech, or the capacity to recognize emotional produced by others . S ubtler clinically may be deficits in recognizing emotion in faces or visual scenes . S uch may be part of the bas is for a finding that may s eem counterintuitive, namely that patients with right hemis phere injury have a poorer rehabilitation outcome than their left hemisphere counterparts .

Frontos ubc ortic al C irc uits T he projection of prefrontal cortex to s ubcortical structures in multiple clos ed loops is a crucial feature of behavioral neuroanatomy. T he key concept is that, in loop, a distinct region of prefrontal cortex projects to a distinct portion of the s triatum, then to an output of the bas al ganglia, then, in turn, to a specific nucleus the thalamus , which itself projects to the given area of cortex. T hus, a s et of parallel clos ed loops of frontos ubcortical connections proces ses information in separate domains . In the motor system, premotor and s upplementary motor area project primarily to putamen, the output of which projects via ventrolateral globus pallidus and caudolateral substantia nigra pars reticulata (S Nr) to ventrolateral-ventroanterior and centromedian nuclei of thalamus and then back to the originating cortical structures. Of particular interest to neurops ychiatris ts are the loops involving dors olateral prefrontal, medial and lateral orbitofrontal, and anterior cingulate cortex: Dors olateral prefrontal cortex projects to caudate; projections from caudate go to 19 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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globus pallidus and S Nr. T he output from basal flows primarily to ventrolateral and ventroanterior nuclei of thalamus (but als o to dors omedial nucleus thalamus ), whence it projects to areas 9 and 46 of dorsolateral prefrontal cortex. Lateral orbitofrontal cortex projects to ventromedial caudate, thence to the caudomedial aspect of S Nr. thalamic level of this loop is repres ented in ventral anterior and dors omedial P.325 nuclei, whence projections aris e back to the lateral as pect of area 12 in orbitofrontal cortex. T he medial orbitofrontal cortex loop features projections from gyrus rectus and medial orbital to ventromedial caudate; output from the basal ganglia arises in S Nr and flows to dorsomedial of thalamus, as well as ventrolateral and nuclei, thence back to medial orbitofrontal cortex. Anterior cingulate cortex, in the dorsomedial as pect the hemis phere, projects to ventral striatum, nucleus accumbens and olfactory tubercle (termini the mesolimbic dopamine system), with output from S Nr flowing through ventroanterior thalamus on its way back to anterior cingulate cortex. Dis ruption of each of thes e loops produces a distinctive clinical s yndrome. As is implied by the concept of a deficits similar to those produced by cortical damage also occur with damage to the subcortical connections the cortical region. B efore a sketch of each of these syndromes, note mus t be made that mos t naturally 20 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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occurring les ions do not res pect the anatomic so that clinical presentations are commonly mixed. Nonetheles s, for analytical purposes , the anatomical specificity is of interes t and importance. Interference with the loop involving dorsolateral cortex prominently produces executive cognitive impairment, with decrements in working memory, problem s olving, and related capacities. Damage to loop commonly arises from traumatic brain injury, and basal ganglion degenerative diseases s uch as P arkins on's dis ease. Involvement of the white matter of frontal lobes by small-vess el dis eas e commonly leads interruption of corticos ubcortical connections in this circuit and the picture of subcortical dementia. Damage to orbitofrontal cortex and its connections produces impulsivity, dis inhibition, dampening of the experience of emotion, irritability and lability of affect, poor judgment and decis ion making (es pecially in to social behavior), and ins ightless nes s about thes e impairments . T hese impairments are generally s een bilateral damage, although unilateral right-sided injury may als o produce them. As a neighborhood s ign, often involves the olfactory nerve (which runs along the orbital surface of the brain) with cons equent anos mia— times the only neurological s ign. C ognitive function, as tes ted by the usual beds ide or neuropsychological may be unaffected even in the presence of devastating personality change. T rauma is a common etiology. Damage to dorsomedial prefrontal s tructures may aris e from tumor or s troke. Abulia and apathy, disorders of initiation of action and the experience of motivation, are the res ult. Abnormalities of initiation of movement, with 21 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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akinetic mutis m as the mos t extreme s tate, may occur. C ingulate cortex is a structure of particular interest. E vidence from animal and imaging s tudies its importance in orienting attention under conflicting stimulus demands , modulating focus ed problem and monitoring performance to optimize reward. A cell type s een only in cingulate cortex, the s pindle cell, in evolution only with the great apes and in ontogeny at 4 months of age, concomitant with the infant's increasing capacity to focus attention. Interference with the output of cingulate gyrus , namely by interrupting cingulum—the procedure of cingulotomy—appears to beneficial in a dis order of excess ive attention, namely obses sive-compuls ive disorder (OC D).

L imbic S ys tem L e grand lobe limbique was delineated in the mid-19th century (by P aul B roca of aphas ia fame) as a ring of and s ubcortical structures on the medial aspect of the hemis pheres . J ames P apez drew attention to the formed by projections from hippocampus via fornix to mamillary bodies of hypothalamus, thence to anterior nucleus of thalamus , thence via the anterior limb of internal caps ule to cingulate gyrus , thence back to hippocampus via presubiculum, entorhinal cortex, and perforant pathway. In addition to this “P apez circuit,” amygdala and its reciprocally connected orbitofrontal cortex are taken to form part of a limbic s ys tem, a term us ed by P aul MacLean one-half century ago. Although some anatomists bristle at its inclusivenes s, the nearly universally us ed, probably because it focuses attention on the “emotional brain.” 22 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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T he core limbic structures are characterized by rich reciprocal monosynaptic connections with these are Hippocampus Amygdala P iriform cortex anterior to amygdala on the medial surface of the temporal lobe S eptal nuclei in the medial wall of the hemispheres , immediately ros tral to lamina terminalis S ubstantia innominata in the bas al forebrain P aralimbic cortices res ide in temporopolar, insular, and orbitofrontal regions, which have primary affiliations amygdala, and in parahippocampal, cingulate, and s ubcallosal regions, with primary with hippocampus . In the limbic s ys tem, broad and direct input from cortices into amygdala and hippocampus is extensively proces sed on its way to effector neurons in regulating autonomic and endocrine activity. In addition to this mediation of the regulation of the internal milieu, the limbic s ys tem gates the activity of the motor in the bas al ganglia, regulating action in the external milieu. T his occurs by prefrontal cortical integration of information in the limbic frontosubcortical circuit, which reaches the cortex via projections from ventral pallidum mediodors al nucleus of thalamus . One reas on for the central importance of the limbic in neuropsychiatry is that the threshold for production 23 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epileptic discharges is lowest in amygdala and hippocampus . T hus, most epileps y in adults is limbic epilepsy. One consequence is the “voluminous mental state,” first identified by Hughlings J ackson. T his refers the range of experiential phenomena encountered as auras in limbic epilepsy: dé jà vu, depers onalization/derealization, microps ia, and and s o forth. S uch s ymptoms are s een not only in but also in mood dis orders and as putative pointers to limbic involvement in paroxys mal disorders not of clear epileptic nature, including those ass ociated with borderline pers onality disorder and with childhood T heir presence, therefore, does not unequivocally mark organic diagnosis. Another reas on for the centrality of the limbic system is that hippocampus, in particular, has a crucial role in explicit memory, further discus sed below. P ers is ting subs tantial amnestic deficits in multiple modalities limbic s ys tem damage.

C erebellum Agains t the prevailing notion that the cerebellum is a motor s tructure, anatomical evidence s hows that cerebellar inputs acces s areas of prefrontal cortex, with relay in thalamus. T hes e areas of cortex project to cerebellum, creating, as with the prefrontal-basal ganglia circuits previously dis cus sed, a set of parallel (relatively) clos ed loops, or channels . T hes e cross ed connections from the cerebellar hemis pheres and the further cros sing of des cending cerebrofugal long tracts mean that motor deficits are manifest ips ilateral to lateralized cerebellar injuries . Additional 24 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P.326 reciprocal connections link cerebellum with monos ynaptically and with other areas of the limbic via a relay in the bas is pontis. T he phylogenetically vermis and fastigial nucleus can be differentiated from neocerebellum of the cerebellar hemispheres and cons idered a “limbic cerebellum.” G rowing evidence of cerebellar contributions to and affect comes from clinical data and studies. T he data are fraught with uncertainty, however, because many cerebellar patients have disorders that not be limited to cerebellum; for example, cerebellar degenerations may include cortical degeneration, and tumors (and their treatment with radiation and chemotherapy) may have remote effects . Moreover, the phenomenon of cross ed cerebellar dias chisis —the reduction in blood flow to connected neocortical areas after cerebellar damage—means that interpretation of deficits as due to abnormal ce rebe llar process ing, as compared to s hutdown of cerebral cortical proces sing, treacherous . Nonetheles s, patients with stroke les ions clinically and by neuroimaging limited to cerebellum have deficits in executive cognitive function, memory, language, and visuospatial function. T he data sugges t lateralized cerebellar damage is as sociated with the predicted lateralized cognitive phenomena (right damage with language impairment, left with visuos patial impairment). R eports of an affective s yndrome after cerebellar injury are les s systematic. Defects in affect regulation, with irritability and lability, are propos ed to as sociated with damage to the limbic cerebellum, 25 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the vermis.

White Matter and C erebral C onnec tivity Whereas the volume of neocortex has increased over cours e of phylogenetic history, the volume of white has increased disproportionately. In humans, the white matter tracts occupy some 42 percent of the volume of hemis pheres . T he great majority of thes e fibers serve corticocortical connectivity rather than projections between cortical regions and s ubcortical sites ; for example, thalamic input is estimated to represent only percent of the total input into primary sensory cortex, remainder being from other cortical areas. T he fibers in white matter are of several types . F irst are longer intrahemis pheric fiber tracts : Arcuate fas ciculus, which connects s uperior and middle frontal gyri to the temporal lobe and (via a superior portion of the fas ciculus called s upe rior longitudinal fas ciculus ) the parietal and occipital Uncinate fasciculus , which connects orbitofrontal cortex to temporal cortex and (via an inferior of the fasciculus called inferior occipitofrontal fas ciculus ) the occipital lobe C ingulum, which lies medially beneath cingulate cortex in cingulate gyrus and connects frontal and parietal lobes with parahippocampal gyrus and adjacent structures S econd are the long projection systems linking cortex, 26 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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subcortical nuclei, and lower portions of the neuraxis . Medial forebrain bundle is the primary connection between limbic s tructures and the brains tem and projections from the monoaminergic cells in the and pons. Others are the thalamic peduncle with reciprocal fibers between thalamus and parietal lobe the corticopontine and corticos pinal tracts descending through corona radiata and internal caps ule. F ibers prefrontal cortex descend in the anterior limb of internal caps ule, so that les ions there may have predominant behavioral and a paucity of elementary sensorimotor effects. Lacunes and degeneration of the white matter due to hypertens ive s mall-vess el dis eas e (B inswanger's interrupt these corticocortical fibers and projections. T he result of progres sive los s of communication among cortical regions and between cortex and subcortical gray matter is the clinical state subcortical dementia, which is prominently by slowing of mental proces sing and failure of control process es. T he latter may be explained in part the preferential occurrence of lacunes in frontal but also by the impairment of connectivity. T hird, U fibers are the short, juxtacortical fibers adjacent cortical regions. T hes e fibers are spared in B ins wanger's disease, cerebral autos omal dominant arteriopathy with s ubcortical infarction and lacunes (C ADAS IL), and certain other dis eas e F ourth are the many specific projection systems linking delimited regions s uch as mammillothalamic tract, connects mammillary bodies with anterior nucleus of thalamus , and fornix, which connects mammillary 27 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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with hippocampus. Interesting neurobehavioral syndromes have been described related to rare cas es focal interruption of s uch pathways. F or example, interruption of mammillothalamic tract or of fornix is implicated in amnesia. F ifth, s everal pathways connect the two hemis pheres , notably corpus callosum but also anterior and pos terior commis sures and mas sa intermedia of thalamus . S yndromes due to interruption of the smaller have not s o far been described, although abs ence of mass a intermedia is reported to be as sociated with schizophrenia in women, and anterior commiss ure and mass a intermedia are larger in women than in men. C orpus callos um is congenitally absent in numerous neurodevelopmental syndromes , and its absence has as sociated with s chizophrenia. C ongenital abs ence is however, as sociated with the interes ting disconnection symptoms s een in les ional interruption of the callosum such as by anterior or posterior cerebral artery s troke surgical callosotomy for control of epileps y. T wo callos al dis connection s yndromes are worthy of specific mention. After anterior cerebral artery with anterior callos al infarction, the right hemisphere is deprived of verbal information; a left-hand apraxia is and the patient cannot name uns een objects placed in left hand. R eciprocally, the right hand shows cons tructional apraxia. T his is the anterior s yndrome . After occlus ion of the left posterior cerebral artery with infarction of the left occipital lobe and the splenium (posterior portion) of corpus callosum, the language cortices of the left hemis phere lose acces s to visual information: T he left visual cortex is damaged, 28 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the projections from the right visual cortex, which cros s the splenium. T hus, reading becomes imposs ible, other language functions are unaffected—the of ale xia without agraphia.

C erebral C ortex T he cerebral cortex develops through complex but increasingly well-unders tood proces ses of cell and migration, axonal projection, and dendritic proliferation and pruning. Abnormalities in these proces ses lead to cortical dysplas ia with clinical cons equences, including mental retardation and S ome 10 percent of intractable epilepsy may be due to such dis orders, and increas ingly, migration are recognizable by imaging before neuropathological examination. F ailure of normal pruning of synapses by elimination of dendrites is now known to be crucial in pathogenes is of the fragile X syndrome and has been speculatively linked to s chizophrenia. R arely, cortical dysplas ia may be pres ent without epileps y or mental retardation; the neurobehavioral cons equences of this abnormality are just coming under investigation. T he organization of s ens ory cortices follows a regular E ach primary s ens ory cortical area projects to as sociation cortices s pecialized for the extraction of features in that particular modality; the unimodal as sociation cortices are dens ely and reciprocally interconnected. F or example, visual ass ociation cortex specialized regions for color, motion, and s hape. T his creates an intricate P.327 29 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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web of s ens ory proces sing; the vis ual cortex in the cat, example, is believed to have 19 process ing regions . Unimodal as sociation cortices project, in turn, to heteromodal cortices , which receive inputs from more than a single sensory modality. Heteromodal cortices located in prefrontal, pos terior parietal, lateral temporal, and parahippocampal regions. Unimodal cortices do project to unimodal cortices in other modalities , only to the higher-level heteromodal cortices . F urther, hippocampal projections to cortex arrive only at as sociation cortices , not primary s ens ory cortices. structural features amount to the isolation of s ens ory proces sing from top-down influences over the first synaptic s tages and presumably increase its fidelity to external phenomena. Lesions of cortical as sociation areas produce an array behavioral and cognitive disorders of intriguing T he specificity can be demonstrated by the occurrence double diss ociations : A lesion in area A produces a in function x but not y; a lesion in area B produces a in function y but not x. T his pattern of findings provides crucial confirmation that the deficits aris e not from task difficulty (if y were s imply more difficult than x, then y would always be dis turbed when x was dis turbed), but from s eparable proces sing components . F or example, some patients s how a greater impairment for naming living things than for naming artifacts after a brain However, occasionally, patients show the opposite greater impairment in naming living things: a double diss ociation. T he explanation of the discrepancy thus cannot depend on ins ufficient process ing res ources but must reveal a property of the organization of the 30 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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system. C ognitive dis orders of the visual s ys tem can s erve as a paradigm of the s yndromes s een with damage to the as sociation cortex. Lesions of primary visual cortex B rodmann's area [B A] 17) produce cortical blindnes s in quadrant, hemifield, or the entire vis ual field. Despite genuine blindnes s, accuracy above chance in visual s timuli can be achieved without awarenes s of the phenomenon of blinds ight, which tes tifies to subcortical visual proces sing inaccess ible to cons ciousnes s. V 1 projects to adjacent cortical regions (B A18 and B A19), which contain neurons that respond specific features of visual s timuli such as color, or s hape. Lesions in thes e cortices produce deficits in identification of these features. T hus arise syndromes as central achromatopsia, demons trated by inability to (as well as to name) colors. T he s tream of information transfer divides into dors al and ventral streams, the specialized for localization of visual s timuli (“where”) the latter for identification of the s timuli (“what”). Dors al lesions involving s uperior parietal lobule can produce impaired reaching under vis ual guidance (optic ataxia), part of B alint's syndrome; the deficit testifies to the integration of vis ual information with motor output in as sociation cortex. V entral les ions, involving inferotemporal cortex, produce defects in recognition (agnos ia). Agnos ic patients are not only unable to elements within the domain of agnos ia but also are to demons trate their us e or show recognition of the in other nonverbal ways. C entral auditory dis orders include cortical (or central) deafness ; pure word deafnes s, the inability to 31 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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words presented in the auditory modality despite preserved vis ual–verbal function; and auditory agnos ia, the inability to recognize words or complex s ounds the meaning of the ringing of a telephone). C entral deafness requires bilateral les ions involving primary auditory cortex in s uperior temporal gyrus or auditory radiations in white matter. P atients with pure word deafness generally have bilateral les ions of as sociation cortex more anteriorly in superior temporal gyrus , although unilateral left lesions , presumably left from right cortices by s ubcortical damage, also are reported. P rimary auditory cortex is partially s pared in these cas es . In agnosia for nonverbal environmental sounds, right hemisphere damage is sufficient to the deficit. Amus ia, the incapacity to recognize musical sounds, is ass ociated with cortical damage, but the laterality is complex, dependent in part on the preinjury level of mus ical s kills . F ull evaluation of these dis orders requires techniques go well beyond beds ide examination or routine paraclinical tools . At iss ue in the agnos ic dis orders is extent to which a deficit is apperceptive—that is , due to impairment in analysis of subtle perceptual elements presumably dependent on more ups tream cortical regions —and as sociative—that is , occurring in the absence of definable perceptual abnormalities and presumably due to dysfunction of more downstream cortical analyzers . T his dis tinction requires detailed neurops ychological and often psychophysical

Modulators of B rain S tates T his account of cognitive proces sing in cortex seems to 32 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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many ps ychiatris ts to leave out of consideration the matters with which they are mos t concerned: pervasive states of altered mood, drive, and behavior. T hat such states are behaviorally pervas ive does not argue that are anatomically global. Limbic structures dis cuss ed provide in part the anatomical s ubs trate for emotional states . F urther, several s ys tems with diffus e cortical projections have the capacity to modulate process ing widespread brain regions. T hes e originate in Intralaminar thalamic nuclei, which project to cortex (es pecially prefrontal and cingulate cortex) and to striatum His taminergic cells in pos terior hypothalamus S erotonergic cells in pontine raphe nuclei Noradrenergic cells in locus ceruleus Dopaminergic cells in the midbrain ventral area giving rise to the mesocortical and mes olimbic systems C holinergic cells in bas al forebrain nuclei s uch as nucleus basalis of Meynert T he last of these is of relevance to cholines teras e treatment of dementia, the preceding three of to treatment of mood, anxiety, and ps ychotic dis orders . T he hypothalamic histaminergic projections are in arousal. “Nons pecific” thalamic projections may have important role in executive dys function s een after lesions . S o as not to become complacent about current unders tanding of s uch pathways, recall that only within the pas t few years were a previously unknown 33 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurotransmitter and its pathways recognized, and the discovery of orexin/hypocretin and its hypothalamic anatomy exposed the secrets of narcoleps y. Neurops ychiatric anatomy is not a closed book.

MODUL A R ITY A ND NE UR OP S YC HIA TR Y T hese focal behavioral syndromes , and many others, compel attention to local proces sing in the brain and almos t irresistibly s uggest a particular model of brain organization. One imagines a box-and-arrow diagram, which each box—representing an elementary cognitive function—maps on to a specialized region of cortex. area of cortex has its job to do, and a lesion of any produces a distinctive, delimited, and predictable T his model rais es the iss ue of modular organization of brain. T he general topic of modularity in cognitive proces sing des erves further cons ideration because it is crucial to the theoretical perspective of neuropsychiatry and, in particular, becaus e it bears on the value of neurops ychiatric data for the understanding of ps ychiatric disorders. Modularity in cognitive refers to a brain organization P.328 characterized by multiple computational devices , each which operates on characteris tically encapsulated input with prewired (perhaps innate) rules, thus being rapid, efficient, and reliable. F or example, elementary visual proces sing can be considered modular, inasmuch as it res tricted input with hard-wired feature extraction (e.g., motion, color, s hape). In another domain, consider that 34 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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easier to teach an animal to as sociate a tas te than a stimulus with the aversive effects of an inges ted toxin. finding implies domain-specific, innate learning cons traints. T he class ic cognitive example of domainspecific prewiring is language—for example, observation that children generate language errors that they have never heard: “He bringed me here,” the child might s ay, although he or s he has never heard an adult say “bringed.” T he implication is that a languageproces sing module pos sess es innate grammatical that have generated a grammatical form without experiential foundation. E volutionary psychologis ts have forcefully argued the for modular process ing, as oppos ed to domain-general problem-solving devices. T he core of the evolutionary argument is that cerebral organization is the res ult of natural selection operating on the adaptational fitness humans' P leistocene hunter-gatherer ances tors . specific proces sing has advantages of speed and that neces sarily lead to an advantage in fitness . T he availability of preexperiential information about the content of domain-specific process ing carries a large advantage over the “combinatorial explosion” of informational pos sibilities requiring evaluation by a domain-general proces sor. F or example, detection of cheating in s ocial exchanges is an es sential element of adaptation in a population group featuring cooperative behavior. Is it a function of a domain-general logical problem-solving device, or is there a “cheatermodule? C ross -cultural evidence s hows that people better at detecting violation of s ocial exchange rules at solving problems of equivalent logical complexity 35 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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posed in other terms, and focal les ions can affect cheater detection. T he implication is that mechanisms, presumably located in a particular brain are “tuned” to recognize and reason about this adaptationally crucial behavior, jus t as innate subs erve language learning and toxin recognition. One the s trengths of the evolutionary approach is to direct attention to proces sing domains the modularity of is plaus ible on adaptational grounds. However, many of the “modules ” that have attracted clinical interest are not plaus ibly directly the objects of natural selection. R eading and writing are clear T hese have arisen too recently in evolutionary time to been the product of natural selection and, thus, must depend on the workings of process ors that are, at leas t this extent, domain general. Moreover, much of the literature on modularity is from a cognitive-ps ychological or philosophical perspective, with les s attention to the “wetware” (i.e., actual brain s ubs tance) implementation of the devices . A foundation in cognitive neuros cience and evolutionary biology can enrich clinical theories, but it creates the potential for mis understanding by clinicians interes ted in the functioning of patients with brain T he modules of the evolutionary biologis ts and philosophically inclined cognitivis ts do not map directly onto brain areas . One of the s triking res ults of neuroimaging experiments is that, however the function under s tudy is delimited, multiple areas of brain are found. A metaanalysis of reports of positron tomography (P E T ) s tudies of cognition found that the mean number of activation peaks per experiment was 36 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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10.24! E ach tas k engaged a mean of 3.3 B rodmann's contrariwis e, each B rodmann's area was engaged by a mean of 3.42 perceptual or cognitive tasks. E ven that s eem ps ychologically fundamental are not implemented in a s imple way, and local process ing components may be recruited into networks s ubs erving variety of tas ks . T his seems to be the case in respect limited number of frontal sites involved in a wide range executive tasks. T he specialization of regions is on input from other regions ; specialization is not dependent on intrinsic properties but partially on topdown influences. T he is sue is not whether different cerebral regions out different modes of information process ing. T his is unques tionably so, and neither unreconstructed holists who believe in the equipotentiality of cortex nor strict localizationis ts who believe only in fully autonomous proces sing devices figure on the current neuros cientific scene. T he question is how regions are linked in out tas ks . F unctions are implemented by networks , or all of the nodes of which participate in multiple functional networks . T his pattern of cerebral has been termed s e le ctively dis tribute d proce s s ing or s pars e ly dis tribute d ne tworks . Although cortical regions have specialized capacities for information process ing, functions cannot be localized to regions (as Hughlings J ackson explicitly warned a century and a half ago). It erroneous, for example, to believe that an area crucial face recognition contains all of the neurons, and only neurons , that respond to faces . Moreover, normal individuals may differ in how they recruit regions into networks. T he methods us ed in 37 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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studying groups of s ubjects in functional imaging experiments may obscure s uch individual differences . example, robust individual differences in patterns of activation emerged in a memory tas k, differences putatively reflecting different s trategies in performing tas k. T he differences were stable within individuals time, yet analys is of group data revealed activations in regions activated in only some of the subjects and disclos e activations in regions cons istently activated in others . Individual differences in organization of cortex are evident clinically in the unusual, but not negligible, occurrence of cross ed aphasia (aphas ia due right hemisphere injury in a dextral), cross ed (lack of aphasia with a left hemisphere injury that to cause aphasia in a dextral), and aphas ic deficits anomalous in res pect to the predicted effects of lesions both dextrals and sinis trals. Another crucial critique for neurops ychiatry of the modularity hypothes is derives from developmental ps ychology. T renchant arguments contradict the as sumption that a mapping of deficits to specific brain structures could be s tatic over developmental time. T o contrary, how the brain performs cognitive tasks with development. Development entails changing patterns of interaction among brain components , and localization may alter as neurons and regions become “tuned” in res pons iveness bas ed on their initial characteristic process ing biases and their patterns of inputs and connectivity. T his reorganization of cortical function could mean that the same behavior has subs trates at different developmental epochs. F or example, in adult s ubjects with Williams s yndrome, 38 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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number proces sing and good language s kills are characteristic; however, in infancy, the opposite pattern seen. W hatever the fundamental process ing disorder genetic origin may be, it cannot be seen as having “knocked out” a module. A large expanse of nonlinear brain development lies between the gene and the phenomena, an expanse that can be unders tood only a better theory than neophrenology (F ig. 2.1-1). T he development of modularity can be anomalous . Indeed, the Williams syndrome cases , magnetic res onance (MR I) data disclos e an anomalous, diffuse pattern of activation for music perception, an area of preserved or enhanced ability in these patients . F ocal syndromes in adults provide an appropriate place to s tart in hypothes es, but a deficit s een in an idiopathic dis order cannot be as sumed to have its bas is in dysfunction in same simple locus as a phenomenologically similar seen after a focal brain lesion occurring in an adult.

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FIGUR E 2.1-1 A phrenological head as pictured in (A) and 1957 (B ). Des pite the interval of 67 years, are s uspicious ly alike. (F rom F owler OS , F owler LN. S elf-Ins tructor in P hre nology and P hys iology. New F owler & W ells ; 1890:iii; and P olyak S . T he V is ual S ys te m. C hicago: T he University of C hicago 1957:456, with permis sion.) P.329 Nothing in this line of argument diminis hes the interes t focal neurobehavioral s yndromes , which are clinical and have a s ubs tantial heuris tic value for the cognitive neuros ciences. Neuropsychiatry, along with other brain specialties , has the task of importing into clinical theory the unders tanding of the mind and brain that is developing in cognitive neuros cience. T he s earch for ps ychopathological unders tanding based on of deficits in cognitive modules that are relatively well unders tood in normal subjects has been termed ne urops ychiatry. T his purs uit inevitably results in deconstruction of the ps ychiatric diagnoses of the fourth edition of Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) or the International Dis eas es P.330 (IC D) into s ymptoms or s yndromes becaus e the diagnostic categories are generally based on folkps ychological notions (s uch as the divis ion between 41 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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“thought” and “affective” disorders ). Much of this chapter is devoted to the anatomical mode thought practiced by neurops ychiatris ts . However, clinicians appear to hope that neuropsychiatry will a localizing taxonomy of behavioral syndromes, s o that particular psychiatric dis orders will carry the same localizing power as, s ay, the B abinski s ign for the corticos pinal tract—the nuclear s yndrome of schizophrenia to the left temporal lobe, for example. the contemporary cognitive neuros cience perspective reviewed, this seems likely to be fals e hope. T he sign is a limiting, not a paradigmatic, cas e of brain– behavior relations hips. F or the fullest understanding of complex mental s yndromes, notably those traditionally the realm of ps ychiatry, a more adequate theory of function is needed than can be offered by the localizationis t tradition.

C L INIC A L E VA L UA TION T he neurops ychiatric perspective places great reliance information that can be gathered at the bedside. No practical inquiry and examination can include all items ; rather, the clinician selects from a toolbox of of the his tory and of the patient's functioning in the examination room to confirm or refute hypotheses generated by the emerging clinical picture. S creening items should have high s ens itivity but not necess arily specificity. B eyond s creening, elements of the his tory examination that might potentially elucidate the nature the disease process under consideration form the corpus of medical ass ess ment and cannot be dealt comprehensively in this chapter. F or example, the 42 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurops ychiatris t cons idering liver dis eas e as the explanation for delirium wants to estimate the liver during the physical examination, but techniques for so are not discus sed below. T he discus sion here is on both common iss ues and techniques dis tinctive to neurops ychiatry.

Neurops yc hiatric His tory T he initial s teps in screening for the presence of disease in patients with mental s ymptoms are eas ily T he phys ician s hould obtain a general medical his tory, including a his tory of dis eas es pos sibly relevant to the neurops ychiatric s ymptoms under consideration, and a review of s ys tems in potentially relevant areas. W ith a cognitively impaired or ps ychotic patient, s uch history taking may be unreliable. C ollateral his tory from a member or other informant and review of medical are almos t always es sential. With virtually every patient, the clinician s hould inquire to a history of Heart, lung, liver, kidney, skin, joint, and eye Hypertension Diabetes T raumatic brain injury S eizures, including febrile convulsions in childhood Unexplained medical symptoms S ubstance misus e C urrent medication 43 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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F amily history of neuropsychiatric disorder T he inquiry about thes e disorders in some settings can quite general. F or example, the question “have you had heart problems ? ” along with a few questions in the review of s ys tems may suffice to screen for heart a young, apparently healthy patient. In other settings, more detailed information mus t be gathered. T he review of systems as well s hould vary according to setting. P os itive res pons es should of course lead to inquiry. T he clinician s hould be practiced in inquiring about C ons titutional symptoms: fever, malaise, weight pain complaints Neurological s ymptoms : headache, blurred or vision, impairment of balance, impairments of auditory acuity, swallowing disturbance, focal or transient weakness or sensory loss , clumsines s, disturbance, alteration of urinary or defecatory function, altered s exual function P aroxysmal limbic phenomena: micropsia, metamorphops ia, dé jà vu and jamais vu, dé jà and jamais é couté, forced thoughts or emotions , depers onalization/derealization, autos copy, paranormal experiences such as clairvoyance or telepathy T hyroid s ymptoms: heat or cold sens itivity, cons tipation or diarrhea, rapid heart rate, alopecia change in texture of hair R heumatic dis eas e s ymptoms : joint pain or 44 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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mouth ulcers , dry mouth or eyes , rash, pas t spontaneous abortions

B irth His tory and E arly Development B ecaus e brain development s tarts before birth, s o does neurops ychiatric history. T he clinician should note Maternal s ubs tance mis us e, bleeding, and during the pregnancy C ours e of labor F etal dis tres s at birth, including Apgar s cores, if available P erinatal infection or jaundice Motor and cognitive miles tones s uch as the age the child crawled, walked, s poke words , s poke T he infant's temperament T he child's s chool performance (including special education and anomalous profiles of intellectual strengths and weaknes ses ), usually the best guide (absent ps ychometrical data) to premorbid function T he role of perinatal injury in cerebral palsy and mental retardation has commonly been overestimated; in instances, developmental disorder is present in before the perinatal misadventure, which may in fact from the preexisting abnormality. However, perinatal injury, in particular hypoxic injury, is probably with later s chizophrenia. 45 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Head Injury and Its S equelae Head injury is common and potentially a factor in later mood and ps ychotic dis orders as well as cognitive impairment, epileps y, and pos ttraumatic s tres s disorder (P T S D). T he clinician should inquire about a his tory of injury in virtually every patient. T he nature of the injury should be clarified by eliciting the circums tances , including ris k-taking behaviors that may have to injury and others who were injured in the s ame often an emotionally powerful aspect of the event. T he loss of cons cious nes s is not a prerequisite to important sequelae; even a period of being stunned, “seeing can presage later neurops ychiatric symptoms . T he of los s of cons cious nes s, or coma, should be ideally with the ass istance of contemporaneous records . T he period of retrograde amnesia—from last memory before the injury to the injury itself—and of anterograde amnes ia—from injury to recovery of the capacity for consecutive memory—should be noted.

A ttac k Dis orders P aroxysmal dis orders of neurops ychiatric interes t epilepsy, migraine, panic attacks, and epis odic P.331 of aggress ion. T aking a his tory of an attack has features irrespective of the nature of the dis order. T he clinician should track through the chronology of the attack. T his starts with the poss ible presence of a prodrome, a warning of an impending attack in the or days before one. T he attack its elf may be presaged an aura, lasting s econds to minutes . In the cas e of an 46 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epileptic seizure, this represents the core of the s eizure its elf and may carry important localizing information the side and s ite of the focus . T he pace of buildup, onset to peak of the ictus, is of differential diagnos tic importance. F or example, epileptic seizures begin abruptly; panic attacks may have a more gradual development to peak intens ity. T he mental and features of the ictus its elf should be elicited in detail collateral informants as well as from the patient, if T he duration of the spell and the mode of its should be elicited. Inquiring whether the patient has one s ort of spell or more than one is an es sential to establishing the frequency of episodes , both at and at maximum and minimum in the pas t. B y interviewing the patient and collateral informants , information necess ary to make a differential diagnos is us ually be elicited. T he differential diagnos is between epilepsy and ps eudoseizures can be difficult, but at if asked properly, the patient makes the diagnosis for clinician by reporting “two kinds of s eizures ,” one of is clearly epileptic and the other of which is clearly dependent on emotional s tates.

C ognitive S ymptoms R ecognizing cognitive symptoms in patients without es tablis hed dementia is a crucial element of neurops ychiatric history taking. S uch symptoms may outweighed by more dramatic behavior or mood but identification of cognitive impairment can reorient diagnostic evaluation of a late-life depres sion, for No doubt the mos t common complaint along cognitive lines is of memory problems. In the s etting of 47 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the more intense the complaint of memory impairment, the less likely it is to have an organic bas is and the likely to testify to depres sive ideation and attentional failure. T he clinician s hould establish whether forgotten material (for example, an acquaintance's name or a meant to be performed) comes to the patient later, as a matter of absentmindedness rather than amnestic C ertain other complaints are highly characteristic of organic disease. T hese include a los s of the capacity divided attention or for the automatic performance of familiar tasks. A patient might report, for example, no longer being able to read and listen to the radio at the same time. G etting los t or beginning to us e aids for such as a notebook, are sugges tive of organic failure.

A ppetitive S ymptoms and C hange Alterations of s leep, appetite, and energy are common idiopathic ps ychiatric disorders , as well as transiently in healthy population, and cannot be interpreted as brain dis eas e. C ertain patterns of altered s leeping and eating behavior and personality, however, are pointers organic disease. E xces sive daytime s leepiness or attacks rais e the question of s leep apnea or narcoleps y in a different temporal pattern, K leine-Levin s yndrome. Abnormal behavior during s leep raises the ques tion of parasomnia. Of particular interes t is rapid eye (R E M) behavior disorder, which may be due to a lesion but, when a focal lesion is abs ent, strongly ingraves cent Lewy body dis eas e. Much more rarely, nocturnal oneiric behavior repres ents a prion dis ease, notably fatal familial ins omnia. Los s of dreaming occurs 48 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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with parietal or bifrontal damage; loss of vis ual imagery dreams occurs with ventral occipitotemporal damage, of the C harcot-Wilbrandt s yndrome (loss of vis ual with brain damage). In medial hypothalamic disease, eating behavior is marked by lack of satiety and obesity. In the K lüver-B ucy s yndrome of bilateral temporal damage (involving amygdala), patients mouth nonfood items . W ith frontal damage, patients may s tuff food into the mouth, a form of utilization behavior, sometimes with alarming or even fatal cons equences. “gourmand” syndrome of exces sive concern with fine eating has been ass ociated with right anterior injury. C hanges in sexual behavior are common brain disease. Hyposexuality is common in epileps y, poss ibly as a consequence of limbic dis charges . A in habitual s exual interests, quantitative or qualitative, developing in midlife sugges ts organic dis eas e. It is poss ible, although understudied, that relevant organic disease, such as the s equelae of traumatic brain injury, common in s exual offenders. Other changes in such as the development of shallownes s of affect, irritability, loss of sense of humor, or a coarsening of sens ibilities , may indicate ingraves cent organic example, frontotemporal dementia.

Handednes s Approximately 90 percent of people designate as dextral, almost all the rest as sinis tral, and a very ambidextrous . T he true state of affairs is somewhat complicated, in that handednes s may be considered dimensionally—that is , as a matter of degrees rather categories . A patient may call hims elf or herself right49 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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handed but us e the left hand preferentially for certain tas ks . Inquiring about a few s pecific tasks —writing, throwing, drawing, using s ciss ors or a toothbrus h— helpful information. A family his tory of s inistrality may be relevant.

Neurops yc hiatric Phys ic al T o the neurops ychiatrist, the physical examination is a central feature of clinical evaluation. In principle, any as pect of the general physical or neurological may be relevant to neuropsychiatric diagnos is, if only in revealing an incidental clinical problem in a neurops ychiatric patient. Here, the focus is on the physical examination with specific relevance to detection and identification of organic dis ease in with mental presentations . T he mental examination, including the cognitive examination, is discuss ed below as sociation with syndromes of behavioral disorder and insofar as it can elicit or elucidate thes e s yndromes in cons ultation room.

G eneral P hys ic al E xamination GE NE R AL APPE AR ANC E Dys morphic fe ature s include so-called minor physical anomalies, s ome of which are captured in the widely Waldrop s cale. T hes e are as sociated with disorders , including s chizophrenia. S ome of thes e are lis ted in T able 2.1-1. T hes e features center on the hands , and feet. No single minor anomaly is diagnos tic pathological development, but the coincidence of anomalies argues that development has gone awry. specific developmental dis ability s yndromes can be 50 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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diagnosed by the constellation of dysmorphic features presented. C le ft lip or palate is as sociated with brain malformations and frontal cognitive impairment. As ymme try of the extremities, often bes t s een in the thumbnails, or of the cranial vault points to a developmental abnormality. Occas ionally, a patient reports wearing s hoes of different s izes on the two feet. T he larger extremity and the s maller side of the head ipsilateral to the abnormal cerebral hemis phere. S hort s tature is an important feature of many developmental syndromes, both common, s uch as fetal alcohol and Down s yndrome, and uncommon, such as mitochondrial cytopathies . Abnormal habitus , s uch as marfanoid habitus of homocys tinuria, may be a clue to diagnosis. W e ight los s is an important P.332 clue to s ys temic dis eas e, s uch as neoplasia; it should be dis miss ed, even in a patient with depres sion, which may—but may not—account for the weight los s. gain equally may point to limbic or systemic disease, es pecially an endocrinopathy, or may reflect toxicity of ps ychotropic drugs .

Table 2.1-1 S elec ted Minor Anomalies Head and face

Mouth 51

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   Head circumference a

   High arch of palate a

   Hair whorls a

   F urrowed tongue a

   F ine electric hair that will not comb downa

   G eographical tongue a

   Abnormal philtrum    F rontal boss ing

   C left uvula

E yes

E xtremities

   W ide-spaced eyes a

   C linodactyly a

   E picanthus a

   Abnormal palm creas e a

   S hort palpebral fis sures

   T oe 3 longer than toe 2 a

   Iris dis coloration or

   P artial

E ars

   G ap between 1 and 2 a

   Adherent lobes a

   S mall nails

   Malformationa

   S ingle creas e 52

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5    As ymmetrya

   

   S oft and pliable a

 

   Low s eateda

 

   P reauricular s kin tag

 

aAnomaly

is part of W aldrop s cale.

VITAL S IG NS E le vate d te mpe rature or he art or res piratory rate never be ignored, even in a patient whose agitation or anxiety might s eem to explain the abnormality. Doing ris ks miss ing infection, neuroleptic malignant connective tis sue disease, or other important caus es of morbidity. Abnormal re s piratory patterns occur in hyperkinetic movement disorders (including tardive dyskinesia). Y awning is a feature of opiate withdrawal serotonergic toxicity.

S K IN Alopecia or ras h may point to systemic connective disease. Alopecia is als o a feature of drug toxicity and hypothyroidism (where thinning of the lateral part of the eyebrow is characteris tic). T he malar ras h of s ys temic 53 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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erythematosus is typically slightly rais ed and tender extends to both cheeks in a “butterfly” pattern while sparing the nasolabial folds. Dis coid rashes in lupus characterized by hyperkeratosis, atrophy, and los s of pigment; the s trong tendency to scarring means that presence of a dis coid ras h does not neces sarily active disease. A pink periungual rash is also of lupus. A vasculitic ras h is clas sically palpable and may be s een in lupus or other connective tis sue diseases . Livedo reticularis, a net-like violaceous the trunk and lower extremities , is not s pecific but the question of S neddon's s yndrome, in which s troke or dementia is a clinical accompaniment. T he neurocutaneous s yndromes have typical skin manifestations: adenoma s ebaceum (facial as h-leaf macules , depigmented nevi, and s hagreen patches (thickened, yellowish skin over the area) in tuberous s cleros is; a port-wine stain (typically involving both upper and lower eyelids) in S turgesyndrome; neurofibromas , café au lait spots, and freckling in neurofibromatos is .

HE AD Head circumfe re nce s hould be meas ured in patients question of developmental dis order. Most reference give normal ranges for head circumference in children but not for adults , and extrapolation is F ortunately, adequate data to establis h normal ranges exis t. Although height and weight need to be taken into account along with gender, the normal range for adult men is approximately 54 to 60 cm (21.25 to 23.50 in.), women, 52 to 58 cm (20.50 to 22.75 in.). O ld s kull 54 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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intracranial s urge ry us ually leaves palpable evidence.

E YE S E xophthalmos us ually indicates G raves' disease, may reveal a space-occupying les ion, es pecially if unilateral. Dry e ye s , along with dry mouth, rais e the question of S jögren's s yndrome, although drug toxicity the aging process is a common confound. Inflammation the anterior portion of the eye, uveitis , can be at the beds ide by the pres ence of pain, rednes s, and a cons tricted pupil; this is commonly ass ociated with connective tis sue dis ease. T he K ays e r-F le is che r ring is brownis h-green discoloration at the limbus of the it sensitively and s pecifically indicates Wilson's pupils, optic disks, vis ual fields, and eye movements discuss ed below.

MOUTH O ral ulce rs can be s een in lupus, B ehçet's s yndrome, other connective tis sue disease. Dry mouth is a part of sicca s yndrome along with dry eyes, dis cus sed above. V itamin B 12 deficiency produces atrophic glos s itis , a smooth, painful, red tongue.

HE AR T AND VE S S E L S A carotid bruit indicates turbulent flow in the vess el but poor predictor of the degree or potential ris k of the vascular lesion. A thickened, tender te mporal artery to giant cell arteritis ; here, the phys ical examination is excellent guide to clinical significance. C ardiac valvular disease, marked by cardiac murmurs , is important in as sess ing the cause of s troke, and congestive failure 55 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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be relevant in delirium. In a schizophrenic patient, a murmur may imply the velocardiofacial syndrome. with developmental dis abilities may have multiple anomalies, including structural heart dis eas e.

E XTR E MITIE S J oint inflammation as an indication of s ys temic disease is dis tinguis hed from noninflammatory degenerative joint dis eas e (osteoarthritis) by the of swelling, warmth, and erythema and is seen in wrists , ankles, and metacarpophalangeal joints, compared with the involvement of the bas e of the distal interphalangeal joints, and spine in degenerative joint dis eas e. R aynaud's phe nome non and signs of connective tiss ue disease.

Neurologic al E xamination OL FAC TION Hypos mia is common in neurological disease but even more common in local dis eas e of the nas al mucos a, must be excluded before a defect is taken to be of neurops ychiatric s ignificance. As ses sment of olfaction often ignored (cranial nerves II through XII normal), but easily performed and gives clues to the integrity of otherwis e hard to as ses s, notably orbitofrontal cortex. olfactory nerve lies underneath orbitofrontal cortex; projections go to olfactory tubercle, entorhinal and piriform cortex in the temporal lobes , amygdala, and orbitofrontal cortex. T esting of olfaction is bes t us ing a floral odorant such as scented lip balms, which inexpens ive and s imple to carry. Although a dis tinction be made between the threshold for odor detection and 56 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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that for identification of the s timulus with differing anatomies , at the bedside without special equipment, best one can achieve is recognition of a decrement in sens itivity—that is , whether the patient s mells anything, even without being able to identify it.

E YE S P upillary dilation may indicate anticholinergic toxicity; pupillary constriction is a characteristic feature of toxicity. Argyll R obertson pupils are bilateral, small, irregular, and reactive to accommodation but not to the finding is characteristic of paretic P.333 neuros yphilis but also is present in other conditions. P apille de ma indicates elevated intracranial pres sure; earliest and mos t s ens itive feature is loss of venous pulsations at the optic dis k. A homonymous upper quadrantic fie ld defe ct is present when temporal lobe disease affects Meyer's loop, the portion of the optic radiation that dips into the temporal lobe. A field defect a delirious patient may point to an etiology in focal vascular disease (as dis cus sed below). T he normal spontaneous blink rate is 16 ± 8 per minute. Hypodopaminergia is as sociated with a reduction in rate. Impairment of voluntary eye opening is s een in as sociation with extrapyramidal s igns , making the common denomination of “apraxia” of eye opening a misnomer. Impairment of voluntary eye closure is s een after frontal or basal ganglia damage. B oth saccadic and pursuit eye move me nts s hould be examined. T he former are ass ess ed by asking the 57 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to look to the left and the right, up and down, and at the examiner's finger on the left, right, up, and down. eye movements are examined by asking the patient to follow a moving s timulus in both the horizontal and vertical planes . T hese maneuvers test supranuclear of eye movements; the oculocephalic maneuver (doll's head eyes )—that is , moving the patient's head—tes ts brains tem pathways and may be added to the if saccades or purs uit is abnormal. Limitation of upgaze is common in the normal elderly. A limitation of voluntary downgaze, however, in a patient with extrapyramidal s igns or frontal cognitive impairment suggest progress ive supranuclear pals y. S lowed are characteris tic of Huntington's diseas e. Impairment initiation of voluntary s accades, requiring a head thrus t head turning, amounts to apraxia of gaze and is s een developmental disorders as well as Huntington's and parietal damage. C ontrariwise, impairment of inhibition of saccades repres ents a vis ual gras p, with forced gaze at environmental stimuli. T his can be tes ted by placing s timuli (a finger and a fist) in the left right vis ual fields of the patient and asking the patient look at the fist when the finger moves and vice vers a. patient's inability to perform horizontal pursuit or movements without turning the head may represent the same impairment of inhibition.

FAC IAL MOVE ME NT B oth spontaneous movements of emotional expres sion and movement to command s hould be tes ted. In pyramidal disorders , spontaneous movements may be relatively s pared when the face is hemiparetic for voluntary movements. C ontrariwise, in nonpyramidal 58 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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motor dis orders , voluntary movement may be poss ible despite a hemipares is of s pontaneous movement. T he latter s ituation is s een inter alia in temporal lobe including temporal lobe epilepsy, for which it has lateralizing value. V ertical furrowing between the eyebrows is known as V eraguth folds and is as sociated depres sion.

S PE E C H A variety of s peech abnormalities is tabulated in T able 2. A s ys tematic examination of speech may include the patient to produce a s ustained vowel (“ahhh…”), performance being as sess ed for voice quality, and loudness ; then s trings of cons onants (“puh-puhand alternating cons onants (“puh-tuh-kuh-puh-tuhthe performance being as sess ed for rate, rhythm, and clarity.

Table 2.1-2 S peec h S yndromes S yndrome

Output

C harac teris tic Les ion Loc ation or As s oc iations

Aphemia

Initial mutis m, recovery

B roca's area (B A44), foot of

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without agrammatism

left third gyrus

Apraxia of speech

Inconsis tent and s lowed articulation, flattened volume, abnormal prosody

Left insula

Ataxic dysarthria

S lowed, equalization of or erratic (s canning), imprecis e articulation

C erebellum, es pecially superior anterior left > right

P yramidal dysarthria

S lowed, strained, slurred

Anterior hemis pheres , us ually bilateral; may be accompanied by ps eudobulbar palsy (dysphagia, drooling, pathological

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laughing and crying) E xtrapyramidal dysarthria

Hypophonia, monotony of intonation, trailing off with longer

B as al ganglia

B ulbar dysarthria

Nas ality, breathines s, slurred articulation

B rainstem

F oreign syndrome

P honetic and prosodic alterations like those of dysarthria cortical damage but giving listener feeling of foreign accent

Motor or premotor cortex or subjacent white matter of left

Developmental stuttering

R epetition, prolongation, arrest of sounds; if overcome in

?

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childhood, reemerge stroke, onset P arkins on's disease Acquired stuttering

No dys tonic facial movements as are seen in developmental stuttering

V arious hemis phere sites

C es sation of stuttering

Not an abnormality but the of an abnormality

V arious hemis phere sites

E cholalia

Automatic repetition of interlocutor's speech or words heard environment, sometimes with reversal pronouns, correction of grammar,

V arious anatomies , but seen in frontotemporal dementia, transcortical aphas ias , settings

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completion of well-known phrases P alilalia

Automatic repetition of own final word or phras e, increasing rapidity and decreasing volume

Usually extrapyramidal system

“B lurting,” “echoing approval”

Automatic utterance of stereotyped or simple res ponses “yes, yes ”)

F rontal system

T he mute patie nt poses a special problem in neurops ychiatric as sess ment. Mutism may occur at the onset of aphemia or transcortical aphas ia due to lesions , and it commonly develops late in the cours e of patients with frontotemporal dementia or primary progres sive aphas ia. T he examiner s hould ass es s nonspeech movements of the relevant musculature, for example, tongue movements , s wallowing, and Other means of communication should be attempted 63 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as gesture, writing, or pointing on a letter board or word board.

AB NOR MALITIE S OF MOVE ME NT T he neurops ychiatric examiner should pay attention to weaknes s, abnormality of mus cle tone, abnormal gait, involuntary movements . W e akne s s due to muscle, peripheral nerve, or lower motor neuron dis eas e is as sociated with atrophy, fas ciculations, characteris tic distributions , loss of reflexes , and tendernes s in the muscle dis eas e. Of greater relevance to P.334 cerebral mechanisms, pyramidal weaknes s, greatest in distal musculature, is accompanied by increased tone in a s pas tic pattern (flexors in the upper extremity, extensors in the lower extremity, with the sudden loss increased tone during pas sive movement, the “clas pphenomenon), los s of control of fine movements, bris k tendon jerks , and the presence of abnormal reflexes as the B abins ki sign (discus sed below). Less well recognized is the nonpyramidal motor syndrome s uch seen in caudate or premotor cortical les ions: decreased s pontaneous us e of effected limbs , weaknes s but production of full s trength with coaxing. Mild degrees of impairment can be elicited with the pronator tes t by s eeking pronation of the outs tretched supinated arms; the forearm rolling tes t, by asking the patient to roll the forearms around each other first in direction then in the other, looking for one s ide that less , thus, appearing to be an axis with the other around; or fine finger movements, with the hands 64 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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facing up on the thighs, the patient touching each to the thumb in turn and repeatedly. Mus cle tone can be increased not only in the pyramidal fas hion just des cribed but als o as a manifestation of extrapyramidal or diffus e brain diseas e. In the latter paratonic rigidity, or G egenhalten, is manifes ted by an erratic, “ps eudoactive” increase in res is tance to movement. T he fluctuating quality of the resis tance reflects the presence of both oppositional and facilitory as pects of the patient's respons e to pas sive T he facilitory as pect can be evoked by repeatedly and extending the patient's arm at the elbow, then abruptly ceas ing and letting go when the arm is the abnormal respons e, facilitory paratonia, is for the patient to continue the s equence by flexion. In the case extrapyramidal diseas e, tone is increas ed in both and flexors and throughout the range of movement, s ocalled lead-pipe rigidity. T he “cogwheel” or ratchety feel the rigidity is imparted by a coexis ting tremor and is not intrins ic to the hypertonus; when paratonic rigidity cooccurs with a metabolic tremor, a delirious patient may mistakenly be believed to have P arkinson's disease. G ait s hould always be tes ted, if only by focus ed to the patient's entering or leaving the room. Attention should be paid to the patient's station, postural stride length and base, and turning. P os tural re flexe s as sess ed by as king the patient to stand in a fas hion, then pus hing gently on the ches t or back, with care taken to avoid a fall. G ait should be stress ed by the patient to walk in tandem fashion and on the outer as pects of the feet. T his may reveal not only mild (representing cerebellar vermis dysfunction), but also 65 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as ymmetric pos turing of the upper extremity (in nonpyramidal motor dys function). Akine s ia is manifes ted by delay in initiation, s lowness execution, and difficulty with complex or simultaneous movements. Mild akines ia may be obs erved in the patient's lack of spontaneous movements of the body while s itting or of the face or elicited by as king the to make repeated large amplitude taps of the forefinger the thumb (looking for decay of the amplitude). characteristically accompanied by rigidity. T hes e s igns, plus rest tremor and postural ins tability, repres ent the features of the parkins onian syndrome, seen not only idiopathic P arkinson's disease (IP D), but in several degenerative, “P arkins on-plus” disorders , such as progres sive s upranuclear palsy and multiple system atrophy, as well as in vascular white matter dis eas e. tremor is les s common in thes e other dis orders than in Dys tonia is s ustained mus cle contraction with twis ting movements or abnormal pos tures . T ypically, dystonia in the upper extremity is manifes ted as hyperpronation, in the lower extremity as inversion of foot with plantar flexion. Dystonia may occur only with certain actions , such as writer's cramp; focally, s uch as blepharos pas m or oculogyric cris is; or in a generalized pattern, such as torsion dys tonia ass ociated with mutations in the DY T 1 gene. T he symptoms and s igns often do not comport with a naäve idea of how things ought to be in organic disease; only expert knowledge suffices for recognition. F or example, a patient with tors ion dystonia may be able to run but not walk the latter action elicits leg dystonia. Or a patient with intens e neck muscle contraction may be able to bring 66 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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head to the midline by a light touch on the chin, a antagonis te ” diagnostic for dystonia. T re mor is a regular oscillating movement around a re s t tre mor, the movement occurs in a relaxed, extremity and is reduced by action. Often an upper extremity res t tremor is exaggerated by ambulation. frequency is us ually 4 to 8 Hz. T his is the distinctive of P arkins on's dis eas e. In pos tural tre mor, s us tained posture elicits tremor. It may be amplified if obs cured placing a sheet of paper over the outs tretched hand. Hereditary es sential tremor pres ents as postural predominantly in upper extremities but als o at times involving head, jaw, and voice. A coars e, irregular, postural tremor is often s een in metabolic encephalopathy. In intention tremor, the active limb os cillates more prominently when approaching its such as touching the examiner's finger with the index finger. Maximizing the range of movement increas es sens itivity of the tes t. Intention tremor is one form of kine tic tremor—that is , tremor elicited by movement; another s ort of kinetic tremor is that elicited by a action, s uch as writing tremor or orthos tatic tremor on standing upright. T he examiner can characterize observing the patient with arms s upported and fully at res t, then with arms outs tretched and pronated, then arms abducted to 90 degrees at the s houlders and the elbows while the hands are held palms down with fingers pointing at each other in front of the ches t. T he patient should also be observed during ambulation. Anxiety exaggerates tremor; this normal phenomenon, example, when the patient is conscious of being should not be mis taken for ps ychogenes is . A good test 67 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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ps ychogenic tremor relies on the fact that, although organic tremor may vary in amplitude, it varies little in frequency. A patient can be as ked to tap a hand at a frequency different from the tremor frequency; if tremulous body part entrains to the tapped frequency, ps ychogenic tremor is likely. C hore ic movements are random and arrhythmic movements of s mall amplitude that dance over the patient's body. T hey may be more evident when the patient is engaged in an activity such as ambulation. the movements are of large amplitude and forceful, the disorder is called ballis m. B allistic movements are unilateral. Myoclonus is a sudden, jerky, shock-like movement. It more discontinuous than chorea or tremor. T he of myoclonus is as terixis , a sudden lapse of muscle contraction in the context of attempted maintenance of posture. B oth phenomena, but more s ens itively are common in toxic-metabolic encephalopathy (not hepatic encephalopathy). Asterixis should be carefully sought by observation of the patient's attempt to extension of the hands with the arms outs tretched because it is pathognomonic for organic diseas e and is never seen in acute idiopathic psychosis or other nonorganic disorders . Myoclonus is additionally an important feature of nonconvulsive generalized s tatus epilepticus , Has himoto's encephalopathy, and J akob disease. Unilateral as terixis rarely may be seen parietal, frontal, or (most often) thalamic structural T ics are sudden, jerky movements as well, but they more complex than myoclonic jerks and are characterized by 68 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P.335 an impulse to perform the act and a s ens e of relief for having done s o (or mounting tens ion if restrained from doing so). C ompulsions are not eas y to differentiate complex tics; the tiqueur may, like the patient with compuls ions, report deliberately performing the act. R epetitive behavior s uperficially s imilar to compulsions may occur in organic disease but represents driven behavior and does not have the s ame s ubjective structure as compulsive behavior. F or example, a with frontal disease may repeatedly touch an alluring object without an elicitable subjective impulse and without anxiety if separated from the object. Organic obses sions and compuls ions occur as well and have as sociated with globus pallidus les ions , among others . Akathis ia is defined by both its s ubjective and its features. T he patient exhibits motor restles sness , for example, by shifting weight from foot to foot while standing, and expres ses an urge to move. At times , ps ychotic or cognitively impaired patients cannot the subjective experience clearly, and the examiner be alert for the objective s igns to differentiate akathis ia from agitation due to anxiety or ps ychosis . T he and the signs in akathisia are referable to the lower, the upper, extremities ; the anxious patient may wring or her hands , the akathis ic patient shuffles his or her Myoclonic jerks of the legs may be evident in the recumbent patient. T he phenomenon occurs in IP D with drug-induced dopamine blockade but also rarely extensive frontal or temporal structural lesions . Ataxia is a dis order of coordinating the rate, range, and 69 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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force of movement and is characteristic of disease of cerebellum and its connections. In the limbs, dys metria represents dis ordered determination of the dis tance to moved, s o that the patient overs hoots or unders hoots target; if the reaching limb oscillates in the proces s, the clinician observes intention tremor. As king the patient touch the examiner's finger and then his or her own tes ts this s ys tem. Accurately touching one's own nos e eyes closed requires both cerebellar and function. E ye movements als o may be hypermetric or hypometric. T he patient's difficulty in performing rapid alternating movements, such as s upination/pronation of the hand or tapping of the foot, is called dys diadochokines ia. T he failure of coordination of movement is also demons trated by loss of check, should not be elicited by arranging for the patient to hit hims elf or herself when the examiner's hand is the normal situation, if the outstretched arms are only a s light waver is produced; the ataxic patient does damp the movement. G ait may be affected by midline cerebellar (vermis) dis eas e in the abs ence of limb which is related to cerebellar hemisphere dis eas e. G ait unsteady, with irregular stride length and a widened (In the normal s ubject, the feet nearly touch at their neares t point; even a few inches of s eparation widening of the bas e.) G ait and limb ataxia may be complemented by cerebellar dysarthria (des cribed in 2.1-2) and by eye movement dis orders , including nystagmus (us ually gaze paretic), slowed s accades , saccadic pursuit, and gaze apraxia. T he catatonic s yndrome has been various ly defined. core of the syndrome is a mute motionles s s tate; 70 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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added are abnormal movements, including grimacing, stereotypy, echopraxia, and catalepsy. T he latter, also as fle xibilitas ce rea (waxy flexibility), refers to of a limb in the position in which it is placed by the examiner or in some other unnatural position. It is not in all or even mos t cases of catatonia, and it can be apart from the catatonic s yndrome in patients with contralateral parietal les ions (as described below as avoidance s ign of parietal dis eas e). C atatonic refers to the sudden eruption into overactivity of a catatonic patient; this probably usually represents ps ychotic mania. T he catatonic s yndrome occurs in the cours e of schizophrenia or mood disorder, or without other psychopathology as idiopathic catatonia, or in the setting of acute cerebral metabolic or s tructural derangements . In the latter case, it is best thought of nonspecific reaction pattern, s uch as is delirium, a comprehensive clinical and laboratory evaluation to the cause of the behavioral disturbance. An important instance is catatonia as part of the neuroleptic syndrome, the diagnosis of which requires exclus ion of other metabolic encephalopathy, notably s ys temic infection. C atatonia is thus a medical emergency, prompt attention to diagnostic evaluation as well as supportive care (fluids, nutrition, meas ures to avoid complications of immobility, including venous thrombosis). Motor s equencing tests as say function of premotor areas and striatum and are related to deficits in cognitive function seen with dysfunction of the dorsolateral prefrontal loop. T he ring/fist test involves as king the patient to alternate between making a ring 71 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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his thumb and first finger and making a fis t with the hand: “ring, fist, ring, fist…” T he abnormal respons e is perseveration of one or the other posture or disorganization of the s equence. At times, patients are unable to perform the correct s eries even when the verbal cues aloud. A more complex alternation is between striking the table gently with the fist, then the edge of the hand, then the palm: “fis t, edge, palm, fis t, edge, palm…” A different approach is to ask the patient extend the arms, make a fis t with one hand while the other hand flat, then switch hands. T he abnormal res ponse has the patient ending up with two fis ts or palms outstretched. Much can be accomplished in the neurological examination by asking the patient to stretch out his or arms. W ith a few additional maneuvers (tapping the outstretched pronated hands, s upinating them and the patient to close his or her eyes , then asking the to touch his or her nos e with the eyes still closed, then as king the patient to perform the alternating fists test), of the following can be as ses sed in a matter of a so: postural and intention tremor, los s of check, and myoclonus , a pronator sign, dysmetria, and motor sequencing. Doing this, plus testing mus cle tone, plus observing the patient's natural and stress ed gait, plus checking tendon jerks and abnormal reflexes , takes few minutes and does not elucidate disorders of nerve, and spinal cord but repres ents a rather as sess ment of the central organization of the motor system.

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Dis orders of sensation are sometimes difficult to reliably in patients with cognitive and behavior Nonetheles s, s everal points s hould be familiar to the neurops ychiatris t. Distal loss of s ens ation, often accompanied by loss of ankle jerks , is characteristic of peripheral neuropathy. Often, all modalities of are dis turbed. If proprioception is s ufficiently s everely reduced, R omberg's s ign is pres ent. R omberg's s ign that clos ing the eyes produces s ubs tantial impairment balance; it is elicited by as king the patient to s tand, allowing the patient to seek a comfortably balanced position, then as king the patient to close the eyes (ensuring against a fall). Loss of s ens ation from sensory cortex injury is limited to complex dis criminations such as (recognizing numbers written on the palm), (identifying uns een objects in the hand), and two-point discrimination (telling whether the examiner is touching with one or two points , as these come closer together space). However, patients with parietal s troke may ps eudothalamic sensory s yndrome (with impairments elementary s ens ory modalities and s ubs equent dysesthesia) or other anomalous patterns of s ens ory At times, thes e patients pres ent with P.336 ps eudomotor deficits : ataxia, fluctuating muscle tone strength (dependent in part on vis ual cueing), and “levitation” and awkward positioning of the arm contralateral (or at times ips ilateral) to the lesion. In the acute phase, the combination of deficits can amount to “motor helpless ness .” T hese deficits result from the 73 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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sens ory input to regions in which motor programs T he less ons are that “cortical” sens ory deficits s hould sought if there is a ques tion of cortical involvement and that more dramatic or unus ual sensory abnormalities also occur with cortical lesions .

S OFT S IG NS An extensive literature about “soft s igns ” of dysfunction is difficult to comprehend becaus e of the varied definitions and batteries used in the various Most of the s igns s ought in these batteries are this chapter under their more s pecific headings , s uch graphes thesia under Abnormalities of S ens ation and alternating fis t (Oserets ky) tes t in the paragraph on sequencing. F rom the corpus of test batteries , a few maneuvers can be extracted that may make a to the neurological examination of the patient with a mental presentation. While the patient is touching each finger to the thumb, examiner can watch the oppos ite hand for mirror movements. Obligatory bimanual s ynkinesias are s een specifically in disorders of the pyramidal pathways , the K lippel-F eil s yndrome, and in agenesis of the callosum but also in putative neurodevelopmental disorders such as s chizophrenia. Asking the patient, eyes closed, to report whether the examiner is touching one or the other hand (with the patient's hands on the lap), or one or the other s ides of the face, or a is called the face–hand test. T he examiner touches the hand and right face s imultaneously. If the patient only the touch on the face—that is , extinguishes the peripheral stimulus —then the examiner can prompt 74 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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(once): “Anywhere els e? ” T hen the examiner touches right hand and left cheek, left hand and left cheek, right hand and right cheek, both hands , and both cheeks . E xtinction of the peripheral s timulus is the pathological res ponse and has been ass ociated with schizophrenia dementia.

AB NOR MAL R E FL E XE S T he B abins ki sign is the s hibboleth of the neurological examination. It s hould be elicited by stroking the lateral as pect of the foot from back to front, with the leg extended at the knee, us ing a pointed object s uch as orange stick or a key. T he response of extens ion of the great toe with or without fanning of the other toes indicates corticos pinal tract dis eas e. T wo confounding factors in as ses sment of the B abinski s ign are the toe and the plantar grasp. T he striatal toe is extens ion the hallux without fanning of the other toes or a flexion synergy in the other mus cles of flexion of the leg. It occur spontaneously or on elicitation in patients with P arkins on's dis ease in the absence of evidence of pyramidal dysfunction. T he plantar grasp, the of the familiar palmar gras p, may mask an extens or res ponse to lateral foot s timulation when stimulation in the midfoot brings about flexion of the toes . Other important reflexes for the neuropsychiatrist are Myers on's sign, a failure to habituate to regular, per-second taps on the glabella (with the tapping hand outs ide of the patient's vis ual field), present in parkinsonis m and diffuse brain disease Hoffmann's s ign, flexion of the thumb with s napping 75 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of the dis tal phalanx of the patient's middle finger, upper extremity s ign of pyramidal dysfunction, although s ometimes present bilaterally in normal subjects G rasp, flexion of the fingers with stroking of the patient's palm toward the fingers during dis traction and despite instructions to relax, as sociated with disease of the contralateral supplementary motor Avoidance, extension of the wrist and fingers to the same s timulus as the grasp, a less well-known s ign points to contralateral parietal cortex abnormality S everal other “primitive reflexes” are les s specific in they are commonly present in the normal subject and, thus, are less us eful for diagnostic purposes. T hes e the suck, s nout, and palmomental reflexes .

FOC A L NE UR OB E HA VIOR A L S YNDR OME S T he idea that the brain is regionally specialized had a difficult gestation in the 19th century, and the key to its acceptance lay in recognition of the effects of focal lesions . At the end of the 18th century and early in the 19th century, phrenology drew adherents to the claim personality traits could be inferred by inspection of the cranium. T his claim was faulty, but phrenology had an underlying theory that was an important step forward the brain s ciences; in particular, the beliefs that the was the organ of the mind and that the mind could be fractionated into functions gave impetus to the development of neuros cience in a modern form. In the middle of the 19th century, the gradual realization that 76 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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aphas ia occurred with damage to s pecific areas of the hemis phere was another crucial s tep. T he subsequent identification of numerous s yndromes of localized damage—such as apraxia, agnos ia, visuospatial impairment in its various forms, and s o forth—is a fas cinating story of as tute and painstaking clinicopathological, and later clinicoradiological, correlation. P atients' introspective access to their deficits may be limited. Much of cognitive proces sing is unconscious, in the sense of being excluded from awareness by motivated defens e, but in the s ens e that it is not even principle open to introspection. J onathan Miller, in his television s how T he B ody in Q ues tion, displayed this by as king pass ers by in a pers on-in-the-street interview, “S ir, where is your spleen? ” No one can s ay from intros pection where the spleen is . T he same is true of much of cognitive process ing. E xplanations provided patients may be confabulations that fill in s uch intros pective gaps in a situation in which the brain is functioning abnormally in a way not fores een in its In neurops ychiatry, s ubjective experience and behavior separate explicanda. F or instance, in the realm of the networks s ubs erving conscious experience— “feelings”—and those underlying the emotional forces influencing behavior are dis tinct, although overlapping, with the amygdala notably absent from the former. T he patient's appraisal of his or her own situation is always relevant to collaboration with treatment and its outcome and s hould be explored in every clinical encounter.

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Although dementia is characteris tically considered a syndrome of “global” cognitive impairment, implying global or diffuse brain dysfunction, each dementing disorder produces a distinct pattern of brain pathology and corres ponding pattern of cognitive dys function. F or this reas on, and against tradition, dementia is under the rubric of focal neurobehavioral s yndromes. In Alzheimer's dis eas e, the earliest neuropathological abnormality is characteristically medial temporal accumulation of plaques and tangles, initially in cortex and subiculum (the input and output zones of hippocampus ). T he disease progres sively involves as sociation cortices in temporoparietal and prefrontal regions. T his burden of pathology determines the characteristic early memory P.337 impairment with ensuing anomia, failure of grasp, and coars ening of pers onality. On occas ion, Alzheimer's disease pathology is predominantly posterior, with concomitant predominance of vis uos patial impairment the clinical cours e. B y contras t, in frontotemporal dementia, the earliest dis eas e manifes tations are pathologically in frontal or temporal cortex, clinically presenting as primary progres sive aphasia, s emantic dementia, or a frontal apathy or disinhibition syndrome. none of these situations is a view of dementia as a impairment of brain function jus tified by the clinical or pathological facts; rather, s elective dis ruption of anatomical networks corres ponds to s ymptomatic features. E xtens ive s ubcortical white and gray matter damage 78 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to s mall-vess el dis eas e is a common caus e of and, in this s ituation, the clinical picture is dominated slowed mental proces sing, forgetfulness with relative preservation of recognition memory (as opposed to recall), and executive cognitive dys function. located s ingle infarctions can also produce dementia. T hese strokes can involve left angular gyrus , genu of internal caps ule, and (perhaps most commonly) medial thalamus . T he thalamic and internal caps ule strokes produce cognitive impairment by interfering with frontal networks .

Delirium C las sically a s yndrome of “global” brain dys function toxic-metabolic infectious encephalopathy, delirium also point to focal brain dis eas e. Delirium may be due infarction in the right pos terior s uperior temporal gyrus caus ed by occlus ion of the inferior division of the right middle cerebral artery or to infarction in the inferior temporo-occipital cortex on the left or bilaterally due to posterior cerebral artery occlusion. In both instances, neurological signs may be limited to a vis ual field cut or absent entirely. F inding bilateral asterixis or multifocal myoclonus strongly indicates a toxic-metabolic brain derangement, and the history and physical examination should provide pointers for the ess ential laboratory confirmation of the abnormality. F eatures of the mental state are of little us e in determining the caus e of the syndrome except that agitation is far more common in certain disorders such as substance withdrawal, and the syndromes of left posterior cerebral artery or of right middle cerebral artery territory s troke with 79 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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involvement of the temporal lobe.

Aphas ia Acquired impairment of lexical or s yntactical is termed aphas ia. Lexicon and s yntax do not exhaust domain of language, and attention is devoted below to prosody and discourse pragmatics . At the beds ide, the clinician s hould be able to distinguis h language impairment from other sources of abnormal discours e (s uch as ps ychos is), delineate the features of in the patient's linguistic function, and tentatively the locus of brain injury. A s imple dis tinction between “expres sive” and defects has s ome power to dis tinguis h between and posterior les ion sites, but it is not in current use in aphas iology because mos t aphas iogenic lesions some impairment in both production and of language, and these impairments are of multiple A widely accepted approach to examination and clas sification in aphas ia identifies six domains for elucidation: s pontane ous s pee ch, naming, re pe tition, reading, and writing. Attention to speech reveals dys fluency and word-finding difficulties . T he dysfluent speaker produces shorter phrases and utterances without a natural “flow.” S ubstantives and verbs ) may be preserved at the expense of words (s uch as prepositions) and grammatical (s uch as tens e endings ), leading to agrammatical utterances that are nonetheles s relatively information Lesions dis rupting fluency are characteris tically the left hemis phere or involve putamen. Naming performance requires the adequate functioning of a 80 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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network, including posterior temporal, temporoparietal, and inferior frontal sites. T his is ordinarily tes ted by confrontation (“What do you call this? ”), which can be conveniently done using body parts or common items the bedside. Naming from description (“What do you the vehicle that travels under water? ”) is an alternative mode of testing, particularly us eful for visually impaired agnos ic patients . C omprehens ion is tes ted bes t using probes with minimal demand on output, so “yes/no” questions (“Does a stone s ink in water? ”) are better motor commands , which may be impaired by apraxia. Impairment of comprehension results from posterior temporal les ions. Disordered repetition is disclos ed by asking the patient to produce longer utterances, reiterating the examiner: “airplane, and s he are here…” R epetition may be s urprisingly (the so-called transcortical aphas ias ) or affected (conduction aphasia). T he latter depends on lesions of insula or external capsule. R eading comprehension (not reading aloud, a different skill) comprehension with a different input modality from comprehension, and s ome patients s how significant diss ociations . S imilarly, writing tests output in a modality from s peech. W riting is a particularly s ens itive probe for the anomia s een in early Alzheimer's disease the disorganization s een in delirium. A clas sification of the aphasias using the data from an examination as just outlined is s hown in T able 2.1-3. C linicians recognize, however, that many patients do fit well into the categories created by this scheme.

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Table 2 Aphas ic S yndrome

S pontaneous R epetition S peech

Naming

G lobal

Impaired

Impaired

Impaired

B roca's

Dys fluent, effortful, agrammatic

Impaired

Impaired

Wernicke's

F luent, paraphasic, absence of subs tantive words

Impaired

Impaired

C onduction

F luent, paraphasic

Impaired

Impaired

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with phonemic errors T ranscortical Dys fluent motor

S pared

Impaired

T ranscortical F luent, sens ory paraphasic

S pared

Impaired

Mixed transcortical

Dys fluent

R elatively spared

Impaired

Anomical

F luent, paraphasic

S pared

Impaired

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Ide omotor apraxia commonly occurs together with aphas ia. T his is a dis order of performance of s killed movements to command in the abs ence of explanatory elementary s ens ory and motor disturbances . Oral is revealed by the patient's incapacity to show, for example, how to blow out a match or lick a pos tage Limb apraxia is shown by the patient's incapacity to for example, how to wave good-bye or us e a hammer screwdriver. P atients with these deficits may, be able to follow whole body commands: “S how me boxer stands ,” for example. P atients rarely complain of apraxic deficits , in part because they are artifacts of the examination in the s ense that they may not be present the us e of real-world items .

Attention S everal related phenomena cluster under the clinical description of attentional disorders . At the mos t fundamental level, alertnes s repres ents a continuum ranging from coma to normal wakefulness . T he faced with a patient who is les s than fully alert should quantify the dis order by ass es sing the patient's to a graded series of probes: Does the patient orient to examiner's pres ence in the room; what does the patient when his or her name is called or when touched or shaken or when a (harmless ) painful s timulus is and s o forth. T hese res ponses s hould be recorded in rather than s ummarized by ambiguous terms s uch as “lethargic.” Alert patients may show deficits in sus tained attention external s timuli (vigilance) or internal stimuli (concentration). Attentional deficits of these sorts are 84 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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characteristic of delirium. V igilance can be ass es sed bedside adaptation of a continuous performance tas k, example, by as king the patient to lift a hand each time examiner says the letter “A” or, to increase the each time P.338 the examiner says the letter “A” after the letter “D.” T he examiner then produces a series of random letters at a deliberate and steady rate over an extended period. error of omiss ion or commis sion repres ents a failure. as king the patient to count from 20 to 1 or give the the week or the months of the year in revers e, the examiner can appraise concentration. Digit span— the patient to repeat a lis t of numbers spoken at a slow, steady rate without separation into chunks —is a clas sic tes t of attention; the lower limit of normal for digit span five. A “higher” level of attentional function is the capacity to manipulate information kept in consciousness over a period—a test of working memory. An excellent is alphanumeric sequencing. T he patient is as ked to alternate between numbers and letters; the examiner provides “1-A-2-B -3-C ” as a model, then allows 30 for the patient to s tart at 1 and give as many as poss ible. If only the number of correct alternations is counted (ignoring errors ), the lower limit of normal is comparable, s imple tas k is alphabetizing the letters of word “world” (or any s imilar word). W orking memory is known to require intact process ing in dorsolateral prefrontal cortex. Hemine gle ct is a focal disorder of attention almos t 85 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of left hemis pace in a patient with acute right disease. Most characteris tically, the lesion is parietal, distinguishable patterns of hemineglect occur with and cingulate lesions . G ros s neglect can be recognized the patient's ignoring, or even denying the owners hip the left limbs or not attending to objects and people in hemis pace. S ubtler degrees of neglect can be elicited presenting an array in which the patient mus t s earch both hemifields to point to items, for example, all the yellow dots in a s timulus card with dots of varied colors both left and right. In the phenomenon of hypermetamorphosis, part of the K lüver-B ucy s yndrome of bilateral anterior temporal damage, animals or patients exhibit an increased level attention to individual items in the environment.

Amnes ia T he term me mory is us ed in s everal ways by clinicians ps ychologists . T he amnes tic s yndrome features impairment of learning of new material (anterograde amnes ia) and a variable period of impaired recall the ons et of the s yndrome (retrograde amnesia). It is to damage to hippocampus or to anterior thalamus P.339 (including mammillothalamic tract). Memory proper is distinguished from retention in consciousness of over the cours e of a few seconds, which may be called “working” or “iconic” or “short-term” memory. T his function is s pared in the amnes tic s yndrome because it depends on frontoparietal mechanis ms dis tinct from hippocampal and thalamic pathways damaged in 86 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Deficits due to hippocampal and thalamic les ions are dependent on the lateralization of the damage, leftdamage producing verbal and right-sided damage producing figural memory impairments . A distinction between free recall and recognition is of neuropsychological s ignificance and generally can made adequately, if imperfectly, at the beds ide. Hippocampal and thalamic patients show accelerated forgetting, so that cues (s uch as providing the semantic category) are relatively ineffective in aiding recall. R ecognition memory is always better than free recall absolute scale; exaggeration of the dis parity—that is , sparing of recognition memory—is characteristic of memory impairment due to dysfunction of frontal mechanisms of effortful search. In addition, frontal patients s how impairments of for the temporal context or s ource of information. T his deficit is probably relevant to the occurrence of confabulation. S pontaneous confabulation occurs in minority of amnestic patients and depends on ventromedial frontal damage. Memory is s o commonly impaired in brain dis orders should be tested in all patients undergoing neurops ychiatric evaluation. R ecall of a test phras e (for example, a name and addres s) over a several-minute distraction is a valid and s imple screening test. more detailed analys is of memory is necess ary in with dis orders likely to affect memory mechanis ms , including (among many others) head injury, epilepsy, dementing disorders. T esting s hould include both and nonverbal material. F or example, tes ting recall of words and three s hapes or three words and three 87 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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directions over s everal minutes' delay is easily F urther, the examiner should be prepared with cues, including appropriate (incorrect) foils, to as ses s sparing the capacity to make use of cues in frontal memory impairment. F or example, if one of the words provided “piano,” the examiner could cue, “One was a mus ical instrument,” and further provide “guitar, piano, violin” multiple-choice options . Only rough inferences can be drawn from this beds ide ass es sment, as compared formal neurops ychological evaluation. Apart from patients with persisting amnestic the neuropsychiatrist may be pres ented with patients experienced an amnestic s tate trans iently or rarely may one during a transient amnes tic state. T he s yndromes transient global amnesia and transient epileptic and their differentiation have been fully des cribed and require thorough his tory taking, neuropsychological evaluation, and electroencephalography (E E G ) T he neuropsychiatrist s hould als o know that amnesia criminal offenses is common; certainly it is not confined those who committed a crime while in a delirious , ictal, postictal s tate, as is sometimes claimed for legal

Vis uos patial Dys func tion T he requirement to test visual, as well as verbal, has just been mentioned. Drawing and copying tasks further the ass ess ment. C opying inters ecting (as in the Mini-Mental S tate E xamination [MMS E ]) or incidental performance) the s hapes used in the tas k begins the as sess ment. W ith more complex failures with a slavish element-by-element s trategy are characteristic of patients with right hemisphere 88 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as is neglect of the left side of the stimulus . T he variety of dis orders of higher visual function has already been mentioned in des cribing the complex structure of visual ass ociation cortices . P ros opagnos ia defect in recognition of faces. S uch a defect may be obvious from the his tory or may be a more s ubtle abnormality; it can be s potted at the bedside, albeit insensitively, with the us e of a few pictures of famous people. Defe cts of topographical s kill, although rarely presenting in an isolated form, als o occur with right hemis phere dys function. T he patient can be as ked to describe a route between familiar places or a question believed to be within premorbid capacities (“If you're going from New Y ork to Los Angeles , is the Ocean in front of you, behind you, to your left, to your right? ”). T he incapacity to grasp in attention multiple visual at once is known as s imultanagnos ia. T he patient may in des cribing a complex vis ual scene by virtue of only a s ingle, perhaps peripheral, element. T ogether ps ychic paralysis of gaze (inability to direct gaze voluntarily, or ocular apraxia) and optic ataxia (a of mis reaching under vis ual guidance), it makes up syndrome, the archetypal disorder of the dorsal visual pathway. T he patient with impairment of reaching visual guidance s hould be examined without vis ual guidance (e.g., pointing to parts of his or her own body with eyes closed) to confirm the defect.

E xec utive C ognitive Dys func tion E xe cutive cognitive dys function refers to initiation of cognition and action, their maintenance in the face of 89 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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distraction, organized but flexible purs uit of goals, and self-monitoring with error correction. E xecutive are crucial in adaptive function, and performance in this realm is better correlated with real-world outcomes of brain-injured patients than are many other domains traditionally analyzed in neuropsychology or many ps ychos ocial variables . B edside exploration of function is of central importance in the neurops ychiatric examination. Analys is of behavioral dis turbance and neurops ychological deficits in patients with cerebral suggests that multiple dis sociable proces ses compos e executive cognitive function, and certainly these are ins tantiated by anatomically dis tributed systems . C urious ly, however, many different tasks recruit a identical set of regions in the middors olateral prefrontal cortex, midventrolateral prefrontal cortex, and anterior cingulate. Nonetheles s, the clinical examiner must that no single probe can screen for all dysfunctions. Many as pects of executive function are illuminated by attention to the patient's performance of elements of history taking and examination. Dis inhibition may be in abnormalities of comportment during s ocial Motor impe rs is te nce , the failure to sustain actions that be undertaken properly, may be noted in the patient's “peeking” when as ked to keep the eyes clos ed, looking back at the examiner's face when lateral gaze (es pecially to the left) is attempted, or not keeping the arms extended or the tongue protruded when to do s o. P ers eve ration is the continuation of elements past actions into present activity. P ers everative may be noted when tes ting naming or attention. E chopraxia, for example, the patient cross ing his or her 90 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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arms when the examiner (spontaneously) does s o, when some other behavior has been reques ted, can be observed during the interview and examination. be havior is an automatic tendency to make use of in the environment, for example, picking up a pen and starting to write des pite this behavior's being inappropriate to the setting. More focused efforts to as sess executive function are almos t always indicated in the neurops ychiatric examination. P ers everation may be specifically s ought the motor s equencing tas ks described above or with a sample of s pontaneous writing. A tapping tas k with conflicting ins tructions may illuminate the inflexibility of goal-directed P.340 behavior that gives rise to pers everative res ponding. patient is instructed to tap once if the examiner taps and twice if the examiner taps once. T he examiner taps on the table in a random s eries of one or two taps . T his can be directly followed by a go/no-go tapping in which the patient is instructed to tap once if the examiner taps once, not at all if the examiner taps Intrusions from the previous task's instructions perseverative res ponding; echopraxic respons es just like the examiner) represent failures of inhibition. Inhibition of reflexive gaze can be tes ted during the examination of eye movements . Looking at the moving stimulus rather than in the oppos ite direction as amounts to a vis ual gras p response and represents of inhibition. S pontaneous word-list generation (“T ell all the animals you can think of” or “T ell me all the 91 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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that s tart with ‘s ’”) depends on the capacity for effortful search of s emantic s tores . A greater decrement in to semantic cues (“animals ”) than to phonemic cues (“words with ‘s ’”) is seen in Alzheimer's disease the degradation of semantic stores due to damage. W orking memory can be ass es sed with the alphanumeric sequencing task described above. Anatomical inferences from dis sociations in on thes e tasks are limited. G o/no-go tas ks depend on integrity of orbitofrontal cortex, other tasks on the dorsolateral prefrontal cortex and its circuit. is as sociated with right hemis phere dysfunction. A diss ociation is between executive cognitive and personality change in frontal injury. E specially with orbitofrontal lesions , executive function can be spared even in the face of grave alterations in emotion and comportment; the two domains cannot s imply be cons idered two sides of the s ame coin. Nonetheless , it bears repeating that neuropsychiatric examiners should cons ider executive cognitive function in their formulation of cases .

Dis ordered Mood and E motion S everal syndromes of dis ordered emotion in organic disease can be delineated. Dis turbance s of re cognition expre s s ion of e motion with right hemisphere les ions already been mentioned. P atients and their familiars rarely aware of these deficits and do not complain of rather, the examiner must recognize the deficit and it into a formulation of the patient's social and functional decline. Impairment of prosodic expres sion s hould not mistaken for depress ed affect. T esting of affective 92 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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can be undertaken at the beds ide without s pecial equipment. T he examiner should as k the patient to say emotionally loaded sentences in a emotional manner, expres sing s urprise, fear, pleas ure, and anger. P eople cons iderably in their native acting talents, and the normal performance is wide. T he examiner als o can neutral sentences in various emotional tones : “I am to the store,” stated with surpris e, and s o forth, with the examiner's face turned away from the patient to avoid providing a s econd input channel. P atients should be to recognize the affect. S eparately, if tes ting materials available, the examiner can as sess the patient's identify emotions in visual scenes and facial Lesions that involve both limbic and heteromodal in the right hemis phere especially impair performance recognizing emotional facial expres sions. P athological laughing and crying also are mentioned as lateralized behavioral dis turbances. T he phenomena displays of affect incongruent with inner experience elicited by inappropriate, nonemotional, or inadequate stimuli. T he examiner may, in the extreme, be able to full displays of affect by waving a hand in front of the patient's face. T he patient is often embarrass ed by the pathological expres sion of affect. T he traditional explanation is that a lesion of des cending frontopontine pathways releases from inhibition a “laughing center” “crying center” in the brains tem. Indeed, features of ps eudobulbar palsy are often pres ent in thes e patients. However, the relevant centers have never been and the poss ibility that the phenomena res ult from cerebellar dis connection has been raised. A broader of affe ctive dys re gulation, which may be called 93 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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“emotionalis m,” is commonly s een, us ually in the of tearfulness . P atients report that they are more emotional than previous ly and that the tears are unexpected, and uncontrollable. However, they are generally congruent with the patient's s ubjective state. S uch patients are often cognitively impaired; les ions the left frontotemporal region. T he rare phenomenon of fou rire prodromique (mad prodromal laughter) acute vas cular les ions of the brains tem or thalamus . Apathy is an emotional dis turbance marked by of affect and motivation. G oal-directed behavior is reduced, and emotional res ponses are lacking. T he distinction from depress ion is crucial: P atients do not report negative emotional states or ideational content. Although they may meet criteria for depres sion the loss of interest in activities , they are mentally empty rather than full of distress . R ecognizing apathy rather mistaking it for depress ion may imply treatment with different pharmacological agents, for example, us e of dopamine agonis ts. E uphoria refers to a pers is tent and unrealistic sense of well-being without the increased mental or motor rate of mania. Although often in connection with multiple sclerosis , it is unusual and almos t always as sociated with extens ive dis ease and subs tantial cognitive impairment. T he K lüve r-B ucy s yndrome , as described in the captive monkey, includes reduction in aggres sion (tamenes s), excess ive and indis criminate sexual behavior, hypermetamorphos is (forced attention to environmental stimuli), and hyperorality (mouthing nonfood items ). mixture of emotional, perceptual, and motivational changes is dependent on bilateral damage to 94 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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human patients, pathologies including trauma, herpes simplex encephalitis , and frontotemporal dementia can produce the s yndrome, us ually in partial form. Depre s s ion is common in patients with brain dis eas es , including s troke, multiple sclerosis, traumatic brain and P arkins on's dis ease. C ertainly, this is in part a to altered circums tances and distress ing dis ability. Nonetheles s, the s yndromal nature of the depres sed and its imperfect correlation with measures of disability have prompted extens ive efforts to seek anatomical correlations. C onverging evidence leads to a model of alterations in a distributed network involving neocortical and limbic elements. In particular, a dors al involving dorsolateral prefrontal cortex, inferior parietal cortex, and the dorsal and posterior portions of gyrus shows underactivity in the depres sed s tate; regions are believed to mediate the cognitive and impairments of depress ion. Invers ely, a ventral compartment containing anterior insula, subgenual cingulate, hippocampus , and hypothalamus is these elements are believed to mediate somatic (“vegetative”) features of the depres sed s tate. between the two compartments are mediated through thalamus , basal ganglia, and, especially, rostral Mania is s ubs tantially les s common than depres sion brain injury. Mania is ass ociated with right-sided involving paralimbic cortices in orbitofrontal or basotemporal regions or s ubcortical sites in caudate or thalamus . S ome evidence s uggests that s ubcortical are more likely to produce a bipolar picture, cortical unipolar mania. As with depress ion, the abnormal state does not necess arily appear in close temporal 95 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as sociation with the injury, so determining whether the mood dis order is organic or idiopathic is not always straightforward. T he absence of a pers onal history of disorder is an obvious criterion, but the presence of a family history of mood dis order may mark a factor not operative in the P.341 absence of the brain les ion. Age of onset is relevant, es pecially for mania: T he ons et of idiopathic mania years of age is rare. A particularly common iss ue in neuropsychiatric as sess ment is the patient with late-onset depress ion in whom evaluation reveals executive cognitive and s ubcortical white matter dis eas e. T his state of “vascular depres sion” is marked by the presence of vascular ris k factors, notably hypertension, a tendency ps ychomotor retardation and anhedonia and not ps ychos is or guilty ideation, and poor outcome with treatments . S ome, but not all, of these patients have apathy rather than depress ion.

Abnormalities in Agenc y Ordinarily, the person performing an action has the of being the one performing it. T he prototype of this normal subjective sense is the “alien hand” phenomenon. P atients with parietal les ions may report sens e of strangenes s of the hand, and the limb may levitation or avoidance reactions. More dramatically, medial frontal or callos al les ions , the hand may engage unwilled behavior (representing unilateral utilization behavior), or intermanual conflict may occur. 96 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Abnormal S oc ial B ehavior T he multitude of behaviors exhibited in s ocial has, of cours e, multiple underpinnings . S everal complexes , the neurobiology of which has come under scrutiny, can be obs erved in their abnormal form in patients and, at times, understood from an anatomical phys iological point of view. T he intens ity of social interaction manifes ted by with temporal lobe epilepsy may be due to deficits in social cognition or to a limbic lesion reinforcing s ocial cohes iveness . F ailures of empathic understanding are common in patients with frontal injury. T hes e res ult both from cognitive inflexibility in ass es sing complex social s ituations, es pecially in patients with dorsolateral prefrontal les ions, and from emotional impoverishment, es pecially in patients with orbitofrontal lesions . T he capacity of humans to understand the mental others —and thus to recognize not just another's goals intentions but also the other's deceptions or pretense— has been termed me ntalization or the ory of mind. and lesion data s ugges t that this capacity depends critically on prefrontal cortex (particularly right medial prefrontal cortex adjacent to anterior cingulate gyrus ), right temporoparietal cortices , and amygdala. P atients with is olated les ions of amygdala are rare, but deficits theory of mind are seen in patients with frontal dis ease and may contribute to their s ocial failure. P atients with right hemisphere les ions have a range of deficits in interaction that may be characterized as a dis order of pragmatics. Although they may grasp the propositional 97 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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content of language correctly, they mis take as pects of communication that require apprais al of the intent, for example, whether an utterance was intended a joke. P ragmatic disorders due to frontal and right hemis phere damage may impair narrative coherence through verbos ity, vaguenes s, and dis regard for the listener's informational needs . T hus, for example, us e may be s yntactically correct but the referents of pronouns obscure to the listener. Although language is normal, the way language is embedded in social interaction is not.

Abnormal B eliefs and E xperienc es Hallucinations are a common feature of diseas es of the brain. V is ual hallucinations in the abs ence of auditory hallucinations are s ugges tive of organic dis ease. V isual hallucinations may occur in a hemifield blind from disease, so-called releas e hallucinations . V is ual hallucinations in the s etting of vis ual impairment due to ocular disease, usually in the elderly, are known as the C harles B onne t s yndrome . T he hallucinations are characteristically vivid images of living figures, and the patient is aware of their unreality. Other is absent, but treatment aimed at the hallucinations is us ually ineffective. E laborate-formed visual may occur with lesions of thalamus or upper brains tem, called peduncular hallucinos is. T he symptoms are the evening (crepuscular), and again, the patient is of the unreality of the visual experiences . P rominent, visual hallucinations in the context of progress ive dementia may s uggest dementia with Lewy bodies . Auditory hallucinations occur rarely with pontine 98 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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More common are mus ical hallucinations in the setting hearing impairment, akin to the C harles B onnet Unilateral hallucinations are characteris tically ips ilateral the deaf ear. Olfactory hallucinations occur as a limbic in partial epilepsy, but they also occur in idiopathic ps ychiatric illnes s. P alinops ia and palinacous is refer to pers is ting or perceptual experiences after the object is gone in the visual and auditory domains, res pectively. Les ions in as sociation cortex—parieto-occipital and temporal, res pectively—are res pons ible, although (for the vis ual sphere more than the auditory) drug toxicity is often the explanation. T he content of de lus ions may yield clues to causative organic disease and its nature. Most notably, misidentification delus ions have been ass ociated with dysfunction of face proces sing and clearly linked—in but not all cases —to right hemis phere dysfunction. Misidentification of place is regularly ass ociated with visuospatial and executive cognitive dys function. Misidentification delusions have been of s pecial cognitive neuropsychiatry, with a focus on face recognition impairment in s uch patients. P erceptual recognition without a s ens e of familiarity (as in syndrome and perhaps the nihilistic delusions of syndrome) may reflect a dis ruption of vis ual–limbic connections . In a s ens e, it is the revers e of dé jà vu, amounts to familiarity without perceptual recognition. However, many patients with mis identification have no evidence of organic disease. Although such patients may have dys function of similar underlying mechanisms to patients with as certainable organic 99 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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disease, the similarity of clinical phenomena cannot be taken to prove an identity of mechanis m. P articular delusional themes may mark delirious such as a focus on danger or harm to others, as the more s elf-centered cons tructions in idiopathic ps ychotic dis orders. However, most delusions in with brain disease are of more banal nature, often with persecutory elements that bespeak cognitive failure theft of one's purse, for example, repres enting a failure memory as to its location). C omplexity or delus ional ideation is as sociated with preservation of intellect, and delus ions tend to become les s complex progres sion of dementia.

L A B OR A TOR Y INVE S TIG A TIONS S pecialized laboratory investigation forms a major part the neuropsychiatrist's arsenal. S ometimes patients are referred for neuropsychiatric cons ultation when a inves tigation—such as a s creening MR I or E E G —gives unexpected abnormal res ult; the neurops ychiatris t is called on to ass es s the meaning of the finding in the ps ychiatric context.

Neuroimaging S tructural neuroimaging with computed tomography and later with MR I revolutionized practice in the clinical neuros ciences. No longer was the organ of interes t invis ible within the carapace of the skull. C T relies on differential absorption P.342 of X-rays by brain tis sues and on the power of 100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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computerized methods to integrate data from multiple perspectives . T he s trengths of C T are its speed and its sens itivity to blood and bone. T hus, for purpos es, situations in which a patient cannot tolerate prolonged imaging procedure may mandate C T . T his problem often aris es with an agitated demented or ps ychotic patient. B ony abnormalities , parenchymal depos ition of calcium, and intracranial hemorrhage are particularly well as sess ed by C T . S uch questions arise acute aftermath of trauma in particular. T he advent of MR I was an advance over C T in several res pects . T he anatomical resolution is substantially and the discrimination of white matter abnormalities exceptionally so. T he capacity to display data from a acquisition in multiple views —sagittal, axial, and coronal—allows improved anatomical understanding. (or s hort relaxation time [T R ]) images give maximal anatomical resolution. T 2 (or long T R ) images and intermediate-weighted (proton dens ity) images give maximum s alience to areas of abnormality, characteristically bright against a darker parenchyma. attenuation invers ion recovery (F LAIR ) images mark the lesions even better, with dark cerebrospinal fluid providing better contrast with regions of abnormality the bright C S F of T 2 images. G radient echo images sens itively reveal the sequelae of hemorrhage and may us eful in as ses sing the damage from trauma. Infusion gadolinium for contrast enhancement is not neces sary delineation of nonvascular anatomical s tructures , s uch is the goal in the case of atrophy or old s troke or but can identify areas of breakdown of the blood–brain barrier s uch as in the meninges in meningitis or in 101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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parenchymal lesions of active multiple s cleros is , tumor, acute stroke. S pecial imaging s equences should be for the identification of cortical dysplas ia or mesial temporal s cleros is . V olumetric MR I allows diagnos is by quantitative ass es sment of delineated brain s tructures such as hippocampus in the cas e of temporal epilepsy potentially Alzheimer's diseas e. One imagines the day the near future when the s cans come (as electrocardiograms now do) with quantitative routinely accompanying the analog image. Magnetic res onance angiography (MR A) allows the delineation medium and large vess els without the adminis tration of contrast material, as is required for conventional angiography. S tenos is of thes e ves sels, such as the of the neck, or the presence of vas cular malformations aneurysms is reliably as certained. However, resolution not sufficient to allow as sess ment of small vess els ; some forms of vasculitis cannot be excluded with MR A require contras t angiography. Additional MR I s equences include diffusion-weighted imaging, which captures acute vas cular injury; diffusion tensor imaging, which dis clos es patterns of white matter; and magnetization transfer imaging, promis es even greater sens itivity to brain lesions than F LAIR imaging. E xcept for diffusion-weighted imaging acute stroke, none has an es tablis hed clinical use. Magnetic res onance spectroscopy is a method for analyzing the regional chemical composition of the T he benefits of its ability to identify neuronal loss and proliferation are s till under investigation, although in certain circums tances , s uch as dis tinguishing radiation necros is from recurrent brain tumor, it is of proven 102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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us efulnes s.

Func tional Neuroimaging F our methods of functional neuroimaging are available: single photon emis sion computed tomography P E T , functional MR I, and brain mapping by quantitative E E G . All are exciting research avenues, but the clinical role for functional imaging is limited. All the techniques have a place in the pres urgical evaluation epileptic patients. S P E C T or P E T in the patient with frontotemporal dementia typically dis closes the lobar nature of the dys function, although their value diagnostically over and above neuropsychological demonstration of the s ame phenomenon is S imilarly, in exactly which circums tances bilateral temporoparietal hypoperfusion advances the diagnosis of Alzheimer's dis ease is not yet clear. T he demonstration of occipital hypoperfus ion strongly supports a diagnosis of dementia with Lewy bodies . evidence for other clinical us es of functional imaging is present limited or anecdotal.

E lec troenc ephalography T he expectation of the originators of E E G was that it allow tracking of mental process es . T his hope has not realized. E E G does have the advantage over other available brain imaging tools that it reflects function at high temporal res olution, res olution corresponding to time cours e of mental proces sing. T hus , at least from a res earch perspective, meas urement of brain potentials relation to stimuli—the technique of evoked has the capacity to identify anomalous modes of 103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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proces sing. R ecordings from electrode placements in subdural or cortical sites provide irreplaceable about the origin and s pread of epileptic dis charges , but this invasive technique is jus tified only under circums tances . F rom today's practical point of view, E E G has s everal uses : Inves tigation of epileps y to confirm the diagnos is clarify the type of epilepsy Differentiation of delirium from acute nonorganic ps ychos is R ecognition of C reutzfeldt-J akob disease Dis tinction of frontotemporal dementia Only 30 to 50 percent of patients with epilepsy show an epileptic abnormality on a single interictal waking E E G . With s leep deprivation, s leep during the recording, and repeated recordings , s ens itivity improves to 70 to 80 percent. Anterior temporal electrodes add to the sens itivity and localizing power of the E E G , but nasopharyngeal electrodes, which are quite uncomfortable for the patient, do not provide additional sens itivity, and are not recommended. A reasonable protocol s tarts with a routine E E G , including anterior temporal leads ; if this is negative but suspicion remains high, a second E E G with sleep deprivation can be undertaken. A third and fourth E E G may be us eful, but rate of dis covery of abnormalities decreas es after that. E ven then, some epileptic patients will not have been shown to have interictal abnormalities. At times , ambulatory E E G is of use to ascertain the epileptic of undiagnosed events, but the restricted montage of 104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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ambulatory equipment limits its us efulness . Hos pitalization for video-E E G recording may be for clarifying the nature of puzzling s pells . Delirium is characterized by s lowing of the E E G , a never s een in acute idiopathic psychosis. T his point can be decisive in a confusing clinical s etting. However, E E G is not indicated as a routine in the of psychotic patients. Among the dementing disorders , frontotemporal dementia is dis tinctive in having a E E G even as the clinical s tate becomes moderately In C reutzfeldt-J akob disease, the E E G is always s low may ultimately (not neces sarily immediately) show the diagnostic feature of ps eudoperiodic complexes. E E G s at weekly intervals may clinch this diagnosis in a puzzling case. E voked potentials can identify abnormalities in neural transmis sion along myelinated pathways such as the pathway or the s ens ory pathways of the s pinal cord brains tem. T his can help in the diagnosis of dis orders as multiple sclerosis or vitamin B 12 deficiency. P.343

L aboratory Inves tigations In general, empirical evidence for the usefulness of laboratory s tudies supports only a limited role for or s creening investigations; for the most part, tes ts should be performed as guided by the his tory and examination. A full discus sion of laboratory strategies all neuropsychiatric s ituations is beyond the scope of chapter. In regard to dementia, a complete blood cell count (C B C ), chemistry panel, vitamin B 12 as say, and 105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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thyrotropin (T S H) as say are indicated as screening addition to a test for s yphilis (the fluorescent antibody test [F T A]) in those areas of the United S tates which the prevalence of s yphilis jus tifies the testing. region of high incidence is a broad belt acros s the addition to s ome urban areas in the North; 30 U.S . contribute more than one-half of the national total of cases.) T he reason the F T A is the tes t of choice is that reagin tes ts (the V enereal Dis ease R esearch [V DR L] or R apid P lasma R eagin [R P R ]) revert to intercurrent antibiotic treatment or with the pas sage of time and, thus , are insufficiently sensitive to serve as screening tes ts for neurosyphilis . Appropriate s creening tests for mental pres entations than dementia, for example, first episode psychosis , less well es tablished. Unfortunately, no cohort studies applying a cons is tent laboratory diagnos tic approach available to provide guidance as to the s ens itivity and specificity of tes ting or even as to the prevalence of organic disease in this s ituation. T he first s tep should neurops ychiatric history and examination. A laboratory screen might include C B C , chemistry panel, urinalys is, and urine toxicology. If it is cons idered to screen for rheumatic disease, an antinuclear tes t (ANA) is adequate for this purpos e, being almos t all cas es of lupus , although not sufficient to that diagnosis. (F als e positives from ps ychotropic induced ANA tests are an important confound.) E xces sive laboratory testing is to be deplored; on the hand, limiting laboratory tes ting to generally familiar diseases is inexpert. C onsideration of rare metabolic diseases s hould be within the neuropsychiatrist's 106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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R uling out aminoacidurias or organic acidurias in with adoles cent or young-adult ons et of ps ychos is be considered, es pecially if unexplained fluctuations poss ibly due to dietary factors , unexplained physical or unexplained cognitive impairment is pres ent. A reasonable broad s creen includes ammonia, plas ma amino acids , and urine for organic acids, although this to detect s uch conditions (known to be as sociated with ps ychiatric pres entations ) as G M 2 ganglios idosis (hexos aminidas e A deficiency) and F urther testing with s pecific metabolic or genetic should be performed as circums tances indicate.

E xamination of the C erebros pinal E xamination of C S F obtained through lumbar puncture sometimes a crucial element of the diagnos tic proces s, particular to diagnos e infection or inflammation, more rarely in neuropsychiatric practice to seek evidence of neoplasia (s uch as meningeal carcinomatos is ). as says are available for the diagnosis of neurops ychiatrically relevant infectious agents s uch as polymerase chain reaction (P C R ) for the herpes virus (HS V ) genome to diagnose herpes encephalitis or cryptococcal antigen ass ay to diagnos e this fungal meningitis. In rheumatic diseases involving the brain, white cell count may not be elevated, but elevated and evidence of intrathecal elaboration of antibodies give evidence of inflammatory activity. T he latter is by the ratio of immunoglobulin G (IgG ) to albumin or, better, by the IgG index, which requires meas urement serum IgG by immunoelectrophores is . C S F antibodies are uncommon but s pecific for cerebral In the future, ass ay of C S F cytokines may provide 107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as sistance in the difficult diagnos is of these diseases . Meas urement of the neuron-derived 14-3-3 protein has adequate s pecificity and s ens itivity to as sist in the diagnosis of C reutzfeldt-J akob disease as long as the pretes t probability of this rare disease is sufficiently In practice, this means that us e of the tes t should be confined to patients with a progres sive dementia of than 2 years' duration. Meas urement of tau and peptides is not yet of s atisfactory validity for general the diagnosis of Alzheimer's dis eas e. R emoval of C S F by lumbar puncture or external also plays an important role in the evaluation of suspected of shunt-revers ible normal press ure hydrocephalus.

Neurops yc hologic al As s es s ment Neurops ychological evaluation has an important role to play in neuropsychiatric care, both for diagnos is and for management. S ound us e of the clinical as a cons ultant requires , as a first step, formulation of cogent cons ultative question. T he more s pecific the cons ultant's ques tion, the more able the neurops ychologist is to integrate the ps ychometric data with the res t of the clinical picture. Much of the early literature on neuropsychological as sess ment focus ed identifying and localizing organic brain dis eas e. W ith advent of neuroimaging, neuropsychological testing is seldom the mos t powerful means of addres sing this although it certainly continues to play s uch a role, for example, in lateralizing cognitive deficits as a tool in epileptic patients. Nor is the role of the 108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurops ychologist to make a dis eas e diagnosis, at times the psychometric picture is strongly s ugges tive a particular diagnosis. In several areas of as sess ment, the neuropsychiatrist particular reas on to turn to the neurops ychologis t. If subs tantial confounds make bedside diagnos is difficult, neurops ychological data may be of cons iderable as sistance. F or example, identifying supervening impairment in a mentally retarded or poorly educated patient or s ubtle impairment in a highly intelligent may be imposs ible for the clinician to do with whereas quantitative ass ess ment may allow these diagnoses. Another example of us ing as sess ment as a probe of brain function is disclos ing a pattern of cognitive s trengths and weakness es to right hemis phere learning dis abilities in a patient with clinical picture s uggestive of pervasive developmental disorder or a clus ter A pers onality disorder. Obtaining neurops ychological data about a dementing patient allows more precis e targeting of behavioral more s pecific education of families , and more confident as sess ment of decline or of benefit from treatments . One common us e of neurops ychological as ses sment requires a word of caution: identifying cognitive impairment in an older patient presenting with mood disorder or psychos is. No neurops ychological findings should deter the clinician from aggress ive treatment of ps ychiatric symptoms, and nons pecific, s tateattentional and motivational factors may confound the neurops ychological res ults. R ather than devoting res ources of time and energy to pinpointing a moving 109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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target in the acute phase, deferring the as sess ment symptoms are reduced is often the wiser course. Another caution about neuropsychological ass ess ment falls under the rubric of ecological validity. T his term to the extrapolation P.344 of results obtained in the neuropsychological laboratory by artificial “paper-and-pencil” methods to real-world performance. T he concern aris es in particular with orbitofrontal lesions , which may produce a paucity of cognitive findings but devas tating personality change. Deriving clinical meas ures from the developing realm affective neuros cience suitable to characterize such patients is a current challenge to neurops ychology.

B rain B iops y B iopsy of the brain has a limited role in evaluation. T he morbidity and mortality of the as performed by an experienced neurosurgeon, are but the sensitivity of the procedure is lower than one might expect. F or example, the sensitivity of biops y for primary angiitis of the central nervous system (C NS ) be only 75 percent. In some circums tances , biops y of a peripheral tis sue can s ubs titute for brain biops y in a patient with primarily cerebral symptoms at lower ris k. example, lung or muscle biopsy may make a diagnosis sarcoid, skin biopsy a diagnosis of vasculitis if a rash is present or of C ADAS IL, temporal artery biops y of giant arteritis. In neuropsychiatric s ituations, the major indication for biops y of the brain is cons ideration of inflammatory disease when the nature and 110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of treatment depend on a tiss ue-proven diagnosis . Although of course it cannot be cons idered a clinical diagnostic test, autopsy s hould not be overlooked by neurops ychiatris t as a learning tool.

C OMMON NE UR OP S YC HIA TR IC C ONDITIONS T his s ection provides a s urvey of s ome is sues brought to the attention of neuropsychiatrists . T he emphasis is on the priorities for clinical and laboratory as sess ment for a variety of presentations . T he is by disease and syndrome, as a complement to the anatomical and s ymptom-oriented discus sion provided far. T his perspective is distinctive for neuropsychiatry within psychiatry; the disease proces ses underlying symptoms in the idiopathic disorders are unknown. F or neurops ychiatric patients, one can hope and work to uncover the disease causing the s ymptoms and, on fortunate occasions , to provide dis eas e-specific

Dementia An extensive lis t of dis eases produces the clinical state dementia. A shotgun laboratory approach to “ruling out treatable disease” is unwise, if only because finding revers ibility is s o unusual. Moreover, clinical clues to revers ible disease are available in the history and examination: us e of ps ychotoxic medicines , rapid mildnes s of cognitive impairment (even s hort of fully meeting criteria for dementia), subcortical features of cognitive disorder, and pres ence of motor s igns. T able 4 provides specific guidance to be gained from clinical clues . T he differential diagnos is of dementia needs to 111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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include differential diagnos is among the degenerative disorders , an exercise that depends very largely on findings rather than imaging or laboratory data. In particular, apolipoprotein E testing is by cons ens us not recommended for routine diagnos tic purposes at the present time.

Table 2.1-4 C lues to the Diagnos is of Dementia in the Neurologic al E xamination Abnormal eye findings    C eliac disease    G aucher's disease type 3    Mitochondrial cytopathy    Multiple s cleros is    Niemann-P ick dis eas e type C    P rogres sive supranuclear pals y    S yphilis    V ascular dementia 112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   W ernicke-K ors akoff s yndrome    W hipple's dis ease    W ils on's dis eas e Ataxia    C eliac disease    C erebellar degenerations    G M 2 ganglios idosis    Hypothyroidism    Multiple s cleros is    Niemann-P ick dis eas e type C    P rion dis eas e    P rogres sive multifocal leukoencephalopathy    T oxic-metabolic encephalopathy    W ernicke-K ors akoff s yndrome    W ils on's dis eas e

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Dys arthria    C erebellar degenerations    Dementia pugilistica    Dialysis dementia    Motor neuron dis eas e    Multiple s cleros is    Niemann-P ick dis eas e type C    Neuroacanthocytosis    P antothenate kinase–as sociated neurodegeneration    P rogres sive multifocal leukoencephalopathy    P rogres sive supranuclear pals y    W ils on's dis eas e E xtrapyramidal signs    Alzheimer's dis eas e    C erebellar degenerations 114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   Dementia pugilistica    Dementia with Lewy bodies    F ahr's syndrome    G M 1 ganglios idosis, type III    Huntington's disease    Multiple s ys tem atrophy    Neuroacanthocytosis    Niemann-P ick dis eas e type C    Normal press ure hydrocephalus    P antothenate kinase–as sociated neurodegeneration    P arkinson's diseas e    P rogres sive supranuclear pals y    P ostencephalitic parkins onism    S ubacute sclerosing panencephalitis    T oxic-metabolic encephalopathy 115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   V ascular dementia    W ils on's dis eas e G ait dis order    Adrenomyeloneuropathy    C erebellar degenerations    Dementia pugilistica    HIV encephalopathy    Multiple s cleros is    Normal press ure hydrocephalus    P arkinson's diseas e    P rogres sive supranuclear pals y    S yphilis    V ascular dementia    W ernicke-K ors akoff s yndrome Myoclonus

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   Alzheimer's dis eas e    C eliac disease    Dialysis dementia    K ufs' disease    Lafora's body dis eas e    Mitochondrial cytopathy    P rion dis eas e    S ubacute sclerosing panencephalitis P eripheral neuropathy    Adrenomyeloneuropathy    B 12 deficiency    HIV encephalopathy    Metachromatic leukodys trophy    P orphyria    T oxic-metabolic encephalopathy

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P yramidal signs    Adrenomyeloneuropathy    B 12 deficiency    C erebellar degenerations    G M 2 ganglios idosis    HIV encephalopathy    K ufs' disease    Metachromatic leukodys trophy    Motor neuron dis eas e    Multiple s cleros is    P antothenate kinase–as sociated neurodegeneration    P olyglucos an body disease    P rogres sive multifocal leukoencephalopathy    S yphilis    V ascular dementia 118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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HIV , human immunodeficiency virus . Modified from S andson T A, P rice B H: Diagnos tic tes ting and dementia. Neurol C lin. 1996;14:45–

T he clinician needs to gather data relevant to management iss ues other than purported reversibility, such as safety of living arrangements , driving ability, preparation of a will and advance directives . patients often develop psychiatric s ymptoms, which res pond to pharmacological and behavioral treatment. these considerations s hould prompt the clinician to cast wide net in data gathering regarding the demented patient. P.345

E pileps y Major concerns in patients with epileps y include differential diagnosis, psychosis, pers onality change, depres sion, violence and other epis odic behaviors , and ps eudoseizures . T he last will be dealt with below along with other conversion dis orders. A 67-year-old woman pres ented with at leas t 1 year of progres sive memory impairment, confus ion, then irritability and s us piciousness . T he mental s tate was 119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of Alzheimer's dis eas e, and the phys ical examination disclos ed only bris k tendon jerks . An E E G , done earlier because of a spell of uncertain nature, had shown left temporal s pikes . Neurops ychological as ses sment had shown a pattern typical for Alzheimer's dis eas e, with memory impairment characterized by rapid forgetting, semantic–phonemic verbal fluency deficits , and MR I, however, demonstrated extens ive white matter disease, with bilateral confluent hyperintensities, which extended into the gyri and involved U fibers . C S F examination was entirely normal. S kin biops y for and s creening genetic as say for C ADAS IL were R epeat E E G s howed bilateral temporal spikes, and carbamazepine (T egretol) was begun. T he clinical diagnosis was leukoencephalopathy due to cerebral amyloid angiopathy, poss ibly with Alzheimer's disease. T he patient's mother had died at 86 years of age, suffered from “the same thing” as the patient. F our of mother's five s iblings demented in the 8th or 9th of life, none earlier, in most cases with a diagnos is of Alzheimer's disease. T he patient was an only child. patient's two daughters, both young adults, were very concerned that they might inherit the same dis eas e as their mother, and they ins is ted the patient undergo the brain biopsy that a geriatrician had recommended. T his disclos ed pronounced congophilic angiopathy. Immunos taining for A-beta confirmed the vess el abnormality and showed neuropil plaques ; immunos taining for tau did not reveal neuritic plaques . Nonetheles s, Alzheimer's diseas e could not be No inflammation was seen. However, s everal days biops y, she developed s tatus epilepticus . 120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P atients with attack disorders can be misdiagnosed as having epilepsy when they do not or as having a disorder when epilepsy is the correct diagnosis. P aroxysmal s ymptoms from panics, cardiac disease syncope or near syncope, endocrine dis orders (pheochromocytoma, carcinoid, systemic conversion dis order can be mistakenly labeled contrariwis e, epileps y can be mis sed when a diagnosis panic dis order, in particular, is accepted. A 59-year-old man was evaluated for 7 years of problems and s pells refractory to treatment on a of panic dis order. T hese spells characteristically lasted 10 seconds and recurred as often as hourly; he was sometimes amnestic for the s pells afterward. During an attack, he had goos eflesh, and his s peech became once at church, he was believed to be s peaking in E xtens ive treatment trials with benzodiazepines and serotonergic drugs had given no consistent benefit. from hyperlipidemia, he had no significant medical E E G had been negative on three occas ions, MR I on Holter monitoring and S P E C T on one each. T he neurological and mental s tate examinations were An attack was witnes sed during the examination: He showed 10 s econds of facial flushing and stereotyped hand movements . T he attacks were s ubs equently abolished by a trial of an antiepileptic drug. T he case illus trates that epileps y is primarily a clinical, not an diagnosis. A 52-year-old woman was referred for the evaluation of spells. In her 30s s he had been hos pitalized for and was subsequently treated intermittently as an 121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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outpatient. T he family history included s everal with depress ion or bipolar dis order. T wo years before evaluation, s he pres ented with headache and proved have an unruptured aneurys m, which was clipped a craniotomy. S everal months later, s he had a convuls ion. S he went on to have s pells at a rate of up a day. T hey were stereotyped and abrupt in ons et and termination; s he could not identify provocative factors social contexts. During a s pell, s he felt cold and had goosefles h for approximately 3 minutes. T hen she rigid and unable to s peak or interact, although she hear others ' s peech. T his las ted s everal minutes. T hen began to cry. T he whole sequence las ted 6 to 10 S he was on phenytoin with a therapeutic s erum level. P revious trials of divalproex (Depakote) and topiramate (T opamax) were not tolerated. E E G s had shown only frontal s lowing with no epileptic features on several tracings. T he neurological and cognitive examinations were normal, and she was not depress ed at the time of evaluation. T he clinical picture was inconclus ive: In epilepsy were the abrupt ons et and termination, stereotyped nature of the s pells , and background of craniotomy; agains t epilepsy were the weeping, length the ictus (if all the phenomena were taken to be ictal), of respons e to treatment, relatively inactive E E G , and background of depress ion. V ideo E E G done after medication withdrawal recorded three complex partial seizures with right anterior inferior temporal ons et with her typical s emiology and no ps eudos eizures . In exploring the psychiatric concomitants of epilepsy, clinician needs to be aware of the nature of the Most adult epilepsy is focal (“localization-related 122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epilepsy”), with the ictal ons et in the temporal lobe. However, other forms of epilepsy, including frontal epilepsy and primary generalized epileps y, are T hese dis tinctions , and the laterality of the focus , can be inferred from the semiology of the seizures as or as observed clinically. A history of febrile childhood and age of onset of epileps y are relevant to likelihood of mesial temporal sclerosis as the pathology. B ody asymmetry and dis sociated facial should be sought as indicators of laterality. T he MR I E E G provide crucial information on pathology and type. Almost all the findings relating ps ychiatric epilepsy are concerned with partial epileps y of onset; linking psychiatric s ymptoms to epileptic syndromes other than temporal lobe, or limbic, epilepsy generally goes beyond the evidence. F urther, to what extent ps ychopathology is as sociated with the epileps y per se and to what extent with the underlying brain disease remain controversial. W ithout ques tion, impairments are related to the lateralization of the temporal focus . P sychotic s tates in epileptic patients are usually into those occurring during the epileptic ictus , often epile ptic twilight s tate s ; thos e occurring for a delimited period in the aftermath of a seizure or, more flurry of s eizures , s o-called pos tictal ps ychos is ; and that are chronic, called interictal ps ychos is . Us ually, chronology can be ascertained by inquiry, but at times, E E G monitoring is necess ary to identify the occurrence seizures in relation to ps ychopathological phenomena, es pecially becaus e patients can be amnes tic for partial seizures . A further iss ue to be elucidated from 123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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history is of a relations hip between s eizure treatment control and the level of ps ychopathology, especially ps ychos is . An inverse relationship is s ometimes P.346 noted, better s eizure control being as sociated with occurrence of ps ychos is, a phenomenon known as normalization. On the other hand, frequent seizures certainly can caus e an increase in confusion and failure in functional capacity. A 35-year-old woman with lupus and intractable was admitted several times with pers ecutory and delus ions (“I'm dead”) and depres sive s ymptoms . Inves tigations to identify active cerebral lupus were unrevealing, even when she had evidence of peripheral activity of the dis eas e. In fact, MR I disclos ed the hippocampal sclerosis, s ugges ting that the epilepsy idiopathic and not due to old cerebral lupus . W ithout specific treatment, the psychotic s ymptoms diminished over the cours e of several days ; this als o was believed make a diagnosis of cerebral lupus unlikely. B etween episodes , s he s howed no ps ychotic phenomena. T he interictal pers onality s yndrome of temporal lobe epilepsy (the G as taut-G eschwind s yndrome) is characterized by hypergraphia; religios ity or deepened metaphys ical interest; intens ified emotionality with a tendency to holding grudges and aggress ion; hypos exuality; and an alteration of social behavior with intens ity of interaction, an inability to end interactions , circums tantiality of discourse (phenomena confus ingly denominated as “viscos ity”). T he syndrome remains 124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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controvers ial; what is of importance for as sess ment is that inquiry be directed to phenomena, as hypergraphia, that are not included in the review of symptoms of idiopathic ps ychiatric disorder. E pisodic aggress ion is often s us pected of being ictal very rarely is . Aggress ion occurring during s eizures is almos t always disorganized, not carefully directed. A threshold is jus tified in attributing a violent act to in the abs ence of typical epileptic features. Amnesia for serious violence is common and not a s trong pointer to epileptic origin. A s pecial is sue in neurops ychiatric as ses sment of the epileptic patient is the presurgical evaluation. S urgical treatment, especially of temporal lobe epilepsy due to mesial temporal sclerosis, is underused; ideally, more more patients with medically refractory epileps y will be evaluated for their s uitability for surgery. Along with intens ive electroencephalographic evaluation, MR I, and neurops ychological as sess ment, the patient's ps ychiatric state s hould be s ys tematically evaluated. patient's ability to cons ent and is sues s uch as the capacity to cope with the stress of monitoring and as well as the expectations held for surgery should be addres sed. Neither depress ion nor psychosis is an contraindication to s urgery, although a chronic probably will not be alleviated by s urgery. Indeed, few, any, psychiatric findings contraindicate s urgery, but ps ychiatric evaluation may well reveal deficits that be taken into account in developing a treatment plan.

Traumatic B rain Injury T raumatic brain injury is epidemic in society, with 125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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advances in emergency medical care leading to growth the prevalence of survivors of s evere injury. Is sues commonly facing the neuropsychiatrist include aggres sion, depres sion and anxiety, and the deficits (sometimes for legal purpos es ) in patients with mild traumatic injury. T he features of the head injury should be as certained, ideally with confirmation from medical records. T he altered behavior and personality common after traumatic brain injury are more burdensome for families than are the physical disabilities. Dis inhibition and aggres sion are particularly uncomfortable and often to treat. A complicating factor is that preinjury and s ubs tance abus e are common, as they predis pos e head injury. A 24-year-old woman was s een 19 months after an automobile collision in which she was an unres trained pass enger. S he was comatose for 3 months and underwent surgical evacuation of a left-sided hematoma. S he had a few weeks of rehabilitation after regaining consciousness and returned home after spending most of a year in a nursing home. T he family at wits' end over epis odes of aggres sion, which to be directed angry behavior elicited by frus tration. did not have depress ive symptoms. On examination, showed severe bilateral s pas ticity, including s pas tic dysarthria, drooling, and a bris k jaw jerk. S he was able recall dates and other details of her illness accurately, she disclaimed behavioral or emotional alterations . Her language comprehens ion was adequate, but output telegraphic. Affect was labile. B ehavior during the 126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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cons ultation was initially appropriate, with an obvious effort to cooperate with the evaluation, although she greeted the examiner with, “I love you.” At the end of examination, however, she urgently requested the examiner's bus iness card and rammed him with her wheelchair while cutting off his access to the door. C hronic-phase C T s howed atrophy and left temporal encephalomalacia. A 59-year-old man was referred by a court for of his ability to take part in proceedings related to his divorce. T hree months before evaluation, he was several times by an unknown as sailant during an altercation regarding who was to get the us e of a taxi. suffered contusions of the left periorbital area but no overt injury. He was able to recount the events in s ome detail, but he explained that this was because, over by comparing notes with others, he had “put it all back together”; of his own recollection, he could remember first punch that s truck him but not the s econd or subs equent events of the altercation. Although he not be certain of the duration of the gap in his it was clearly a matter of some s econds , conceivably a minute or two, and at no time was he uncons cious . In aftermath, he was “confused” and had a headache. He found that he could not come up with names , dates, or numbers, although this information generally came to him later or with considerable unaccus tomed effort. also noticed that he “couldn't visualize” geographical scenes, so that in planning to go to a familiar place, he unable to picture it in his mind. Although he did not get lost, he found that he turned the wrong way or mis sed turn because of inattention and had to correct himself. 127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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noted that his memory, previous ly highly trustworthy, could not be counted on: “I had to write everything He found that he had to “take time to think,” “strain my brain to focus .” He distanced hims elf from busines s decis ions and relied on trus ted subordinates to counsel him. He acknowledged s ens itivity to light, noting that had begun to wear sunglass es even when the weather cloudy and to turn off the room lights when he was watching televis ion. T o a less er extent, he was noise. He noted that he was more readily irritated than characteristic of him. He did not have depress ive symptoms, intrusive recall of the altercation, or nightmares . T he s ymptoms had gotten gradually less severe. T he history included s everal head injuries in adoles cence, two of which resulted in los s of cons ciousnes s of a few hours without recognized sequelae. T he noncognitive mental s tate and P.347 examinations were normal. He s cored 21 on the Mental Alternation T es t, a clearly normal performance on a mental s peed and working memory. He s cored 16 out 18 on the F rontal As ses sment B attery, a collection of as sess ing executive cognitive function. T he two lost were on the go/no-go tas k, on which he made perseverative errors. He was mildly dis organized on performing the ring/fis t tes t of motor s equencing. MR I E E G had been normal. T he picture was believed to be cons istent with organic s equelae of traumatic brain T he case underlines the importance of prior traumatic brain injury in determining the effects of s eemingly mild trauma and that los s of cons cious nes s is not a 128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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for significant s equelae.

Movement Dis orders C ognitive impairment due to involvement of subcortical structures is a common neuropsychiatric feature of the movement disorders . T his applies to cerebellar, as well basal ganglia, diseas es for the anatomical reas ons described above. T he anatomy of the clos e relation between emotion and movement was als o described above. C linically, mood disorders are common in IP D other movement disorders . Anxiety disorders , although less emphas ized in the literature than depres sion, are common. T he evaluator s hould take into account that mood and anxiety can fluctuate according to the timing doses of dopaminergic drugs . A mood dis order can occasionally pres ent in advance of overt movement abnormalities , s o IP D mus t be considered in the differential diagnosis of late-onset mood disorders . A 43-year-old woman with no personal or family history ps ychiatric illnes s developed a ps ychotic depress ion. had a s evere extrapyramidal reaction to risperidone (R is perdal). T wo years later, when euthymic and unmedicated, she developed progres sive shuffling gait, upper-extremity tremor, and micrographia. S he then suffered another episode of depres sion. T hree years she had s evere anxiety, no cognitive impairment, and motor features of IP D. P sychotic reactions to dopaminergic drugs are an important feature of movement dis orders. S ometimes is the res ult of overuse of prescribed dopaminergic in an effort to increas e time in the “on” state. 129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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A 63-year-old man with long-standing IP D developed delus ions while being treated with high-dose levodopa (S inemet) on a five-times -a-day s chedule, pramipexole (Mirapex), tolcapone, and amantadine (S ymmetrel). Under inpatient obs ervation for several on the pres cribed dos es, he remained ps ychotic. He res ponded well to quetiapine (S eroquel).

Developmental Dis abilities Adult patients with developmental dis abilities are enormously unders erved by the medical and s ocial communities and are frequently referred for neurops ychiatric attention. F ew of thes e patients have adequate diagnostic evaluation for the caus e of the disability. B eyond clinical as sess ment, with particular attention to dysmorphology becaus e features of the mental s tate and neurological examination are nonspecific, the most us eful diagnostic tes ts are MR I karyotyping. S pecific genetic probes can confirm clinical recognition of syndromes of mental retardation. P atients with developmental disabilities are indeed, es pecially vulnerable—to the mood, anxiety, ps ychotic dis orders that can afflict anyone and can be treated effectively for these; diagnostic overs hadowing (attributing all psychological and behavioral to “retardation” tout court) is to be avoided. T hese syndromes may pres ent atypically in the disabled population, and the clinician mus t be alert to indirect indicators of mood dis turbance or psychotic experience. F or example, although the patient may not report depres sed mood verbally, the caregivers may the loss of interest in favorite activities and the other 130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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features of a depres sive syndrome. Of particular neurops ychiatric interes t is the question of behavioral phenotypes, specific psychological developmental s yndromes. S yndromes recognized to behavioral phenotypes (and their correlates ) include Lesch-Nyhan s yndrome (s elf-injury) P rader-Willi syndrome (exces sive eating) Williams s yndrome (anomalous cognitive profile, elevated s ociability) V elocardiofacial syndrome (schizophrenia)

Infec tious and Inflammatory Infectious and inflammatory diseases of the brain need always to be cons idered in acutely or s ubacutely mental disorders . Among the infectious dis eas es, HS V encephalitis has a particular claim on attention delay in diagnos is , even by hours , can lead to increased morbidity and mortality. Definitive diagnosis poss ible without biopsy by as saying for HS V in the with the P C R , but treatment may be indicated if is high in advance of firm diagnos is . C hronic example, from infection with fungi, is a rare in subacutely evolving dementia; the definitive tes ts are C S F ass ays or serological tes ts (e.g., for toxoplas mos is ). In the acquired immunodeficiency syndrome (AIDS ) era, infection with opportunis tic and with the human immunodeficiency virus itself to be kept in mind, even in circumstances not suggestive of AIDS . 131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Noninfectious inflammatory dis eas es include the rheumatic dis eases , of which the prototype is systemic lupus . A rheumatic disease review of systems is importance in exploring the differential diagnosis of a puzzling case, es pecially in a young woman. Although ps ychos is is often cons idered the ps ychiatric hallmark lupus , in fact, psychotic states (other than delirium) are unusual, and a variety of other ps ychiatric pictures be included in the clinician's consideration. F ew clinical features of lupus are risk factors for cerebral disease, even dis eas e activity, which may be misleading in positive or a negative direction. One feature that is a factor for neuropsychiatric s ymptoms , including impairment, is the presence of antiphos pholipid antibodies; the primary antiphos pholipid syndrome similarly carries mental risk. A 40-year-old woman pres ented with the typical of a ps ychotic depress ion. T here was a family history depres sion, and s he had s uffered two episodes of depres sion earlier in her adult life, both of which were brief, nonpsychotic, and res ponsive to treatment. F or previous year, however, her depress ion had been res ponsive to pharmacological and electroconvuls ive therapy (E C T ) treatment P.348 E xamination dis closed no definite cognitive abnormality and brisker reflexes on the left. R eview of MR I her previous treatment venue, presumably performed routine before the adminis tration of E C T , evinced areas of white matter abnormality in the right 132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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E xtens ive laboratory inves tigation, s hort of and biops y, revealed only high-titer IgA anti-β2glycoprotein-1 antibodies . Neurops ychological performed after partial remis sion of the depres sion showed deficits in attention and mental proces sing T he working diagnostic formulation was that an ordinary idiopathic depress ive disorder had been treatment resistant and gravely s evere by a wave of cerebral injury due to the antiphospholipid syndrome. less on of the case is to always look at the imaging. Other rheumatic dis eas es, such as S jögren's s yndrome the vasculitides, are als o of neurops ychiatric Has himoto's encephalopathy—subacutely developing cognitive impairment and myoclonus or s eizures with high-titer antithyroid antibodies—is important in the differential diagnosis of C reutzfeldt-J akob disease and subacute confus ional s tates. P rominent among nonrheumatic inflammatory dis eas es is paraneoplas tic limbic encephalitis, an autoimmune complication of several tumors, notably small cell carcinoma of the A 60-year-old woman was admitted for confusion. S he been drinking more heavily than us ual after a forced retirement several months earlier. T he family noted that she had been forgetful and behaviorally erratic for 1 to months. S he s moked cigarettes and had hypertension. examination, s he had mild gait instability but no other phys ical s igns. T hought was disorganized, but no ps ychotic ideas were present. P s ychomotor rate and were normal. S he s howed verbal memory impairment disinhibition, with many errors of commis sion on a go tas k and inability to inhibit reflexive gaze. C S F 133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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examination revealed a mild lymphocytic pleocytos is no other abnormalities. E E G s howed intermittent slowing. T he following were negative or normal: serological studies, thyroid function and antibody tests, anti-Hu, MR I, MR A, ches t and abdominal C T (except a benign adrenal tumor), and cerebral angiogram. T he patient's family refus ed brain biops y. On a differential diagnosis of primary angiitis and paraneoplas tic encephalitis , the patient received a puls e of (IV ) methylprednisolone, without benefit, then a cours e oral cyclos phosphamide and prednis one, again without benefit. S ome months after dis charge, she died Autops y revealed pulmonary embolus to be the cause death. P erivas cular T -cell infiltrates and activated were seen in the medial temporal lobes and to a less er degree wides pread in the cortex. No tumor was found the lungs or elsewhere. Nonetheless , the pathology supported the clinical consideration of “paraneoplastic” encephalitis , which has been reported to occur in otherwis e typical form but without a dis coverable Often, extens ive evaluation is necess ary for patients suspected of inflammatory brain dis eas e; at times , extensive evaluation does not s uffice.

C onvers ion Dis order Neurops ychiatrists often see patients whose symptoms appear to arise from brain diseas e but do not. T hes e patients' conditions have been described under various names : hys teria, functional disorder, psychogenic conversion dis order, and medically unexplained symptoms. None of the designations is entirely satis factory. F or example, the DS M-IV -T R 134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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conve rs ion dis orde r is based on an outmoded notion of conversion of emotions into phys ical form. W hatever designation, such patients are not uncommon. C omplicating matters is the common coexis tence of organic disease and conversion s ymptoms . F or sizable minority of patients with pseudos eizures have epilepsy as well. B rain disease may, in s ome of these patients, have produced organic pers onality change reduction in the maturity of defens es and the too-easy res ort to s omatization. V arious techniques have been advocated for of nonorganic disease by the physical examination. have several shortcomings . F irst, they easily lend thems elves to a countertherapeutic alliance in which examiner is trying to trick the patient—not a good start the treatment, whatever the findings. S econd, they fail distinguish deliberate fals ification on the patient's that is , malingering—from convers ion dis order. T hird, most s uch findings are commonly pres ent in patients organic disease who are trying to help the examiner the diagnosis. T hat is, they may mark a patient as or s ugges tible but fail to rule out organic disease. T hus, example, reporting a difference in vibratory sensation between the two sides of the s ternum is by no means confined to patients with convers ion disorder. to this caution occur in cases in which the nonphysiological finding is precisely the phenomenon the complaint. E ven then, however, the phenomena of brain dis eas e are sufficiently odd that the examiner maintain an attitude of humility about achieving diagnostic certainty by recognizing the at a glance. Of the described “signs of hys teria,” 135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the best is Hoover's s ign. T he examiner places a hand underneath the heel of the affected leg of a supine who complains of leg weaknes s. Asked to press down the heel, the patient does not generate power with the Asked to raise the opposing leg, however, the patient produces an automatic s ynergistic downward of the affected leg. R ecent systematic findings of progress ively greater methodological s ophistication confirm the belief that experiences of abus e in childhood are common in the background of patients with conversion dis order. T his indirectly account for another progres sively more subs tantiated finding, namely, that the prognos is of conversion dis order is poor. Although a given s ymptom may wax and wane or dis appear, patients commonly a chronic course of dis ability, interpers onal difficulties , ps ychiatric symptoms, and fruitles s s eeking after help. Although hys terical symptoms have often been taken to represent s ymbolically a psychological conflict, the fundamental difficulty is that patients who make prominent use of somatization have a dis order of the symbolic function its elf. T he goal of the examiner not be to catch the patient out but to establish an that allows exploration of areas of the patient's life the presenting symptoms and cons truction of a plan to reduce dis tres s (including focused treatment of coexisting depress ive disorder) and to develop ways of seeking attention and as sistance for dis tres s.

NE UR OP S YC HIA TR IC T he neurops ychiatris t thinks anatomically about mental state disorders , even as cognitive neuroscientis ts 136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to construct a sufficiently s ophisticated model of largescale brain function to do justice to the complex mental states of neurops ychiatric interes t. T he relies on rich data gathered at the bedside and on laboratory methods of inves tigating brain s tructure and function and of P.349 diagnosing diseas e. T he effort is to identify not jus t behavioral s yndromes as found in DS M-IV -T R or IC D, the pathological proces ses underlying them in two F irst, neurops ychiatry s eeks medical diagnoses of or brain dis eases to account for the patient's illness . S econd, neurops ychiatry seeks to understand clinical phenomena in terms of the disruption of elementary mental proces ses, the nature of which is beginning to elucidated by the cognitive neuros ciences . T he res ult is highly differentiated diagnostic enterprise. With refreshment from a multidisciplinary bas e—ranging cognitive neuros cience to general medicine—the neurops ychiatric approach to the patient is certain to remain exciting.

S UG G E S TE D C R OS S S ection 1.2 provides a review of neuroanatomy. 1.15 discus ses nuclear MR I and S ection 1.16 covers radiotracer imaging. T he other s ections in this chapter in detail with neuropsychiatric aspects of various proces ses. T he s ections inC hapter 7 deal with the diagnostic process in general ps ychiatry, including the examination of the mental s tate (see S ections 7.1 and neurops ychological evaluation (s ee S ection 7.5), and 137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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laboratory tes ting (see S ection 7.8).

R E F E R E NC E S *B ogouss lavs ky J , C ummings J L, eds. B ehavior and Dis orde rs in F ocal B rain L e s ions . C ambridge: Univers ity P res s; 2000. D'E s posito M, ed. Neurological F oundations of Neuros cie nce . C ambridge, MA: MIT P ress ; 2003. Dolan R J : E motion, cognition, and behavior. 2002;298:1191. Duchaine B , C osmides L, T ooby J : E volutionary ps ychology and the brain. C urr O pin N eurobiol. 2001;11:225. Duncan J , Owen AM: C ommon regions of the frontal lobe recruited by divers e cognitive demands . T re nds N euros ci. 2000;23:475. Duus P . T opical Diagnos is in N eurology. 3rd ed. Y ork: T hieme; 1998. F riston K J , P rice C J : Dynamic repres entations and generative models of brain function. B rain R es B ull. 2001;54:275. G eschwind N: Dis connexion s yndromes in animals man. I. B rain. 1965;88:237. G eschwind N: Dis connexion s yndromes in animals 138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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man. II. B rain. 1965;88:585. G olomb M: P s ychiatric symptoms in metabolic and other genetic dis orders: Is our “organic” workup complete? Harv R e v P s ychiatry. 2002;10:242. Halligan P W , David AS : C ognitive neurops ychiatry: T owards a s cientific psychopathology. Nat R e v 2001;2:209. J ohns on MH, Halit H, G rice S J , K armiloff-S mith A: Neuroimaging of typical and atypical development: A perspective from multiple levels of analysis. Dev P s ychopathol. 2002;14:521. K opelman MD: Dis orders of memory. B rain. 2002;125:2152. Levitin DJ , Menon V , S chmitt J E , E liez S , White C D, G lover G H, K adis J , K orenberg J R , B ellugi U, R eiss Neural correlates of auditory perception in W illiams syndrome: An F MR I s tudy. Neuroimage . Liddle P F . Dis orde re d B rain and Mind: T he N eural Me ntal S ymptoms . London: G as kell; 2001. *Lis hman W A. O rganic P s ychiatry: T he C ons equences of C e re bral Dis orde rs . Oxford: S cience; 1998. Lloyd D: T erra cognita: F rom functional to the map of the mind. B rain Mind. 2000;1:93. 139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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*Mesulam MM. B ehavioral neuroanatomy: Largenetworks , as sociation cortex, frontal syndromes, the limbic s ys tem, and hemispheric s pecializations. In: Mesulam MM, ed. P rinciple s of B e havioral and Neurology. London: Oxford University P ress ; 2000. Mesulam MM: F rom s ensation to cognition. B rain. 1998;121:1013. Middleton F A, S trick P L: B asal ganglia and loops : motor and cognitive circuits. B rain R es B rain R ev. 2000;31:236. Miller MB , V an Horn J D, Wolford G L, Handy T C , V alsangkar-S myth M, Inati S , G rafton S , G azzaniga E xtens ive individual differences in brain activations as sociated with epis odic retrieval are reliable over J C ogn Ne uros ci. 2002;14:1200. *Ovsiew F . B eds ide neurops ychiatry: E liciting the phenomena of neurops ychiatric illnes s. In: Y udofsky Hales R E , eds . Ame rican P s ychiatric P ublis hing of Ne urops ychiatry and C linical Ne uros cie nces . Was hington, DC : American P sychiatric P ublis hing; Ovs iew F : S eeking revers ibility and treatability in dementia. S emin C lin Ne urops ychiatry. 2003;8:3. Ovs iew F , B ylsma F W : T he three cognitive S emin C lin Ne urops ychiatry. 2002;7:54. Ovs iew F , J obe T . Neuropsychiatry in the his tory of 140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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mental health s ervices. In: Ovs iew F , ed. and Me ntal H ealth S e rvices . W ashington, DC : P sychiatric P ress ; 1999. P aterson S J , B rown J H, G sodl MK , J ohns on MH, K armiloff-S mith A: C ognitive modularity and genetic disorders . S cience . 1999;286:2355. S chmahmann J D, S herman J C : T he cerebellar affective syndrome. B rain. 1998;121:561. *S hallice T . F rom Ne urops ychology to Mental C ambridge: C ambridge Univers ity P res s; 1988. S ilver J M, McAllister T W : F orensic iss ues in the neurops ychiatric evaluation of the patient with mild traumatic brain injury. J Ne urops ychiatry C lin 1997;9:102. S tone V E , C osmides L, T ooby J , K roll N, K night R T : S elective impairment of reas oning about social exchange in a patient with bilateral limbic s ys tem damage. P roc Natl Acad S ci U S A . 2002;99:11531. S ugiyama LS , T ooby J , C osmides L: C ros s-cultural evidence of cognitive adaptations for social among the S hiwiar of E cuadorian Amazonia. P roc Acad S ci U S A. 2002;99:11537.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 3 - C ontributions of the P s ychological S ciences > 3.1: S ens atio P erception, and C ognition

3.1: S ens ation, Perc eption, and C ognition Louis J . C ozolino Ph.D. Daniel J . S iegel M.D. P art of "3 - C ontributions of the P sychological S ens ation, pe rce ption, and cognition refer to three broadening tiers of human information proces sing. S ens ation is us ually defined as the immediate res ult of stimulation of s ens ory neurons , whereas pe rce ption involves the organization and evaluation of thes e sens ations to obtain information about the inner or environments . C ognition refers to a set of vas tly proces ses, such as language, problem solving, and thinking, that apply plans and strategies to s ens ations perceptions. Although dis tinguis hing between perception, and cognition has a long history, the and value of s eparating them are increasingly unclear light of growing knowledge of nervous system functioning. Most information proces sing depends on the brain. B ecaus e the brain is built and maintained through the interaction of biological, psychological, and s ocial the study of s ens ation, perception, and cognition is neces sarily broad and far reaching. T he rapid increase knowledge of neuroanatomy and the development of 142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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hypothetical models to unders tand its functioning this an exciting time in the cognitive s ciences . T his reflects the juxtapos ition of many new and old models , containing much of the excitement and uncertainty that emerge as res earchers strive to understand how perceive and understand the world.

C OG NITIVE S C IE NC E T he fields relevant to this overview are a part of the interdisciplinary s tudies of cognitive science, which includes cognitive ps ychology, developmental ps ychology, ps ycholinguis tics, computational science, the emerging field of interpers onal neurobiology. E ach these dis ciplines provides an important and unique perspective on the human ps yche. B iological, ps ychodynamic, and s ocial ps ychiatry find a common home within cognitive s cience in which the usual of nature versus nurture and biology vers us ps ychology disappear in an examination of the building of the brain and the origins of mental proces ses. In recent years , discoveries in the neuros ciences have revealed a wide range of findings relevant to One of the major dis coveries was that the brain's and function are a res ult of the transaction of s everal factors , including genetic, physiological, and variables . In particular, brain development requires forms of experience to foster the growth of neural involved in a wide array of mental proces ses, including attention, memory, emotion, attachment, and selfreflection. T hus, experiences shape the unfolding of genetically programmed development of the central nervous s ys tem (C NS ). G enes function as a template 143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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information and as a mediator of trans cription of the proteins that determine neural structure. E xperience directly shapes the selection and timing of how the of genes influences the structure of the brain. T he human brain, especially the cerebral cortex, is immature at birth. T his immaturity requires that the brain use the caregiver's brain to grow and to organize. F indings from developmental neuros cience point to the centrality of interpers onal relations hips in the development of the brain. T he cooperative communication of infant–caregiver attachments is thought to provide the infras tructure not only for emotional development, but als o for abstract reasoning and cognitive abilities. T he patterns of interaction child and caregiver have a direct impact on the way the brain develops and the mind of the child functions. T hus, cognitive proces ses need to be considered as way in which the mind emerges from within the genetic, phys iological, and experiential factors that shape the development and maintenance of mental function.

Hot and C old C ognition T raditionally, cognition was studied by experimental ps ychologists in university laboratories, whereas were explored by ps ychoanalys ts in cons ulting rooms. C ognitive psychologis ts, striving to avoid the subjective and imprecis e nature of emotions, devised flowcharts algorithms s imilar to thos e us ed to describe proces ses within organizations or, later, in programming Input was calibrated, output was measured, and were generated des cribing what happened within the “black box” of the brain. T he increasing complexity of 144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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these models did not s eem to improve their power, and words s uch as motivation and emotion invariably aris e. As knowledge of brain functioning has increased, it is becoming increasingly clear that neural networks in sensation, perception, and cognition are inextricably interwoven with other networks process ing survival emotion, motivation, and s omatic states . T he myth of cognition, that is, cognitive proces ses devoid of influence, is gradually fading. F low charts and other diagrams depicting linear input-output proces ses are being replaced with more s ophisticated models to the complex neural s ys tems that psychologists are attempting to des cribe. Not all cognition is “hot,” such traumatic memories or scanning the environment for dangerous or s exually attractive others . S ome may be cool, such as adding rows of figures or checkbook. T hese s ame tasks, for s omeone with math anxiety, during an P.513 examination, or before an Internal R evenue S ervice may become warm or even hot. T he fundamental principle, however, is that s ens ation, perception, and cognition occur in the context of feed-forward and feedback networks , interwoven with and guided by complex (and largely uncons cious) emotional determinants.

E motion What is an emotion? T he answer to this question is as complex as the mind its elf. Although the lack of clear 145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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definitions and good animal models has hindered empirical res earch, it is clear that emotions play a role in perceptual and cognitive proces ses. One view considers emotion as a primary value s ys tem the brain, allowing activations to be s electively F or example, emotionally charged experiences may be more readily recalled than uneventful ones . According this view, the mos t fundamental aspect of emotion is arousal-appraisal s ys tem in which the brain responds given stimulus with the signal of “this is important— note and pay attention now!” E motion thus gives value a repres entation by arousing attentional mechanisms by focus ing a s potlight of attention on the s timulus. T he second s tage would then appraise the meaning of s uch emotional arousal by as sess ing its hedonic tone: “Is good or is this bad? S hould this be approached or avoided? ” E motion thus directs the flow of energy—the activations within s pecific circuits of the brain—as the arousal-appraisal system focuses cognitive process es elements of the internal and external environment. A level of emotional process ing is the elaboration of this appraisal into a more specific form, called a categorical emotion, s uch as joy, interest, surpris e, fear, anger, or s hame. T hes e categorical emotions have universal expres sions of affect found in all cultures, which may distinct ps ychophysiological manifes tations . An additional view examines the way in which the in the body's state are repres ented in the brain in the of what Antonio Damas io has called a s omatic marke r. According to this view, the energizing or deenergizing bodily responses let the brain know how the individual feels about an experience. S uch a s omatic marker can 146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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be us ed in future emotional ass es sments , or gut to an experience. A part of the brain called the orbitofrontal corte x has implicated as the s ite of s omatic marker proces sing or what is called intuition. Allan S chore has als o noted the importance of early experiences with caregivers in the maturation of this region and als o its central role in coordinating self-regulatory functions early in development with bas ic emotional reactions and s ocial functioning. T he orbitofrontal cortex has been not only in monitoring, but also in regulating bodily and may pos sibly be involved in psychiatric ranging from autis m to mood dis orders. Disorders in organization and social functioning may be better unders tood by examining the central role of emotion perhaps , the orbitofrontal cortex and related regions in development and maintenance of dysfunctional mental states . S tudies also sugges t that this region is for the capacity for s elf-knowledge and the s ubjective experience enabling the mind to reflect on the s elf in past, pres ent, and the potential future. Inborn and experiential factors may play important roles in allowing this region to develop the capacity to integrate a wide range of important functions of the mind, including the appraisal of meaning, emotional regulation, social cognition, and autobiographical consciousness .

NE UR A L NE TWOR K G R OWTH INTE G R A TION T he growth and s elective connectivity of neurons is the basic mechanism of all learning and adaptation. can be reflected in neural changes in a number of 147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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including (1) the growth of new neurons , (2) the of existing neurons, and (3) the changes in the between exis ting neurons . All of thes e changes are expres sions of plas ticity, or the ability of the nervous system to change. T he birth of new neurons , or neurogenes is , is a controversial field of study. S ome res earch s ugges ts that new neurons are generated in different areas of primate and human brains, es pecially regions involved with new learning, s uch as the hippocampus , the amygdala, and the frontal and lobes . E xisting neurons grow through the expansion and branching of the dendrites they project to other T here is now sufficient evidence for the fact that demonstrate growth and changes in reaction to new experiences and learning. Although neurons to form neural networks, neural networks , in turn, integrate with one another to perform increas ingly complex tas ks . T he brain is modular, that is , different networks have evolved to perform divers e tasks. networks converge and coordinate to perform higher level tas ks . F or example, networks that in language, emotion, and memory interact and for humans to recall and to tell an emotionally story with the proper affect, correct details , and appropriate words . Ass ociation areas within the brain serve the role of bridging, coordinating, and directing the multiple neural circuits to which they are connected. E xecutive within ass ociation areas , like a s witchboard operator, the capability to interconnect different neural networks. Although the actual mechanisms of this integration are 148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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not yet known, they are likely to include some combination of changes in (1) the biochemical within neurons, (2) the s ynaptic connections between neurons , (3) the relations hips between local neuronal circuits , and (4) the interactions between functional systems . C hanges in the synchrony of activation of multiple neural networks may also play a role in the coordination of their activity. If everything humans experience is repres ented within neural networks, then psychopathology of all kinds, the mildest neurotic symptoms to the mos t s evere ps ychos is , must be repres ented within and between neural networks. Healthy functioning requires proper development and functioning of neural networks organizing cons cious awarenes s, behavior, emotion, sens ation. P s ychopathology correlates with the suboptimal integration and coordination of neural networks . P atterns of dys regulation of brain activation specific disorders support the theory of a brain-based explanation for the s ymptoms of psychopathology. In general, ps ychological integration sugges ts that the cognitive functions of the executive brain have access to information across networks of sensation, behavior, and emotion. Dis sociation among these proces ses can occur when biochemical changes high levels of s tres s inhibit or disrupt the brain's integrative abilities. P hys ical trauma, disease genetic predispositions that disrupt the development functioning of neural networks can all result in neural dysregulation and ps ychiatric s ymptomatology. Applying this model to treatment, ps ychotherapy, ps ychopharmacology, and psychosurgery can be s een 149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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ways of creating or res toring integration and between various neural networks . F or example, has demonstrated that success ful ps ychotherapy correlates with changes in activation in areas of the hypothes ized to be involved in disorders , s uch as obses sive-compuls ive disorder (OC D) and depress ion. return to normal levels of activation res ults in reestablishing positive reciprocal control between neural structures and networks.

MIND A ND B R A IN A generally accepted view of the mind is that it from a portion of the activity of the brain. W hat is this activity of the brain, P.514 and how does it give rise to s uch mental process es as perception and cognition? How do the human of s ens ation, thought, emotion, attention, selfand memory emerge from neural proces ses? T he brain is compos ed of approximately 10 to 20 billion neurons . An average neuron is connected to approximately 10,000 other neurons at s ynaptic With hundreds of trillions of connections within and among thousands of web-like neural networks, there countles s combinations of poss ible activation profiles . term ne ural net profile is us ed to describe a certain of activation of the complex layers of neural circuits . neural net profile is the fundamental way in which proces ses are created. T hes e activations can lead to neural proces ses in a cas cade of dynamic interactions produce a range of internal events and external 150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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T he es sential components of the mind come directly how these neural events create the flow of energy and information.

E NE R G Y A ND INF OR MA TION T he mind is a proces sor of patterns in the flow of and information within the brain (T able 3.1-1). of individual neurons , groups of neurons, circuits, or networks of neurons all involve the flow of energy the complex system of the brain. T his energy reflects flow of ions acros s membranes, the consumption of oxygen and nutrients by neural cells, and the active transport of molecules into and out of nervous tis sue. However, the mind is much more than s ome outcome energy flow—the function and purpose of this flow of energy are to process information.

Table 3.1-1 B as ic Ideas of the T he mind is a proces sor of energy and E nergy is contained within the activations of circuits . Information is contained within the patterns of activation, termed a ne ural net profile or me ntal re pre s e ntation.

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T hese representations serve as symbols that further effects in the mind, leading to the of information.

Information is created within the brain by a proces s of representation. F or example, when an individual s ees E iffel T ower, the brain res ponds in particular regions of visual s ys tem with the activation of a neural net profile. When the E iffel T ower is recalled at a later time, the cortex activates a similar neural net pattern, and the T ower is visualized. T he activation of a particular neural firing thus contains within it information about something (the E iffel T ower). E xamples of forms include perceptual, s ens ory, linguistic, and more abstract repres entations of concepts and categories.

INF OR MA TION P R OC E S S ING S everal elements of the brain's function as an proces sor can be des cribed (F ig. 3.1-1). At the mos t level (F ig. 3.1-1A), energy leads to neural respons es. energy can be in the external form of light on the retina sound waves vibrating the tympanic membrane. It may also take an internal form in which the flow of energy within neural activations thems elves produces neural res ponses.

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FIGUR E 3.1-1 Information-proces sing models. A s econd level of unders tanding information (F ig. 3.1-1B ) is in the idea that an input (internal or external) leads to a repres entational respons e (a profile of activation), which, in turn, produces a downstream effect or output. T his output can be such as the generation of other repres entations, or external, in the form of observable behavior. proces sing becomes even more complex when the thems elves carry information. W ithin cognitive ps ychology, these information-proces sing events can seen as the contrasting, comparing, generalizing, chunking, clus tering, differentiating, and extracting proces ses that lead to interwoven sets of increasingly complex mental repres entations. A third level of viewing information process ing in the (F ig. 3.1-1C ) is the conceptualization of forms of perception, attention, and memory. According to this external energy is s ens ed by the peripheral nervous system and is registered as s ens ation within the brain. 153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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selective process ing of aspects of thes e s ensations , filtering, leads to the production of perception. T hes e perceptions are thems elves s ubject to further filtering in which only a s elect few are placed within working memory. T his is sometimes called the “chalkboard of mind.” It is within working memory that representations can be cons cious ly manipulated, contrasted, clustered, and reass embled. T hus, cons cious nes s may be related to this as pect of mental functioning. S ens ation refers to the initial s tages of the basic information-proces sing model (F ig. 3.1-1). In traditional experimental paradigms , sens ory memory is conceptualized as las ting for approximately 0.25 Items in sensory memory are then filtered into working short-term memory, where they last for approximately minutes. W hen humans attempt to cons cious ly learn information, working memory is able to handle approximately s even items, unless further process ing creates linkages to other items within longer-term memory. R ehears al allows thes e repres entations to for longer periods of time. C ognitive process es that can group bits of information into large chunks (chunking) increase the capacity of working memory by making unit more information rich. R epresentations are then proces sed and placed within long-term memory from which they can be retrieved for future us e.

A TTE NTION Attention is the proces s that controls the focus and flow information process ing. T hereare many aspects to attention that may derive from P.515 154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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their neuroanatomical localization. T hree components attention (s electivity, capacity, and sustained concentration) have traditionally been us ed to describe cognitive deficits in psychiatric disorders such as schizophrenia and attention-deficit/hyperactivity (ADHD). All aspects of attention in normal and patient populations are influenced by the emotional or motivational value of the s timulus. E arly conceptualizations of attention were based on Donald B roadbent's idea of a filter that s elects a limited amount of incoming stimuli to be further proces sed. Limited capacity of attention was thus attributable to inability to proces s the overwhelming amount of stimuli. An attention bottleneck was des cribed as occurring early in the sens ory process (automatic) or the perceptual proces sing s tage (identification and clas sification).

S elec tive Attention One aspect of attention is that it focuses a spotlight on external s timuli or internal mental representations. In B roadbent's conceptualization, selectivity has three dimens ions: (1) filtering, focusing specific attributes (e.g., large s quares vs . s mall categorizing, based on stimulus class (e.g., attending letters in whatever script they are written); and (3) pigeonholing, reducing perceptual information needed place a stimulus into a s pecified category (e.g., using long hair to clas sify individuals as female). E ach of as pects of attention acts on incoming s timuli to make a determination of fit for the sought-after characteristic. 155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S chizophrenic patients, for example, s how greater difficulty with pigeonholing than with filtering when they are symptomatic. Another conceptualization of selective attention distinguishes between two interactive ways of sens ory input. P reattentive proce s s ing (a parallel as sess es global, holistic patterns and appears to be an early component of the perceptual process . F ocal (a s erial process ) follows preattentive process ing and involves a detailed analysis of stimuli characteristics . attention can be directed at one s timulus form only and thus limited in its capacity. In contras t, parallel (preattentive) attention process es do not appear to limited capacity and can detect ges talt as pects of environmental s timuli from numerous sources . T he to hear one's name called out by a nonattended voice crowded, noisy room is an example of an ongoing proces s with the ability to detect gestalt features and extremely familiar (and thus automatically process ed) stimuli.

Attention C apac ity T he concept of proces sing capacity involves the idea given task makes a demand on a limited pool of A task with a high process ing load draws more from the finite pool than does a task with a low load, thus inhibiting the access ibility of resources for simultaneous functions drawing from the same pool. attention requires cognitive effort and thus has a high– proces sing load demand. C ognitive models describing several resource pools sugges t an executive process distributes res ources to various cognitive functions. 156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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proces ses that demand process ing capacity inhibit the simultaneous action of other s erial high-load contrast, parallel proces ses have low or no process ing capacity demands and can function simultaneous ly numerous other functions without inhibiting them. Optimal performance is attained with moderate levels arousal that allow for the es tablis hment of task goals feedback from the performance of the tas k, leading to appropriate res ource allocation. Low levels of arous al impair those proces ses and lead to inadequate allocation. High levels of arousal may be detrimental to performance because of poor dis crimination of stimuli diminis hed efficiency of allocation, resulting in poor attention functioning.

S us tained Attention T he ability to sustain attention is called vigilance and be tes ted with task demands for alertness and concentration over a period of a few minutes to an T he tes ts usually involve detection requirements for stimuli that occur infrequently at random intervals . An example of s uch a test is the C ontinuous P erformance which has been us ed to s tudy various psychiatric disorders . Important aspects of the tests are derived signal detection theory and include the factors of sens itivity and res ponse criterion. S ensitivity is the distinguishing of target s timuli from nontarget s timuli. res ponse criterion is the amount of perceptual required to support the decision regarding a target item versus a nontarget item.

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T he es sential feature of information process ing in the is that the patterns of activation of neural circuits (the neural net profile) contain information. T hese mental representations, in turn, produce further neural events . T he location and pattern of neural activations the nature of what the neural net profile repres ents. F or example, activity in the optic nerve in response to light leads to a cascade of neural res ponses within the cortex generating a visual s ensation. F uture activation those layers in the visual cortex in that general pattern the experience or recollection of the vis ual image. and localization determine the kind of repres entation the information that it specifically contains .

S E NS A TION A ND P E R C E P TION F orms of repres entations include sens ory and ones that derive from input from the external world via peripheral sensory nervous s ys tem. T he initial s tage of encoding a vis ual representation is called an iconic and is held within sensory memory for a brief period. F eatures of the initial stimulus , s uch as its s ize, and color, are the information held within this sens ory representation. S ens ory repres entations are the least proces sed of mental representations and are thought be as close as the brain can get to representing the as it is. T his is a form of proces sing termed bottom-up proce s s ing and is in contrast to more elaborately representations that are directly influenced by more abstract aspects of prior experience, called top-down proce s s ing. As the initial s ens ory activations are (clas sified, compared, and linked to repres entations prior experience) they become influenced by higherproces ses and become organized as perceptual 158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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representations. Attentional proces ses at the level of s ens ory memory on the initial image with higher cognitive functions , as clas sifications and chunking. In their es sence, these down proces ses compare, contras t, and transform the initial repres entation to create new perceptual images within working memory. S tudies of patients with schizophrenia reveal s pecific deficits at this early stage perceptual proces sing. P erception is created by the top-down transformations sens ory images but does not neces sarily involve the experience of consciousness . T his has important implications in that patients may be influenced by and s timuli that they cannot cons cious ly recall. cons cious, focal attention is involved in perception, the representations are proces sed differently. T he involvement of focal attention appears to be necess ary the activation of the hippocampus in memory which allows for the encoding of explicit, consciously access ible, autobiographical memory. P os ttraumatic diss ociative s tates may involve the blockage of focal proces sing P.516 of perceptual repres entations , thereby leading to a disconnection among cons cious and nonconscious elements of experience. Imagery involves the activation of brain circuits res ponsible for perceptual proces sing. R epres entations (neural net profile activation patterns ) can thus be by external or internal means . Mental imagery can 159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the generation, ins pection, retention, and of perceptual images . T his proces sing involves s imilar effort and timing as when the object is perceived from external s ource. T hus , complex visual images require effort and time to rotate in internal and external reality. T he ability of the mind to generate mental images is in various forms of psychotherapy and may also be an important mechanis m in the pathological production of hallucinations and illus ions seen in several disorders .

ME MOR Y S YS TE MS T he neural networks of the brain are capable of res ponding to experience by the activation of particular patterns of dis tributed activation. Donald Hebb a bas ic principle of memory that has been repeatedly supported by research: “Neurons that fire together, together.” Neurons that are activated in a particular pattern at one time tend to fire together in a s imilar pattern in the future—this is the ess ence of memory. T he brain has various forms of circuits res ponsible for different s ys tems of memory (T able 3.1-2). T he form of memory mos t commonly thought of as me mory is explicit or de clarative memory. T his form involves the cons cious sensation of s omething being recalled at the time of retrieval and allows for the awarenes s of the autobiographical or factual knowledge to be s hared, verbally, with others and the s elf. T his explicit memory system requires the involvement of focal attention and activation of the hippocampus for encoding and Items focally attended to are placed in working proces sed further, and then placed in long-term After a period of weeks to months , items are thought to 160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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undergo a process called cortical cons olidation that them in permanent memory, where their retrieval no longer requires the hippocampus . C ortical helps to explain the phenomenon of retrograde after head trauma.

Table 3.1-2 Memory S ys tems Implicit    A behavioral, emotional, and perceptual form of memory devoid of the subjective internal of recalling of s elf, or of pas t. C an include mental models that are s ummations of representations from numerous experiences .    Also known as early, procedural, me mory. C annot be express ed in words.    P resent from birth. Does not involve the hippocampus or require focal, cons cious P robably involves various circuits, including those the bas al ganglia, limbic s ys tem (amygdala, cingulate, and orbitofrontal cortex), and cortices . E xplicit

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   A form of memory requiring cons cious and involving the s ubjective sense of recollection and, if autobiographical, of s elf and pas t.    Also known as late , epis odic or s e mantic, or de clarative memory. C an be express ed in words drawings .    T he autobiographical component of explicit memory does not fully develop until pas t the firs t years of life, as the hippocampus and cortex on which it depends are maturing.

B efore explicit autobiographical memory process ing becomes available after the first years of life (during time the hippocampus and cerebral cortex are form of memory called implicit or nonde clarative already in place and remains active throughout the life span. Implicit memory involves a wide range of including behavioral, emotional, and perceptual When these circuits are activated in retrieval, they do include the cons cious s ens ation of something being recalled. F or example, when riding a bicycle, a pers on not recall having learned to ride and may not even feel that anything is being recalled. S imilarly, a pers on with fear of dogs may be unable to explicitly recall any event that may explain s uch an emotional T he exis tence of intact implicit recollection in the of explicit memory is found in various conditions , 162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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including s urgical anes thes ia; the advers e effects of benzodiazepines; neurological conditions, such as K ors akoff's syndrome and bilateral hippocampal and childhood amnesia. S uch diss ociation may also in res pons e to trauma. T hus, patients with stress disorder (P T S D) may have an inability to recall a traumatic event and yet may avoid contextual stimuli similar to the initial trauma, may evidence s tartle res ponse and anxiety, and may have intrus ive images for the event. T hese latter symptoms may the cons cious awarenes s of implicit memory retrieval lacks the s ubjective s ens ation that s omething is being recalled.

C ONS C IOUS NE S S T he vast majority of mental proces ses are outside of cons cious awarenes s. C ons cious awarenes s is a as pect of some cognitive process es. In general, many authors ' views converge on the idea that there exis t fundamental forms of consciousness : a he re -and-now a pas t-pre s e nt-future form of awarenes s. T hes e two proces ses are likely mediated via the integration of different neural circuits in the brain. T wo hypotheses focus on the way in which representational process es are linked or bound during the flow of informational transformations within the mind. One hypothes is sugges ts that a 60-cycle-persecond s weeping process extends from the thalamus the neocortex. T his s weep may s erve to bind representational process es together in the internal experience of consciousness . P roces ses that are the time of the sweep thus become linked within 163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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cons ciousnes s. Another view implicates the role of the lateral prefrontal cortex and its role in working memory. Working memory s erves as the chalkboard of the mind, and representational process es that become linked to activity in this region are then a part of the attentional spotlight of conscious awarenes s. B as ed on a biological as sess ment of brain function, E delman's theory describes two forms of that derive from the res onant interactions between of neurons . In his model, primary cons cious nes s s tems from the interaction between perceptual and conceptual categorizations. T his form of cons ciousnes s, called the re membere d pre s e nt, is also found in higher animals and is unable to trans cend momentary awarenes s. It is embedded in the pres ent is influenced by categorizations from the past. In beings , the capacity for lexical or language proces sing enables a secondary or higher-order cons cious nes s to and s tems from the resonance between thos e and conceptual categories. Higher-order frees inner experience from the prison of the present allows for views of the pas t and plans for the future. Included in these forms of consciousness is a scene of present s ituation in which the s elf is placed in a temporospatial context. C ortically blind patients state that they cannot see stimuli, but they res pond behaviorally as if they were sighted. T hey describe being unaware of vis ual but they make eye and P.517 hand movements that reflect the proces sing of 164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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information about stimulus location, shape, orientation, and direction of motion. In information-proces sing behavioral tests reveal that blind-sighted patients do sens e and perceive visual s timuli but do not have cons cious awareness of the perceptual process , an example of a dis sociation of the normally as sociated proces ses of perception and consciousness or of phenomena. Misidentification syndromes are other examples of subjective, cons cious experience disturbances . In prosopagnosia, patients are unable to cons cious ly memories regarding persons familiar to them. C apgras syndrome patients are able to recognize a familiar face but feel that it is not really that person. B eing as in recognition, is one as pect of cons cious nes s as a cognitive process . T he pathological uncertainty of with OC D theoretically can be viewed as a disturbance that as pect of cons cious functioning. C ons cious nes s provides a sense of continuity. Many ps ychiatric patients experience a profound s ense of discontinuity and confusion that may be related to a dysfunction in the s ense-making, continuity-creating proces s of cons cious nes s. S ome ps ychiatric including derealization and depers onalization, may be unders tood in terms of alterations in conscious functioning (as s een in some patients with mood dis orders, anxiety dis orders, dis sociative P T S D, and s ome personality disorders ), distorted body image (as in eating dis orders or mood disorders ), memories and flashback phenomena (as in P T S D), hallucinations (as in ps ychotic s tates). 165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Mental Models and S c hemata S tudies of perception and memory support the view the mind has organizational s tructures that influence interpretation of s ens ory data, s hape the encoding of information into long-term memory, bias the retrieval of items stored in memory, and help determine the behavioral res ponse. T hose organizing cognitive are called me ntal mode ls or s che mata. Mental models are unconscious, highly organized, structural process es derived from pas t experiences guide in interpreting present s timuli and influence the direction of behavior. Mental models exis t for various situations. W hen a s ituation activates a given mental model, that model, in turn, guides s ubs equent proces sing and behavior. T he adaptational value of a mental model depends on an accurate reading of the survival demands of the s ituation. T he downside of models is s een when their unconscious and automatic activation occurs in s ituations in which they are inappropriate. Aaron B eck's theory of depress ion is on the idea that mental models or s chemata can depres sive thinking and depres sed moods . J ohn us ed the concept of internal working models to the development of early forms of s chemata for attachment relations hips. Difficulties in intimate relations hips and related behavioral dysregulation can seen as derivatives of models of inadequate early attachment and the presence of multiple, conflictual models. T he inner obje cts of ps ychodynamic theory are examples of mental models. Mardi Horowitz's view of certain personality dis orders and maladaptive interpersonal behavior also includes the role of mental 166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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models or pers on schemata. S ome ps ychiatric s igns symptoms can be s een as derivatives of conflicted schemata and s ituations. C lass ic des criptions of interpersonal patterns in some patients with pers onality disorders , such as idealization and devaluation, can be seen as maladaptive s chema functions .

Thought, L anguage, and C ognition T here is no universally accepted definition of thought. S ugges ted bas ic elements include propos itions containing meaning), images, and lexical and s emantic symbols . C ognitive proces ses can be carried out in simultaneously, and without cons cious nes s. C ognitive proces ses, such as thoughts, are often directly known through translation into cons cious nes s and language. in the study of mental models, clinical obs ervation and experimental paradigms can infer the nature of thought proces ses only through indirect meas ures . T hese are important in defining the term thought dis orde r. T hinking involves the mental representation of s ome as pect of the world or of the s elf and the manipulation those representations . T hinking depends on explicit implicit memory of prior experiences . In addition, proces ses are influenced by a pers on's emotional mental models, and other uncons cious determinants. basic components of the cons cious components of thinking include categorization, judgment, decision making, and general problem s olving. T he as signment representations of events or objects to categories is important to s ubs equent thought process ing, because thoughts can act on the general clas s to which an item belongs rather than on individual repres entations; this 167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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another example of top-down proces sing influences. R ational thought contributes to the ability to judge the probability of uncertain events and the decis ion to among various options. T hes e process es contribute to problem s olving in which data are as sess ed, class ified, transformed, and compared on the bas is of logical produce a choice that s olves a problem. F ailures in steps can res ult in limitations and distortions in normal thought proces ses. P s ycholinguis tics focus es on the cognitive process of language formation and s emantic analysis. C ognitive science has traditionally viewed language as a dominant influence on s ubjective experience. It is the medium that dominates human communication and is one of the major features distinguishing Homo s apie ns from other species. shapes the ways in which the world is perceived, the manner in which desires are communicated and and the way in which society responds.

Modes of Proc es s ing and L aterality T he mind is capable of dis tinct modes of proces sing mental repres entations. A serial mode us es sequential proces sing in a linear fashion, which is said to be slow energy-cons uming, becaus e only a few items can be proces sed s erially at a time. F ocal, conscious attention believed to occur in s erial fashion. A parallel mode the simultaneous manipulation of large numbers of representations in a nonlinear fas hion. P attern is an example of s uch a rapid, low-energy consuming proces s that can deal with a wide array of s timuli at the same time. Another dis tinction in contras ting modes of proces sing 168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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has been identified in the type of mental proces ses primarily attributed to the right or left cerebral hemis phere. S tudies drawing on the findings in patients whos e corpus callosum has been surgically severed, have unilateral neurological lesions , or in s ubjects undergoing brain-imaging protocols have found a remarkable cons istency in trends of left-hemis phere functioning vers us right-hemis phere functioning. S ome general principles from this array of studies s uggest many proces ses involve both hemis pheres ; however, are distinct patterns primarily originating from each side the brain. T he following generalizations relate to right-handed individuals and to most left-handed people as well. In right hemisphere are fast-acting, parallel, holistic proces ses, including vis uospatial perception. T he right specializes in repres entations, s uch as images and sens ations, and the nonverbal meaning of words, sometimes referred to as analogic re pres e ntations . T he right hemisphere is thought to work as a pattern recognition center, capable of as sess ing the ges talt context of a s cene and providing a s ynthetic interpretation. P.518 On the left s ide are primarily more slowly acting, linear, time-dependent, serial proces ses . Left-hemis pheric proces ses manipulate the verbal meaning of words in a logical analytical mode of process ing. A generalization from a number of s tudies is that the right hemisphere tends to note the patterns in the world and creates contextual meaning; the left hemis phere can only make 169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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rationalization of the details of what it perceives to sens e of meaning from a logical view that lacks context and thus may actually seem like a dis continuous and irrational set of data. T he proces sing of emotion also appears to have a lateralized distribution. T he expres sion of emotion to be mediated primarily by the right hemisphere. recognition of the affective expres sion of others als o appears to be a specialty of the right hemisphere. Of is that the right hemisphere appears to have a more integrated repres entation of the body's s tatus, that may be ess ential for individuals to know how they feel. J erome B runer has described the distinction between earlier mode of thought, called narrative cognition, the later mode, called s cie ntific, logical, or paradigmatic cognition. Narrative thinking is a context-dependent of proces sing that incorporates the internal the teller and the perceived expectations of the lis tener the production of a story. S tories als o involve the subjective experiences of the characters involved in the unfolding sequence of events . Logicos cientific paradigmatic proces sing is s aid to occur in a contextindependent manner that focus es on abs tract concepts and their logical, caus e-and-effect relationships . develop narrative thinking by 2 years of age, and the cons truction of s tories between parent and child is a primary mode of communication in all cultures throughout the world.

Metac ognition and S elf-R eflec tive C apac ity 170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Metacognition concerns cons cious proces ses that act cognitive process es—thinking about thinking. of cognition appears to develop by approximately 6 of age; this knowledge takes various forms , including is known as the appearance -re ality dis tinction (things not be as they appear). T wo components of this are repres entational diversity (the s ame object may to be different to different people) and repres entational change (thoughts today are different from those of yesterday and may be different again tomorrow). T his of knowledge about the pers on-specific meaning of cognitive repres entation requires s ome s ens e of the person's awarenes s of the s eparateness of minds, a theoretical domain in developmental cognitive ps ychology called the the ory of mind. T he regulation of cognition, als o called me tacognitive monitoring, includes s uch proces ses as planning monitoring activities, and checking outcomes . Metacognitive monitoring may involve the ass ess ment thinking sequences for fallacious logic, factual errors , contradictions in the content of speech. P eter F onagy colleagues explored the development of reflective function, or an internal obs e rve r of mental life. P arents teach children how to be self-reflective by including own internal state in interactions and by encouraging children to s hare their own. C hildren who have been taught to tell s tories that include mental s tates demonstrate a greater frequency of s ecure attachment. B eing able to unders tand and to consider the mental states of s elf and others has als o been s hown to dependency on defensive s trategies. R es earch that what is created in parent–child narratives about 171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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experience is not just a s tory. E mbedded within the storytelling is the s election of information to be how it is process ed and understood, and if it is or has multiple s ubjective centers (empathic capacity).

S oc ial C ognition B ridging the fields of social ps ychology and cognitive ps ychology, the s tudy of social cognition focus es on mental proces ses involved in s ocial interactions . T he domains include the s tudy of empathy, interpersonal communication (verbal and nonverbal), pers on perception, relations hip scripts , and group process es . Other related areas include s tudies of attribution bias , memory for social interactions , s tereotyping, mental control of social cognitive process es, and cognitive of a s ens e of self. S ocial cognition can be s een as a of social ps ychology that us es information-proces sing theory to as sess the components of attention, encoding, memory, retrieval, and s chemata. A theme in social cognition res earch has been that topdown, theory-driven proces sing influences of social s ituations and actions in s uch s ituations. Developmental ps ychologis ts have focused on the of social cognitive functioning and its deviations. F or example, children with autistic disorder have significant deficits in empathic capacity and in the ability to social cues . S ocial cognitive deficits may be present in different domains in other ps ychiatric dis orders.

Dis c ours e and Narrative Dis course is communication from one pers on to is thought to involve a sense of intention or plan. 172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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discours e follows a set of rules that ens ures the and effectivenes s of communication: W hat is intended be stated by the s ender is unders tood by the listener or receiver. S ome researchers support the idea that is a cognitive function that follows the basic principles information process ing, including a s chema for communication, and of social cognition, s uch as taking into account the listener's pers pective. Incoherent discours e can be noted by analyzing unlicens ed of the primary maxims of discours e. Another technique that of dis course analysis , which examines the ways in which dis course deviates from an as sumed discours e T he exact method to quantify abnormalities in remains controversial, but clinical impres sions of incoherence remain important for ass ess ing deficits in social communication. T he deficits may res ult from behavior, inherent cognitive abnormalities in thought or language, or deviations in s ocial cognitive functioning. Deviations from normal discours e can be a general in need of further as sess ment. Abnormal discours e is clinically evident in ps ychos is , s pecifically in Narrative is a broad domain ranging from the literary of fiction to the developmental psychology of the origin of autobiographical accounts . F rom a cognitive point of view, narrative is important in unders tanding the relations of language, memory, cons ciousnes s, mental models, self-schemata, and cognition. Narrative can be generally defined as the which a person creates a verbal account of a s equence events in the world and the internal s ubjective of the characters of the s tory. Autobiographical narrative begins early in life as the 173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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capacity for language develops. S tudies of early monologues find that young children interpret and meaning to events in their world from an early age. Narrative helps record and make s ens e of the pas t, interpret the present, and anticipate the future. T he has been called an “anticipation machine,” and mental models, pros pective memory, and narrative are the ways in which top-down proces sing attempts to for the pos sible future. T he enactment of narrative directly affects the way in which individuals live out the story of their lives. Anthropologists who study psycholinguistic acros s cultures have described a phenomenon called cons truction, in which family members collaboratively create a s tory of daily events P.519 in their lives. How thos e family behaviors influence the child's emerging capacity to organize experiences and encode them into long-term memory to be retrieved in the production of autobiographical narrative is a fundamental ques tion for many dis ciplines in cognitive science as well as a primary focus of ps ychodynamic of ps ychotherapy. S pecific deficits in early family experiences and in innate cognitive capacities may theoretically impact the child's narrative capacity. differences can be s een in how different individuals tell stories of their lives and the way that they make in life.

C ognitive Development Developmental theories and research can be divided 174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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several views . S tage theories (J ean P iaget, and the sociocultural s chool of Alexander Luria and V ygots ky) des cribe dis continuous periods of with times of s tability and consolidation alternating with instability and trans ition. Information-proces sing have not been explored in as much detail with regard child development, but the models postulate a theory, in which the emergence of cognitive capacity is continuous process that does not require a s et of sequences. S tage and nonstage views embrace the that a hierarchical integration and an ongoing differentiation are fundamental as pects of cognitive development. Another dis tinguis hing feature is the degree to which theories view the contributing role of innate, biological factors and the role of culturally determined s ocial experiences . Do cognitive capacities emerge from a genetically determined plan, as in the P iagetian view, they develop in respons e to experience, as in the sociocultural view? Developmental ps ychologists have found features of both views , s upporting the idea of a transaction between innate factors and environmental experiences . More recent conceptualizations have on the functioning of complex systems to conceptualize development as the continual emergence of ever more complex capacities . P sychiatric dis turbances in cognition may reflect patterns of normal cognition (as in mental retardation), deviant developmental pathways (e.g., s ocial cognitive functioning in persons with autis tic disorder), and cognitive impairments (e.g., s chizophrenia) that may been present early on or only became evident as life 175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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requirements, such as s chool, became demanding cases of ADHD). Investigations into the developmental features of these dis orders is a major focus of the field developmental ps ychopathology.

S elf-Organizational Proc es s es An understanding of the development and s ubjective experience of cognitive process es has been greatly informed by the insights from the fields of evolutionary neurobiology and the nonlinear dynamics of complex systems , otherwis e known as chaos the ory. W ith neurons , each with an average of 10,000 synaptic connections with other neurons , the brain is capable of organizing an incomprehens ible number of pos sible activation patterns. In s electionist theory, the billions of neurons become clus tered into groups that have functions and, when activated, become reinforced. Neuronal groups that are not activated die off; thos e are activated s urvive. In other words , the brain divers ity of activity that can then be s elected by interaction with the environment. In addition, the brain has value s ys tems that s electively reinforce the activity neuronal groups that enhance s urvival. In this way the brain's neuronal groups compete and differentiate the brain and create an ongoing and evolving system. C haos theory s uggests that complex s ys tems adhere specific s et of principles . T hree principles — self-organizational process es, and movement toward complexity—are es pecially relevant to psychiatry. Nonline ar refers to the finding that s mall changes in (or initial conditions) can lead to large and 176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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changes in output. C omplex s ys tems function on the of probability, which predict that certain combinations activity within the s ys tem are more likely than others tend to move the s ys tem toward s elf-organization. T his probability also predicts that the s ys tem moves its elf toward increasingly complex s tates of functioning. T he state of activation of the various parts of the can clus ter into repeated patterns called s tate s . In the brain, a s tate of mind or me ntal s tate describes the way which various neuronal groups may become activated given time. R epeated patterns of neuronal group activation, a neural net profile, can become reinforced they occur frequently or if the value s ys tem of the brain ingrains their profile. T hese ingrained patterns of activation are called attractor s tate s ; thos e s tates that least likely to occur are called re pe llor s tate s . T he states are determined by the constraints on the Modification of constraints allows the nature of attractor and repellor s tates to be altered. C onstraints are and internal. T hus , features of the external such as the way other people behave and relate to an individual, can directly affect which mental state is likely to be activated within the pers on. Internal cons traints include the synaptic strengths of as determined by constitutional features and genetics, those learned from experience, as encoded within proces ses. Daniel J . S iegel has propos ed that complexity theory offer a us eful working definition of mental health applicable to individuals , families , and larger social systems . In complex systems , s elf-organizational that move the system's states toward maximal 177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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are mathematically shown to be the mos t s table, and flexible. T hese features may be us eful in defining he althy s ys tems. T he movement toward complexity is between the extremes of samenes s, with rigidity and on the one s ide and change, randomnes s, and chaos the other. C omplexity is achieved when the of the system achieve a balance in the two proces ses of differentiation (specialization in function) integration (coming together as a functional whole). F or single individual, such a balance can be achieved as genetically and experientially influenced growth of circuits combines differentiation of s pecialized regions with their functional integration via neural fibers that connect widely distributed areas into a functional similar balance would be seen in larger systems as Dis order can be seen in this view as occurring when a system is stress ed in its flow toward complexity, as revealed in movement toward either extreme: rigidity or chaos . T rauma may impair integration in an individual, revealed in the finding of negative effects on the integrative regions of the corpus callosum and hippocampus in abused and neglected individuals . A dysfunctional family s ys tem would be conceptualized occurring when the individuals are excess ively differentiated (without emotional connections ) or integrated (enmeshing that inhibits individuality from being expres sed). S uch s tres sed s ys tems are limited in their movement toward complexity and, hence, their stability, flexibility, and adaptability. P sychiatric dis turbances may be conceptualized as disturbances in s elf-organizational process es. Inherited and experiential internal determinants and ongoing 178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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external, environmental, and social influences on the cons traints of the s ys tem can thus directly affect the development and effective use of s elf-regulatory mechanisms. C linical interventions may function at the level of external constraints (ps ychotherapy) or internal cons traints (pharmacological treatments ) that alter the ways in which the individual's mind is able to achieve healthy forms of self-organization. V iewing psychiatric disturbances P.520 in this way allows for a synthesis of the views of ps ychodynamic, biological, and s ocial psychiatry.

S tates of Mind One way of des cribing the brain's self-organizational proces s is in the concept of s tates of mind. R epeatedly reinforced patterns of neuronal group firing link the cognitive process es of attention, perceptual bias, mental models, behavioral res pons e patterns, and emotional tone and regulation. T hese states of mind in the patterns of cognitive, emotional, and behavioral symptoms s een in various ps ychiatric disorders . F or example, in a depres sed s tate of mind, one may pay cons cious attention to negative aspects of experience, may interpret incoming stimuli in a pess imis tic manner, may have greater acces s to depres sing past may have the activation or instantiation of a mental of the self and others as bad or guilty, may have the behavioral pattern of withdrawal, and may have a depres sed mood with difficulty regulating intense Healthy mental functioning may depend on a flow of 179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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states of mind through time, allowing for flexible adaptation to an ever-changing environment. C haos theory sugges ts that nonlinear complex s ys tems mus t move continually toward maximizing complexity. Achieving such a goal requires a balance between predictability and novelty. Dys functional mental s tates may be conceptualized as a dis ruption toward either of this balance: with exces sive rigidity, as in the case of character pathology, or excess ive fluidity, as in the disorders of thought or of mood.

S E NS A TION, P E R C E P TION, A ND C OG NITION IN P S YC HIA TR IC DIS OR DE R S S ince the time of E mil K raepelin and E ugen B leuler, ps ychiatris ts have known that certain disorders include profound disturbances in cognitive functioning. S ince 1950s , res earchers have attempted to determine the nature of s uch deficits. W ith advances in computer technology and an increasing technical ability to stimulus presentation and respons e times on the order tens of milliseconds , cognitive ps ychologists have been able to devis e res earch paradigms capable of tes ting presence of increasingly s ubtle as pects of cognitive proces sing. P roces sing res earch has focused on all three domains sens ation, perception, and cognition. S ensorystudies focus on posts timulus events for as long as a maximum of 1 s econd, using simple stimuli. P erceptual studies examine process ing after a period of as long as approximately 5 seconds after a slightly more complex stimulus . C ognitive proces sing experiments can 180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the early aspects of proces sing (e.g., phenomena within the first 30 s econds ) of complex, as well as longterm, process es that occur over hours , days, or years . R ecent attempts have been made to correlate complex cognitive findings with clinical pres entations. A general problem correlating cognitive process es with clinical populations is the divers ity of patients falling the same syndrome clas sification. S chizophrenia, major depress ive disorder, and P T S D are all by symptomatic heterogeneity. T hus, the array of dysfunctions identified for certain syndromes mus t be interpreted in light of the diversity of patient A related problem is the distinction between general specific deficits . C are mus t be taken in interpreting experimental data that s how differences among normal controls and patient groups. Do ps ychiatrically ill perform les s well on a given paradigm because they or becaus e of a deficit s pecific to the disorder? F or example, ps ychomotor slowing, as meas ured by time and respons e rate, is s een in schizophrenia, depres sion, and other psychiatric and neurobehavioral disorders . T he side effects of medications can also influence proces sing and respons e s peed. on the creative design of experimental tas ks to help distinguish between general and s pecific deficits. A comparis on of target patient populations with matched healthy persons and other ps ychiatric patients can help determine dis order-specific cognitive dys function. Another general iss ue is that of s tate markers versus markers. F or example, a patient with s chizophrenia have a cognitive deficit when actively ps ychotic (state) also when asymptomatic (trait). T hes e abnormal 181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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have been found in certain cognitive tests of attention correlate with improvement on medications; some abnormal results are als o found in the non-ill firstrelatives of schizophrenic patients. Is the marker of vulnerability a coincidental finding or part of the core deficit in s chizophrenia? An exploration of the of thes e cognitive abnormalities for the daily life of the patient is an important application of the res earch to clinical psychiatry.

S c hizophrenia In the late 1890s, K raepelin described a primary deficit in his elaborate clinical des cription of patients schizophrenia. Numerous investigators have since attempted to define the nature of the cognitive deficits schizophrenia. A general approach is that an early perceptual process ing deficit leads to problems in perceptual organization and cognition. In general, information-proces sing models note that two things are proces sed: energy (in the form of external stimuli impinging on the senses) and information (a stimulus carries a signal value bas ed on s ignificance derived the prior process ing of s imilar energy configurations ). S chizophrenia patients appear to have deficits in the proces sing of energy as well as information. S ome cognitive tasks have been identified as traitmarkers of schizophrenia: reaction time cross over, backward masking, dichotic listening, s erial recall vigilance (s us tained attention) tas ks requiring high proces sing loads, and span-of-apprehens ion tes ts with large vis ual arrays. Deficits in those areas have been explored through many s tudies examining various 182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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of proces sing.

R eac tion Time C ros s over and S hift E ffec ts T hese paradigms examine the general finding that schizophrenic patients have a slower than usual on tas ks that require rapid reaction times . A s timulus is presented with varied combinations of warning signals and preparatory intervals . S chizophrenic patients s how advantage only with s hort preparatory intervals and res ponse times with regularly spaced s timuli, a pattern distinct from that of normal controls (cross over effect). related paradigm, when the modality of the stimulus is varied (e.g., light is inters pers ed with tone), the latency (delay) of the respons e in schizophrenic patients, when compared with controls , is longer if the preceding was of a different modality. T hat is termed the modality s hift e ffect, revealing a greater degree of cros s-modal retardation in s chizophrenic patients than in controls . A number of theories have been proposed to explain effects. T hey may be quantitative rather than distinctions from normal control groups . However, the cross over and modality shift effects support the idea schizophrenic patients are overly influenced by s timuli that occurred immediately before the effect. T he information-proces sing s tages that explain the of prior stimulus effects are under investigation.

Vis ual B ac kward Mas king, G ating, and Habituation In vis ual backward mas king, a stimulus is followed by interval of time, and then a s ubs equent s timulus is 183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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presented. P.521 F igure 3.1-2 s hows a typical masking experiment. T he presentation of the secondary s timulus leads the schizophrenic patient not to report (or mask) the initial stimulus . Lengthening of the interstimulus interval 500 milliseconds can lead to normalization, with no masking pres ent. T hus, the rapidity of pres entation of secondary s timulus is the factor determining whether it influences the perception or at leas t the reporting of the initial s timulus. S ome studies find that the impairment improves with treatment by medication and can be induced in normal patients given catecholaminergic agents . Other studies find that the impairment may be marker of increas ed vulnerability to s chizophrenia.

FIGUR E 3.1-2 Diagram showing the difference in the reports of normal vers us schizophrenic s ubjects with a s ingle backward mas king trial with a 100inters timulus interval (IS I). T he T repres ents the target stimulus , and the Xs represent the masking stimulus . 184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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B raff DL, S accuzzo DT , G eyer MA. Information dysfunctions in s chizophrenia: S tudies of visual masking, s ens ory motor gating and habituation. In: S teinhauer S R , G ruzelier J H, Zubin J , eds . Handbook S chizophre nia. V ol 5. Neurops ychology and Information P roces s ing. New Y ork: E lsevier S cience; 1991, with permis sion.) S ensorimotor gating and habituation are the proces ses which the reaction to s timuli decreas es with repeated presentation. S ens ory gating and habituation are to involve automatic preattentive process ing, whereas visual mas king requires higher cognitive functions. S chizophrenic patients show a markedly diminished capacity to habituate. One common s tudy examines persis tent acous tic s tartle reflex as the pers on blink with repetitive tones . Lysergic acid diethylamide (LS D) adminis tration and the intracerebral injection of dopaminergic agents in rats lead to similar findings , supporting the idea that excess ive dopamine activity, thought to be central in s chizophrenia, can induce deficits . In general, deficits in habituation and vis ual backward masking lend support to the idea that s chizophrenic patients have a diminished capacity to regulate the flow rapidly presented information. T hey experience being inundated by stimuli that are filtered out in the brain of normal person. Deficits in process ing externally derived stimuli, as demons trated in experimental paradigms , also occur with internally generated s timuli. 185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S elec tive A ttention In general, selective attention paradigms pres ent the person with a target stimulus and dis tracters . In listening tas ks , the s ubject is as ked to attend to presented to one ear and to ignore mes sages the other ear. S tudies of schizophrenic patients have revealed cons is tent deficits in their ability to repeat the mess age they were as ked to focus on. Analys is of findings sugges ts that schizophrenic patients have an impairment in their ability to avoid distracting stimuli (to filter) and to pigeonhole (to us e category features to reduce stimulus qualities needed to res pond). T he suggest that dis tractibility is a core cognitive deficit, supported by its high incidence in genetically persons, its worsening in acutely psychotic s tates , and improvement with medications. T hese findings were explained by us ing the framework an impaired filtering structure and pigeonholing but recent conceptualizations have examined a generalized impairment of the information-proces sing capacity in s chizophrenia. T he capacity model the way in which a pool or pools of attention capacity be allocated across mental activities. T wo components quantity of res ources available (capacity) and allocation policy. Other areas of deficit may involve an impaired respons e s election process , leading to res ults on tas ks . S everal pos sibilities have been proposed to explain attention deficits in schizophrenic patients on the basis the capacity model: (1) deautomatization of normally automatic preattentive process es, (2) disproportionate 186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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allocation of attention to schema-relevant but task-irrelevant information, (3) inability to s ustain controlled proces ses needed to maintain attention allocation without shifting, (4) inability to shift allocation biases to correct wandering attention, and (5) res ponse s election because of heightened arous al distracting conditions . S tudies of s elective attention begin to examine these pos sibilities in a capacity rather than in the previous ly explored s tructural framework.

S us tained A ttention S us tained attention, or vigilance , is required to proces s stimuli of long duration. T he most common res earch paradigm us ed to examine sustained attention is the C ontinuous P e rformance T e s t. T he test consis ts of a presented set of tasks with varied spacing and timing target and nontarget stimuli. T he process ing load for a C ontinuous P erformance T es t can be varied by blurring the stimuli presented or by changing the pace of presentation. V igilance tes ts, such as the C ontinuous P erformance require analysis of res ponse features on the basis of signal detection theory. T he two elements are sensitivity and the res pons e criterion. Diminished sens itivity is a sign of decreas ed vigilance and res ults high mis s rate (errors of omis sion). T he respons e can be diminis hed, leading to a high false-positive rate (error of commiss ion). T he analysis is important in the interpretation of res ults. T he vigilance studies using the C ontinuous P erformance T es t reveal that patients have a deficit in their ability to dis tinguis h 187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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stimuli from nontarget s timuli when the s timuli are presented as brief signals at a rapid pace. S chizophrenic patients als o appear to have a s pecific diminis hment in sens itivity but not a lowering of the res ponse criterion for verbal and s patial stimuli. T he impaired respons es were s ignificantly as sociated with specific clinical features in patients and their firs trelatives . T est abnormalities, although pres ent in other disorders , appear to be most robus t in s chizophrenia. P os itron emis sion tomography (P E T ) in s chizophrenic patients performing a C ontinuous P erformance T es t lower metabolic activity than in normal persons in the prefrontal cortex bilaterally but normal or elevated activation in the occipital region. T hat finding is with other findings supporting the idea of impaired functioning in s chizophrenia. P.522

L anguage and Dis c ours e Ass es sments of language dys function in schizophrenia have focused on the bas ic question of whether the abnormalities in speech are reflections of a core thought or an abnormality in s peech production. T he search for a s chizophrenic language has yielded conclus ions. Discours e analyses of conversations with schizophrenic patients s uggest that they may have significant difficulties in the maintenance of a specific topic (derailment) and in the lack of a dis course plan directing speech (disorganization). Other inves tigators have argued that schizophrenic patients have impaired capacities to perceive the 188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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others and may be schema driven in the direction of speech, rather than intending to communicate One s tudy s howed that delus ion-cons istent material presented in the nonattended channel in a dichotic listening tas k leads to diminis hed attention to the target channel. A clinical implication of this experimental is the pos sibility that s chema-driven proces sing during speech production may be diverting attention to stimuli and away from the potentially confusing s ocial demands of convers ation.

S pan of A pprehens ion In the span-of-apprehens ion tes t, an array of letters is displayed for a brief period (from 50 to 100 most studies). One of the letters is a T or an F , and the person must detect which letter is present. T he number nontarget letters is increased, and s ignificant detection are found for dis plays of ten or more letters . F igure 3.1-3 provides an example of a vis ual dis play for span-of-apprehens ion tes t.

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FIGUR E 3.1-3 S ample arryas us ed in the wideangle vers ion of the partial report span-ofapprehens ion task.(C ourtesy of R obert T he serial scanning proces s is an element of focal attention. P arallel process ing in the s earch involves increased as pects of ass ess ment of figure-ground and textual s egregation and is thought to be an automatic proces s. S tudies have shown that the s equential of the attention spotlight is directly affected by the complexity of certain dis play characteristics , increased errors in detection. T his is logical, because iconic image has a limited dis play time, and the of the image may be incomplete by the time it decays such an ultrabrief form of memory. 190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S chizophrenic patients show significantly increased in the s pan-of-apprehens ion tes t under conditions of increased complexity of dis play. T heir s cores are als o wors e in ps ychotic conditions and are improved with symptomatic improvement while taking medications. Increased errors are als o found in nons chizophrenic mothers of children with s chizophrenia. T hus the s panapprehens ion tes t is a meas ure of s tate and trait in cases of s chizophrenia. Only approximately one-half of the patients with the diagnosis of s chizophrenia have abnormal results on of-apprehens ion tes ts. T hos e who do have abnormal res ults also have the clinical s ymptom of anergia. ps ychiatric disorders studied did not reveal these T hus, the abnormal res ults on the test appear to be to some forms of schizophrenia. S hort-term and longoutcome studies have found that those patients with abnormal test res ults whos e s cores improve after antips ychotic medication have a good clinical res ponse pharmacotherapy. T he span-of-apprehens ion tes t taps into some aspect cognitive function specific to s ome patients with schizophrenia, their nonschizophrenic relatives , and persons at ris k for developing the s ymptoms of schizophrenia. T o s can the iconic image, the person (1) engage attention to the iconic regis ter, (2) move the focus of attention, and (3) dis engage the focus of attention. Impairments in performing any one of thos e tas ks can explain the test-res ult abnormalities . Another caus e of the deficiency may be that, with each fixation attention, les s information is process ed. T hus, although individual s teps of iconic s canning may be intact, les s 191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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visual information is process ed, and more errors occur. third poss ibility is that the initiation of the attention proces s is delayed; this pos sibility is consistent with the increased reaction times revealed on numerous other tas ks . T he delay in the face of a rapid decay rate of memory places the patients at a disadvantage when res ponses are required; this pos sibility is als o with the other forms of attention deficit described previous ly. S chizophrenic patients may have a number structural and capacity deficiencies , and thes e are not mutually exclus ive. F urther studies are needed elucidate the nature of the cognitive state-trait marker schizophrenic patients and persons vulnerable to the disorder.

Attention-Defic it/Hyperac tivity Dis order In the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ), integrates two categories from the revised third edition the Diagnos tic and S tatis tical Manual of Me ntal (DS M-III-T R ): ADHD and undifferentiated attentiondisorder. Diagnostic criteria embrace a number of the syndrome, and res earch into the cognitive deficits outlined a wide array of tas ks in which attention abnormal. T he pervasive findings of cognitive in the s etting of numerous intact cognitive functions left the res earch field with no clearly accepted view of a core deficit in the disorder. C linically, child and patients pres ent with problems in school, with peers, at home that reflect academic and behavioral dysfunctions. Many s tudies sugges t that the cognitive behavioral dysfunctions in the disorder may be 192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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independent process es with different bases . F or example, the finding that children with are impulsive may be true behaviorally but cannot be stated as a generalization about their cognitive functioning. R es earchers have attempted to find clear-cut criteria to help clarify the dis order, but individuals clas sified as meeting diagnostic criteria at this point appear be quite heterogeneous. T here is no definitive for the dis order nor is a positive res ponse to ps ychopharmacological intervention pathognomonic. B iochemical studies have found abnormal urinary catecholamine metabolites that normalize as the behavior improves when taking ps ychostimulants . findings and P E T scan data suggest abnormal brain functions in patients with ADHD. P.523 Data from numerous studies s how that the patients ADHD have dysfunctions on a variety of tasks ranging those involving monitoring, perception, memory, and motor control. Intact performance has been found on a number of memory tas ks requiring verbal process es digit span, word tes ts, and s tory recall) and nonverbal proces ses (e.g., recall, visual arrays , and block s eries). A number of theories have been elaborated to explain those differences between patients with the disorder normal persons. E ach theory has s trengths , and varied support from the data, but each highlights complexity of the cognitive dimens ions of the disorder. general, patients with the dis order evidence behavior 193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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has been compared to that of patients with frontal lobe damage: deficits in the control of motor res ponses , in execution of fine-motor movements , and in the of ongoing res ponse patterns. Memory tas ks and basic as pects of information process ing are intact, but the patients have impaired performance across modalities (auditory, vis ual, motor, and perceptual-motor), suggesting s ome global deficit. T he patients also be unusually s usceptible to boredom when the required tas ks are long and repetitive. Another view examines two propos ed systems —an underactive behavioral inhibition s ys tem and an behavioral reward s ys tem—to explain the behavioral problems that children with the disorder often have. A related view is that the rule-governed behavioral not intact; patients with the disorder appear to do es pecially poorly in a system with delayed or rewards, as in tasks that require s ustained attention, accuracy, or task-directed activity governed by another person's direction or rules . Under those conditions, the patient's poor regulation and inability to meet functional demands are revealed. A related is sue is a diminished motivational drive and, poss ibly, a diminis hed arousal regulation system. Y et another approach supported by research data is the patients have metacognitive deficits. According to perspective, metacognitive process es that help plan, monitor, and regulate performance are impaired. T he patient's ability to as sess the tas k and to determine strategies also has deficits . T hat is an example of topas pects of attention, with impairment of the higher cognitive process es that regulate information flow. 194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Additional bottom-up deficiencies involve bas ic as pects attention focus because of abnormalities in arous al, selectivity, and capacity. T he finding that numerous factors can influence the appearance of deficits led V irginia Douglas to the hypothes is that ADHD is a self-regulatory disorder with pervas ive effects. T he impairments affect each of four domains —attention, inhibition, reinforcement, and arousal—res ulting in deficits in several aspects of selfregulation: (1) the organization of information including planning, metacognition, executive functions, adapting appropriate cognitive s ets for a given tas k, regulating arousal levels and alertness , and s elfmonitoring and s elf-correction; (2) the mobilization of attention, including the deployment and the of adequate attention; and (3) the inhibition of inappropriate respons es, such as withholding extraneous s timuli and reinforcers. T hese deficits in regulation imply that increased process ing demands would lead to a diffusion of attention process es and to subs equent impairment of the in-depth, coherent acquisition of knowledge and understanding. One line of research has been based on the additive method, in which experimenters attempt to is olate the stage of the deficit. T he model for that approach entails four stages : encoding (the identification of a s timulus), serial comparis on (of the stimulus with elements the category in long-term memory), decis ion (pertaining the category into which the s timulus is s tored), and translation and res ponse organization. S tudies us ing evoked potentials s ugges t that deficits are found after search and decision s tages (the first three stages ). T he 195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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res ponse preparation and execution process es appear be impaired. F eatures that increas e the process ing such as s peed demands, complexity of s timuli, leading to divided attention, and increased duration of tas k—reveal different areas of deficit. T his fact may the divers ity of methods and res earch data supporting various theories . T he variables affecting outcome information-proces sing demands , the availability of alternate s timuli to which to attend, and the presence of an external regulator. T he divers ity of research findings and theoretical explanations is paralleled by the clinical finding that children who are severely impaired in the clas sroom have no attention problems in the confined, one-on-one setting of the psychiatrist's or psychoeducational examiner's office. S uch children may also be able to for indefinite periods to video games and yet be unable follow complex conceptual information. T he important principle is that cognitive dys function in ps ychopathological conditions may be tas k s pecific as function of the nature of the cognitive impairment. T he patient's clinical history and evaluation mus t cons ider potentially hidden domains of abnormal cognition.

Autis tic Dis order E arly descriptions of autism delineated the s ocialfunctioning deficits that impair normal functioning. Autistic children were seen as having difficulties in emotional contact. C ognitive dysfunctions in autis tic disorder were des cribed later and were found to number of areas , including abstraction, sequencing, language, and comprehens ion. R es earchers are now 196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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focus ing on the nature of the core deficit in the Is sues of s pecificity and universality of areas of in the dis order are important. How the cognitive relate to the s ocial-affective deficits is of particular S eventy-five percent of patients with autis tic disorder also mentally retarded. Mental retardation involves cognitive and language impairments that may make it difficult to distinguis h autis tic dis order features. G eneral cognitive impairments may be es pecially difficult to if language functioning is s everely limited. S tudies of functioning patients with autis tic dis order have various deficits to be determined. S tudies of the cognitive deficits in autis tic disorder have distinguished an array of dysfunctional areas , including numerous language problems , excess ive or impaired res ponsiveness to stimuli of various modalities , encoding of auditory stimuli, and impairment in the to extract important features from incoming information. T his range of deficits is thought to require the transformation of s ymbolic representations . In contras t, some patients with autistic disorder have relatively visuospatial and gestalt functions , mus ical abilities, and rote memory. P erformances on s tandardized tests relatively good results in object ass embly and block but poor results in comprehens ion. Language deficits vary and include s yntactic and phonological domains . T hese findings initially left-hemis phere deficit, but other findings , including deficits in pros odic and pragmatic language functions, suggested right-hemis phere involvement as well. T he findings can be interpreted as deviations from normal language functioning as well as delays in language 197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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functioning. T he wide array of dys functions in autis tic disorder may be due to a number of subtypes, with characteristic deficits and poss ibly different brain loci of dysfunction. Other studies have focused on the social cognition of patients with autis tic disorder. T hey have examined the nature of the patient's emotional P.524 behavior and understanding to as ses s the earliest descriptions of an abnormal emotional connection between autis tic children and their parents . R ecent neurobiology sugges ts a role of the orbitofrontal cortex and the cerebellum in mediating s ome of thes e deficits . T wo findings s upport the initial impress ions: Autis tic children are much less likely than usual to imitate adult vocalizations and ges tures, and they show much les s sophisticated repres entational play with objects than do normal children. T hes e findings led to the sugges tion a core deficit in autis tic disorder is the representation of representations (metarepres entations), leading to in symbolic play and the inability to unders tand the mental s tates of others. T he inability to transfer representations into language symbols may als o be a related metarepres entation deficit. A s eries of studies explored the relation of thes e cognitive impairments to s ocioemotional behavior. In contrast to clinical lore, children with autistic disorder found to look at their parents; they had eye contact with their parents when s ocial interactions were parentally elicited, and they revealed normal behavioral patterns attachment. T he s tudies found a marked lack of s ocial 198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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referencing (looking to parents for emotional cues in ambiguous s ituations) and protodeclarative gestures (pointing to objects and s howing objects to familiar adults ). T hree domains have been propos ed to explain these findings: (1) Autistic children may not have the capacity to have a representation of another pers on as having ideas , perspectives, or emotions that can be T his proposal is cons istent with a theory-of-mind hypothes is, in which the core deficit is believed to be inability to have a sense of another's mind. (2) Autis tic patients may have an impaired ability to perceive or to comprehend the emotional (us ually facial) s ignals of others . (3) T he core deficit may involve a lack of others or an avers ion to responding to others . S tudies found that although children with autistic disorder do expres s emotions, they have les s positive affects in res ponse to their (relatively infrequent) periods of joint attention. F urthermore, they have an impairment in res ponsivity to the dis play of s trong emotion by whether of distress or of pleas ure. T es ts of high-functioning autis m patients reveal poor performance on emotion-recognition tasks, little comprehension of and empathy with depictions of situations, and difficulty in talking about s ocially derived emotions , s uch as pride and embarrass ment. Autis tic patients with relatively high intelligence use adaptive cognitive s trategies to interpret s ocial stimuli to compens ate for impaired emotion-proces sing abilities. development of s ocial cognition and socioemotional unders tanding requires complex interactions among cognitive, perceptual, and emotional process es . A interactive elements es sential to the development of 199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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unders tanding has been proposed (F ig. 3.1-4). T his describes the basic precursors of emotional res ponsiveness : the ability to attend to, to encode, and interpret verbal and nonverbal social s timuli; the awarenes s of one's own and others' emotional and the ability to contrast ones elf with others. Out of matrix develops the ability to unders tand others ' views , desires, and beliefs . Accordingly, a deficit in any of basic elements may explain the characteris tic deficits observed in the s ocial understanding of persons with autis tic dis order.

FIGUR E 3.1-4 S igman's model for the development of socioemotional unders tanding.(C ourtesy of M.S igman.)

Mood Dis orders In contras t to schizophrenia, ADHD, and autis tic the mood disorders do not appear to have core deficits that are diagnos is s pecific. Instead, cognitive abnormalities appear to be related to the degree of ps ychopathology and to the severity of the mood 200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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disturbance. Mos t s tudies have examined patients with depres sion; only a few studies have as sess ed functioning in patients with bipolar I dis order in a manic state. In depress ed patients, the severity of the has ranged from mild depress ion in s tudents to s evere illness in hos pitalized patients with major depress ive disorders . T he studies have primarily examined and memory for neutral and emotionally toned s timuli. the majority of these studies, the concept of s elforganizational process es and state regulation has not the primary focus of attention. T hes e recent conceptualizations of the brain's functioning as a nonlinear complex s ys tem capable of s elf-organization may aid in the future investigation of the primary deregulatory aspect of disorders of mood.

Depres s ive Dis orders Depress ed patients often complain of difficulties with concentrating, learning, and remembering. S tudies documented that s uch patients perform poorly on tas ks that require sustained attention or effortful and rehears al. T hus , controlled limited-capacity proces ses appear to be impaired in major depres sive disorder. limitation on access to capacity-demanding res ources appears to be directly related to the s everity of the depres sion and normalizes with remiss ion from a depres sive epis ode. Depress ed patients have als o been found to have an increased res ponse criterion; they require increas ed supportive data from the presented s timuli to respond tes t s ituation. W hether this need to be certain before res ponding is a psychological respons e to being 201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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depres sed or a specific feature of the depress ion its elf not yet been determined. T he reluctance to res pond to be cons idered in interpreting research data and interview findings . T he attention and memory findings have suggested several theoretical frameworks that are clinically useful. schema theory of depres sion outlines a positive loop in which negative s elf-schemata prime pers ons to have negative thoughts, to recall negative events in lives , and to interpret present events with a negative Whether as a caus e or as a maintaining influence, depres sogenic s chemata are thought to create a s eries cognitive functions that produce and maintain a depres sed mood. A network theory of memory and emotion has been supported by res earch on depres sed and persons in which mood P.525 leads to a spreading activation of items in memory that congruent with the mood. T hus, emotion directly influences retrieval by a proces s of s tate-dependent learning and memory. While depress ed, patients are to encode items in a form that makes them readily access ible when retrieved in a depress ed state; mood thus becomes an internal context cue that depres sion-related memories . T he network and schemata theories of depress ion are cons onant with res earch findings but do not explain all cognitive and clinical findings in depres sion. T hey a framework for unders tanding how emotions and 202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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influence cognitive proces sing, such as memory and mental models. T he conceptualization may be applicable to transient mood s tates and s evere mood episodes . T hus, emotions in health and illness can the mental state instantiated at a given time and thus as a context cue, leading to the activation of previous ly formed schemata for ones elf and others. T he activated schemata, in turn, can produce retrieval biasing and behavioral res ponses, fundamental to a mental state, can further elicit a negative emotional res ponse. A reinforcing loop is established to support the of the depres sed mood and depress ive cognition. S ome patients may be es pecially prone to marked cognitive alterations because of an emotional s tate that may be a fundamental part of a clinical presentation. rapid s hifts in s tate of mind may be a learned or cons titutional feature of the individual. F rom the dynamics view, these rapid s hifts in mental s tate can conceptualized as sudden and intens e changes in the cons traints on the s ys tem, which determine the flow of states of mind across time. Activating a s et of that es tablis h and maintain a depres sed s tate can then lead to the pers is tence of the factors that created the in probabilities of that s tate being active. T he state becomes a deeply ingrained attractor state that becomes difficult to alter. P harmacological may directly alter the s ynaptic cons traints maintaining such a s tate. P sychotherapeutic interventions , s uch as cognitive-behavioral and interpersonal therapy, can be propos ed to produce changes in the internal cons traints and in external social cons traints ,

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B ipolar I Dis order P atients with manic episodes present with a s pectrum cognitive dysfunctions that appear to be related to the severity of their mood epis ode and that normalize with remis sion. T he disturbances have been described as rapidly paced thinking and speech, quick self-generated or other-generated s timuli, grandiosity, increased distractibility. F ormal studies of patients with bipolar I dis order are technically difficult to carry out because of the patient's lack of cooperation and res tless nes s, and becaus e patients are few in number. T he s tudies have high rate of combinatory thinking, the inclus ion of as sociated but related intrus ions, and increas ed distractibility. T he clinical impress ion of humor (even in face of an underlying dysphoria) in some patients with bipolar I disorder is corroborated by playful, or flippant elaborations and intrus ions in s peech. T hes e findings seem to indicate primarily state-dependent symptoms that improve on recovery. T hus , forcedspan-of-apprehens ion and backward masking tas ks impairments similar to those seen in actively patients but unlike thos e s een in s chizophrenic patients who have persistent deficits in the remitted state. disorder patients who are not actively ill reveal normal information process ing. T hus, bipolar dis orders can viewed as a disorder of s elf-organization in which the system fluctuates between the extremes of highly activated manic and highly deactivated depres sed of mind.

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Pos ttraumatic S tres s Dis order S tudies of P T S D have extended the findings of information-proces sing abnormalities in anxiety attention bias es toward fear-related and threat-related stimuli. Many of the s tudies were hampered by poorly defined clinical populations and control groups. some general trends, noted es pecially in the wellcontrolled paradigms , are promising and provide important ins ights into the psychopathological cognitive mechanisms in P T S D. C ognitive s tudies of patients with anxiety dis orders focus ed primarily on attention or memory. V arious res earch paradigms have been applied to as ses s bias and memory retrieval for neutral and emotionally activating s timuli. S tudies find that anxious patients an increas ed tendency to attend to fear-related and related words . One research approach includes a listening tas k in which an anxious patient is more easily distracted than are controls by fear-related stimuli in nonattended channel. T his finding s ugges ts that the patients have automatic, parallel attention process es are primed to detect certain types of stimuli. Another approach uses the S troop paradigm, in which words presented in different-colored inks , and the person's to look at the word and s tate the color of the ink. patients have a s ignificant delay in their res ponse times fear-related words , a finding that sugges ts that attention capacity or cognitive proces sing is necess ary when those words are perceived and the color of the determined. One theory that explains these findings is the idea of a 205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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network that encodes fear-related information in a memory s tructure that is readily access ible and able to influence cognitive, motor, and ps ychophysiological res ponses . T he theoretical fear networks, which may similar to mental models, are thought to contain three related forms of information: fear-eliciting s timulus specific res ponse patterns , and the meaning of the and the res ponses for that particular pers on. According this theory, patients with anxiety disorders are believed have fear networks that are es pecially coherent and and that require few environmental cues to become activated. P atients with P T S D have been found to have attention biases toward threat-related stimuli s pecific to the experienced traumatic event. Many of the patients were combat veterans, and further work is needed to es tablis h the generalization of those findings to other forms of P T S D. T he dis order is clinically characterized intrus ive proces ses (memories, images , emotions , and thoughts) and avoidance elements (psychic and numbing, amnes ia, behavioral avoidance of cues res embling the initial trauma). T he patients are thought to have a unique configuration of fear networks with s timulus cues (environmental s timuli), res ponse components (cognitive, motoric, and ps ychophys iological), and meaning elements (e.g., the moral implications of the trauma, survivor guilt, and the meaning of intentional trauma vs. accidental trauma). S ome theories argue that states of exces sive arous al during trauma impair attention capacity and memory encoding during the event. E motional process ing and after the traumatic experience may als o be 206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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by the s tates of ps ychophys iological arousal and memory s torage. T he part of the brain necess ary for explicit memory process ing, the hippocampus , has shown to be abnormal in individuals experiencing P T S D. T he s ubs equent clinical s yndrome may have as pects that are adaptive: C ognitive attention bias es are primed to detect fear-related stimuli may permit the early detection of threatening s ituations that, if not avoided, would produce incapacitating ps ychophys iological arousal. Automatic, noncons cious behavioral avoidance respons e patterns, embedded in propos ed fear networks or mental models, allow the patients to minimize excess ive arous al by avoiding trauma-related situations . P atients who us ed mechanisms during P.526 and after a traumatic experience appear to be at far greater risk for developing P T S D. Diss ociation is a proces s that ess entially involves the disass ociation of us ually ass ociated process es, such as attention, perception, memory, consciousness , and sens e of self. T he ps ychopathological as pects of P T S D can be cognitively exemplified as follows : A combat veteran chronic P T S D may have no direct recall (impaired memory) of a helicopter cras h in which his bes t friend, was seated next to him, was killed. Y ears later, avoidance of airports , amnes ia for combat, general and s ocial withdrawal (avoidance elements) combined with startle res pons e, panic attacks , intrus ive images, nightmares (intrus ive components) all sugges t intact implicit memory for the combat trauma. T he veteran is 207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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emotionally, behaviorally, and cognitively impaired.

S peec hles s Terror S cott L. R auch and colleagues explored the of intense fear us ing patients with P T S D. T hey took patients with P T S D and exposed them to two One was emotionally neutral, and the other was a a traumatic experience. W hile they were listening to tapes , measures of their heart rate and regional blood flow (rC B F ) were meas ured via P E T s cans. rC B F greater during traumatic audio tapes in right-sided structures , including the amygdala; the posterior orbitofrontal, insular, anterior, and medial temporal and the anterior cingulate cortex. T hese are the areas thought to be involved with intens e emotion. An extremely interesting and potentially important finding was a decreas e in rC B F in B roca's area (left frontal and middle temporal cortex). T hes e findings suggest a potential active inhibition of language during trauma. B ased on these results , speechless often reported by victims of trauma, may have neurobiological correlates consis tent with what is about brain architecture and brain–behavior T his inhibitory effect on B roca's area impairs the of conscious memory for traumatic events at the time they occur. It then naturally interferes with the development of narratives that s erve to proces s the experience and lead to neural network integration and ps ychological healing. Activating B roca's area and left cortical networks of explicit epis odic memory may be es sential in ps ychotherapy with patients experiencing P T S D and other anxiety-based disorders . 208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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T he evaluation and treatment of patients can be greatly enhanced by an unders tanding of development, diss ociation, and cognitive proces ses (including and its careful application to the ass ess ment of symptoms and s igns. S everal areas that have clinicians for decades have become of great societal concern. T wo topics that inspire intense controversy the delayed recall of repress ed memories of traumatic events and the s uggestibility of patients influenced by clinicians , s ociety, or friends to believe that they are the victims of childhood trauma.

Delayed R ec all Many scientis ts and clinicians believe in the cognitive capacity of patients to be unaware for years or severely traumatic experiences that took place in their childhoods. Other researchers dis agree and paucity of s tudies of corroborated cases of childhood trauma that have been followed prospectively into adulthood with documentation of impaired acces s of cons ciousnes s to events presumably stored in cognitive s cience view of delayed recall can examine role of memory proces ses and development and the of trauma on the proces sing of information to des cribe theoretically coherent but yet-to-be-proved set of mechanisms. A repres sed memory can be thought of as originating the active, intentional suppres sion of memory from cons ciousnes s. T he mechanisms underlying the then may become automatic, and the contents of may be inhibited from retrieval into conscious ness . T he blockage may exist to avoid flooding the pers on's 209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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awarenes s with information that is ass ociated with excess ive anxiety or fear that would impair normal functioning. T his is an example of knowledge is olation which information may be layered in the nervous and certain as pects may be kept from conscious awarenes s. In contras t, a traumatic event may be s o overwhelming that normal process ing may be impaired. If focal is divided, the nonfocally attended (traumatic) material only process ed implicitly. T hus , to adapt to a traumatic event, some pers ons may have the capacity to focus attention on a nonthreatening aspect of the or on their imagination during the trauma; this may be underlying mechanism in a proces s called dis s ociation. T raumatic memory that has been only implicitly affects behavior and emotions and pos sibly contains intrus ive images and bodily s ens ations that are devoid sens e of pas t, of self, or of something being recalled. may partly explain the findings of P T S D with amnes ia (blocked conscious access to a memory or its origin) in setting of avoidance behaviors , hyperarousal, intrus ive images, and flas hbacks. T hus, two distinct mechanis ms that may explain recall of childhood trauma are the concepts of memories and diss ociated memories . A pers on may both mechanisms for different as pects of a traumatic event. R ecollection of the traumatic memory may take different forms . R epress ed memories may have been proces sed to some degree in narrative form, whereas diss ociated memories probably lack that more proces sing. T he latter form thus may be experienced nonpas t and nons elf, making the intrus ive retrieval of 210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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diss ociated memories a confusing and frightening experience. S tudies of the development of memory in children that the s hared cons truction of narratives about experienced events is often crucial in making the access ible to long-term retrieval. T he establishment of personal memory system appears to be a function of memory talk in which parents discus s with children the contents of their memory. In children who have been forced to keep traumatic events a s ecret, as may occur childhood abus e, the normal developmental process of narration may be blocked. T his may be an additional cognitive mechanism underlying the inacces sibility of some forms of childhood trauma to cons cious nes s in patients.

S ugges tibility K nowledge is olation, s uch as in dis sociation and repress ion, provides a theoretical s cientific explanation the underlying mechanisms that may lead to delayed recall of childhood trauma, but clinicians mus t also be aware of other cognitive proces ses that influence Numerous s tudies have demonstrated that the human mind is eas ily influenced. Human sugges tibility can be us ed to the benefit or detriment of others. S uggestibility adaptive for a s ocial being that relies on the others to inform its knowledge of the world and thus to increase its chance for survival. T hus, lis tening to the stories of others, reading a textbook, and being athletics all require the receiver to accept data from the sender. T he learner (lis tener) needs to trus t the the teacher (teller) to accept the incoming information. 211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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C ritical analysis of the data received is an important component of learning. T he metacognitive function of as sess ing the accuracy or us efulness of newly information may be s us pended under certain including hypnosis, drug-altered states , and conditions severe threat. S tudies of human s ugges tibility indicate that postevent questioning can bias the metamemory process es that determine the P.527 source and accuracy of a retrieved memory. T he verbal nonverbal cues given by the interviewer may influence person to believe that as pects of an event or an entire event that may have never happened actually took A person can be convinced of the accuracy of an event despite its lack of corres pondence with actual F actors that may influence the biasing of interviewees include a belief in the trustworthines s and authority of interviewer, not being aware that “I don't know” is a permis sible res ponse, repetition of a ques tion that has been ans wered, and the interviewer's beliefs as communicated through emotional tone and nonverbal gestures. It is crucial for clinicians to be aware of human suggestibility to avoid iatrogenic distortions. S imilarly, it important for persons who experienced severe trauma early in life to receive informed and empathetic evaluations and treatment. T here is a delicate balance between supportive neutrality and active advocacy in as sess ment and intervention. Awareness of these fundamental cognitive process es may help guide the 212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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clinician toward achieving that goal. Approaches to the treatment of patients with P T S D careful evaluation but generally include the view that impaired emotional process ing of the traumatic event requires the active recollection, in explicit terms , of the details of the experience. T he process of effectively treating unresolved trauma us ually involves the active cognitive process ing of s pecific memories, including emotional res ponses , derived belief s ys tems, and the ps ychophys iological arousal at the time of the event. T he provis ion of new cognitive information in the cours e of psychotherapy can, in theory, alter the configuration of the fear networks and can allow previous ly inaccess ible information to be explicitly proces sed and made available to conscious ness for incorporation into an ongoing autobiographical S pecific techniques , s uch as those which facilitate such cognitive process ing of previous ly diss ociated or in ways isolated cognitions, such as beliefs, images , and sens ations, may be us eful in alleviating the s ymptoms dysfunction after acute or chronic trauma. S uch and changes in mental process ing may diminis h the avoidant and intrusive components of the clinical syndrome of P T S D and may improve s ocial, emotional, cognitive functioning.

C omplex P TS D C omplex P T S D occurs in the context of prolonged and inescapable s tres s and trauma. It is complex becaus e extensive phys iological effects and its impact on all of development and functioning, es pecially if it occurs during early childhood. E nduring pers onality traits and 213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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coping s trategies evolving from traumatic s tates tend to increase the individual's vulnerability to future trauma. T his manifes ts in a traumatic resonance through engagement in abus ive relationships , poor judgment, a lack of self protection. Long-term P T S D has been to correlate with the pres ence of what are called ne urological s oft s igns , pointing to s ubtle neurological impairments . T hese neurological s igns could s uggest a vulnerability to the development of P T S D or reflect the impact of the long-term phys iological dysregulation caus ed by P T S D. When confronted with threat under normal the process es related to arousal and the fight-or-flight res ponse become activated; the threat is dealt with and soon pas ses . F or obvious reas ons , children are not equipped to cope with threat in this way. F ighting and fleeing may actually decrease their chances for because their survival depends on dependency. When child firs t cries for help, but no help arrives, or when trauma is being inflicted by a caretaker, he or she may from hyperarous al to dis sociation. T raumatized who are agitated may be misdiagnosed as having attention-deficit disorder, whereas the numbing in infants can be misinterpreted as a lack of sensitivity pain. T his may als o be true for women who are often unable to outrun or outfight male attackers . Until recently, surgery was performed on infants anesthes ia, becaus e their gradual lack of protest was mistakenly interpreted as insensitivity to pain, as to a traumatic reaction to it. R ecent s urvey res earch suggests that less than 25 percent of phys icians performing circumcis ion on newborns use any form of 214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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analgesia, despite physiological indications that are experiencing stress and pain during and after the procedure. T hes e practices appear to be a holdover of beliefs that newborns do not experience or do not remember pain. It makes sense that an appreciation for poss ibility of P T S D reactions in neonates and young children has lagged behind other areas . Dis sociation allows the traumatized individual to the trauma via a number of biological and proces ses. Increas ed levels of endogenous opioids sens e of well-being, pain reduction, and a decreas e in explicit proces sing of the overwhelming traumatic situation. P sychological process es, such as and depers onalization, allow the victim to avoid the of his or her s ituation or to watch it as an obs erver. proces ses provide the experience of leaving the body, traveling to other worlds , or immers ing oneself into objects in the environment. Hyperarousal and in childhood es tablis h an inner biops ychological environment primed to es tablish boundaries between different emotional s tates and experiences for a it is too painful to experience the world from ins ide body, s elf-identity can become organized outside the phys ical s elf. E arly traumatic experiences determine biochemical and neuroanatomical networking, impacting experience and adaptation throughout development. T he tendency diss ociate and dis connect various tracks of process ing creates a bias toward unintegrated information acros s cons cious awarenes s, s ensation, affect, and behavior. G eneral diss ociative defens es res ulting in an aberrant organization of networks of memory, fear, and 215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the social brain contribute to deficits of affect attachment, and executive functioning. T he of thes e interdependent s ys tems res ults in many res ulting from extreme early stress . C ompulsive related to eating or gambling and somatization in which emotions are converted into phys ical can all be unders tood in this way. P T S D, borderline personality dis order, and self-harm can all reflect adaptation to early trauma.

FUTUR E DIR E C TIONS C ognitive s cience offers a breadth of for unders tanding the way in which the mind functions health and dis ease. T he broad interdis ciplinary field provides numerous research paradigms that are helpful further elucidating the nature of ps ychopathology techniques from the neuros ciences to computer brain functioning and biological applications of chaos theory. T he cognitive unders tanding of emotions and cons ciousnes s may als o expand psychiatry's knowing about human s ubjective experience. C linical tools , from medications to in-depth ps ychotherapy, may also find wider application as the process es of s elforganization and psychological change are better unders tood. P sychiatry, in turn, has much to offer the field of science. T he long history of descriptive and the attempt to s ynthes ize views of the mind and brain can provide nonclinical cognitive s cientists with unique data and relevant ques tions. P sychiatry is join in the s earch for understanding the cognitive proces ses of the human mind. 216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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P.528

S UG G E S TE D C R OS S P iaget and emotional development are discuss ed in 3.2, memory is dis cuss ed in S ection 3.4, cognitive are dis cuss ed in C hapter 10, s chizophrenia is C hapter 12, mood disorders are dis cuss ed in C hapter and anxiety disorders are dis cuss ed in C hapter 14. Dis sociative disorders are dis cuss ed in C hapter 17, and personality disorders are dis cuss ed in C hapter 23. therapy is discus sed in S ection 30.2, hypnosis is S ection 30.3, and cognitive therapy is dis cus sed in 30.6. Mental retardation is discuss ed in C hapter 34, disorders are dis cus sed in C hapter 35, pervasive developmental disorders are dis cuss ed in C hapter 38, ADHD is dis cuss ed in C hapter 39.

R E F E R E NC E S Andreas en NC : Linking mind and brain in the study mental illness es: A project for a s cientific ps ychopathology. S cience. 1997;275:1586. B addeley A: W orking memory: Looking back and forward. Nature . 2003;4:829. *C ozolino LC . T he Neuros cience of P s ychothe rapy: and R ebuilding the Human B rain. New Y ork: W .W . 2002. Damasio AR . Des carte s ' E rror: E motion, R eas on and Human B rain. New Y ork: P utnam; 1994. 217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Douglas V I. C ognitive deficits in children with deficit disorder with hyperactivity. In: B loomingdale S ergeant J A, eds . Atte ntion Deficit Dis orde r: C ognition, Interve ntion. Oxford, UK : P ergamon 1988. F onagy P , S teele M, S teele H, Moran G S , Higgitt capacity to understand mental states: T he reflective in parent and child and its s ignificance for s ecurity of attachment. Infant Me nt He alth J . 1991;12:201–218. J ohns on MH, Magaro P A: E ffects of mood and on memory process es in depress ion and mania. B ull. 1987;101:28. J ohns on-Laird P N. Me ntal Mode ls : T owards a S cience of L anguage, Infe re nce and C ambridge, MA: Harvard University P ress ; 1983. K andel E R : A new intellectual framework for Am J P s ychiatry. 1998;155:457. K os slyn S M. Image and B rain: T he R es olution of the Image ry De bate . C ambridge, MA: MIT P ress ; 1994. Le Doux J . T he S ynaptic S e lf. New Y ork: V iking 2002. Lewis MD: S elf-organizing cognitive appraisals. E motion. 1996;10:1. MacLeod C . Mood disorders and cognition. In: 218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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MW , ed. C ognitive P s ychology: An Inte rnational C hichester, E ngland: W iley; 1990. Main M. Metacognitive knowledge, metacognitive monitoring, and s ingular (coherent) vs. multiple (incoherent) models of attachment: F indings and directions for future research. In: Marris P , Hinde J , P arkes C , eds. Attachment acros s the L ife New Y ork: R outledge & K egan P aul; 1991. Mesulam MM: R eview article: F rom sens ation to cognition. B rain. 1998;121:1013. *Metcalfe J , S himamura AP . Me tacognition: about K nowing. C ambridge, MA: MIT P ress ; 1994. Milner B , S quire LR , K andel E R : C ognitive and the study of memory. Neuron. 1998;20:445. Morris R G M, ed. P aralle l Dis tributed P roce s s ing: Implications for P s ychology and Ne urobiology. UK : C larendon; 1989. Osherson DN, S mith E E , eds . T hinking: An C ognitive S cie nce . V ol 3. C ambridge, MA: MIT 1990. *P os ner MI, ed. F oundations of C ognitive S cience . C ambridge, MA: MIT P ress ; 1989. R auch S L, van der K olk B A, F is ler R E , Alpert NM, S avage C R , F is chman AJ , J enike MA, P itman R K : A 219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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symptom provocation s tudy of P T S D using P E T and script driven imagery. Arch G e n P s ychiatry. 387. *S chore AN. Affe ct Dys re gulation and the Damage S elf. New Y ork: Norton; 2002. S iegel DJ : T oward an interpersonal neurobiology of developing mind: Attachment, “minds ight” and integration. Infant Me nt Health J . 22:67–96. S iegel DJ . An interpers onal neurobiology of ps ychotherapy: T he developing mind and the res olution of trauma. In: S olomon M, S iegel DJ , eds . Healing T rauma. New Y ork: Norton; 2003:1–55. *S iegel DJ . T he Deve loping Mind: T oward a of Inte rpers onal E xperie nce . New Y ork: G uilford; S igman M. W hat are the core deficits in autis m? In: B roman S H, G rafman J , eds. Atypical C ognitive Deve lopme ntal Dis orde rs : Implications for B rain Hillsdale, NJ : E rlbaum; 1994. S pringer S P , Deutsch G . L e ft B rain, R ight B rain. 5th New Y ork: W H F reeman; 1998. S teinhauer S R , G ruzelier J H, Zubin J , eds . S chizophre nia. V ol 5. Neurops ychology and P roces s ing. New Y ork: E lsevier S cience; 1991. T aber K , R ausch S , Lanius R , Hurley R : F unctional 220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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magnetic res onance imaging: Application to posttraumatic stress disorder. J Ne urops ychiatry Neuros ci. 2003;15:125. van der K olk B A: T he neurobiology of childhood and abuse. C hild Adole s c P s ychiatr C lin N Am. 2003;12:293. Watts F N, ed. Neurops ychological P e rs pe ctive s on E motion. V ol 7. C ognition and E motion. Hills dale, E rlbaum; 1993. Wheeler MA, S tus s DT , T ulving E : T oward a theory episodic memory: T he frontal lobes and autonoetic cons ciousnes s. P s ychol B ull. 1997;121:331.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 4 - C ontributions of the S ociocultural S ciences > 4.1 T he S cientist and the P s ychoa nalys t

4.1 The Ps yc hiatric and the Ps yc hoanalys t Armando Favazza M.D. M.P.H. P art of "4 - C ontributions of the S ociocultural S ciences " B ehavior is determined by the interplay among a environment, life experiences, and biological C ulture is the matrix within which these psychological, social, and biological forces operate and become meaningful to humans; it is important for ps ychiatry, because it affects not only patients ' experiences of illness , but als o lay and profess ional theories of diagnostic procedures, and therapeutic approaches . C ulture is not a thing that a pers on has, but rather is an ongoing process created by s hared interpersonal experiences that reverberate throughout a s ociety and affect its institutions and the daily life of its members. Matter is neutral; molecules and energies are until they are pers onally interpreted, explained, and accepted as reality through the cultural proces s. Health and illness are cultural categories bas ed on universal biological events and culturally diverse bodily experiences that may be interpreted and acted on differently. S uppos e, for example, that a woman somewhere in the world experiences an enduring and difficult-to-control s ens e of apprehens ive expectations , 222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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tense muscles , irritability, and difficulty falling as leep. reaction to this complex of experiences depends on her culture. Does her culture provide a word or a cons truct to identify and to explain what s he is experiencing? S hould her experiences be cons trued as normal s uffering or as evidence of a moral flaw, a disharmony of inner energies , an exis tential crisis, deflected rage, nerves , or generalized anxiety What is the culturally accepted limit that she must before dis closing her experiences ? W hom does her sanction to receive her dis closures? G od, perhaps, or a priest, a congregation, a local healer, a televangelis t, a help group, a friend, a family member, a counselor, a phys ician, or a psychiatrist? T he remedies she may be offered—prayer, acts of contrition, increased group participation, change of diet, exercise, interes ting changing jobs, going on a vacation, family or marital couns eling, individual therapy, meditation, are culturally determined, as are the criteria us ed to the efficacy of the remedy.

C UL TUR E C ulture is a vast, complex concept that is us ed to encompas s the behavior patterns and lifestyle of a society—a group of pers ons sharing a s elf-sufficient system of action that is capable of existing longer than life s pan of an individual and whos e adherents are recruited, at leas t in part, by the s exual reproduction of group members . C ulture consis ts of s hared s ymbols, artifacts, beliefs , values, and attitudes. It is manifes ted rituals , customs , and laws and is perpetuated and in shared sayings, legends , literature, art, diet, religion, mating preferences , child rearing practices, 223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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entertainment, recreation, philos ophical thought, and government. C ulture serves many purposes. It overall cons is tency to a society's patterns and over the generations. It helps organize diversity and mediate between the forces of s tability and conformity and those of new ideas and actions . B y class ifying phenomena into good and bad, right and wrong, and s ick, desirable and undes irable, people are with behavioral guidelines and an interpretation of life's events. B ecause cultural components change at speed (for example, technological advances may a s ociety's capacity to deal with new ethical is sues), cultural s ys tems attempt to minimize s tres s. C ulture is learned through contact with family, friends, teachers, significant persons, and the media; the term this process is enculturation. It res ults in a personal belonging to one's own s ociety and in a native identity. E xcept, perhaps, for a few totally is olated, small s ocial groups , there are no pure cultures. S ocieties are not Acces s to printed media, radio, telephone, televis ion, easy travel, as well as geopolitical changes , has a great deal of cultural blending. Adults s uch as or refugees who only in part adopt the culture of a hos t society are said to be as s imilate d, whereas those who as sume a new cultural identity consonant with that of host culture are s aid to be acculturated. P ersons who, voluntarily or by force, abandon their native culture but to be ass imilated or acculturated usually lose their identity or purpos e in life and are at high ris k for subs tance abus e, and alcoholism. T he holis tic and functional concept of culture also for the exis tence of s maller subcultural groups and 224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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patterns within the larger society. Native Americans, for example, have distinct cultures, es pecially in tribal that live on reservations . On a smaller, les s scale, there are many subcultural groups and units in which there are s hared feelings , ideas , and behaviors , example, cults , neighborhood ass ociations , institutional inmates, athletic teams, s tudents and teachers at a and unions. Many s ubcultural patterns serve to and to integrate the general society, but s ome may be socially disruptive (organized criminal groups ) or truly destructive (terroris t organizations). E ach family may said to have its own microculture. Although the term culture is a grand abstraction that implies stability, homogeneity, and coherence, social life is often replete with change, heterogeneity, and inconsistencies . Anthropologists traditionally have been the major profes sional group to s tudy culture, whereas have studied P.599 social class . A culture is not the same as a s ocial class . Within every society, one may find the five levels described for social s tratification ranging from clas s I, characterized by high financial income, pres tigious occupations , and poss ess ion of des iderata, to clas s V , characterized by just the oppos ite. In a geographical one or more differing cultural systems may be present, each containing members of the five s ocial class es. such as the culture of pove rty and me ntal he alth of the are misleading, becaus e they imply that all members of lowest social clas s s hare a common culture. It may be that impoverished areas outwardly appear similar and 225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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slum dwellers s hare some common attitudes and patterns, but these s ocioeconomic phenomena s hould be confus ed with culture. Anthropologists and s ociologis ts have s eparate methodologies, and points of view. Anthropologis ts, for example, study acculturation, whereas sociologis ts migration. B oth of thes e proces ses s hare identical referents in many ins tances . Acculturation studies emphasize s mall-scale, non-Wes tern populations, contact between investigators and their subjects, and a focus on behavior itself; however, migration studies typically emphas ize sociodemographic variables, ps ychiatric us e rates , large W estern populations , and or no direct contact between investigators and their subjects . S ociologists do not have mus eums; anthropologis ts do—this reflects the anthropological concern for biology and artifacts , as well as for B oth sciences are pertinent to medicine, in general, ps ychiatry, in particular. Medical anthropologists s tudy the impact of proces ses on health and on people's experiences of es pecially by us ing cross -cultural comparisons. T heir studies on the lives of patients in mental hospitals and then, after deinstitutionalization, in the community have had direct clinical impact. More than any other medical specialist, ps ychiatris ts have developed expertise in unders tanding sociocultural proces ses and in using this unders tanding clinically. American psychiatric interest culture began in the mid-1800s when mental hos pitals admitted a large number of Iris h and G erman T oward the end of that century, E uropean ps ychiatris ts African, As ian, and C aribbean colonies described a 226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of unus ual s yndromes s uch as latah, amok, and koro. R . R ivers , a B ritis h psychiatris t renowned for the field of s ocial anthropology, did research on healing and on the perception of pain in S outh P acific Is landers that he then us ed in treating mentally traumatized s oldiers in World W ar I. At the turn of the century, E mil K raeplin traveled from E urope to Asia, des cribed differences in s ymptomatology among patients, and developed the field of comparative ps ychiatry. S igmund F reud's psychoanalytic office was filled with archeological relics, and, as he dug through the layers his patients ' neurotic minds , he believed that he could recons truct past epochs of human behavior and Among the conclusions of his widely read books written between 1913 and 1938, T ote m and T aboo, T he Illus ion, C ivilization and its Dis contents , and Mos e s Monotheis m, are that culture and repres sion are reciprocally related and that the superego was socially created to control the dangerous human des tructive instinct. Many psychoanalysts , including Otto R ank, T heodor R eik, and C arl J ung, publis hed studies of and myth. G eza R oheim, E rik E rikson, and G eorge Devereux were ps ychoanalyst anthropologists with field experience. R oheim founded the series known as P s ychoanalytic S tudy of S ocie ty. He used his vas t of arcane cultural details to support his extreme ps ychoanalytical theories and then to twit his anthropological colleagues , whom he accused of obvious proof of the oedipal complex becaus e of their own repres sed conflicts. E riks on wrote psychocultural studies of Mahatma G andhi and Martin Luther. His 227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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experiences with Dakota and Y urok Indians ins pired C hildhood and S ocie ty, written in 1950, in which he the intrins ic wis dom and uncons cious “planfulness ” of cultural conditioning with the ongoing process es of individual psychosocial development. Devereux, with American P lains Indians, believed that s hamans caus ed a social remis sion in patients by repatterning ethnopsychologically s uitable defens e mechanis ms. In treating Mohawk Indian patients, he explicated such as dream interpretation and trans ferencecountertransference, which are encountered in clinical work with ethnically diverse populations . B ecause ps ychoanalys is developed from the s tudy of the its application to cultural phenomena is at least one removed and is open to ques tion. Als o, the concepts of mind and mental process es may not be applicable or meaningful when applied to non-Wes tern groups . T he trend among some ethnopsychoanalysts attend to informants' explanations of their behavior and synthes ize ps ychological and sociocultural exemplified in R obert LeV ine's work and in articles published in the J ournal of P s ychoanalytic and in P s ychiatry, a journal founded by Harry S tack with the as sistance of E dward S apir, a cultural anthropologis t. Modern cultural psychiatry began in 1955, when a T ranscultural P s ychiatry Divis ion was started at McG ill Univers ity in Montreal with the leadership of E rick Wittkower and H. B . M. Murphy. R aymond P rince and, recently, Laurence K irmayer have continued leading Divis ion, including publication of the journal P s ychiatry. In 1971, a T rans cultural P s ychiatry section 228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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es tablis hed in the W orld P s ychiatric Ass ociation; recent directors include W en-S hing T seng, a C hines ewho wrote the first truly comprehensive Handbook of C ultural P s ychiatry in 2001; W olfgang J ilek, an C anadian with extens ive experience in working with refugees in S outheast Asia and Africa; and G offredo B artocci, an Italian who has vitalized E uropean cultural ps ychiatry and who has published in the area of the United S tates , the journal C ulture, Me dicine and P s ychiatry was es tablis hed in 1976 by Arthur prominent cultural psychiatric researcher, and B yron a medical anthropologis t. T he S ociety for the S tudy of P sychiatry and C ulture was founded in 1979 by F avazza, E dward F oulks , J ohn S piegel, J oseph Wes termeyer, and R onald Wintrob. S imilar exis t in C hina, G ermany, Italy, J apan, and the United K ingdom.

C UL TUR E A ND THE HUMA N Wes tern science now locates the construct of mind in brain; in past times, it was linked with the heart, the and other organs . J us t as s ome body parts can be through us e patterns —for example, physical exercis e affects mus cle strength and s ize—so too can the neural network be modified. R epetitive thoughts , sounds, s mells , tastes, and touches tend to increase specific neuronal dendritic connections and to intensify neurotransmitters, so that certain sensations and become phys ically patterned in the brain. T he ability to speak a particular language, for example, depends on culture-specific neural organization that influences cognitive process ing and creation of cognitive schema as to structure a pers on's perception and experience of 229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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world. C ulture exerts a great influence on the birth, development, and death of the human body. T wo New G uinean tribes, the E nga and the F ore, provide an of how culture may affect fertility. T he E nga, who live in state of chronic overpopulation and have reached the upper limits of s urvival for their territory, have cultural patterns that s erve P.600 to limit population growth. P remarital s ex is forbidden, celibacy is highly valued, and inces t taboos are broad; woman cannot marry any man related through men to paternal grandfather. Men cannot marry until they are years of age; on the death of a man, his widow is or s trangled to death. Infanticide is practiced, and not a caus e for anguis h. In contrast, the F ore live in an underpopulated area, and their cultural practices serve increase population growth. S exual experimentation early marriage are encouraged, widows are inherited the dead hus band's male relatives, tribal ceremonies erotic elements, and death caus es great communal anguis h. In large, complex societies , fertility rates are affected by monetary incentives, for example, taxation encourage or to discourage large families . In C hina, government policies to lower population growth reportedly have included forced abortion and even infanticide. In Italy, the exceedingly low birth rate secular culture s hift away from the C atholic church's traditional stance that birth control is sinful. C ulture als o affects the ways in which the body is Hunger could be eliminated if all food s ources were but the people of W estern nations are unwilling to eat 230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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cats, dogs, rats, beetles , and grubs . Dietary and food process ing may affect mental status ; pellagra its as sociated dementia are caus ed by a niacindiet. In 1912, J os eph G oldberger discovered that in the American S outh was caus ed by the removal of from corn during the milling proces s. C orn is currently the center of a great s ocial debate over genetically modified foods; proponents argue that genetically modified corn is safe to eat and produces prodigious yields, whereas opponents refer to it as F ranke ncorn call for more tes ting before it is allowed into the marketplace. B eyond its s cientific merit, this debate reflects the cultural conflict between traditionalis m and progres sivis m and mirrors other contemporary cultural clas hes over s uch disparate topics as homos exuality, abortion, global warming, and creationism. P roblems ass ociated with the drinking of alcohol greatly on culture. T he C hines e have a low rate of alcoholism, whereas the J apanese have a high rate of alcoholism. B oth groups contain many pers ons who an unpleasant “flush” reaction to alcohol, but the low alcoholism rate in C hina appears to be the res ult of a cultural emphas is on moderation and s elf-control, low res pect for problem drinkers, the ass ociation of and eating, and a traditional belief in the medicinal of alcohol. Deviant and culturally s anctioned behaviors that alter destroy body tis sue are found in all s ocial groups. Mos t body modification practices are performed to promote beauty and to enhance s exuality, to s ignify a particular group, or to express rebellious ness and individuality; examples of these behaviors are earlobe 231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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piercing to affix jewelry, ins ertion of nipple rings , tattoos identify gang members, and a s imple tattoo on the T he widespread fad of body piercing and tattooing in Wes tern nations has no particularly significant meaning other than, perhaps , a diss atisfaction with an bureaucratic and computer-driven society in which are identified by numbers and in which artificial are replacing “the real thing,” for example, chemical organic s ubs titutes and vitamins in pill form. Although a group of persons who have modified their bodies (excluding s ingle earlobe piercing) probably would more psychopathology than a control group, a diagnosis cannot be inferred simply by the presence of tattoos or piercings. B ody modification rituals, unlike fads and practices , are socially functional, integrative, adaptive, and enduring cultural components . P articipants believe that the promote health, heal pathological conditions, maintain social s tability, enhance s pirituality, and provide for religious salvation. B ody modification rituals for promoting health and illness often focus on the importance of blood. Many native tribes in P apua New G uinea, for example, womb blood to be a pathological s ubs tance that in the circulatory s ys tem of adults . Mens truation allows women to purify thems elves naturally, but men must res ort to periodic penis cutting, tongue abras ion, or hemorrhages. T hrus ting sharp, stiff grass into the once a month induces copious nas al bleeding, thus supposedly eliminating womb blood. Members of the Hamads ha, a Moroccan S ufi healing s ect, believe that healers poss es s a s acred force known as baraka that 232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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promote health and cure mental and physical illnes ses caus ed by jinn s pirits. Afflicted patients gather in a and the healers enter into an ecstatic trance induced rhythmic music and wild dancing. T he healers then open their heads. P atients acquire the healer's baraka eating sugar cubes or bread bits dipped into the flowing blood or by s mearing thems elves with the blood. B ody modification rituals frequently also serve to social s tability; they may help to define group and adult status, to control gender-linked behaviors, to solidify social bonds . E laborate patterns are carved the flesh of T iv (Nigeria) females on reaching puberty. scars repres ent the T iv family, heritage, land, genealogy, and myth, and they duplicate the on sacred objects. T his scarification ritual transforms girl into a woman and into a sacred object on whom the group's fertility depends . In some cultures in which sexuality is cons idered problematic, body modification rituals have been es tablis hed to control women's In an analogy to a ps ychodynamic formulation in which morbid symptom s erves to bind conflict-caus ed anxiety an individual, thes e rituals with their consequent ps ychological, and s ocial morbidity s erve to bind communal anxiety in societies in which s exual conflicts have the potential to disrupt the male–female T hrough the practice of foot-binding, for example, men literally prevented their women from “running around” by crippling them. G irls' feet were tightly bound with bandages to keep them from growing; the flesh became infected, and, s ometimes , one or more toes sloughed off. T he pain lasted for almos t 1 year and diminis hed when the feet became numb. Men extolled 233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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beauty of the “lotus foot” and cons idered it erotic. women with bound feet could not walk any distance without the help of attendants , men could be s ure of whereabouts . T he practice exis ted for a millennium and ended in the 1920s . A more direct approach to the of female sexuality involves genital modification of girls in S udan and S omalia and parts of E thiopia, K enya, and Nigeria. S imple circumcis ion involves off the clitoral prepuce; excis ion involves als o removing the tip of the clitoris. Infibulation involves removal of the clitoris, the labia, and mon veneris ; the vagina is then shut except for a small opening. Immediate or early medical complications include infection, urinary urethral and anal damage, and hemorrhagic shock or death. Long-term morbidity includes chronic pelvic urinary tract infections, dermoid cysts and absces ses , dyspareunia, and complicated childbirth. An infibulated woman is marriageable, becaus e s he is a guaranteed virgin. E xcis ion of the sensitive clitoral area is done to attenuate the woman's sexual desires and to free her personal lus t. Uncircumcis ed women are regarded as unclean and not worthy of being a wife and a mother; Arabic word tahur refers to purity, cleanlines s, and circumcis ion. T he rituals are perpetuated, in part, becaus e marriage motherhood are often the only s ocial roles available to women; attempts to ban them have been modestly succes sful. C ircumcised women who move to cultural settings in which the experience of pleasure in females cons idered desirable may become clinically depres sed P.601 234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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when they realize that an important part of their has been cut away. In many cultures , es pecially ones, dis comfort with female sexuality is evident; a rationalization for this discomfort is that untamed sexuality caus es men to act irrationally. T he path to enhanced s pirituality and religious often involves body modification. In the index ritual of P lains (American Midwest) Indians, the stronges t of the braves , while tethered to a rope affixed to s kewers in ches ts, danced, gazed at the s un, and ripped through muscles in a s truggle to be free from the s nares of the flesh. S evere s elf-flagellation occurs in S hia Islam and C hris tianity. T he C atholic church has canonized many saints who zealously mortified their flesh; s ome “holy” anorectics. In the E as tern Orthodox mys tical tradition, the beardles s, corpulent 18th and 19th castrated themselves to achieve the purity of the firs t Adam, before he ate the forbidden fruit, which G od supposedly grafted onto his body as testicles. In R ome and the Middle E ast, the s elf-emas culation of who was unfaithful to the G reat Mother G oddess , was memorialized annually in the ritual of the Day of when cult pries ts flagellated themselves and cut off genitals; the emperor J ulian called it “a holy harves t.” In Hindu T haipusum festival, many persons pierce their bodies with replicas of Lord Murugan's magic trident. An appreciation of the purposes s erved by culturally sanctioned body modification rituals helps demys tify seeming senseles s deviant s elf-mutilation of the ill. As stated by E dward P odvoll: T he self-mutilator can incorporate into his actions which, to a greater or less er degree, remain 235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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in most of us . T hat is, s uch patterns already exist in intens ities within the patient's s ocial field.… S till the patterns involved are those which elicit s ilent levels of admiration and envy. T he history of these images as far back as the pass ion of the cross and has among some of the most res pected members of our culture. B ody modification rituals and deviant self-mutilation are not alien to the human condition; rather, they are culturally and psychologically embedded in the elemental experiences of healing, social s tability, and religion. T hes e acts acknowledge disruptions within the individual and the collective social body and provide a mechanism for the reestablishment, however brief, of harmony and equilibrium. T he self-inflicted cuts of Wes tern adolescents are not so different from those experienced during the rite of pass age by aboriginal initiates , blood brothers des perate to achieve social acceptance and integration into the adult world.

C UL TUR A L IDE NTITIE S T his s ection deals with three types of identity that as sume or have thrust on them, namely, race, and charis matic group members hip. Among the many other identities that are greatly influenced by culture those ass ociated with age and gender.

R ac e and R ac is m In standard medical cas e presentations, psychiatrists identify patients by age, gender, marital status , occupation, race, and, s ometimes , ethnicity. R ecipients such information immediately proces s it, cons cious ly 236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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unconsciously, and make certain as sumptions. Of concern to cultural ps ychiatry are ass umptions bas ed race or ethnicity, because both of thes e cons tructs are emotionally evocative that they may distort the and therapeutic process . A characteristic of human beings is to compare to other persons for reasons of enhancing s elf-es teem for setting behavioral boundaries. T he comparative is us ually found lacking in one regard or another. T he ability of a group to perceive flaws in a different group so prodigious as to encompas s every aspect of such as political systems , s kin color, religious beliefs , practices , and gender. R elationships between so-called superior and inferior groups range from friendly rivalry enslavement, from covert hostility to mass murder. Depending on the place and time, men have women, whites have dis paraged blacks, free persons disparaged s laves, the rich have dis paraged the poor, heteros exuals have dis paraged homos exuals ; the complete list of superior-inferior polarities is discouragingly long. W hen cultural patterns based on perceived superiority and inferiority continue over generations, their pers is tence may be thought to reflect natural order that culture then s erves to protect. rationalizations , as well as political expediency, are us ed to perpetuate polarities , for example, men have denied suffrage to women in the belief that they s hould tend to cooking, children, and church activities rather deal with political iss ues that are far too complicated for them to unders tand. T he F ounding F athers of the S tates wrote a C ons titution and B ill of R ights that all men are created equal and have a right to 237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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happines s, yet slavery was common at the time in the northern and s outhern s tates. Healthy cultures have capacity to change their s ocial patterns in res ponse to ideas , desires, and technologies; change may come gradually, es pecially when many of the perceived group members come to believe that they are truly inferior, or it may come rapidly with forceful rebellion civil war. T he notion that pers ons can be categorized by race has been abandoned by mos t scholars but universally in the general public. P hysical traits , skin color, are the mos t common lay markers of bas ic divis ions into white, black, red, and yellow races . the 1950s , some anthropologis ts class ified the races C aucas ian with Nordic, Alpine, and Mediterranean Mongoloids with Mongolian, C hinese, J apanese, V ietnames e, and T ibetan groups ; Malays ian and Indonesian; Native Americans ; Negroids with Negro, Melanes ian, Negrito, B ushman, and Hottentot groups; Aus traloids . Deoxyribonucleic acid (DNA) tes ting demonstrates the fallacy of racial divisions, becaus e great majority of human alleles are pres ent in all population groups , although their frequencies vary; genetic variability within populations is greater than the variability between them. Moreover, s kin color, hair nose shape, and other physical traits are independently inherited and are not linked one to another. T he saving grace of ancient beliefs about different was the provision of methods for overcoming alleged faults . B arbarians could gain acceptance from G reeks learning to speak and to write the G reek language. B y religious conversion, R omans and J ews could join the 238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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C hris tian community. Modern forms of differentiation, es pecially those bas ed on the flawed biological of race, however, rarely permit the inferior group to ris e the s tatus of the superior one. Modern racis m began in 15th century S pain, where C hris tians were divided into old and new groups. Old C hris tians had “purity of blood,” whereas the new converted J ews —was hounded by the Inquis ition. On biological grounds, J ews , and later Mus lims, were incorrigibly inferior and therefore were excluded from mains tream S panish society. In the New W orld, conquerors brutalized and enslaved the local to mine for gold; their justification came from s ome theologians who declared that Indians lacked rationality and morality and therefore were, in Aristotelian terms , “natural slaves.” Als o, the famous physician, determined that Indians were s oulles s, inferior beings because they P.602 had not descended from the biblical Adam. A great ensued, and, in 1537, P ope P aul III ruled that “the are truly men.” However, economic interests prevailed, papal declaration was ignored, and harsh slavery continued for several hundred years. B efore the 17th century, there was no tradition of whitenes s among E uropeans or of blacknes s among Africans. Distinctions among groups of people in the in G reek and R oman histories , and in the writings of P olo who traveled from Italy to C hina were made on basis of food preference, cos tume, political s ys tems, rituals ; s kin color was not mentioned. W hite and black 239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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became cultural categories in the 17th century when transatlantic slave trade was developed to stock colonies in the New World. E uropeans and Americans exploited local populations participated in the s lave trade for economic profit. R ationalizations for thes e practices came from philosophical, and then-current scientific theories. (many B ritish referred to all nonwhite pers ons as supposedly were curs ed by G od as des cendents of an Old T estament biblical figure who s aw his father T he S cottis h utilitarian philosopher, Dave Hume, wrote that only white pers ons were capable of creating nations and of producing ingenious manufacture, art, science. During the E nlightenment, the E nglis h philosopher J ohn Locke s upported the degeneracy namely, that the normal natural s tate of human beings typified by the white E uropean and that other races of men developed through biological and psychological degeneration. S cientis ts noted that white was the true color of nature and that the degenerative process persons of different colors might be reversed through expos ure to E uropean culture. Nonwhites were be ps ychologically flawed and unable to rule as demonstrated by the ease with which E uropean colonialis ts s ubjugated vas t areas of the world. E ven as 1963, a noted B ritis h historian took the position that, although black Africans have darkness , only have a history in Africa. In the United S tates, a 19th century profes sor of named S amuel Morton measured the cranial capacity various s kulls by filling them with peppercorns. He that the cranial capacity was unchanged for at leas t 240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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years and was largest for whites , followed by Asians , Americans , and Africans. T his finding was confirmed in 1906 by R obert B ean, P rofess or of Anatomy at T he Hopkins Univers ity in B altimore; bas ed on brain size, reported that Negroes have well-developed lower faculties , s uch as smell and melody, whereas whites well-developed higher faculties, s uch as s elf-control reason. In 1856, a S outhern psychiatrist coined the diagnostic term drapetomania, which was applicable to slaves and cats who had an irres trainable propensity to away from their mas ters . Another diagnos is given to slaves was dys oe s thes ia oe thiopica; s ymptoms idleness , s loth, careless nes s when driven to work by compuls ive power of white mas ters , breaking tools, not paying attention to the rights of others . A 19th scientific theory that became ins titutionalized in the of southern states was based on the trans miss ion of heredity in blood from parents to offs pring. P arental supposedly blended in the offs pring; thus , children received one-half of their nature from each parent, onefourth from each grandparent, and s o on. T his belief ris e to such words as half-bre e ds , quadroons , and octoroons . B lack blood was considered to be more than white blood; a pers on with even one drop of black blood was class ified as negro. T he blood theory is scientifically baseles s. G enes undergo neither blending contamination. At the turn of the 20th century, American psychiatrists published articles in pres tigious journals suppos edly demonstrating that the lower rate of mental illness slaves, as compared to blacks in the free s tates, that s lavery protected the mental health of blacks 241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of the supervision they received. One study in 1914 concluded that the negro mind is irrespons ible, unthinking, easily aroused to happiness , and rarely experiences depres sion. A W orld Health Organization (W HO) monograph in 1953 perpetuated the myth that black pers ons rarely experience depres sion; the same author noted that Africans are like leukotomized E uropeans, thereby “proving” that Africans did not use the frontal lobes of their brains . In his writings on the collective C arl J ung noted that the brains of blacks probably have whole historical layer less than E uropeans; he also that “racial infection” exercised a tremendous pull on white persons who are expos ed to blacks . S ome educational psychologis ts, namely Lewis T erman, in and Arthur J ens en, in 1969, claimed that racial genetic factors accounted for low s cores by blacks on tes ts . F rantz F anon, a black ps ychiatrist from who studied in F rance and then actively participated in 1950s ' Algerian revolution against F rance, angrily concluded that the color black symbolizes evil, sin, wretchednes s, death, war, and famine in the collective unconscious of Western thought. A trend in many Wes tern societies is the replacement biologically based racis m by s ocial theories and policies that often are meant to attenuate racism but actually may wors en it. A psychodynamic s tudy of 25 American blacks in 1951 cons idered the legacy of to be family dis organization, low self-es teem, pass ivity, and a wretched internal life. Other s tudies negatively out the matriarchal s tructure of black families in the S tates and B ritain, as well as the ps ychological 242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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emas culation of black males . S uman F ernando, a B ritish cultural ps ychiatris t, notes : T he arguments are bas ed on a naive view of human development where negative experiences are ass umed lead to personality defects . T he lack of cohesion of family life and the pas sivity of black people are clearly deductions made by whites. B lack experience is looked from the outside; the fact that oppress ion may uplift as well as depres s s elf-worth and may promote as well as destroy communal cohesion is not cons idered. After all, this argument is applied to the J ewish people, of pros ecution s hould have left them incapable of any leadership quite apart from being able to establish a political s tate. In studying American immigrants, F ranz B oas , the of modern anthropology, found that the head shapes of second-generation children were more like those of dominant, es tablished Anglo-S axon Americans. F or this proof of the plasticity of physical traits clearly contradicted biological theories that claimed that racial groups had fixed physical and, by extrapolation, fixed ps ychological and personality characteris tics. Despite and other evidence debunking the s cientific validity of race, racial prejudice exis ts throughout the world. In the Wes t, it is us ually directed against pers ons of color. P igmentation s uppos edly indicates deficiencies ranging from intellectual capacity to morality to the capability for experiencing normal emotions. R acism is s o culturally embedded in s ocial structures that even rational, wellmeaning persons are not only affected by it, but als o often amazed and taken aback when the racial undercurrents of their behaviors are pointed out to 243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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P sychiatrists are probably les s racis t than mos t groups , but they are not immune from bias es . S tudies show that white ps ychiatris ts dealing with black are more apt to diagnos e s chizophrenia, to prescribe higher dos es of tranquilizing medications, to fail to recognize depres sion, to us e involuntary commitment more frequently, to extend hospital stays , and to ps ychotherapeutic treatment. T he S urgeon G eneral's supplemental report, Me ntal H ealth: C ulture , R ace and E thnicity, concluded that the rates of mental illnes s are similar for African Americans and whites who live in a community; rates are much higher in vulnerable populations in which African Americans are P.603 overrepres ented, s uch as the homeless , prisoners , and children placed in foster care. Mentally ill African Americans are less likely than whites to receive treatment. T hey tend to seek help in primary care and, because they often delay s eeking treatment until their symptoms are more severe, in emergency rooms and ps ychiatric hos pitals . E ven African Americans with adequate insurance coverage are les s inclined to seek ps ychiatric treatment. T he report notes that the legacy slavery, racism, and discrimination continues to African Americans' s ocial status , economic s tanding, health-related behavior; additionally, there is a lack of African-American mental health s pecialis ts. In practice, patients are customarily identified as black or white; with other s kin colors typically are identified by In E uropean-American s ocieties , the revelation that a patient is white is relatively meaningles s and, in fact, 244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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us ually is proces sed as meaning that the patient is not black. On learning that a patient is black, ps ychiatris ts infer that the patient has been victimized to s ome by institutional and personal racism. However, the emergence of a s ubs tantial black middle class , as well high-profile leaders in the pas t s everal decades , along sociopolitical changes, has challenged the concept of a typical black cultural experience. White psychiatrists , in dealing with black patients, must confront their own countertransference and must be attuned to the actual perceived, and unperceived, impact of racial prejudice patients' lives, s ymptomatology, and prognosis.

E thnic Identity E very pers on ass umes multiple roles in the cours e of a lifetime. Infants, for example, mature through adulthood, and old age. P eople also develop personal, family, and group identities that change with circums tances , s uch as remarriage, relocation to a region, religious convers ion, or s witching vocations. E thnicity is a type of group identity based on cultural heritage, including place of origin, cuisine, cos tume, language, and rituals. Unlike the ps eudos cientific biological concept of race, ethnicity is a purely cultural identification that denotes connectednes s to other persons who claim the same identification. T he feelings of connectedness may fluctuate widely as and their s ocial context change. In times of extreme duress , for example, people may deny a certain or they may embrace it fervently, depending on is more psychologically and s ocially advantageous. G overnmental and other programs may reward or persons who select a certain ethnicity. E thnicity is a 245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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phenomenon. It may be a caus e of great s tres s in immigrant families , es pecially when parents cling to the “old ways ” while their children come to identify more host cultural groups . B arriers to interethnic marriages decreasing, especially in W estern countries ; a pers on marry into an ethnic group and adopt its identity. T he children of parents who are Mexican and American decide to identify thems elves initially as Mexican, American, Mes tizo, C hicano, Latino, or Mexican these self-identifications may change over time. T he concepts of race and ethnicity may be Adolf Hitler combined G erman ethnicity with a Aryan race to promote a Nazi s ociety. He s elected two ethnic groups , J ews and gyps ies, for extermination. history of the world is filled with examples of who have exploited ethnic pass ions, even to the point genocide. S ome persons, becaus e of their s kin color phys iognomy, may be stuck with a racial designation makes it difficult, if not impos sible, to change their ethnicity. J oseph Westermeyer studied American Indian mental patients reared in non–American Indian foster, and group homes in Minnesota. As children they developed ethnic identities, s uch as rural, NorwegianAmerican, Lutheran, s mall-town G erman-American C atholic, or urban S cotch-American P res byterian. T hey referred to American Indian people as the y instead of P roblems arose during adoles cence when society to accept their non–American Indian ethnicity. rejections by the s ame ethnic groups with whom they shared values, attitudes, and behaviors gave ris e to and attempts to reject their ethnicity. T hey were red on 246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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outside and white on the inside. T he psychiatric they developed—the apple s yndrome —included alcoholism, drug abuse, s uicide attempts, chronic panic attacks, depres sion, and legal and behavioral problems . All thes e s ymptoms were far in excess of might be expected in persons reared in fos ter, group homes. Mos t of the syndromic patients tried to as sume an American Indian ethnic identity by wearing traditional clothes, adopting American Indian drinking behaviors , and marrying American Indian spous es. attempts usually resulted in failure, and their symptoms became chronic. S ensitivity to ethnicity facilitates accuracy in evaluation and s ucces s in treatment. However, it is pos sible to be overly s ens itive and to mis interpret psychopathology as some sort of ethnic quirk. In uncertain s ituations, the as sistance of pers ons familiar with the patient's sociocultural s tatus s hould be obtained.

C ulture and P ers onality T he culture and personality s chool of anthropology, influenced by ps ychoanalys is and influential in the mid-20th century, attempted to link individual with various identifications , es pecially ethnicity. R uth B enedict's popular book, P atte rns of C ulture , written in 1934, held that cultures were really the summation of individual psychologies over a long time span. S he thought that persons with normal personality types are those who conform to a s ociety's dominant cultural configuration, whereas de viants do not, although s ome deviants might be cons idered normal in a different, congenial cultural s etting. T his formulation is applicable 247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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homos exuals who can lead normal lives in many large American cities but who might be tormented and cons idered deviant in rural towns . In the mid-20th century, anthropologists and s ome ps ychiatris ts developed the concept of national T he personality of R us sian peas ants was supposedly characterized by depres sive and manic traits that from the practice of fairly s evere s waddling of infants farm-worker mothers; the arms were tied close to the with tight cris scross lashing, and the infant was a blanket, so that only its face was visible. Depress ion linked to the impotence experienced in s truggling the swaddling bandages ; mania was linked to orgiastic R us sian feasts and drinking bouts that exemplified the feeding and love that accompanied the removal of bonds . T he rage caus ed by s waddling led to later guilt feelings, such as thos e express ed in Dos toevsky's T he celebrated expres sivity of R uss ian eyes was the of restricted infant mobility that perforce emphasized vision as a means of contact with the world. S uch in the nurs ery” studies were criticized for their reductionism. It als o became apparent that findings were biased, as is evident when the American military commis sioned national character studies of enemies in World W ar II. J apanese brutality was said to res ult from severe toilet training practices , G erman culture was described as paranoid and neurotic, and the hars hsounding G erman language was s een as the of a crude mentality. A 1997 s tudy grouped the of the American national character into six clus ters : reliance, autonomy, and independence; communal volunteerism, and neighborly cooperation; confidence 248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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the trus tworthiness of others ; openness to new experiences ; antiauthoritarianism; and the equality of justice for everyone. T he American national character doubtless ly would be delineated differently from a E as tern or As ian pers pective. Although national stereotypes may contain a kernel of truth, there is more pers onality variability within a group than there is among different groups. T raits perceived to be peculiarly P.604 G erman, F rench, or Italian turn out, in reality, to be generally human, Occidental, or continental E uropean. current cons ens us is that a clinically meaningful about an individual's personality cannot be made on basis of nationality alone.

C haris matic G roups T he proces s of conversion—the des truction of the old and the cons truction of a new self with new cognitive frameworks and behaviors—can take many pathways. naturalis tic settings, the process us ually involves incubation, s teps forward, and backs liding. Artis ts , and others have written about their convers ion after enduring “a dark night of the soul.” In 1934, B ill W ils on, an alcoholic stockbroker and a cofounder of Alcoholics Anonymous (AA), was for depress ion. He was not a s piritual pers on but cried in des pair for G od to show himself. S uddenly, the room up with a great white light, and he was caught up in an indes cribable ecstasy. He pictured hims elf on a in a s piritual windstorm and realized that he had 249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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free man. As the ecstasy subsided, he experienced a world or cons cious nes s. All about him and through him there was a wonderful feeling of the pres ence of G od. great peace came over him, and he thought that, no matter how wrong things s eem to be, they are all right. was reass ured by his ps ychiatris t, W illiam S ilkworth, his experience was not the res ult of a brain damaged alcohol. Wilson's life changed for good when he dis covered J ames' book, T he V arie tie s of R eligious E xpe rience . In learned about the ecs tas y that accompanies religious conversion and the hopeless ness that often precedes change. T he book pres ented many case histories , including that of a homeles s, friendless , dying drunkard who became an active and us eful rescuer of alcoholics after his convers ion. J ames described the s pecial of the state of ass urance that accompany convers ion; a sens e that all is ultimately well, a s ens e of perceiving not known before, and an internal and external s ens e clear and beautiful newnes s. W ils on talked about the hopeless nes s of his condition and his subsequent conversion with a friend. F rom thes e talks, he imagined chain reaction among alcoholics in which the mess age about the poss ibility of change would be s pread. Of special concern to society, in general, and to ps ychiatris ts, in particular, are those convers ions of that occur when young adults, us ually between the 15 and 30, are indoctrinated into charismatic groups us e duplicitous methods, have a totalis tic philos ophy, are as sociated with ps ychological and social morbidity. What distinguishes charis matic groups from other clubs , and ass ociations is their strict control over 250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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behavior and the belief that their leaders or mis sion poss ess es a trans cendent power. C lass ification of groups is problematic, becaus e they may overlap with benign, fringe groups, and becaus e they may be as progres sive in certain cultural settings. Mark includes among these groups cults, zealous religious some highly cohes ive s elf-improvement groups, some political action movements, and terrorist groups. C harismatic groups may be s mall (the S ymbionese Liberation Army of the 1960s had less than a dozen members) or large (R everend S un Myung Moon's neoC hris tian Unification church has thous ands of R ecruiters for these groups cas t a wide net in the hope gaining a few new members. T here is no way of personality type who responds to the bait, although a study of recruits to the Divine Light Mis sion (Hare cult found that 30 percent had previously s ought ps ychiatric help. Many recruits s eem to be quite normal albeit naively idealistic and trusting. S ome may be disillusioned with life, frustrated by romantic failures, and unhappy with s chool. Other vulnerabilities include loneliness and a sense of disorientation that be apparent in newly arrived college s tudents , and runaways. T hey often feel flattered when by a recruiter, often of the oppos ite sex, who offers friends hip, convers ation about s ocial injustices and meaning, and an invitation to attend a meeting or s tudy group. P ersons usually do not know that they are being recruited or the name and purposes of the group. T hey greeted warmly by the group and only hear vague generalities. T hey are then invited to intens e retreats that may las t s everal days, during which they 251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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overwhelmed with attention, exposure to nons pecific laudable generalities on the need for more s elfand s elf-improvement in the world, and joyful of the love and acceptance that group members have one another. T he emotionality of those few days may powerful that the recruits may experience a convers ion, although they are still unclear about to what they are converting; may accept new beliefs ; express high commitment; and develop a sense of well-being that follows a brief dis sociative epis ode. F as cination turns to reliance as recruits continue their indoctrination and s lowly learn the nature and purpos es the group to which they now belong. Any potential res is tance is prevented by a number of techniques, including decreased and eventual total lack of contact with family and friends, participation in many group activities so as to leave no free time and to create the confes sion of doubts to the group in “struggle sess ions,” and the induction of altered cons cious nes s through meditation, chanting prayer s es sions , or drugs . Louis J . W es t described a cult indoctrination s yndrome includes the following features: 



Dras tic alteration of the victim's value hierarchy, including abandonment of previous academic or career goals. T he changes are often s udden and catas trophic, rather than the gradual changes that might res ult from maturation or education. R edirection of cognitive flexibility and adaptability. V ictims answer ques tions mechanically, cult-specific res ponses for what their own reasoned answers might have been. 252

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Narrowing, blunting, or artificiality of affect. T he may appear emotionally flat and lifeles s or almost frantically cheerful and ebullient. R egress ion. V ictims become childishly dependent the cult leaders, who are expected to make for them. S ometimes there are phys ical changes , s uch as or weight loss , with deterioration in the victim's phys ical appearance, s trange or mask-like faces, stares , or darting, evasive eyes. C lear-cut ps ychopathological changes may appear, including depres sion, dis sociative phenomena, states , obsess ional ruminations , delus ional hallucinations , and various other psychiatric s igns symptoms.

T he disconnection between the “everything's fine” selfperceptions of group members and the perceptions of them by their family members and friends is s triking tes tament to the power of the group. Members their autonomy and their worldly poss ess ions in for a s ens e of being protected. T hey abandon their independence and conform to the group's behavioral norms in return for a sense of well-being and G alanter has described the relief effect that motivates persons to remain with the group: T he relief of neurotic distress depends on the affiliated commitment of the group members . Attempts to leave the group res ult in increased distress . T his can even be seen in members of AA who P.605 253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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become irritable and uncomfortable when they mis s meetings . T he group fosters dependency and group identity, becaus e it then becomes the agent of relief. effect can be seen in what is called the S tockholm s yndrome : Hos tages whos e lives are in deadly peril for period of time become s o dependent on their captors they then may identify with them, come to support their caus e, and even attempt to thwart res cue attempts . T he leaders of charis matic groups often lie to members maintain group morale and to negate unfavorable comments made by outs iders. T hey s olidify the group's boundaries when they feel threatened; techniques staring vacantly as a respons e to outsiders ' ques tions aggres sively counterattacking perceived enemies . the xenophobia of a leader turns to full-blown paranoia, the group members may s hare the leader's delusions ; res ult may be catas trophic. In the 1970s, J im J ones , the charismatic, Africanleader of a neo-C hris tian apocalyptic s ect, moved with followers from S an F rancisco to the remote jungles of G uyana, S outh America. In this captive society, he was called Dad by the members. He demanded total and cons tant vigilance, preaching about persecution by enemies and the extermination of all blacks. He members who committed crimes , such as s moking, even forced a celibate woman to have intercours e with man whom s he dis liked in front of the entire As J ones ' persecutory and grandiose delus ions he repeatedly drilled his followers in preparation for the final battle by arming them with rifles and giving them a red, supposedly fatal liquid to drink. In 1978, he 254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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announced that anarchy was rampant in the United that drought had forced the evacuation of Los Angeles, and that the K u K lux K lan was marching through the former city, S an F rancisco. A month later, a U.S . C ongres sman violated the borders of J onestown by coming to inspect it. W hen four group members to leave with the C ongres sman, J ones attacked him then drilled his group for the true final battle; this time, however, the liquid that they drank was real poison. He succeeded in encouraging more than 900 persons, including 216 children, to die by telling them that they were committing a revolutionary act and not s uicide. Noxious charismatic groups appeal to various human interes ts , such as religion (Universal C hurch of C hrist), outer s pace (the Heaven's G ate group practiced all of its small membership committed suicide in 1997 the expectation of being trans ported to a spaces hip the Hale-B opp comet), and s cience (the C hurch of S cientology is violently antipsychiatry, antimedication, litigious ). P ers ons who eventually leave charis matic groups do because of disgust at the group's behavior and strong ties to family and friends. S ome ex–cult are hired as exit counselors by desperate families to persuade their children to leave the group; elaborate may be used to achieve this goal. T he proces s is difficult and protracted. P s ychiatris ts called on to treat res cued cult members s hould collaborate with reentry couns elors who have knowledge of, and often firsthand experience with, the s pecific groups . V ictims typically display symptoms of what the West terms a disorder characterized by doubts about their “true” 255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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identity, along with depres sion and feelings of and ambivalence about the entire process of indoctrination, group members hip, and res cue. Among therapeutic is sues that need to be address ed are guilt over abandoning their family at the onset and their group at the end, the reestablishment of independent behaviors , and the forging of a new s ens e of self and direction in life. T he prognos is depends on a victim's premorbid pers onality, the s everity of symptoms, family s upport, the use of reentry and, if neces sary, psychiatric care.

C UL TUR E C HA NG E In the broadest sense, persons experience culture when moving into a different culture or by staying put while their own culture changes around them. Acute wide-sweeping change may overwhelm the adaptive mechanisms of individuals and of their social s upport systems . Dis tortions in parenting and in life may occur, and cultural landmarks may become and difficult to interpret; the result may be individual sociocultural disintegration. T he four categories for situations that necess itate coping with marked culture change are (1) s ojourning, (2) s ettling, (3) segregation, (4) changes in society. In a more narrow s ens e, the changes that result from events such as retirement, into a profess ion, marriage, and adoption may be cons idered s ubcultural mobility; these changes require coping s kills that, when deficient, may result in disorders , as well as more enduring psychopathology.

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S ojourners are persons who have a brief, usually expos ure to a new culture; examples include touris ts; business repres entatives; s cientific field workers ; cons ultants and aid workers, such as P eace C orps volunteers ; military personnel; and limited contract workers. S wiss mercenaries in the 16th century were described as having the prototypical s ojourner's syndrome; phys icians referred to it as nos talgia and recorded its s ymptoms as fever, diarrhea, delus ions, convuls ions. Later, nos talgia was des cribed as a ps ychos omatic condition. Napoleon's troops reportedly were devastated by nos talgia, and it was cons idered to a mild form of insanity among troops in the American War. T he name was changed to home s ickne s s and diagnostic entity in military ps ychiatry during W orld W ar it was the mos t common maladjus tment reaction experienced by American soldiers. Adjustment can be prevented in s ojourners by a proces s of about the new culture before arrival, by providing to telephone and e-mail communication with supportive persons back home, and by shortening the lengths of in the new culture. E xposure to intense trauma or to unanticipated environmental toxins in the new culture, es pecially during wartime, may res ult in delayed and ps ychiatric symptoms.

S ettling S ettling involves a more permanent, forced, or move to a new culture, for example, a change made by refugees and international or internal immigrants . can be a relatively eas y process or a dramatically one. In general, the stress of settling may be with adjus tment dis orders , panic, anxiety, depres sion, 257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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alcohol and substance abuse, s uicidal behaviors, the triggering of mania, and transient psychotic epis odes . 1932, Odegaard concluded that a higher rate of s tate hospital admis sion for s chizophrenia in Norwegian immigrants to Minnesota than in the native-born Minnesotans or in the population of Norway was bes t explained by s elective migration. S ome s ubs equent studies have s upported this explanation, but others not. E arly African and As ian immigrants to the new of Israel were far more likely to be admitted to a mental hospital than were E uropean immigrants whos e hospitalization rate paralleled that of the local S elective migration may play a minor role, but current evidence demonstrates that enduring psychotic may be exacerbated, but not caused, by s ettling. the factors that affect ps ychopathology in settlers are premorbid mental and physical health status , characteristics of the host society and locale of and conditions necess itating the move. In an ideal immigration scenario, a mentally P.606 and phys ically healthy, intact, multigenerational family voluntarily resettles in a new area in which all the members are welcomed warmly, in which decent and jobs are readily available, in which the language is same as the country of origin, in which an es tablis hed of settlers from the s ame region already lives , and in public and private programs are in place to provide legal, and financial aid. R efugees are typically involuntarily dis placed becaus e warfare and natural disas ters . T hos e who have 258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and have been the victims of horrific atrocities are at ris k for posttraumatic s tres s disorder (P T S D), panic, depres sion. E ven after real danger is over, refugees are placed in camps often project their fear of their persecutors onto neutral personnel and continue to experience anxiety. T he struggle for self-preservation access to food and shelter may lead to a deterioration moral behaviors; recognition of this deterioration and of the inability to adhere to the values of their lost may result in demoralization and depress ion. R efugees who are res ettled to a foreign land may initially their country of as ylum and may develop s avior about pers ons of authority. However, symptoms may emerge among refugees after the realizations that they may never return to their country origin and that they had been forced to decide among unattractive alternatives in their new place of res ettlement. Most international migration stems from a des ire for upward economic mobility. P remigration mental illnes s tends to wors en with the s tres s of moving to a new culture; this situation may be encountered when healthy immigrants bring mentally ill family members them. C hildren usually adapt better to immigration than do elderly persons who may be fixed in their ways and unable to learn a new language or to find in new customs . Middle-clas s persons with ordinary occupations us ually handle the migration experience better than upper– and lower–social class pers ons , because employment may be easier to find. Women are confined to their homes may become socially and depres sed. E lderly family members may los e the 259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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prestige they once had in their country of origin as their children adopt the mentality of the hos t culture, thus creating intergenerational stress es . Acces s to s upport s ys tems depends on personal family preferences , traditional patterns, and hos t country practices and programs, such as welfare and legal aid. Immigrants often do better when they live in areas populated by others from the same country of origin. a s ituation can provide comfort and ease of trans ition first but, in the long run, may delay acculturation and even foster res entment in some segments of the host society. Marital conflicts among immigrants often on differences between gender-appropriate behaviors their old and new countries . Intergenerational conflicts may aris e over communications, becaus e children the language of their new culture more rapidly than parents and tend to los e interest in their original in addition, children are more rapidly acculturated than their parents because of the knowledge gained through socialization experiences in school. It is not uncommon immigrants, especially thos e from third world countries, develop acute ps ychotic episodes with persecutory delus ions (the s o-called aliens' paranoid reaction syndrome). T hese episodes us ually have clear-cut precipitants, may recur several times , and do not neces sarily progres s to chronic mental illnes s. In a 1998 major s tudy of 3,012 adult Mexican living in F resno C ounty, C alifornia, those born in had a prevalence rate for any mental disorder of 24.9 percent, compared to a rate of 48.1 percent among born in the United S tates. S ubs tance abus e and dependency rates were s even times higher in native260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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women than in immigrant women; the ratio for men 2:1. Another C alifornia study of 1,500 us ers of primary medical services found that immigrants , one-half of were born in Mexico and C entral America, had a significantly lower prevalence of depres sion and P T S D, despite their lower s ocioeconomic s tatus, than Latinos born in the United S tates. Other s tudies indicate that immigrant Mexican women, in comparis on to Mexican women born and living in the United S tates , have lower infant mortality rates , much better nutritional intake, are significantly less likely to test positive for drugs at of delivery. T hes e s omewhat shocking findings may, in part, be due to the migration of the fittes t, healthiest, most resilient Mexicans ; a more powerful explanation is that the immigrants are buffered by their clos eness to a traditional culture characterized by clos e-knit, extended families that offer s ocial support, low rates of divorce, healthier eating habits. T he generalization and sustainability of thes e negative findings on the effects acculturation to other cultural s ituations remain to be seen. A typical pattern is that each succeeding of immigrants over time more clos ely approximates the behavioral patterns and phys ical characteris tics of the majority of persons in the host country.

S egregation P ers ons may be removed from the community and in more-or-less total care ins titutions. E rving G offman five types of s egregated institutions : (1) thos e that care incapable harmless persons (orphanages and old-age homes ), (2) thos e that care for ill pers ons who pos e an unintended threat to society (mental hos pitals and lepros aria), (3) thos e that protect the community from 261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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persons who pos e intentional threats (pris ons and concentration camps ), (4) those established to purs ue work-like tas ks (boarding s chools and military and (5) thos e designed as retreats from the world (monas teries and convents ). Ins titutional inmates all their activities in the s ame place and are regulated the same authority. T his s ituation, incompatible with family life and the bas ic work-payment structure of is reinforced by a s trongly enforced split between and s taff with res trictions agains t social mobility the two. Until the 1950s , large s tate mental hospitals were cons idered to be a static setting within which treated patients . T hes e neatly lands caped, tightly and tranquil hospitals were thought to ins till a beneficial sens e of neatnes s, order, and tranquility to the T he impact of these hos pitals' s ociocultural on patient care became evident in 1954, when Alfred S tanton and Morris S chwartz published their study on C hes tnut Lodge, demonstrating that patients usually improved during periods of effective collaboration personnel and deteriorated during periods when s taff disagreements were not dis cuss ed openly. T his link between a hospital's adminis trative process and patient–staff therapeutic process was also by William C andill, an anthropologis t influenced by Maxwell J ones' work in establishing therapeutic communities on mental hospital wards , who admitted hims elf as a patient to the Y ale P sychiatric Institute to make around-the-clock observations about life on a T hese and other studies, combined with the growth of community mental health movement in the 1960s and 262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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development of effective medications , have led to the demis e of large s tate hos pitals and to the placement of patients in the leas t res trictive environment, that is , the community. T he deinstitutionalization process has fraught with difficulties, but there now exis ts a number res idential facilities, supervised apartments, day and other placements for patients with s evere and persis tent mental illness es. Unfortunately, because of shortage and inadequacy of facilities , a major P.607 of thos e patients who have been unable to live succes sfully in the community now res ide in jails and prisons.

C hanges in S oc iety Human beings have always had to deal with social induced by natural disas ters , warfare, colonization, revolutions, and new technology. However, in the past centuries , the rapidity and extent of change have been more vas t than the total previous accumulative of human existence. Many benefits, such as improved public health, better communications , and ease of transportation, have resulted, but some of the costs include degradation of the environment, homeless nes s, and the increased lethality of weapons. C hange the number of s tres sful events in people's lives; thes e events range from annoying traffic jams to disastrous loss es of jobs . P ers ons whos e mental health is already marginal may decompensate when confronted by rapid change. E ugene B rody examined rural to urban res ulting from indus trialization in B razil. He identified 263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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many pers ons , “the lost ones ,” who needed psychiatric care. T hey had feelings of rootless nes s from the loss of familiar cultural guidepos ts, from sadness and due to alienation from work and s eparation from and from s uspicion and dis trus t of the unknown. was a major factor in determining the mental health of “the lost ones ,” because it decisively limited their to understand and to manipulate s ymbols, to receive to integrate information, and to form relations hips with the more dominant members of s ociety. C ultural adaptation always lags behind rapid s ocial change; the more resilient the culture, the briefer the S ocieties whos e culture is unprepared for rapid change may dis integrate. S ome overwhelmed Native American tribes , for example, have died off. T he native Alaskan population in newly discovered oil-rich areas rapid s ocial upheaval. A report on the Inupiat in B arrow found that (1) 72 percent of an adult sample s cored in definite or sugges tive alcoholic range on the Michigan Alcoholis m S creening T est; (2) 42 percent had been detained or arres ted for alcoholis m at least once; (3) that had been almost free of s uicide and homicide marked increase; and (4) when the only liquor store clos ed, wides pread bootlegging ensued as an the social relations hips among family and friends. problematic behaviors have diminis hed somewhat over generation as Inupiat culture has adjusted to the on its traditional way of life.

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biotechnological advances. Diagnostic machines are replacing hands-on examinations , robots are already performing some s urgical procedures , computerized ps ychotherapy programs are being perfected, are replacing dialogue, and doctor–patient are giving way to provider–client interactions that are overs een by economically driven and faceles s organizations . One reaction to the impersonality by these changes has been the newfound alternative medicine, an approach that emphas izes traditional, folks y remedies and encourages pers ons to take a more active role in their health care. Another reaction is increas ing interest in the importance of personal religion and spirituality in medicine. In 1995, instruction in religious and s piritual is sues was made mandatory for accredited psychiatric res idency in the United S tates. T his s ection focus es on religion and spirituality. It information on religious and spiritual problems and on objective unders tanding of the human experience of B as ic material about sacred texts, es pecially the B ible the Qur'an, is pres ented because they are at the core two mos t widespread religions, C hris tianity and Is lam. reconfiguration of sin, once a central force in W estern into mental illness and criminality is dis cuss ed, as is influence of religion on problematic behaviors related to sexuality, gender, the drinking of alcohol, and healing. relations hip between religion and mental health is examined, as are differences between religion and spirituality and the psychiatrist's role in dealing with is sues.

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R eligion T hroughout his tory, human beings have held religious beliefs and have engaged in religious practices. the divers ity of thes e beliefs and practices is s o vast is impos sible to define the word re ligion s uccinctly. It generally refers to belief in a s upernatural, creative and in the practice of rituals meant to appease, to to obey, or to relate better with this G od. F or some persons, religion is an ongoing, s elf-actualizing quest holiness , whereas , for others, it is an achievable destination. R eligions s erve the mythopoetic yearnings humankind and provide a stable orientation and moral compass . R eligious systems have greatly influenced human behavior for millennia and often underlie a society's political, legal, medical, and educational T he three great monotheistic religions —J udaism, C hris tianity, and Islam—believe in a single omnipotent G od and in a book, the B ible or the Qur'an, that reveals G od's plan for believers . B uddhis m, a religion prevalent C hina, J apan, K orea, S ri Lanka, and S outh As ia, has traditions ; T herovada B uddhis m emphasizes a s piritual quest for wisdom, whereas Mahayana B uddhis m compass ion, the divine power of the S avior B uddha, spiritual rituals . Hinduis m, prevalent on the Indian subcontinent, emphasizes the many manifestations of G od, reincarnation, a divine power that sus tains life, a dazzling array of religious s ymbols, yoga, and T he revis ed fourth edition of the Diagnos tic and Manual of Me ntal Dis orde rs (DS M-IV -T R ) now includes re ligious or s piritual proble m as an Axis I condition that be a focus of clinical attention. E xamples include over the loss or ques tioning of faith, problems 266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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with converting to a different faith and ques tioning of spiritual values , and the s ens e of damnation that may experienced by pers ons with P T S D. Modern times seen jolting crises of faith; many C hristians, especially C atholics , are shocked by the revelation of pederasty among clergy, whereas many Mus lims feel that have replaced traditional Is lamic values with and militaris m. DS M-IV -T R has als o reduced the us e of religious examples to illustrate psychopathology. R eligious problems have long been part of the human experience. S ome problems are due to the fact that the faith required for a belief in the s upernatural can be In the face of horrific individual tragedies , such as the death of a child or the accidental disfigurement of a guiltles s person, as well as large-scale disas ters , s uch world wars , concentration camps , ethnic cleansing, and famine, s ome people rely on their faith for s trength and turn to G od and to religion for consolation, whereas may abandon their faith and adopt the belief that beings are res ponsible for their own fate. None of the major religions is monolithic, but rather are compris ed of numerous subdivis ions that may some core beliefs but disagree dramatically in their interpretation of s acred texts and in their rituals and practices . C hristianity alone has hundreds of examples include R oman and E astern R ite C atholic, Orthodox, B aptist, P entecostal, P res byterian, C optic, Maronite, C hristian S cience, J ehovah's and C hurch of P.608 J esus C hrist of Latter-Day S aints. Among C hristians 267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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claim to be “born again in the Holy S pirit” and to be in C hrist,” E vangelicals recognize the authority of the and a duty to s hare their faith with others in addition to having a pers onal experience with G od; are like E vangelicals but ins ist on the absolute every word in the B ible; P entecos tals are like but place a major emphasis on an immediate with the Holy S pirit and on an exuberant s tyle of C harismatics are pers ons in mains tream C atholic and protes tant churches who practice a P entecos tal form of wors hip. A growing number of C hristians belong to nondenominational churches in which the ministers congregation as a group agree on their beliefs and practices ; extension of this trend is the formation of groups in which members do not attend any church but rather meet in individual homes to study the B ible and attempt to relate it to their lives. T he subdivis ions of the major religions often have other subdivisions bas ed on the degree of orthodoxy and the adoption of local customs . Orthodox J ews , for conform their behavior to a s trict interpretation of laws , whereas “cultural” J ews may practice their predominantly by taking part in selected rituals . In the injunction that women mus t dress modes tly in may have differing interpretations; Orthodox women fully cover their bodies except for eye s lits , whereas may s imply wear a head s carf, and s till other women disregard any special dres s code. R eligious problems believers may aris e out of dis cord between major groups , s uch as Hindus and Mus lims in India, and subdivisions, s uch as conservative and liberal B aptis ts the United S tates . E ven among groups that s hare the 268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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beliefs and practices, there is a uniqueness to every church, temple, mos que, and synagogue, based on the characteristics of the clergy and the congregation. R eligious problems may aris e when there is dis cord members of a congregation or when the institutional leaders behave inappropriately. Neither religious institutions nor religious leaders, like their secular counterparts, are immune from petty politics and from sexual, financial, and other scandals . R eligion may stir feelings of altruism, forgiveness , tolerance, charity, creativity, and, mos t of all, hope. However, it may be problematic when used to rationalize hatred, irrespons ible behavior, and bodily mortification: include anti-S emitism becaus e J ews were implicated in crucifixion of C hrist, prejudice agains t blacks becaus e are suppos edly cursed in the B ible, indulging in compuls ive behaviors because of s upposed demonic oppres sion, and s evere fasting. T he intens ity of feelings arous ed by religion is so prodigious as to produce a wide variety of reactions . A well-known quote from E dward G ibbon's T he Decline F all of the R oman E mpire s tates that “the various wors hip which prevailed in the R oman W orld were all cons idered by the people as equally true; by the philosopher as equally false; and by the magis trate as equally useful.” T he 16th century conflict in which was forced by church authorities to recant his that the earth moved around the sun set the s tage for modern conflict between naturalis tic and explanations of events and behavior that began with Age of R eason in 18th century E urope. Most anthropologists regard religion, or s acred culture, 269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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a projection of human wishes that serve to cope with anxieties . W estin La B arre, for example, des cribes as a group dream that originates in the visionary state of the s haman-originator, for example, in dreams , trances, epis odes of spirit pos sess ion, epileptic and periods of s ens ory deprivation. In another theory, sound is a link to religion; infras onic s ound waves in low hertz range can produce a high-intens ity s ound press ure in the abs ence of audible s ound. S ound perceived and proces sed in the brain, but, becaus e cannot be heard or their source identified (commonly distant thunder), they have a mystifying, uncanny, provoking effect on a person who then labels the experience as religious . Drumbeats and chants religious experience not by what can be heard but by what cannot be heard, namely subauditory, sound waves. T his theory involves process ing of the in the temporal lobe, a portion of the brain in which lesions are ass ociated with symptoms s uch as hallucinations , delus ions , illus ions, déjà vu hyperreligios ity, feelings of ecs tas y, intense and cosmological concerns, pos tseizure psychosis with religious content, and mystical states . T here is a long W estern medical tradition of conflict cooperation and religion. Once Hippocrates declared epilepsy to be a biological and not a divine illnes s, phys icians have continued to provide naturalis tic explanations for illnes ses once thought to be caus ed or influenced by the s upernatural. T he s truggle to rescue mental illness from demonology, although s till ongoing many third world countries and some W es tern groups, generally has been success ful. P erhaps this s truggle 270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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played a role in antipathy toward religion sometimes expres sed by ps ychiatris ts. S tudies have s hown cons istently that psychiatris ts are not as religious as general public; in s urveys done in 1975 to 1976, belief G od was endors ed by 90 percent of Americans but 43 percent of psychiatrists and 5 percent of only 27 percent of ps ychiatris ts s urveyed in London in 1993 reported a belief in G od. A study of articles in ps ychiatric journals from 1977 to 1982 found that only out of 2,348 articles contained a religious variable, a s imple listing of a patient's denomination. F reud regarded religion as an infantalizing, neurosis producing, tyrannical force, and most psychoanalysts followed his critique with the prominent exception of J ung. E ven when they s aid something pos itive about religion, they often managed to find a rankling counterbalance. E rnes t J ones , for example, wrote the “enormous civilizing influence of C hristianity” and “sublimated homosexuality” in the same s entence. Henry Mauds ley, the mos t influential E nglish of his time and certainly not a F reudian, wrote in 1918 “the corporeal or the material is the fundamental fact— mental or the spiritual only its effect.” In 1975, the outspoken ps ychologist, Albert E llis , declared that its elf is a s elf-depreciating, dehumanizing mental However, at approximately that time, ps ychiatris ts turnaround in their thinking about religion. More and more, psychiatrists are treating patients with s evere mental illness es by using new and better medications spending les s time talking with patients. In s uch an environment, psychiatrists have come to realize the importance of programs and personnel such as cas e 271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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managers, sheltered works hops , s upervised apartment living, and s elf-help groups in helping patients survive occasionally, pros per in the community. Ministers, and rabbis are now regarded as allies in dealing with mentally ill, and church congregations are s een as a potentially healing res ource. E zra G riffith, for example, demonstrated the psychological benefits of rituals in African-American churches. Mos t clergy now accept us efulnes s of psychiatric treatment, although a minority fundamentalists s till regard psychiatrists as agents of devil and mental illness as a moral flaw.

God and the S ac red T hroughout his tory, people have s ought an about the purpos e and meaning of life, the world, and cosmos . T his ques t invariably has led to a belief in sort of divine power or process that is called G od, the or P.609 the S acred. In 1917, the theologian, R udolph Otto, published an influential s tudy in which he cons idered Holy to be s o s pecial a category that neither it nor the human experience of it can be denied. In the pres ence the Holy, a pers on is filled with emotions that Otto in Latin mys te rium tre me ndum e t fas cinos um, that is, sublime, numinous , as tounding feelings of wonder and dread. He regarded these feelings as primary, unique, underived from anything els e, and the basic factor and impulse underlying the entire process of human P aul T illich, one of the mos t influential 20th century theologians, as serted that the sense of the numinous 272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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presence of the Holy is really an awarenes s of the reality of G od who is being itself and not a being. He claimed that it is jus t as atheis tic to affirm the exis tence G od as to deny it. Apart from being and exis tence, nothing and nonexis tence; psychiatrists can treat anxiety, but exis tential anxiety can be dealt with only by encountering G od, the ground of being. F or T illich, true wis dom demands a religious experience that is a transformation and an illuminating revelation not of a personal god but rather of a G od on whom everything dependent. A leading C atholic theologian, K arl R ahner, as serts G od and s elf come together in the mys ticism of life, the discovery of G od in all things, and the s ober intoxication of the Holy S pirit. In addition to everyday mys ticis m, persons may experience mys tical states which cons cious nes s is briefly altered and all things experienced as interrelated. In religious conversions or illuminations, the mystical state may be perceived as extraordinarily meaningful and coherent; the pers onal expands to a close contact with G od. Inner peace and may give ris e to a vision or s pecial mess age. B ehavioral scientis ts have offered mundane of religion and mys tical states. In 1923, F reud wrote individuals form the idea of G od by merging the image an exalted childhood father with the inherited memory traces of the primal father; thus, G od is a type of father subs titute. R omain R olland, the F rench humanist, then chided F reud for not appreciating the eternal, richly energetic, beneficent, real core of religion that an oceanic-like experience. In C ivilization and Its Dis contents , written in 1930, F reud cons idered the 273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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experience as the es sence of mystical states and it as an adult regress ion to the earliest undifferentiated state of infantile life in which there is a communal unity between infant and mother. T his unity recedes as the emerges, but many persons retain a connection to this primal unity, which may be experienced more as awe, wonderment, and creative insight. T he of the earliest stages of being, when infants record first experience of mother as a “proces s ” rather than an “object,” is found in the ps ychoanalytic work of C hris topher B ollas. He theorizes that thes e primal experiences are not process ed through language or mental representation but rather as bodily s ens ations emotions . An infant first knows mother existentially as recurrent experience of being. T he infant eventually transforms into a self, and mother is experienced as a proces s of this trans formation. Adults carry the memory this process as evidenced by their s earch for a person, place, event, or ideology that promises to transform the self. Humans revere objects that may transform us and may consider them to be sacred. Humans are religious beings because they carry with them the potential to be transformed and recreated. F rom this perspective, the experience of G od is ultimately bas ed on the transformative potential of creating the self, but this act creation depends on a relations hip with another human being. Although B ollas ' configuration is wholly human, poss ible to imagine a broader dependency and relations hip on what T illich called the ground of be ing namely G od. P sychiatrists W illiam Meiss ner and Ana-Maria R izzuto each propos ed a nontheological understanding of the 274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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human experience of G od through the life cycle. A initial image of G od is based primarily on the image of parents . T he child's G od may be loving and protective, well as fearsome, cruel, and not always available to the child's wis hes . A positive mother–child experience this s tage res ults in a bas ic sense of trust that, in later years , may lead to a trus ting faith in G od, whereas a negative, insecure experience may dis tort the of G od. As the child begins the process of s eparation of becoming an individual with some independence, it hears about s omething called G od but lacks the to understand what a s pirit or trans cendent force is. child hears that G od has made the world and, thus , G od to the most powerful person that is known, namely both parents but es pecially father, who tends to be the more forceful or aggres sive parent. Over the next few years , as the child comes to recognize that its parents neither know everything nor are all powerful, a view of a perfect, heavenly father may emerge, as well distorted view of the family. G od and parents may be idealized as totally protecting, or there may be a split a good G od and mean parents or into good parents mean G od. B etween 6 and 11 years of age, the child to appreciate symbols. T he concept of G od s hifts from of a flesh and blood pers on to a s till imperfectly unders tood s pirit whos e power mus t be revered and feared, becaus e G od exacts punis hment for every In this s tage, an immature obsess ional religios ity may emerge in conjunction with ritualis tic behaviors . During adolescence, G od becomes more personalized “my S avior” or “my F ather” and is more connected to emotions and to s ubjective attitudes , such as love, 275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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obedience, trust, and fear. G od is experienced as the leader and advisor who patiently and kindly lis tens to one's innermos t problems and desires. When not tempered by s ome maturity of judgment, this of G od may lead to fanatical tendencies . As become moralis ts, the burden of s infulness emerges, they may engage in the extremes of loose or behavior. R ebellion against parental authority may over to the parent's religion as well as to the G od the parents symbolically represent. As adoles cents step into adulthood, they mus t decide follow the religion of their parents, to s eek a different religion, or to avoid religion altogether. A true religious faith that is bas ed less on conflict and more on mature unders tanding probably is not acquired until 30 years age. F or some, the inner repres entation of G od solid; for others, it may change; and for still others, it be rejected or replaced. T houghts about and the of G od us ually return in old age, es pecially when death nears. A pers on may decide to embrace G od gracefully grudgingly, for reas ons that include mature acceptance the cycle of life, hope of entering a heavenly afterlife, avoidance of eternal damnation, and neurotic fear, or spurn G od's ultimate encroachment; a pers on's las t may be an inspiration or an expiration. F reud regarded belief in G od to be an illusion that fears about the dangers of life; the moral world order G od promises instills hope that justice will be served, belief in an afterlife creates an ultimate s etting for the fulfillment of wis hes . F or F reud, this illusion was because it distorted reality and promoted a state of ps ychic infantilism. However, in s ome modern thought, 276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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G od is a benevolent illus ion neces sary for the growth nouris hment of mental and s piritual health. G od is like baby blanket or teddy bear that is special to the infant endows it with a unique quality, cuddles it lovingly, and sometimes hates it. As the child matures , these objects are neither mourned nor forgotten but rather simply lose meaning. T hey are the s tuff of illusion and P.610 mentally somewhere between subjective and objective reality. In this formulation, G od is a s pecial transitional object who does not los e meaning totally and who is always available in religion. R izzuto concludes that a person's humanity depends on illus ion; the type of selected, be it s cience, religion, or s omething els e, our pers onal history and the trans itional space each of has created between his objects and hims elf to find a res ting place to live in.”

S ac red Texts S ome, especially tribal, religions have only an oral and tradition, whereas others have books considered authoritative; examples include the four Hindu V edas , T ibetan B uddhis t G re at L ibe ration through H earing in B ardo, and the T aois t T ao T e C hing (T he W ay and its T his s ection dis cuss es the two most globally influential sacred texts , the J udeo-C hris tian B ible and the Mus lim Qur'an.

The B ible T he B ible is a compilation of papyrus or parchment into two books: Hebrew S cripture (relabeled as the Old 277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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T es tament by C hris tians) and the New T estament. S cripture, written in a language that belonged to Israel never really s pread geographically, presents the s tories creation; the s election of the J ews by the one, true G od the chosen people; and the s uffering of the J ews in quest for holines s. It contains a lengthy catalogue of rituals , and commandments for the faithful to obey, as as a variety of historical recollections , ps alms, wise and prayers . T he book of the prophet Is aiah refers to as a s uffering servant, a man of s orrow who was and rejected yet who “carried our sorrows, was for our trans gres sions , was bruised for our iniquities … his wounds we are healed” (53:3–5). C hris tians claim that their New T estament completes fulfills the Old T estament. T he s uffering servant, for example, is identified as J esus C hrist, the S on of G od allowed himself to be crucified to s ave humankind. T he New T estament also speaks of the problems with starting a new religion, of healing miracles, of the res urrection of J esus , of the power of the Holy S pirit, an impending apocalypse. It was written in koiné language known throughout the cultures of the Mediterranean area and of the ancient Near E as t. J esus C hrist was born and reared as a J ew and many early followers were converted J ews , but the religion founded in his name spread to include converts from many religions. A J ew named P aul, who was a of C hristians , had a profound religious experience on road to Damascus, claimed that he directly came to J esus and G od the F ather as a result of this equated hims elf with the 12 apostles who had known C hrist. His genius and hard work were greatly 278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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res ponsible for the development and growth of the new religion, C hris tianity, which s uperseded the Levitical of Hebrew S cripture and promised believers and eventual res urrection. Hebrew S cripture was written from approximately 900 to 165 B C ; all the s crolls were edited over the centuries and, in approximately 150 AD, reached a form that approximates what appears in modern B ibles. T here many s crolls , each somewhat different, s o that there was a unique s et of original scrolls. Hebrew S cripture is divided into the 22 B ooks of Law (also known as the of Mos es , the P entateuch, and the T orah), the and the W ritings. B etween 150 B C and 50 AD, no religious material was written that entered into the B ible. T he C hris tian began to compile revered written documents in the second century. In 367 AD, Athanasius, the bis hop of Alexandria, elected 27 books that he considered and large, this list, which contained four G os pels, 13 of P aul's letters , and other writings, was accepted by the C hris tian community and came to be known as the T e s tament. In 50 AD, the firs t entry was written, P aul's Letter to the G alatians; the las t entry, II P eter, written in approximately 150 AD None of the G ospel writers, with the poss ible exception of J ohn, knew personally. Modern versions of Hebrew S cripture are of an idealized text and are based on an uns atisfactory century translation of the text into G reek (the B ible), S t. J erome's 4th century updated translation of S eptuagint into Latin (the V ulgate B ible), and portions from s crolls found in the 20th century in the Dead S ea 279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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area. T he oldes t exis ting complete copy of Hebrew S cripture was written in 1009 AD (the Masoretic B ible). K nowledge about the New T es tament text comes from few ins cribed pottery remnants ; fewer than 100 fragmentary 2nd, 3rd, and 4th century E gyptian manus cripts ; 250 incomplete 4th to 9th century parchments called uncials ; 2,500 manus cripts , called minis cule s , written from the 9th to 18th centuries; quotations from the early C hurch F athers ; nearly 5,000 G reek manus cripts , each one different than the other; translations, such as the V ulgate, from the G reek no existing trans lations of a manuscript before the 4th century). V ariants in every New T estament sentence found in the manuscript tradition. In 1966, the United B iblical S ocieties iss ued a “standard” text but noted more than 2,000 choices had to be made concerning significant alternative readings of manus cripts ; in 1975 new, improved, “standard” edition was publis hed. problems have been compounded by the difficulty of translations into nearly all the languages of the world. Hundreds of E nglis h language trans lations of the B ible available; thes e range from the magisterial K ing J ames version to a B asic E nglis h vers ion that limits its to 1,000 words to a politically correct inclusive vers ion which, for example, the opening line of the Lord's translated as “Our Mother-F ather in heaven.” In addition to varying and s ometimes confus ing of events presented in the B ible, textual and differences have influenced the interpretations and practices of believers , some of whom hold that in the B ible is literally true. S uch fundamentalists for example, that Adam and E ve were actual pers ons 280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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whom all human beings have descended, that the s un moves around the earth, that Noah's ark really pair of every animal, and that the earth itself was at 9 AM on October 23, 4004 B C However, most hold that the B ible was ins pired by G od but written by men who compiled their narratives in their own style; the B ible is truthful on significant s piritual matters, s uch faith and s alvation, but is not neces sarily accurate in scientific matters , such as astronomy, animal and botany; and that many biblical accounts are bes t unders tood as meaningful allegories. Although there always been s keptics about s upernatural events in the B ible, s uch as the res urrection of J es us , the truth about fundamental facts is being ques tioned by many s cholars . T here is no good evidence outs ide of B ible itself, for example, that Mos es and J es us were persons or, if they did exis t, that their lives were accurately. T he effects of thes e reports on believers undoubtedly played some role in the marked decline of religious attendance and influence in E urope; the Archdioces e of Dublin, Ireland's larges t archdiocese, example, ordained only one priest in 2001. T he United S tates presents a mixed picture in that, although mos t people profess a belief in G od, church attendance is sporadic, and the number of persons adopting a vocation has fallen dramatically. However, C hris tianity bloss oming in third world countries .

A l-Qur'an Al-Qur'an is a compilation of poetical verses divided 114 chapters ; it is the s acred text of Is lam. Mus lims that, in 610 AD, the angel G abriel confronted in a cave atop a mountain near Mecca, proclaimed him 281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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mess enger P.611 of the one true G od, Allah, and ordered him to read the verses from written S criptures that exis ted in heaven. experiencing doubts about this experience, cons ulted a man familiar with J ewish and C hris tian S cripture who convinced him that Mos es had seen the same angel. W hen Mohammed realized that he was , indeed, a prophet, he followed the angel's instructions and, over the next 23 years, while in trance-like s tates in many geographic locations , read and spoke aloud heavenly verses (Al-Qur'an means the R eading). His utterances were written down by various scribes. varying collections of the vers es were collected that included material from persons who claimed to have memorized s ome of Mohammed's words that had not been written down. W ithin a generation, the C aliph Uthman iss ued a s tandard vers ion that is s till us ed although there are s ome variations because the Arabic s cript neither noted vowels nor contained dots, thus complicating the parsing of a verb as active pass ive. T he Qur'an has no s tory line; the chapters with the longes t pass ages and end with the shortes t pass ages . T ranslations have been pedestrian and invariably fail to convey its augus t and lofty language. T he content of the book focus es on the necess ity of profes sing faith in the unity of one G od who was known the J ews and C hristians . T hey were the original protoMuslims, but then they suppos edly turned from the true path. T hey must become Muslims again by now Is lam (submiss ion to G od). Abraham, Is hmael, and 282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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were true prophets , and Muslims anticipate the return J esus in an apocalyptic time. T he book es tablis hes the of Mus lims to pray s everal times daily, to give alms to poor, to fas t during the month of R amadan, to make a pilgrimage to Mecca, and to obey certain seven of which are similar to the T en C ommandments found in the B ible. In the 8th century, Muslims solidified a belief that their behaviors and laws s hould parallel thos e of his C ompanions, and followers. T hus , collections of were gathered into books of tradition called hadith. T he literature on hadith is enormous; out of several hundred thous and hadith that have been propos ed, only s everal hundred are generally regarded as absolutely whereas the others are clas sified into numerous based on the s trength of the evidence that they can be traced back to Mohammed's time. T wo other forces have influenced Mus lim behaviors and laws are reasoning applied to similar cases and consensus by learned persons. C onsideration of all thes e factors has res ulted in a class ification of behaviors into five obligatory, recommended, indifferent, disapproved but not forbidden, and prohibited. A combined s ys tem of secular and religious law emerged, the s haría. In not covered by the s haría, highly esteemed judges may is sue an opinion called a fatwa. S hi'ite Mus lims , only to the S unnis in number, have replaced the of consensus by a belief that G od selects an infallible, authoritative leader, or Imam, who is descended from Mohammed to lead the faithful of each generation. T here are many S unni, S hi'ite, and other Muslim and s ubdivisions with differing interpretations of his tory, 283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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sacred texts , and s haría. Local customs , the of political states based on Islamic principles , the among fundamentalis ts , moderates , and liberals , and encroachment of W es tern ideas and attitudes have influenced behaviors and caus ed religious problems . homicide-suicide bomb attacks on Is raeli civilians have been both denounced by a majority and prais ed by a minority of differing interpreters of Is lamic principles s haría. T urkey exemplifies a Muslim nation that has adopted a secular, democratic constitution. S audi exemplifies a kingdom caught up in the battle between modernization and adherence to fundamentalist principles: Non-Muslims are not allowed to enter the of Mecca, nor are they allowed to display their own religious symbols or to be buried in S audi soil, yet clothes, fas t food, and televis ion shows are widely available.

S in One of the most profound accomplishments of the was the moral delineation of s in as a rebellion against one true G od and its characterization as wicked, evil, guilt evoking. Hebrew S cripture notes that wicked are es tranged from the womb and go astray as s oon as they are born, following the dictates of an evil heart. century B C J ewis h theologians believed that, from the moment of his creation, Adam, the firs t human, had a of evil s eed that all subs equent humans pos sess . T he penalties for trans gres sing G od's laws included death stoning, horrible diseases, financial failure, severe humiliation, and chronic s adness . However, most J ews are not Orthodox and, rather than referring to notions of innate badnes s or goodness , teach about 284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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personal respons ibility for one's actions . C hris tianity claims that Adam's mis us e of free will—he forbidden fruit—is the original s in that affects and that it can be removed only by baptis m in the Holy S pirit and belief in J esus C hrist, the R edemptor. rejected a majority of J ewish laws and teaches that, through confes sion and repentance, it is poss ible for to be forgiven and unrighteousness to be cleans ed. A of seven capital s ins bas ed on the T en J esus' S ermon on the Mount, and S t. P aul's writings completed by P ope G regory (1540 to 1604) and the present: pride (from which all the others derive), avarice, envy, wrath, lus t, gluttony, and sloth. elevated the role of S atan, a rebellious evil spirit, and a host of less er demons who enticed humans to s in. It perfected a concept of heaven and hell after death and predicted a cosmic apocalyptic conflict in which G od vanquish S atan and then usher in a new bless ed age the faithful. Although apocalyptic s eminars and “fire and brims tone” sermons persist, in modern times, the notions of s in, and hell have gradually withdrawn into the recess es of Wes tern cons ciousness . In 1973, W illiam Menninger in the popular pres s that s in had dropped out of daily conversation and debate. No longer were people of being s inners, nor were they expected to dis play remors e for their s ins . Indeed, attempts by s ome high profile politicians , as well as common pris oners, to their problematic behaviors as s inful are nowadays met with cynicis m and derision. C urrent s ocial morality reconfigured s in into criminal behavior, defective character, or a s ymptom of mental dis order, and mind 285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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replaced s oul in ps ychiatry. F ree will, a necess ary ingredient of s in, has become les s meaningful as accumulates demonstrating that much of human is determined by genetic factors, neuronal functioning, learned res ponses , peer press ure, childhood and a hos t of other naturalistic forces.

S exuality and Gender T he major monotheis tic religions reflect the patriarchal cultures in which they were founded. G od and his are masculine. W omen traditionally were valued for roles as mothers and house keepers and were duty to obey their husbands and to remain silent on mos t matters . J ewis h S cripture contains many references to prostitutes and adulteres ses ; the phras e “to play the harlot” is us ed to describe the act of abandoning one's faith. Dis trus t and fear of women's s exuality are T he book of P roverbs s tates that “the mouth of an woman is a deep pit; he who is abhorred by the Lord fall there.” Mens truating women were shunned as P.612 J esus elevated the status of women somewhat when healed a woman with chronic vaginal bleeding who had touched his robe, talked with women on the s treet, allowed women to accompany him and his male and absolutely forbade divorce (s cholars believe that, later addition to the B ible, J esus s upposedly made an exception in the case of an adulterous wife). Despite several New T estament letters encouraging husbands love their wives, S t. P aul and many of the C hurch tolerated marriage only if a person could not exercis e 286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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sexual s elf-control. W ith E ve as a model, women were perceived as s educers who stimulated men's lustful appetites ; to S t. B ernard (1109 to 1153) was attributed sentiment that “a beautiful woman is like a temple built over a sewer.” F emale virginity became a pathway to heaven, and, in 649, P ope Martin I officially declared perpetual virginity of Mary, the mother of J esus , a belief of the C hurch. Devotion to Mary has remained a hallmark of C atholicism, es pecially among women for whom s he is a model of comportment. T he between virginity and motherhood has been a cause of sexual confusion for some believers who dichotomize women into two types , the s o-called Madonna-whore complex, in which “good” women are like the asexual V irgin Mary, whereas “bad” women are like the biblical prostitute, Mary Magdalen. T he church's recent rehabilitation of Mary Magdalen, who is no longer cons idered a harlot but rather is revered as the firs t to see the res urrected J es us , reflects a s lowly attitude toward women. C atholicis m holds that all acts should not limit the pos sibility of achieving pregnancy, therefore prohibiting the us e of birth control devices . T he defiance of the prohibition by C atholics represents the growing challenge to ecclesiastical authority seen among many C hris tian groups ; in a survey, 75 percent of sexually active C atholic women contraceptives. B y reference to their sacred texts, J ews , C hristians , Muslims traditionally have cited the s ocial superiority of men over women. However, from a his torical the 20th century may be bes t remembered as the era which W estern women achieved a great meas ure of 287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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equality with men. T his revolution in gender began in earnest in 1878, when the American National Women S uffrage As sociation pass ed resolutions that religion had been used to subjugate women, that female s elf-sacrifice and obedience were s elfand that women s hould claim the right of individual cons cience and judgment that men alone claimed. E lizabeth C ady S tanton gathered together 20 learned women in the 1890s to publis h the firs t real document the revolution, T he W omen's B ible . F eminis t biblical scholars hip has blos somed since the social ferment of 1960s in an attempt to liberate the B ible from its orientation and its us e by political religious groups to women's rights and freedoms . F eminis t scholars that they are continuing the tradition of the biblical prophets who expres sed G od's will by pass ing on injustices and on the perversion of religion. Is lamic societies generally limit the freedoms of women comparis on to W estern s ocieties, although change is slowly becoming apparent. Men are s till legally allowed four wives, although each mus t be treated like the in fact, mos t Muslims today have only one wife. S ome S hi'ite Mus lims recognize mut'a marriages in which a pays a woman for her sexual services for a day or so, which the marriage automatically is diss olved. In a few areas, Muslim women can get a divorce somewhat than in the pas t, whereas men cannot get a divorce without incurring the same s ort of civil liabilities as in Wes t. In areas under F undamentalist control, women not travel alone without getting a permit, and adulterers may be s toned to death (it is eas ier to convict a es pecially if s he becomes pregnant, than a man). 288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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little, if any, feminist quranic scholars hip. R es is tance to change in gender relationships stems from the of patriarchal attitudes in Islamic s ocieties with high of poverty and low levels of education, from the inward looking nature of Islamic intellectual life over the past centuries , and from a strong belief in a literal and unchanging interpretation of the Qur'an. C ondemnation of homos exuality, a s ocially divis ive is often based on several biblical citations . T he B ook of Leviticus contains myriad laws, s uch as prohibitions agains t trimming one's beard, eating s hellfish or pork, wearing garments made of a mixture of linen and wool; addition, crops mus t not be planted every seventh and adulterers , fortune tellers, and male homosexuals should be put to death. Although C hristians are not obligated to follow the Levitical laws , most groups have selectively chos en to uphold the prohibition again homos exual behavior. T he book of G enesis tells the story of two angels as men who came to the city of S odom, where a man named Lot allowed them to stay in his home. A group townsmen s urrounded the home and asked about the men, s aying “bring them out to us that we may know them.” F rightened, Lot told them to leave his guests and offered his virginal daughters in their place. T he townsmen failed to break down the door and left. T he day, G od rained fire and brims tone on the city, killing inhabitants, although Lot and his children escaped. T he earliest interpretations of this s tory focus ed on the S odomites ' arrogance and rudenes s to s trangers ; G od killed them for incivility to his angels. T he theme of sexuality emerged full force in the 1s t century B C in the 289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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writings of P hilo of Alexandria, a J ewish his torian. R abbinical writings about S odom in the T almud and the Midras him (commentaries) generally did not mention homos exuality. Although some C hurch fathers agreed with P hilo, others did not, pointing to a parallel s tory in C hapter 19 of the B ook of J udges in which was not implicated. T he S odomite towns men wanted know” the men; the verb “to know” is us ed 943 times in J ewish S cripture, and in only 10 places does it clearly to sexual intercours e. However, over time, the interpretation won out: the K ing J ames B ible translates townsmen's request, “that we may know them whereas the New E nglish B ible says , “so that we can sexual intercourse with them.” S ome s cholars refute translations and note that Lot was not a full citizen of S odom. T he towns men were sus picious becaus e he allowed two s trangers to s tay in the city at night without as king permiss ion of the proper officials and, thus, they wanted “to know” who the two men were. J esus does not mention homos exuality. However, he link S odom with the inhos pitality that his dis ciples might encounter when preaching (Matthew 10:14–15). S t. who barely tolerated marital sexuality, s eems to have disapproved of homosexual behavior, but the exact meaning of the specific words he us ed is unclear. In I C orinthians 5:11, for example, he includes in his list of unrighteous who will not go to heaven people who are malakoi and ars enokoitai. T he translations of thes e vary widely and include effeminate, child moles ters , homos exual, masturbators, immoral, s exually immoral, depraved, and male prostitutes. In fact, sacred, cultic and female prostitution ass ociated with the god B aal 290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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the goddes s Ishtar are condemned in J ewish S cripture. Although homos exual behavior was practiced the ancient world, the designation of a pers on as a homos exual did not become prevalent until the 11th century AD when S t. P eter Damian coined the word s odomia, thus es tablishing an abs tract es sence: who indulged in s odomia were thereafter sodomites (homos exuals).

Alc ohol Des pite the Qur'an's clear prohibition of alcohol, many cultural Muslims drink. Although the total quantity cons umed in Muslim countries is s mall, problem is prevalent, becaus e alcohol is feared and is not integrated into daily life. J ews have drunk alcohol for thous ands of years with minimal disruptive P.613 T he basis of J ewish sobriety was es tablis hed during 200-year period after the return to Israel in 537 B C of J ews who were held captive in B abylon. B efore this, B ible contained many references to drunkennes s, but afterwards , even though J ews continued to make wine, drink it ritually and for pleasure, and to pour sacrificial libations . In addition to the banis hment of pagan gods whos e rituals demanded heavy drinking, alcohol was positively integrated into religiously oriented in the home and synagogue. Drunkennes s a s ocial problem once wine came to be regarded as a subs tance that s hould be drunk in moderation and only conjunction with food and holy rituals. E ven the fear of drunkenness vanis hed, as evidenced by a scientifically 291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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unsound medieval rabbinical ruling that E uropean wine was not as potent as the wine produced in biblical and therefore could be drunk undiluted. Drunkennes s alcoholism became alien to J ewis h identity; the Y iddish expres sion s kikke r vi a goy means “drunk as a However, with the increasing los s of Orthodoxy, J ewis h alcoholism rates are ris ing. No C hristian religious group condones drunkennes s, there are variations in attitudes to alcohol. T he official stance of C atholicis m, reflecting the view of S t. Aquinas , is that drinking wine is lawful, except if a takes a vow not to drink, if a pers on gets drunk easily, drinking scandalizes others. P rotes tants leave about drinking to individual dis cretion, but groups such the Lutherans and Methodists preach moderation, whereas P entecos tals and B aptists preach abs tinence regard alcohol as an invariably des tructive s ubs tance. T hese variations stem from conflicting biblical T he clearest negative comments on drinking are found the book of P roverbs 23:29–33: “Who has woe? W ho sorrow? Who has complaining? Who has rednes s of Do not look at wine when it is red, when it s parkles in cup, and goes down smoothly. At the last it bites like a serpent and s tings like an adder. Y ou will s ee s trange things , and your mind utter perverse things.” Among the Hebrew prophets, Isaiah des cribed E gypt akin to a drunken man who s taggers in his vomit and Is rael's leaders as irrespons ible, because they devote thems elves to intoxicating drinks. Hosea warned that harlotry and wine enslave the heart. J esus warned being drunk at the time of his second coming. S everal in the New T es tament cite drunkenness among the 292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of thos e persons who do not walk with C hris t, who will inherit the kingdom of G od, and who live doing the of the G entiles ins tead of G od. Other biblical pas sages consider wine as a staple of a bles sing from G od. Is aac as ked G od to give his son, J acob, the dew of heaven, the fatnes s of the land, and plenty of grain and wine. In the book of Amos, G od promis ed to return the J ewis h captives to Is rael, where they s hall plant vineyards and drink their wine. notes that when the people of J udea and Is rael are res tored, then their hearts will rejoice as if with wine. J udges 9:13 refers to wine “which cheers both G od and men.” P roverbs advocates giving wine to pers ons who bitter of heart, s o that they can forget their misery and poverty. I T imothy 5:23 encourages the use of wine “for sake of your s tomach and your frequent ailments .” In the United S tates, alcohol and religion have a linked history. T he consumption of alcohol was quite after the R evolutionary W ar. Americans felt patriotic drinking liquor distilled from healthful, native corn and regarded intoxication as a freedom cons onant with hard-won independence. B enjamin R ush, one of the founders of the American P s ychiatric As sociation, cons idered whiskey and rum as the ruination of the nation, although wine and beer in moderation were the 1780s , Methodis ts and Quakers were like-minded forbidding the drinking of hard liquor, the former it interfered with religious practices and the latter it interfered with s elf-control. In 1826, a P res byterian minis ter in C onnecticut delivered six s ermons on the of liquor that became a basic text of the American T emperance S ociety. Local temperance s ocieties grew 293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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from 222 in 1827 to 8,500 in 1834, and antidrinking became popular. New towns were established to temperance values, the bes t known being P alo Alto, C alifornia, the s ite of S tanford Univers ity. In 1874, the Women's C hris tian T emperance Union was founded demanded the worldwide prohibition of alcohol, prostitution, child marriages , foot binding in C hina, the J apanese geisha s ys tem, and the sale of opium. frontier churches held that temperance was not enough claim s alvation; only total abs tinence would do so. In 1893, a minis ter from Ohio founded the Anti-S aloon League and s ucces sfully delivered votes for politicians supported prohibition. J ames C annon, a Methodis t from V irginia, pushed through the prohibition to the U.S . C ons titution in 1917 by demonizing alcohol the major caus e of the nation's ills. Although alcoholis m rates declined, prohibition res ulted in wides pread lawles sness and the creation of a vast criminal Ins tead of pros perity, the nation experienced a great economic depres sion. B ishop C annon was dis graced charges of war profiteering, illegal s tock deals , and corrupt political practices . T ired of austerity and nays ayers, Americans repealed prohibition in 1933.

Healing In the earlies t days of humankind, spiritually powerful and women known as s hamans healed disease and revers ed mis ery by retrieving lost souls , by pacifying exorcising malign spirits , and by providing counterT heir legacy continues today in “faith healers ” that exis t all cultures , although, especially in W estern nations, are impostors. 294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Hebrew S cripture attributes mos t disease to G od's retribution against dis obedient believers ; E xodus 15:17 the definitive s tatement on G od the healer: “If you diligently heed the voice of the Lord your G od and do what is right in his sight, give ear to his and keep all his statutes, I will put none of the diseases you which I have brought on the E gyptians . F or I am Lord who heals you.” T he early Hebrews dis dained medical practice, because it diminis hed G od's position. However, by 180 B C , the book of E cclesiastes noted sick persons s hould pray to the Lord for healing but also consult phys icians who can provide medicines that heal and take away pain. T he approach of J esus to the sick, many of whom had disenfranchised from full participation in temple was revolutionary. He welcomed the sick and did not blame them for their illness es . Almos t 20 percent of the G ospels are devoted to J es us ' 41 healing encounters individuals and groups . He healed medical and spiritual and ps ychological disorders ; his mos t common was to s ay a few words and to touch the s ick person. A disproportionate number of his healings involved the exorcism of demons, and he pas sed on this power to disciples and all of his followers. T he class ic healing found in the book of J ames 5:13–16 in which sick were enjoined to call the C hurch elders to their be anointed with oil in the name of the Lord, to confes s their s ins , and to pray for one another, and “they will be healed.” In approximately 400 AD, S t. J erome the B ible into Latin; instead of “they will be healed,” J erome wrote, “they will be s aved.” B y this alteration, spiritual salvation displaced the healing of illness as the 295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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central focus of the text and res ulted in a neglect of phys ical healing for almost 1,500 years. In fact, suffering became a C hristian avocation that allowed a person to s hare in J esus ' suffering on the cross . W hen refused to cure P aul (he may have been epileptic) on occasions, the B ible notes that G od's grace was and that his power was made perfect in weakness . defects were no longer liabilities but rather were opportunities to receive the power of J esus. T his formulation enhanced the self-worth P.614 of dis abled and ill pers ons , but it als o contained the potential for persons to accept their infirmities with pass ivity or even to mortify thems elves in purs uit of a higher, spiritual goal. Medicine was devalued, physicians ridiculed, and healing forgotten (except for occasional exorcisms), so people turned to dead s aints for help. A cult of relics , namely, the pres erved body parts of saints who supposedly had performed miracles , prospered for millennium from the 4th century. T he church ass igned saints to specific diseases ; S t. V itus was the patron of persons with chorea, S t. Lucy was the patron of with eye disease, and S t. Dympna was the patron of mentally ill. T he many shrines that held the healing faded into obs curity when medical practice became effective. A major exception is the relatively new shrine Lourdes in F rance, where S t. B ernadette had her vis ion “the lady” in 1858. Local enthus iasts identified “the the V irgin Mary. Although S t. B ernadette died of tuberculos is at 35 years of age and never s tated that 296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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lady” would cure anything, the s hrine at Lourdes was promoted by merchants as a place for healing. S everal million vis itors from around the world travel there including many des perate pers ons whos e illness es not res ponded to medical treatment. Lourdes has an official medical bureau for the certification of healing; les s than 100 have been iss ued. T he Lourdes are emotionally charged and spiritually so that temporary functional improvement in some does occur despite the lack of organic changes . Interes t in religious healing in the form of “mind cures ” emerged at the end of the 19th century in New Mary B aker E ddy, for example, wrote S cience and 1875; s he declared that s ickness is a fearful belief manifest on the human body and that it can be by the divine mind. T he real rebirth of C hristian healing occurred in T opeka, K ansas , when a preacher gloss olalia, linked it to healing, and started a revival that relied on the verses found in the G os pel of Mark 16:16–18: “He who believes and is baptized will saved; but he who does not believe will be condemned. And thes e s igns will follow those who believe: In my they will cas t out demons; they will speak with tongues ; they will take up serpents ; and if they drink anything deadly, it will by no means hurt them; they will lay on the sick, and they will recover.” T he American Midwest proved to be a congenial setting for P entecostal faith healing. F rom its humble beginnings in s mall churches , faith healing ceremonies have progress ed to radio and large scale television presentations that raise millions of dollars throughout North and S outh America, E urope, and Africa. T he 297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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presentations us ually are s pectacular extravaganzas replete with extremely large and expectant crowds, tech lighting, fast-paced music, and continual choruses praise. T he healers have celebrity s tatus and are performers. T he healings often consist of the dramatic exorcism of illnes s—demons who have s uppos edly poss ess ed the sick pers on. S ome s ophisticated speak more about demonic oppress ion rather than poss ess ion, es pecially in pers ons with impulsivity problems , such as compulsive gamblers , alcoholics , subs tance abus ers, and self-cutters . E ven mainstream C hris tian churches have turned to healing, although in a les s s pectacular and calmer in a charismatic renewal that includes s peaking in uttering prophecies, and prayers for healing. After a of 1,600 years , the C atholic C hurch redis covered during the V atican C ouncil II in the 1960s. T he of E xtreme Unction, for example, was renamed of the S ick and is no longer reserved for the dying in private but is given publicly as soon as any of the begins to be in danger of dying from s ickness or old Many flamboyant faith healers have been exposed as charlatans , whereas others probably believe they are doing G od's work. F ollow-up studies have consistently found no evidence of cures, although many pers ons feel better briefly. A study of 71 P entecostal C hristians experienced hands -on faith healing for conditions from leukemia to peptic ulcer to warts found that all the subjects reported an ins tantaneous or gradual healing, despite the fact that the original symptoms were unchanged. T hey proclaimed thems elves to be healed because their belief in G od increased, as did their 298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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conviction that they were leading a proper, righteous S tudies of attempts to heal persons by prayers offered distant s ite, so that subjects have no knowledge of the prayer attempts , have shown no great advantage to prayed-for vers us control groups . An often-cited study coronary care patients did s how a slightly better cours e among prayed-for patients , but a flawed methodology cas ts doubts on the results : No was provided about the psychological characteris tics of the subjects or the treatment practices of the various health care plans ; the coordinator of the s tudy not only knew which patients were in the prayed-for and control groups , but also was responsible for record keeping on subjects ; and, when the s tudy was returned by a editor with a revision request, the author reconstructed the criteria about what establis hed a good or bad cours e after he knew which group each patient was in. E specially in times of crisis, prayers offer hope. may point to the New T estament, which states , things you ask in prayer, believing, you will receive” (Matthew 21:22), and, “whatever you as k the F ather in My name, He will give you” (J ohn 16:23). However, when a petitioner's prayers are not is us ually the cas e, theologians turn to the biblical of J es us in the garden of G eths emane before his and capture when he prayed to G od the F ather, “not will, but what Y ou will” (Matthew 31:39). Any interpretation of a s upernatural intervention, s uch as intercess ory prayer for a sick pers on, depends on the mind-set of the participants. If a prayed-for pers on is cured, the skeptical scientis t may pos it a natural, but yet unders tood, mechanism; if the pers on is not cured, 299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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skeptical theologian may contend that the wrong prayer or not enough prayer was offered, that G od was angry being tes ted, or that the res ult was G od's will.

R eligion and Mental Health T he complicated relationship between religion and health is due, in part, to definitions. Is mental health, for example, merely the abs ence of ps ychopathological symptoms or does it imply happines s, contentment, tranquility, s pontaneity, the capacity to love and to the maintenance of a right relations hip with G od, and fulfillment of one's intellectual potential? Is it mentally healthier to criticize or to s ubmit to authority, to be independent or to be dependent on family and friends ? it religiously healthier to focus on self-realization or to accept dogma that demands obedience? G ood data on relations hip between religion and mental health are to come by, especially in non-Wes tern countries in so-called official s tatistics are often misleading P sychiatry has a formal lis t of ps ychopathological s igns and s ymptoms, but there is no such lis t for religion. because at leas t 21 variables have been identified as components of religios ity, the selection of appropriate variables to include in scientific s tudies is problematic. most us eful delineation of religios ity is probably G ordon Allport's and J . Michael R os s' intrinsic and extrinsic T he former implies a sincere commitment to one's which are internalized and serve as a guiding behavior, whereas the latter implies the use of religion obtain status , s ecurity, s elf-justification, and s ociability. P sychiatric studies on the relationship between religion and mental health have generally treated religiosity 300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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superficially. R eligious P.615 studies, although numerous , tend to rely on s elfoverrepres ent churchgoers and college s tudents , exclude nonbelievers , emphasize church attendance variable, and lack longitudinal data. Mos t s tudies are correlated: A cons istent finding that elderly pers ons attend church demons trate better mental health than those who do not, for example, may s imply mean that elderly churchgoers are in good enough physical health make the trip to church. B ecause there is a pos itive relations hip between physical and mental health, attendance in this group may s ignify good physical and may have little to do with mental health. No meaningful general conclusions can be made at time about the impact of religion on mental health. A conceptually s ound s tudy of 1,902 female twins over a year period found that, except for a lower us e of and alcohol and a poss ibly lower level of depress ion, was little evidence overall for a relations hip between current ps ychiatric symptoms , lifetime and religiosity. A survey of 14,000 youths found that sort of religious commitment was related to a likelihood of s ubs tance abus e. S tudies of religious meas ures in pers ons who had experienced s tres sful events within the pas t year found that religious rituals times of crisis were helpful in 40 percent of cases and harmful in 23 percent. T hese coping meas ures were helpful to religious pers ons who had les s access to material resources and power, s uch as the elderly, the poor, the less educated, African Americans , the 301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and women. R eligious beliefs may affect the express ion of ps ychopathology. S ome psychotic and manic patients proclaim thems elves to be a god, a prophet, a a s aint. P aranoia may focus on s atanic plots . may be interpreted as supernatural events. Depres sion special cas e in that its psychological torments have, recently, often been cons idered an authentic part of the religious experience; for C hris tians, it is a sharing of sufferings of the martyrs and of J es us on the cros s, whereas many S hi'ite Muslims, during the ritual remembrance of the martyrdoms of religious heroes , flagellate thems elves frenetically and recall the words Hus ain: “T rial, affliction and pains, the thicker they fall man, the better do they prepare him of his journey heavenward.” T he tribulations of Moses are an component of J ewish identity. B uddhism acknowledges the Noble T ruth that s uffering is univers al and that aging, and death are s uffering produced by a craving and repuls ion of s ense pleasure, for existence and nonexistence, and for becoming and s elf-annihilation. Indeed, the calmnes s and s eeming pas sivity of s ome B uddhis ts in dealing with their suffering may tes t the patience of W estern ps ychiatris ts who are accustomed patients s eeking rapid s ymptomatic relief with G uilt, another component of depress ion, and s in are reported by fewer patients nowadays. E ven though obses sive-compuls ive disorder (OC D) mimics the calculated rituals of s ome religions , fewer patients ruminate about right and wrong and good and evil. shifts indicate a decrease in religiosity and an increase naturalis tic, scientific beliefs and modes of express ion. 302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Although conversion dis orders are s till prevalent in world countries , their decline in W es tern nations has attributed to the transparency of the s ymptoms in the of wides pread, public understanding of ps ychological principles. In fact, pers ons with conversion disorders be overrepres ented in the throngs of uns ophisticated attendees at faith healing revivals and crusades , s ome which may attract 100,000 participants, as well as a television audience. Attraction to thes e s pectacles represents a disappointment that modern medicine, despite its technological advances , s till cannot cure all diseases . T he rapid growth of C hristian groups that emphasize unabashed emotionality, mus ic, singing, gloss olalia, and a ques t to attain s piritual joy may res ponse to what seems to be a worldwide increas e in depres sion. G loss olalia or s peaking in tongues is a unders tood, nonpathological phenomenon in which a person utters a series of words that are totally unintelligible to the speaker and to listeners . It can quiet or in highly emotional s ettings , in groups or in solitary privacy, in children as well as adults , and in and lower–social class pers ons . It usually is not with an altered s tate of consciousness . It rarely is a negative experience; mos t of the time, it is mildly and s ometimes very positive. It pos sibly benefits depres sed and anxious pers ons a little bit. T he practice mentioned in the New T es tament as a minor gift of the Holy S pirit, ranking below wis dom, faith, healing, and prophecy.

S pirituality S pirituality is a somewhat nebulous concept. In 1990, David E lkins, a psychologis t, outlined the values of 303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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persons as belief in a “greater s elf” or pers onal G od, a sens e of purpose in life and quest for meaning, of the sacredness of nature and of all human knowledge that ultimate fulfillment is found in and not in material things , altruism, idealism, suffering and death, and leading a life that has a effect on people, nature, and whatever they consider to ultimate, trans cendent reality. S piritual and religious values overlap, but a person with extrins ic religiosity be lacking in s pirituality, whereas a nonchurchgoer who volunteers at a homeles s s helter and is active in environmental caus es may be spiritual but lacking in religiosity. T he spectrum of s pirituality is exceedingly broad. At end is religious s pirituality as exemplified by the quiet prayerful practices of monks and nuns and by the enthus ias tic, highly motoric practices of S ufi Mus lims P entecostal C hristians . At the other end is New Age spirituality, which includes ethereal mus ic, cosmic vibrations, abductions by aliens from outer space, readings, pas t-life regres sions , being touched by and near-death experiences that occur when persons in a s tate of what appears to be death but then are S ome persons later report that they were out of their bodies during the near-death period, looked down at thems elves , and felt thems elves moving through a dark tunnel peacefully. T hey reviewed their lives as in a panorama. T hey s aw a glowing light with a human cities of lights , and a border from which there is no T hey met deceased relatives and friends . T hey heard doctors or spectators who pronounced them dead, but they were res cued from death by a s pirit. R emarkable 304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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similarities exis t between the reports of near-death survivors and by us ers of hallucinogenic or other drugs. is likely that, when a person approaches death, there is decrease in respons e to external s timuli, a turning of attention, the releas e of old memories , and a fear of death that triggers hallucinations , dreams , and fantas ies of G od, heaven, and rescue. S hould the person survive, then the near-death experience may be interpreted as a valued s piritual phenomenon, various s tudies , as much as 22 percent of s uch have been des cribed as hellis h and terrifying. It is not s urprising that the therapeutic approach of AA centers on s pirituality because of the nature of alcohol. T he V arietie s of R eligious E xpe rie nce , written in 1902, commented on alcohol's power to s timulate the faculties of human nature, to bring drinkers to the core of life, and to make them, for the moment, one truth. Dis tilled spirits were originally called aqua vitae — water of life. T he ancient G reeks worshiped the god Dionys us , who suppos edly invented wine. At his chaste orgies , women were intoxicated with wine, danced ecstatically in the darkness of the mountains, and then ripped apart wild animals and devoured them in the P.616 that each mors el contained a bit of Dionysus hims elf. was als o revered as the Lord of S ouls, his likeness , drunken revelers to a happy afterlife, painted on sarcophagi. T he B ible calls wine “the blood of the and, in C hris tian thought, J es us ins tituted the sacrifice at the Las t S upper, when he offered his bread and wine that he declared to be his body and 305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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B y eating the bread-flesh and drinking the wine-blood, disciples ingested their G od, and his immortality theirs , an immortality available forevermore to believers who partake of this s acrament of Holy C ommunion. J ellinek, one of the greates t alcohol researchers , that alcoholics us ed drunkenness as a type of s hortcut higher life and higher mental state without an emotional or intellectual effort. T o be “high” is to be clos er to AA is not a religion, although s ome critics have as a religion in denial. Its roots are C hris tian; its steps and traditions unconsciously recall the 12 tribes Is rael and the 12 dis ciples of J es us . T o fulfill the s teps , members mus t believe in a power greater than thems elves , turn their lives over to G od as they him, improve their cons cious contact with G od through prayer and meditation, and experience a spiritual awakening. T he most detailed s tudy of AA dynamics is E rnest K urtz's book, Not G od: A H is tory of Alcoholics Anonymous . T he curious title refers to the fundamental mess age of AA, namely, that each alcoholic mus t claim to be more than human. R eligion's aspiration for perfection and absolute truths was too grandiose for founders of AA, who broke away from the C hristian G roup and es tablished AA's miss ion of s aving “drunks ” not the world. One of the founders noted that, before he was trying to find G od in a bottle. F or many the spiritual approach of AA is undoubtedly effective, although the organization's commitment to remain forever nonprofes sional has hampered impartial

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of religion and spirituality in their lives, the frequency intens ity of their participation in religious and spiritual practices , and the leadership s tyle and members ' behaviors of the religious and s piritual groups in which they are involved. G eneral familiarity with the beliefs behaviors of certain groups in which patients are must be joined with knowledge about s pecific local groups . S ome patients may es chew participation in congregational life—they may lack trans portation, have health problems, feel embarrass ed by their shabby or get panic attacks in crowded churches —and watch televangelis ts in the comfort of their homes . Many pray, put their trust in guardian angels , and read s acred texts daily; although their level of unders tanding may be unsophis ticated, the mere presence of the s acred text their reading of it s uffice to provide a sense of s ecurity purpos e, feelings of hope and solace, and reaffirmation a G od who pers onally cares for them. P sychiatrists s hould ass ess patients' religious and involvement in terms of mental health and social and must be alert to the misuse of religion; an example the citation of s acred texts by some C hristians , J ews, Muslims to jus tify the humiliation and physical abuse of wives. B y using pass ionately pious appeals , abusers gain the s upport of their in-laws and local groups . P sychiatrists who treat the wives of s uch persons may portrayed as evil doers who s ubvert the will of G od, they endors e the s tatus quo. However, if therapeutic efforts to ameliorate the abus ive situation fail, then must be cons idered, even though the patient may find herself es tranged from her family, her congregation, maybe even her religion. 307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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It is improper for a ps ychiatris t to pros elytize or to dispense s pecific s piritual advice or to pray with other than to remain res pectfully s ilent if a patient does pray. It is proper to suggest to appropriate patients that participation in religious and s piritual activities may some ps ychos ocial benefits and to respect and to encourage thos e religious and s piritual beliefs and practices being used by patients to cope with their However, it is important to know that religious organizations are not mental health providers, although the promotion of mental health may be provided such activities as caring human contacts , forums for open discus sion of values and behaviors, and material help, prayers, and moral support in times of cris is. T he ultimate purposes of religion are not mental health and euthymia but rather salvation and the quest for P sychiatrists s hould warn patients about membership cultic groups and s hould refer patients to mental health chaplains when is sues such as s alvation and dogma “B orn-again” C hris tians us ually s eek out ps ychiatris ts therapists who belong to their congregation or who publicly identify themselves as C hristians , may pray their patients , may use biblical examples in treatment, regard homosexuality as a sin, and may be loathe to cons ider divorce as an option. However, mos t C hristian ps ychiatris ts are aware of the tendency of some disguis e ps ychological problems by a religious presentation. In a study of C hristian-oriented cognitivebehavior psychotherapy, religious and nonreligious therapists were equally effective.

C UL TUR E A ND ME NTA L IL L NE S S Mental illness is the res ult of a complicated chain of 308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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that implicate flawed biological, psychological, s ocial, cultural process es . S ometimes, the proximal caus es of ps ychopathology are clear cut; examples include storm, drug intoxication, and the experience of a event. However, in most cas es , ps ychopathology slowly in ways not fully unders tood over the cours e of a lifetime. S cientific explanations of ps ychopathology are based on naturalistic, material findings, although the observation, determination, and interpretation of thes e findings may be incorrect and bas ed on cultural biases ; various times, psychiatrists have believed that female masturbation may res ult in mania and epileps y, that mothering may caus e children to be s chizophrenic, that homos exuality in its elf is pathological, and that one or expos ures to heroin invariably res ult in addiction. C ulture influences mental illnes s in many ways. T he content of people's delus ions, auditory hallucinations , obses sional thoughts, and phobias often reflects what significant in their culture; examples include the delus ion of being J esus, Mohammed, or B uddha; the delus ion of being persecuted by terroris ts , the C entral Intelligence Agency (C IA), or space aliens; and contamination by germs , nuclear was te, and environmental toxins. S ocial phobia, as it is known in Wes t, may be shaped by J apanese culture into a known as taijin-kyofu-s hio, an exces sive concern about interpersonal relations, body odor, and eye contact, with flushing. T he J apanes e psychiatrist, S homa developed a s pecial therapy rooted in Zen B uddhism this condition in which patients undergo res t and followed by participation in s imple tas ks , make entries diary for written comments by the therapis t, learn to 309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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appreciate and to accept things as they are, and their attitudes toward life. C ulture can elaborate normal behaviors , s uch as the reflex and s leep paralysis. In Malaysia and Indonesia, hypers tartling persons, called latahs , may be gleefully goaded by onlookers until they are s o flus tered that utter obscene words , obey forceful commands , and the onlookers ' behaviors. In Newfoundland, C anada, experience of s leep paralysis, which occurs when as leep or awakening P.617 and may be ass ociated with hallucinations, has been elaborated into an “old hag” syndrome. C ulture can facilitate the prevalence of disorders such as abuse and suicide, whos e rates differ depending on attitudes. T he cultural acceptance of technological advances has contributed to global obesity; the replacement of bicycles by motorized vehicles and of shovels and saws by mechanized tools has res ulted in sedentary lifes tyles . In some areas of Africa, obesity come to be valued as an indicator that a person is not infected with human immunodeficiency virus (HIV ). C ultural mating patterns may influence the prevalence ps ychopathological genes ; intermarriage on the s mall is land of B elau, Micronesia, has resulted in a high schizophrenia rate, whereas the effects of female infanticide in C hina, which has caused a surplus of 50 million single men and the ris e of cous in-marriages in “inces t villages,” remain to be s een. C ultural attitudes res ulting in s tigmatization affect the prognos is of disorders ; a positive effect of the current, albeit 310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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overs implified, notion that major mental illness is the res ult of a “chemical imbalance” has led to greater acceptance of the mentally ill by family, friends , and society and greater access to treatment res ources .

C ulture-R elated S yndromes T here is extreme diversity among the peoples of the concerning the recognition, class ification, and unders tanding of mental behavior s ymptoms. W es tern ps ychiatris ts class ify mental diseases according to the DS M-IV -T R and the International C lass ification of (IC D), which are thought to reflect scientific categories. P eople living in W es tern countries, in part because of economic might and military prowes s, have ass umed their world view is basic and true, whereas the world of others are variations on what is natural. However, lack of biological markers and the differing of behavior contribute to the ethnocentricity of thes e clas sifications. T he DS M-IV -T R and IC D are not applicable; ps ychopathological s yndromes exist, in non-Wes tern cultures that do not fit the scientific nomenclature unless they are placed into the “atypical” category. T hes e s yndromes are perceived to be more influenced by culture than are most W es tern and, therefore, have been labeled culture -bound, culture -re late d is a better term. S ome syndromes are in dis tinct cultural groups , whereas others are found in large cultural regions . Malgri, or intruder sicknes s, is a syndrome of s ome Aus tralian aborigines in which an offended s pirit attacks pers ons who enter the s ea or a foreign territory without performing a proper ceremony and caus es fatigue, headaches, and painful dis tended abdomens . F amily s uicide is a J apanese behavior 311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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which dis graced parents kill thems elves rather than live with shame; they als o may kill their children for fear their orphans would be s ocial outcas ts. K oro in and s uoyang in C hina are disorders in which men panicked and fearful of death, because they believe their penis is s hrinking into their abdomen. W estern patients with koro-like symptoms tend to be schizophrenic, brain damaged, or intoxicated with or drugs , s uch as amphetamines . Amok runners are Malaysian men who, after a period of brooding, erupt a s tate of frenzied violence and indis criminate attacks that end with exhaus tion and amnes ia. Often runners are killed by the police, although attempts are made to s ubdue them. Most s urviving amok runners been diagnos ed as s chizophrenic. Indis criminate mas s homicidal behaviors have been increasing in W estern cultures, es pecially in the United S tates , in schools and workplaces , s uch as factories and pos t offices. T hes e behaviors differ from terrorist attacks in that they are driven by political and religious motivations . P s ychiatric diagnoses have rarely been made in Wes tern cases , although, on autopsy, a s mall pineal tumor was found man who climbed a tower at the Univers ity of T exas shot at a pas sers by. F ear-of-becoming-fat anorexia appears to be a culture-related syndrome in Wes tern countries , as is diss ociative identity disorder, which to derive from a lingering notion of demon pos ses sion; well-publicized cas e in F rance in 1611 involved a girl, after being seduced by a priest, was s ent to convent at which s he and a young nun were found to be by more than 6,000 demons after developing visions of demons , and lewd behaviors with a crucifix. 312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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FOL K B E L IE F S A B OUT ME NTA L IL L NE S S T he distinction between cultural explanations of symptoms and true s yndromes is often problematic. beliefs about mental illnes s are rarely found in written form, fall outs ide of the s cientific tradition, and are often magical, integrative, and definitive. Although irrational, they offer explanations for life's vagaries and make the seeming capricious nes s of pathology more acceptable. S cientific and folk beliefs are ritualistic and, regard to mental illness , have s uccess es and failures . systems may function s imultaneously within a culture within a pers on. A mentally disturbed pers on may seek ps ychiatric help and, at the same time, indulge in folk therapies. F olk beliefs about the caus ation of mental illness may to naturalis tic and supernatural forces . E xamples of caus ation include heart dis tress in Iran and renal and nervous s ys tem exhaustion (neuras thenia) in Mys tical theories include fate, astronomical influences, predes tination, bad luck, ominous sensations, contact with mens trual blood or a corps e, violation of taboos , s peaking forbidden words, trespass ing, and improper conduct toward kinsmen, strangers, social superiors , or spirits . Animistic theories include s oul los s and aggres sive acts by s pirits. Magical theories ascribe illness to the use of s orcery or witchcraft; s orcerers their power by s uch means as apprenticeship, theft, whereas witches poss es s inherent powers . techniques include spells; hexes; prayers; curs es ; the supposed intrusion of objects into a pers on's body; performed over portions of a person's body (e.g., nail 313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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clippings and hair), excreta, or poss ess ions; of poisons that are us ually inert pharmacologically; capture of a victim's soul; sending alien spirits to victim; and rites performed over pictures and dolls thought to resemble the victim. S cientific beliefs hold that dis harmonies in the environment and in s ociety may be linked with mental phys ical disorders in individuals, whereas folk beliefs include s piritual and s upernatural dis harmonies. In traditional C hines e medicine, pathology of the human body and of emotional express ion reflects imbalances cosmic forces ; epilepsy and koro res ult from excess ive a female negative force, whereas mania res ults from yang, a masculine, pos itive force. In this system, emotions are linked to five visceral organs that are to five elements and that are affected by humidity, heat, dryness , and cold. V itality and health in this also depend on jing (vital energy) and qi (vital air). ps ychological concepts have little place in C hines e medicine in which the focus is on a holis tic balance of internal and external forces and on the prescription of herbal remedies, medications, diet, and acupuncture. T raditional Indian medicine, Ayurveda, has s ome similarities with C hinese medicine, although it pays attention to mental disorders , is somewhat more ps ychologically minded, allows for sorcery, and has a broader pharmacopeia. W es tern alternative medicine practitioners, es pecially thos e who practice in luxurious health-spa s ettings , often claim to us e traditional and Indian practices ; patients are us ually told to s top smoking, to eat a nutritious diet, to drink green tea, to relax, to meditate, to get mas sages , to practice yoga, 314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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to take s ome herbal “medications ” (one well-known phys ician has sold an expensive herbal mix that he described as “pure knowledge compress ed into herbal form”). P.618 F olk beliefs about mental illness are too numerous to report; however, three examples—nerves , hexing, and spirit pos sess ion—are presented.

Nerves T he E nglis h-language terms ne rvous , a cas e of the and ne rvous bre akdown are us ed commonly to mental disturbances ranging from mild anxiety to a ps ychotic epis ode. Among Latinos , the word ne rvios similar general meaning but is more frequently us ed has been elevated by cultural psychiatrists to an idiom distress . It is us ually as sociated with feeling frustrated stress ful situation. Ataque de ne rvios (nervous attack), prevalent among P uerto R icans , is characterized by sudden, dramatic, loss -of-control, anger-discharging behaviors , s uch as falling on the floor, flailing limbs , grinding teeth, and clinching fists. It may involve aggres sion toward others , in which cas e, it often is as sociated with amnesia. Attacks have been likened to adult temper tantrums and epileptic seizures. S ome persons may appear to be in a diss ociative s tate during attack but are not uncons cious . Attacks always occur in the presence of observers, and, unlike true seizures, there is no incontinence or tongue biting. T hey are attention getting and may be used for secondary gain, such as family control; persons may instill fear and guilt 315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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family members by threatening to have an attack if they are angered.

Hexing: The E vil E ye More than one-third of world cultures hold a belief in evil eye hex. It is widespread throughout E urope, the E as t, His panic America, the Indian subcontinent, and Africa. It is called mal occhio (Italian) and mal de ojo (S panis h). T he evil eye is generally considered to be a sudden, destructive power—sometimes unknown even to the persons who pos sess it—from the eye of a human an animal. T he victim who is hexed may develop headaches, s leepiness or fitful s leep, exhaustion, depres sion, hypochondrias is, spirit poss es sion, failure to thrive, anorexia, listles sness , diarrhea, disrupted social relations hips , and s udden death. T he supposedly can caus e the death of animals , the food, and the wilting of crops; in centuries pas t, J ews in G ermany were forbidden to look at crops for fear that glance (J ude nblick) would be damaging. P ers ons who thought most likely to pos sess the evil eye are those phys ical deformity (es pecially a hunchback), strangers, jealous kin or neighbors , marginal members of society, barren women, the poor and hungry, persons with their lot in life, children who return to their mother's breast after weaning (seen among S lovak-Americans ), most importantly, anyone who utters a word of prais e compliment. T he evil eye can strike anyone, but mos t susceptible are wealthy, handsome, and weak children; and women, es pecially when pregnant. A has been reported of a 27-year-old Italian-American 316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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living in P hiladelphia, who thought hims elf hexed in his community agreed with him) and s ubsequently murdered s ix people whom he believed were sorcerers res ponsible for s triking him with the evil eye. Diagnos is of the mal occhio in southern Italy reflects practices found in other cultures . A female s pecialis t three drops of oil into a bowl of water, cros ses herself, recites ritual words , calling on G od to remove the evil If the oil and water mix, the patient's s ickness is to be organic. C oagulation of the mixture is evidence of the evil eye. S ymbolically, the water repres ents and the oil repres ents evil. T he force of the Holy T rinity counterbalances the evil eye, thought, and desire. techniques are us ed to ward off evil eye attacks ; include building high, solid fences or walls around home, avoiding the dis play of one's wealth, smudging face of an infant with dirt to make it appear invoking G od's name immediately after one receives a compliment, and pos sess ing amulets in the s hape of horn or of a hunchback holding a horseshoe.

R oot Work P robably derived from hoodoo, root work is a hexing found among s ome African Americans, especially with lower social clas s, rural, S outhern backgrounds. hex is adminis tered by tampering with a victim's food or drink or by a touch or an evil glance. Other techniques include s prinkling s and, salt, or pepper on a victim's step; burying a knife with its point towards a victim's house; and magically manipulating various items — household goods , blood, excreta, and hair—in with special times, such as s unrise or the dark of the 317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and s pecial days, such as F ridays, and the 13th day of month. P ers ons who believe thems elves to be hexed may emergency rooms with symptoms s uch as chest and abdominal pain, unresponsivenes s, fainting s pells, lip smacking, and epileptic seizures or ps eudoseizures . P sychiatrists may encounter s uch patients becaus e of severe anxiety, hallucinations, and persecutory or grandiose delusions . B ecause they think that might be ignorant about or disparaging of the notion of hexes , victims rarely report their belief that they have hexed. It is important to ask s pecifically about the poss ibility of root work or hoodoo.

S pirit Pos s es s ion Altered states of cons cious nes s can be induced pharmacologically, ps ychologically, and phys iologically and are experienced in many ways, s uch as s leep, concuss ion, a reaction to drugs , delirium, depers onalization and other diss ociative states , and meditation. Depers onalization is a fairly common experience and becomes pathological only when as sociated with marked dis tres s and impaired S ome of the features seen in diss ociative dis orders, in general, and depers onalization, in particular, may be interpreted in various cultures as pathological include the frenetic excitement and s eizures known as pibloktoq among Arctic native peoples and s ome forms amok), but they may also be regarded as purpos eful even des irable. T rance is the most common s ocially institutionalized altered s tate of cons cious nes s, and poss ess ion is the most common cultural explanation 318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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trance. In s ome belief s ys tems, s pirits are thought to permanently within a person and may even s erve as an explanation for a variety of s cientifically defined such as epileptic s eizures , s chizophrenia, and slowgrowing viral encephalopathy. It is more usual for stay within a pers on for brief periods of time. W es tern expres sions such as “What got into you? ” and “What poss ess ed you to do that? ” reflect this old belief. In the spirit pos sess ion belief probably is the most ancient prototype of many medical dis orders, s uch as an axis I ps ychiatric disorder, in which people theoretically can disposs ess ed of a dis eas e which comes on them. In situations, pos ses sed persons may be diagnos ed as ill their own culture, as is the case in s ome culture-related syndromes. A world view that allows for spirit pos ses sion can be unders tood fully only on its own terms and not scientifically; within a given culture, s pirit poss ess ion be quite logical, and the pantheon of consens ually validated spirits is unlike a projected paranoid ps eudocommunity. C ultural s ettings conducive to the occurrence of spirit pos ses sion are thos e in which an oppres sive s ocial structure s tifles pers onal protes t and weakens trust in the efficacy of social institutions and in direct actions to res olve s ocial conflicts. S ome healers make diagnoses and perform therapeutic acts while the influence of s pirits ; examples include C hris tian televangelis ts who P.619 are “moved” by the Holy S pirit and male S ufis (Mus lim), known in Morocco as the Hamads ha, who must tame 319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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she-demon spirit of ‘A’is ha Qandis ha. However, mos t poss ess ed persons have a low s ocial status and are B y watching others, they typically learn how to react to spirits within them; s ome s pirits have a s pecific name agenda, whereas others may be ambiguous in their character and demands . P os sess ed persons become spirit carriers and are not personally res ponsible for what the s pirits force them to or s ay, although there always are some social on their behaviors . Malevolent spirits may demean, chas tis e, and caus e their carriers mental, bodily, and interpersonal harm. During positive experiences , may improve their own social s ituation as well as make as tute diagnoses and prescribe treatments for persons seeking help. T he s pirits are us ually judgmental and speak openly about social injus tice, abus ive and flawed family dynamics . T hey may call on es teem the carriers and to fulfill the carrier's des ires for certain poss ess ions and for improved relationships. men poss es sed by female spirits act like women, and women poss es sed by male spirits act like men, the cons truct of s exual identity is publicly examined. T he intricate dynamics of spirit poss es sion vary greatly cultures, and attempts to reduce and to explain them by us ing Wes tern ps ychiatric concepts are invariably unsuccess ful. Although s ome s pirit carriers may, be paranoid, ps ychotic, or hysterical, the proces s is not pathological. Analogous ly, the psychiatric process not be invalidated just becaus e s ome ps ychiatris ts are mentally ill.

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T he number of pers ons who, to s ome extent, fall into category of folk healer is large, and they range from the ludicrous to the sublime; examples include palm and card readers , astrologers, channelers , herbalis ts, New couns elors, psychic surgeons, and shamans. S hamans persons who follow a divers e call to healing and who receive and communicate instructions from s pirits. Different types of s hamans exis t in almos t all cultural groups , s uch as Haitian hungans , Wes t Indian Obeah P uerto R ican s piritis ts, and C hris tian faith healers. P sychos ocial profiles of s hamans s how that s ome are impos tors , s ome are mentally ill, and s ome are healthy, mature individuals . T rue shamans have an ability to recognize and to organize uncons cious needs and concerns , in thems elves and in their cultural group. T hose as piring to be shamans typically undergo an initiation that includes formal didactic training and recovery from a frightening, culturally-formulated, like experience. S ome W estern observers have regarded this experience as evidence of ps ychopathology—“the crazy witch-doctor.” S hamanic therapy usually takes place in a group is a public drama in which the patient and the shaman given strong support by the group. S hamans often thems elves as extraordinary persons, becaus e supernatural world and negotiating with s pirits is harrowing, even dangerous , work. Hallucinogens may taken to facilitate contact with s pirits ; an almos t instantaneous contact may be achieved when hallucinogenic snuff is blas ted up the s haman's nos e through a blowpipe, a practice of the Y amomomo in S outh America. T he s haman's tas ks include the 321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of los t s ouls, the pacification and exorcis m of demons, the provis ion of counter-magic, often by suppos edly sucking out harmful stones and animal parts from a person's body. B y demons trating objectively that has been dispelled, the s haman may effect cures suggestion. Other s hamanic treatments that may be therapeutic include herbal and other medications, surgery, bandaging, and chiropractics. F inally, prescribe steps through which patients can s tabilize cure and demonstrate their healthy s tate. P atients may told to perform acts of atonement and to adopt a new name or a new manner of dress . T he varieties and contexts of folk healing rituals are so that it is impos sible to generalize about them all, but shared commonalities can be delineated: F olk healing often is a group phenomenon, even a s ingle person is identified as sick; healer–patient relations hips are not emphasized. Healing groups are often ongoing rather than time limited. T hey occur with some regularity, and may drop in or drop out of the groups whenever desire. Healing groups may be quite large, sometimes involving hundreds of pers ons , thus enhancing support for participation, the magnificence of the ritual, and, through contagion, the manifestation of desired effects, s uch as trance states and Healing rituals are public events . Attendees include not only identified patients or troubled persons, but also family, friends , community members , and cult 322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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devotees . P ers ons who are healed and prove to be adept at healing others may rise through the ranks to as sistant and then primary healers with a personal following. Alterations in consciousness are central to many healing experiences . W hen in a trance, healers or patients may expres s thoughts and emotions that otherwis e might be repress ed or suppres sed. T his expres sion may be therapeutic in its elf, but it als o often s erves to call attention to interpersonal and social conflicts that are troubling the entire group. T hese conflicts have a better chance of res olution when they are brought out in the context of a controlled healing ritual, rather than in private confrontations . Als o, becaus e s uggestibility during altered states of cons cious nes s, patients res pond positively to the s ugges tion that their experience clearly indicates success ful therapy. T he concept of insight, as usually unders tood by ps ychiatris ts, does not play a role in folk healing P erhaps the most psychiatrically detailed s tudy of a healing ritual is that of the P acific Northwes t C oast G uardian S pirit ceremonial described by W olfgang 1982. T he ceremonial appears to be therapeutic for society as a whole, as well as for depres sed, alcoholic, aggres sive pers ons . Initiates are reduced to a state of infantile dependency during 10 days of seclusion in the quasi-uterine shelter of the dark longhouse. P ers onality depatterning and reorientation are accomplis hed 4 days of alternating s ens ory overload and deprivation, 323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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which result in rapidly alternating s tates of techniques include sleep deprivation, fasting to the of dehydration and hypoglycemia, rhythmic drumming and chants, blindfolding, restricted mobility, forced runs the woods, and s udden grabbing of initiates to stage a symbolic clubbing to death of their diseased, faulty Initiates then go through a phase of phys ical training, as s wimming in ice-cold water and dancing to the point exhaustion. T his is accompanied by intense and instruction in tribal lore. T he mythic theme of the ceremonial is death and rebirth. Initiates are “reborn” when they fully accept the wis dom of their culture, they s ee the G uardian S pirit in a dream or vis ion, and they are given new clothes and a new identity. A large number of tribal group members participate in the S uccess ful initiates who straighten out their lives may invited to return as leaders in s ubs equent ceremonials . A number of Native American tribes have the inges tion of peyote and other cons ciousnes s hallucinogens to achieve a religious and healing experience. However, the Navajo, perhaps the mos t therapeutically oriented of all cultures , focus instead on mind-numbing, ritual, group sings that may last as long P.620 1 week to treat illness es . P atients first undergo s elfpurification by bathing, sweating, and emes is. T he are invoked through specific s ongs and prayers, and healing powers are channeled onto a symbolic design then onto the patient, while tribal members work to reharmonize the patient's natural, s upernatural, and human environments . Ancient, relevant myths are 324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and the gods are compelled to help, provided that the ceremony is performed s incerely and accurately. Analogous to the C hristian belief in demons is the belief in jnun (masculine singular: jinn), whims ical but potentially malevolent spirits. W hen insulted or they may pos sess a person and caus e depres sion, ps ychos is , s udden blindnes s, seizures, anorexia, or paralysis of the face and limbs. T reatment may the spirit, but sometimes, when the s pirit res ides permanently within a person, treatment is aimed at placating it by following its orders and by joining therapeutic cults . S imilar s pirits, as well as a healing are termed zar in northeast Africa and the Arabian penins ula. Zar illness often is diagnosed when us ual herbal, medical, and magical treatments fail to cure a person. V ictims, who are us ually frus trated women, elaborate healing rituals with their families, friends, and cult devotees . W hen a spirit's special s ong is played, entranced victim must dance and tell everyone what and favors her spirit wants to be appeased with to stop symptoms. T his thinly veiled attempt to get attention desirable things us ually is effective, at leas t V ictims may attend fairly regular zar rituals not only for ongoing therapy, but also as a form of entertainment.

C linic al Ps yc hiatric Prac tic e T he history of modern American ps ychiatry reveals that various s chools , each fairly certain, at the time, that held the key to unders tanding and treating mental have aris en, made contributions , and eventually have found lacking. T hus , in one period, intrapsychic conflict and the need for accurate interpretations were 325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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T his was followed by an emphasis on interpersonal relations hips , replete with schizophrenogenic mothers, double binds , and catch 22s . Next came s ocial embodied by the community mental health movement. T he current new s chool is biologically oriented and guilt-relieving, politically savvy, and financially reimbursable brain disease metaphor for mental Opposite to reductionis m is synthesis , the core of the cultural ps ychiatric approach. T his approach demands cons ideration of all the biological, ps ychological, and social forces that impinge on mentally ill pers ons and treatment. It broadens the biopsychosocial model by pointing out that culture overarches and provides meanings for biological, psychological, and s ocial cons tructs, such as brain dis eas e, ins ight, and trance. However, the use of this approach in everyday clinical practice is quite difficult; it is eas ier to go with the flow one's culture, becaus e it feels right and natural, and because there are incentives to do s o. T he role of culture often becomes apparent only when ps ychiatris ts as sess and treat patients whose cultural backgrounds differ from theirs . T he s pecial problems arise in s uch s ituations can be resolved only if are able to adapt their s tandard procedures . T his need adaptability in clinical practice may be regarded with skepticism by those ps ychiatris ts who have embraced certain theory or approach that they apply to all However, from a cultural perspective, no one ps ychological, or social approach can fulfill the needs patients. DS M-IV -T R provides an outline for a cultural formulation designed to ass is t in the s ys tematic and treatment of patients. T he formulation calls for data 326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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on (1) the cultural identity of the patients , including ethnicity, involvement with original and host cultures, language abilities; (2) the cultural explanations and of dis tres s used by patients and their community concerning their illnes s or situation; (3) the cultural impacting patients' s ocial situations , including work, religion, and kin networks; (4) the cultural and s ocial differences between the patient and clinician that may affect as ses sment and treatment, including problems communicating, negotiating a patient–clinician relations hip, and dis tinguishing between normal and pathological behaviors ; and (5) the formulation of an overall cultural ass es sment for diagnosis and care.

As s es s ment E thnic stereotyping is a problem not only for the but also for the patient and for society as a whole. T his practice is ins idious ly fostered in s cientific and popular articles, books , and polls that lump groups of people together in one category, s uch as African Americans , whites, or C atholics , and make generalizations. need to know about the various ethnic identities of patients as well as their current importance. One as sume that all Hispanics are alike; MexicanP uerto R ican Americans , for example, share as many cultural differences as they do commonalities . S ocial is a major variable. T his basic information may be through direct ques tioning and by observation of the patient's language, dres s, knowledge of social and interpersonal style. C linicians s hould not jump to conclusions bas ed on knowledge of a patient's culture. Having visited a 327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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homeland or community, having read a book about it, having a pers onal friend whos e cultural heritage is to that of the patient does not make one an expert, although it may help clinicians to ask appropriate questions and alert them to poss ibilities , for example, a P uerto R ican may engage in s piritis m or that a G reek immigrant may believe in the evil eye hex. It is better to approach ethnic patients without preconceived notions even the mos t basic areas ; in s ome cultures, for sibling may include a person other than those regarded brothers or sis ters in the W es t. Attitudes and with authority figures should be determined. An upperclas s Anglo patient is apt to react negatively to an authoritarian s tance by a ps ychiatris t, but a patient another culture may regard such a stance as and helpful. S imilar attention should be given to toward s ex-related roles; male patients from a culture emphasizes machismo may have difficulty in working a female clinician and so may distort their complaints history. C linicians mus t determine whether patients' reluctance discuss certain topics is the result of pers onal s hynes s, ps ychopathology, or adherence to their s ocial group's customs and etiquette. F rank and detailed ques tions sexuality, especially in the initial evaluation, may be perceived as inappropriate and even offens ive by from cultures in which sexuality is cons idered a private matter. E thnic patients may be touchy about many such as immigration s tatus, family relationships , and finances . An Algerian man with a long history of panic disorder evaluated in an American clinic with a chief complaint 328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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need medicine.” He told the ps ychiatris t that he had unable to find a job in 6 months and that he depended the charity of several people at the local mos que at he was allowed to sleep. He planned to return home for week, to get married, and to return to his current When asked how he planned to s upport himself and a wife, he became angry and said, “that is none of your business .” He refused any more conversation and demanded medication. T he psychiatris t P.621 explained that the question he had asked was routine that he was concerned about the patient's welfare. T he patient was given a 1-month supply of medication but not keep his return appointment. T he case als o typifies many Muslim patients who expect only medications ps ychiatris ts; in P akistan, ps ychiatric patients usually therapy but rather demand intravenous (IV ) fluids, in to demons trate to family and friends that their illnes s is medical. In contras t, s ome Hindu patients may regard ps ychiatris t as a type of guru and accept advice and guidance, es pecially if family members can be drawn the proces s. Mains tream Americans may talk about depress ion, hallucinations , and conflicts , but persons from other cultures may talk about s omatic pains , liver problems, heavenly or s atanic visions , brain ache, and s hadowy figures . T he us e of ps ychological terms and constructs expres s distress is a relatively recent phenomenon in cours e of human his tory; it is neither s uperior nor to somatic presentations. However, ps ychiatris ts may befuddled by patients reared in cultures in which 329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ps ychologizing s eems to be an odd way of selfIn fact, s omatic pres entations may be advantageous in they avoid the s tigma of mental illness . Als o, they may serve to elicit help and social s upport without directly confronting persons or institutions who might retaliate agains t the patient. It is true that adminis tration of medications labeled as antidepres sants is often us eful treating patients with s omatic presentations , but the complex pos sibilities as sociated with somatization may completely miss ed if they are regarded me rely as depres sive equivalents. V erbal and nonverbal communication patterns vary greatly among cultural groups. T seng and J ohn F . McDermott provide the following examples: T he J apanese patient nods his head and keeps saying (yes).…T he hai and the nod probably show only polite participation in the convers ation. T he Hawaiian may your eyes because he was brought up by a who taught that eye contact is rude and has an meaning.…T he S amoan's miss ed appointment may no more than a cultural-social cas ualnes s toward fixed dates and arrangements.…T he C hinese client who “My mother is always kind,” when the mother has been dead for some time is not neces sarily s uffering from unrealized, incomplete grief. T he C hines e language past tens e verb forms .…P eople of Oriental background tend to smile and laugh when they are embarras sed, anxious, or sad. Ass es sment of emotionality and motor behavior is influenced by the cultural norms of the ps ychiatris t and the patient. R es erved Anglo psychiatrists may interpret flamboyant or seemingly overs incere behavior of some 330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Mediterranean area and Middle E as tern patients as histrionic, whereas the patients may judge the to be uncaring. T he diagnosis of hyperactivity in often depends on the tolerance levels of family, and ps ychiatris ts. A study involving ps ychiatris ts from Asian countries who were s hown videotapes of active children demons trated great national differences in thresholds for diagnosing hyperactivity. Hallucinations may be a symptom of psychosis, but, among some His panic groups, they may be ass ociated with milder ps ychopathology or may even be normal. A teenage girl who has vis ions of the V irgin may s imply be indicating her own purity. W hen persons may experience positive hallucinations in they receive advice and s upport from a dead parent. as sess ment of delusions can be tricky, because, by definition, a delus ion is a belief cons idered fals e by members of a society. T he exis tence of the devil verified s cientifically, yet so many people believe in the devil that such a belief cannot per se be considered delus ional. Although there is no s uch entity as the race, belief in it among G ermans in the Nazi era was widespread that it could not be regarded as delusional. V arious subcultural religious cults , political groups, and organizations , s uch as the white s upremacis t Aryan B rotherhood, may hold beliefs considered false by persons in s ociety at large, but they are probably not delus ional in a traditional ps ychiatric s ens e; exceptions include odd beliefs that may result in s uicide pacts or truly harmful behaviors. C ases involving established religions , s uch as J ehovah's W itness es and C hris tian S cience, in which pers ons may refus e certain medical 331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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treatments when severe bodily harm and even death ensue, are us ually handled by the legal s ys tem; courts generally have upheld the rights of adults to withhold neces sary medical treatment for thems elves but not for minors under their control. B ehaviors that may appear ps ychotic may, in fact, be normal when unders tood in their cultural context; a traditional C hines e treatment for kidney deficiency disorder requires an adult to drink the firs t morning of a young boy. C onversely, some behaviors that may appear normal may be pathological. Among the Amis h, example, symptoms of mania may include racing one's horse and buggy, driving a car, using illegal drugs, with a married person, excess ively us ing a public telephone, and treating lives tock too roughly. However, recent years, the “E nglis h” (outside) world has intruded Amish society, so that teenagers engaging in the previous ly lis ted behaviors may be acting out as to manic. P sychiatrists must not only ass ess patients vis their particular cultural groups but als o must as ses s each patient's group vis -à -vis the mainstream culture which the group is a part. W hen in doubt, the should as k members of the patient's social group if cons ider the patient's beliefs and behaviors to be T his process also allows the ps ychiatris t to ass es s, superficially, the s ocial group itself. P atients experience and des cribe their illness es , ps ychiatris ts diagnos e and treat dis eas es. E ach has her own way of comprehending the patient's condition. is extremely important for the ps ychiatris t to elucidate patient's explanatory model of the illness . What does patient think caused the illness ? How is the illness 332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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affecting the patient's mind and body? T hrough what mechanisms does the illnes s work? Does the illness name? What does the patient think will happen if the illness goes untreated? W hat treatment does the think may be effective? W hat treatments have already been tried? If the patient's explanatory model differs that of the psychiatrist, then as sess ment and treatment become problematic. S pecial problems arise when the psychiatris t and the patient do not s peak the s ame language. T here is a tendency to diagnos e more psychopathology when bilingual patients are interviewed in E nglis h rather than their native tongue, for example, slow speech may depres sion and grammatical errors, a thought dis order. Interpreters function best when they have s ome with and training in mental health. Wes termeyer has described three models in which interpreters may (1) as an as sistant to the ps ychiatris t who conducts the interview, (2) as a partner to the psychiatrist in a interaction with the patient, (3) as a primary interviewer the presence of and under the direct s upervis ion of the ps ychiatris t. Interpreters must be taught when to translations that are word-for-word summaries or elaborations of what the patient pres ents. It is helpful the ps ychiatris t to inquire about the trans lator's feelings about and identification with the patient, the patient's cultural group, and social clas s or caste differences might dis tort the accuracy of the translation. S imilarly, patients s hould be as ked about their level of comfort and confidence in the translator. F amily members interpreters pos e s pecial problems in that they may their trans lations to achieve a specific goal, s uch as 333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ensuring hospitalization or s pecial treatment. P.622 F inally, great caution s hould be us ed in interpreting the res ults of ps ychological tes ts and rating s cales unless have been validated for the cultural group under cons ideration. More and more, such tes ts and scales , suitable for use in s pecific groups, have become C linicians s hould not attempt to us e their own because the results may be quite mis leading. In a study of 1,005 adult, low-income, primary care patients New Y ork C ity, the typical profile of a pers on among 20.9 percent of those who endorsed ps ychotic was a s eparate or divorced Hispanic who s poke a primary language. Although the rating ins truments translated from E nglis h to S panish and then backtranslated to identify and to correct translational difficulties , they were not validated for the mainly immigrant Dominican and P uerto R ican groups under study. It is likely that many of the so-called ps ychotic symptoms were really misperceptions of s timuli with depress ion and anxiety, a well-known in C aribbean cultures .

Therapy P sychiatrists are trained in what anthropologists call an approach in which scientific and presumably valid cons tructs apply to all patients, although there is a for atypicality. T he emic approach eschews cons tructs and, instead, attempts to dis cover patients' unders tandings of their illness es as experienced within context of their cultures . T he culturally s ens itive 334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ps ychiatris t balances the etic and emic approaches some cases , may attempt to “convert” patients to the ps ychiatric pers pective of their condition. However, some patients' explanatory models for mental illnes s be embedded within a cultural world view that is to change by negotiation or education. In s uch cases, ps ychiatris ts mus t be flexible in their therapeutic and must respect the patients' beliefs. If ps ychotic for example, inflexibly attribute their symptoms to a work hex, psychiatris ts may support family efforts to obtain folk antidotes or protective amulets and may attribute s pecific antihex properties to the medicine that they prescribe. T his is not trickery on the part of ps ychiatris ts (patients will detect insincerity quickly) but adaptation of s cientific therapy to make it acceptable to patients. T he better the ps ychiatris ts' unders tanding of patients' explanatory models , the better they are able develop an adaptive strategy. In s ome cultures, even color of the medication may alter its effectiveness for patient. P os sible medication s ide effects , even minor ones , mus t be explained in great detail, because some ethnic patients may become noncompliant at the first inkling of a side effect, although, out of respect or deference to the ps ychiatris t, they may s tate that they still taking their medication. T he field of ethnopsychopharmacology, pioneered by K en-Ming showing that genetic and dietary ethnic differences alter responses to medication. Many Asian patients, for example, metabolize benzodiazepines slowly and to lower dos es of lithium (E skalith) and haloperidol (Haldol) than do C aucas ians. Mains tream psychotherapy often focus es on the 335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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achievement of independence as a result of working through conflicts . T he goal and the process us ed to it may be inappropriate for patients from many cultural groups . T herapy with a Hindu in India, for example, focus on restoration of the patient within a family and a social group that values dependence and the of angry thoughts; therapy with a Hindu Indian to the United S tates , however, may have a different Immigrant patients may be torn between maintaining values of their homeland and adopting thos e of their country. T he process of acculturation may be painful, therapeutic attempts to hasten the process may exacerbate the situation with resultant depres sion, and even acute psychotic episodes . Immigrants often best when they are able to retain some of their old and behavior patterns and to participate in ins titutions and rituals that have been transplanted from their homeland. Immigrant children through their in schools tend to acculturate rapidly and to act as socialization agents for adult family members ; the proces s may be a caus e of intergenerational s trife. P sychotherapy with patients from different ethnic and social backgrounds may require much flexibility and awarenes s of s tated and unstated is sues that must be addres sed. T rust is an is sue in a white therapis t–black patient relationship, whereas s tatus contradiction is an is sue when the s ituation is revers ed, and identity is an is sue when the patient and ps ychiatris t are black. from groups who believe thems elves to be victims of discrimination may be unwilling to engage in selfdisclos ure unless the ps ychiatris ts ans wer questions thems elves . S ome patients may present gifts or may 336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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their families to sess ions. P s ychiatris ts mus t be able, in these ins tances , to dis tinguish between ps ychologically and culturally motivated disorders . S ometimes , it is des irable to collaborate with folk In 1978, the W orld Health As sociation and United C hildren's F und (UNIC E F ) is sued a joint declaration on primary health care which called on clinicians to folk healing practices that were proven or considered the community to be helpful. C ollaboration is feasible when the ps ychiatrist and the folk healer are ethical practitioners who respect each other's s kills and patient, for example, may accept medication and hospitalization from a ps ychiatris t and psychological social help from a folk healer. It is not uncommon for a patient independently to seek help from ps ychiatris ts folk healers at the same time. R ecognition of the importance of culture in as sess ing treating patients is evidenced by a 2002 report of the G roup for the Advancement of P s ychiatry. It provides to-date, helpful examples of cultural formulations and culturally informed therapy on s ix patients: a middle depres sed, alcoholic, sexually troubled Irish American whos e s ymptoms subsided after he was reintroduced spirituality through AA and who then entered a to pursue a religious vocation; a middle aged, devout Muslim, P akistani housewife with severe depres sion acculturation and personality problems who believed had been hexed and was helped during a 5-year individual and couples therapy; a F ilipino-American medical student with social phobia and academic problems whos e culturally mediated distorted thoughts were helped with cognitive-behavioral therapy; a 30337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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old black, K enyan immigrant with major depres sion, alcohol and cocaine dependence, and religious and spiritual problems who was helped by an inpatient interdisciplinary team that he likened to a traditional, African, tribal “C ouncil of E lders ”; a 30-year-old, s ingle, dysthymic “good C atholic girl” who resolved her oedipal and rage is sues with ps ychodynamic psychotherapy; 56-year-old E cuadorian, B aptis t minis ter with many personality problems who finally trusted a S panishspeaking therapist with whom he could dis cuss is sues without fear of being criticized, denounced, or stigmatized. J ust as culture strives to organize a society into a integrated, functional, s ens e-making whole, so too cultural psychiatry s trive to make clinical psychiatry logically integrated, functional, and s ens e making. insights from cultural psychiatry are applicable to the entire spectrum of ps ychiatric practice, from ps ychoanalys is to ps ychopharmacology.

S UG G E S TE D C R OS S S ection 4.2 covers s ociology and ps ychiatry. An review of s ocioeconomic as pects of health care is contained in S ections 51.5a and 52.2. Also relevant to sociocultural iss ues in psychiatry is the discus sion of ps ychiatry (in S ection 52.1).

R E F E R E NC E S P.623 Alarcon R D, F oulks E F , V akkur M. P ers onality 338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and C ulture. New Y ork: W iley; 1998. *Al-Is sa I, ed. Handbook of C ulture and Mental Inte rnational P e rs pe ctive . Madison, C T : International Univers ities P ress ; 1995. B erry J W , P oortinga Y H, P andey J , eds . Handbook C ros s C ultural P s ychology. 2nd ed. B oston: Allyn B acon; 1996. B olhenlein J K , ed. P s ychiatry and R e ligion. DC : American P s ychiatric P res s; 2000. B os well J . C hris tianity, S ocial T ole rance , and Homos e xuality. C hicago: University of C hicago 1980. B rown LB . T he P s ychology of R e ligious B e lie fs . Academic P res s; 1987. C omas-Diaz L, G riffith E E H. C linical G uide line s in C ultural Me ntal He alth. New Y ork: W iley; 1988. C rapanzano V , G arris on V , eds . C as e S tudie s in P os s e s s ion. New Y ork: W iley Inters cience; 1977. Des jarlais R , E is enberg L, G ood B , K leinman A. Me ntal H ealth: P roble ms in L ow Income C ountries . Y ork: Oxford Univers ity P res s; 1995. *F avazza A. B odies Unde r S ie ge : S e lf-Mutilation Modification in C ulture and P s ychiatry. 2nd ed. 339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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J ohns Hopkins University P ress ; 1996. F avazza A. P s ychoB ible: B e havior, R eligion, and B ook. C harlottes ville, V A: P itchs tone P ublis hing; F ernando S . Me ntal H ealth, R ace , and C ulture . New S t. Martin's P ress ; 1991. *G alanter M. C ults : F aith, H ealing, and C oe rcion. New Y ork: Oxford University P ress ; 1999. *G roup for the Advancement of P s ychiatry. C ultural As s es s ment in C linical P s ychiatry (F ormulate d by C ommittee on C ultural P s ychiatry, R e port No. 145). Was hington, DC : American P sychiatric P ublis hing; Hollifield M, G eppert C , J ohns on Y , F ryer C : A V ietnames e man with s elective mutism: T he of multiple interacting “cultures ” in clinical ps ychiatry. T rans cult P s ychiatry. 2003;40:329. J elek W G . Indian He aling: S hamanic C e re monialis m P acific Northwe s t. S urrey, C anada: Hancock Hous e; J ones J W . C onte mporary P s ychoanalys is and New Haven, C T : Y ale Univers ity P res s; 1991. K irmayer LJ : As klepian dreams: T he ethos of the wounded healer in the clinical encounter. T rans cult P s ychiatry. 2003;40:248–277. K leinman A. R ethinking P s ychiatry: F rom C ultural 340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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C ate gory to P e rs onal E xpe rie nce . New Y ork: F ree 1988. K oenig HC , ed. Handbook of R e ligion and Me ntal S an Diego: Academic P res s; 1998. K urtz E . Not G od: A H is tory of Alcoholics Wayzeta, MN: Hazeldon E ducational S ervices; Littlewood R . T he B utte rfly and the S erpe nt: E s s ays P s ychiatry, R ace , and R e ligion. London: F ree B ooks ; 2000. Mezzich J E , K leinman A, F abrega H, P arron DL. and P s ychiatric Diagnos is . W ashington, DC : P sychiatric P ress ; 1996. P arament K I. T he P s ychology of R e ligion and Y ork: G uilford P ress ; 1997. P edersen P B , Iraguns J G , Lonner W J , T rimble J E , C ouns e ling Acros s C ultures . 4th ed. T hous and S age; 1996. P odvoll E M: S elf-mutilation within a hospital setting. Me d P s ychol. 1969;42:213–221. R andi J . T he F aith He ale rs . B uffalo, NY : B ooks ; 1989. R izzuto AM. T he B irth of the L iving G od. C hicago: Univers ity of C hicago P ress ; 1979. 341 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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S atcher D. S urge on G e nerals ' R eport on Me ntal C ulture, R ace , and E thnicity. R ockville, MD: U. S . Department of Health and Human S ervices; 2001. S imons R C . B oo! C ulture, E xpe rience, and the R efle x. New Y ork: Oxford University P ress ; 1996. *T seng W S . Handbook of C ultural P s ychiatry. S an Academic P res s; 2001. T s eng W S , McDermott J F . C ulture, Mind and New Y ork: B runner, Mazel; 1981. Ward D, ed. C ulture and Altere d S tate s of B everly Hills, C A: S age; 1989. Warner M. Alone of All He r S e x: T he Myth and C ult V irgin Mary. New Y ork: Landon House; 1976. Wes termeyer J . P s ychiatric C are of Migrants . Was hington, DC : American P sychiatric P ress ; 1989.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 5 - Quantitative a nd E xperimenta l Methods in P sychiatry > 5.1 E pidemiology

5.1: E pidemiology J uan E . Mezzic h M.D., Ph.D. Tevfik B edirhan Üs tün M.D., Ph.D. P art of "5 - Quantitative and E xperimental Methods in P sychiatry"

G eneral C onc epts E pidemiology is one of the fundamental sciences of health and a major approach to the unders tanding and advancement of medicine and health care. is a useful tool for clinicians to link their work to populations and complete the clinical picture. It perspective about the health of the general population, including the caus es and courses of thes e illness es . As concept of health is undergoing dis cernible expans ion, subject and methods of epidemiology require growing differentiation and refinement. C onsequently, it is important that epidemiology be understood and discuss ed in a comprehensive manner s o as to the fulfillment of its mis sion and broad objectives . In line with the above pers pectives , this chapter on ps ychiatric epidemiology, although concise, attempts to take a broad look at its subject matter. It s tarts with an examination of its definition, evolution, and context, striving for a capsular understanding of the of this burgeoning field, as well as of its his torical and 343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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cross -sectional contextualization. It proceeds to review methods of epidemiology, including its key cons tructs variables , the design of epidemiological s tudies (iss ues types ), and the properties , forms, and validation of epidemiological instrumentation. Next, some important epidemiological findings are pres ented and commented on as they deal with the dis tribution of mental disorders and its related factors , of disability and the burden of disease, and of the positive aspects of health social s upports , and quality of life), as well as findings concerning the application of epidemiological methods health care and the formulation and evaluation of policies . T he final section explores future perspectives, including the integration of genetic and environmental analyses , a fuller cons ideration of the social matrix and cultural frameworks , and the more active us e of informational, and communication technologies , all contributing to the broadly based development of international class ification and diagnostic systems for health and their effective us e for health restoration and health promotion at clinical and population levels.

Definitions of E pidemiology and Ps yc hiatric E pidemiology T he etymological roots of epidemiology include (diseases vis iting a community) and logos (their s tudy). and the cons ideration of the origins of epidemiology within the medical field seem to have led the R andom Hous e Dictionary of the E nglis h L anguage to define epidemiology narrowly as “the branch of medicine with epidemic diseases.” T he evolving broadening of the range of diseases 344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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to epidemiology and an incipient interest for its contextualization contributed in recent decades to definitions s uch as that in Maus ner & B ahn's “the study of the distribution and determinants of and injuries in human populations .” T his notion is s till quite prevalent. An emerging new concept of epidemiology pres ents discipline as the s tudy of health and dis eas e as a full spectrum across the human life s pan with a population approach, including etiological factors, comorbidities, and uses and outcomes of clinical care. line with this, Mervyn S us ser propos es cogently that epidemiology is the s tudy of the occurrence, caus es , control of health events in human populations . F urthermore, the las t 2001 edition of the Dictionary of E pidemiology, fourth edition, defines epidemiology as study of the dis tribution of health-related s tates or in specified populations and the application of this to the control of health problems. T o arrive at a reasonable definition of the specific field ps ychiatric epidemiology, it should be helpful to be cons istent with the emerging concept of epidemiology outlined above—concerned with both ill and positive as pects of health—as well as with a modern concept of ps ychiatry involving the diagnos is and treatment of mental disorders and the promotion of mental health. T hus, ps ychiatric epide miology may be defined as the of the dis tribution of mental illnes s and pos itive mental health and related factors in human populations . the principal pos itive mental health variables to be cons idered are individual s trengths , s ocial functioning participation, social s upports , and quality of life. T hes e 345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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positive health aspects are, of cours e, not only relevant mental health, but also to general health. Among factors , one could include contributing etiological as sociated general health conditions , and cours e characteristics , mental health s ervices, and mental health policies . E vidence-based medicine enhanced by experience and wis dom is a basic methodological approach for epidemiological study.

E volution of the C onc epts of E pidemiology and Ps yc hiatric E pidemiology T he intricacies of epidemiology in its goals and can be organized paradigmatically acros s recent in ways reflective of the prevailing cultural framework social matrix. In effect, E zra and Mervyn S us ser have propos ed an elegant s chema formulating the evolution modern epidemiology in terms of the following eras and symbols : P.657 1. T he era of s anitary statis tics (firs t half of the 19th century), emblematized by the concept of mias ma, and focus ed on foul and toxic environmental conditions. 2. T he era of infectious dis eas e epidemiology (late century through the firs t half of the 20th century), emblematized by germ theory. 3. T he era of chronic dis eas e epidemiology (second of the 20th century), allegorized with a black box, involved with a myriad of ris k factors. 346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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4. An emerging era of ecological epidemiology, allegorized with C hines e boxes, and concerned gene–environment interactions and the different layers of the social matrix. F urther delineation of thes e paradigms is provided in T able 5.1-1, which als o includes features of the and preventive approaches characteris tic of each era. schema is valuable not only to organize and explain complex history of epidemiology, but also to point out importance of public health as an ultimate goal in each era, transcending variations in social circums tances instrumental methodology.

Table 5.1-1 Four E ras in the E volut Modern E pidemiology E ra

Paradigm

Analytical Approac h

Preventi Approac

S anitary statis tics half of 19th century)

Mias ma: poisoning by foul emanations from s oil, and water

Demons trate clus tering of morbidity and

Draining, sewage, sanitatio

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Infectious disease epidemiology (late 19th century through firs t half of 20th century)

G erm single relate one to one to specific diseases

Laboratory is olation culture from disease experimental transmis sion, and reproduction of les ions

Interrupt transmis (vaccine is olation the affec through quarantin and feve hospitals and, ultimately antibiotic

C hronic disease epidemiology (s econd half of 20th century)

B lack box: expos ure related to outcome without neces sity for intervening factors or pathogenes is

R is k ratio of expos ure to outcome at individual level in populations

C ontrol r factors b modifyin lifes tyle (diet, exercise, etc.) or agent food, etc environm (pollution pass ive smoking, etc.)

E cological epidemiology

C hines e boxes :

Analys is of determinants

Apply bo informati

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(emerging)

relations within and between localized structures organized in a hierarchy of levels

and outcomes at different levels of organization: within and acros s contexts (us ing new information systems ) in depth (us ing new biomedical techniques)

and biomedic technolo to find leverage efficaciou levels, fr contextu to

F rom S us ser M, S us ser E : C hoosing a future for II. F rom black box to C hinese boxes and ecoJ P ublic He alth. 1996;86:674–677, with permiss ion. T he above schema is also applicable to ps ychiatric epidemiology, although the his tory of this specialized started in full force in the cours e of the 20th century— es pecially in its second half—and has now entered energetically into the 21st century. T hus, psychiatric epidemiology as a recognized dis cipline today largely corres ponds to the chronic diseas e era and, at a s tage walk into more tentatively, to the era of ecological epidemiology, the general s chema outlined earlier. 349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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It would be useful now to examine briefly the various phases or generations of ps ychiatric epidemiology that corres pond principally to the types of des ign and instrumentation used for epidemiological inves tigation.

F irs t-G eneration S tudies F irst-generation studies, which tended to be relatively unsystematic inquiries, often dealing with treated populations, extended typically through the mid-20th century. S ome illustrative examples follow. In 1838, J ean E tienne E s quirol documented that the number of individuals admitted to hospitals in P aris because of insanity had increased fourfold in 15 years (from 1786 to 1801). A s tudy of the prevalence of mental derangement and retardation in Mass achus etts us ing key informants (general practitioners, clergy) and hospital records 2,632 “lunatics ” and 1,087 “idiots ” that needed care. J oseph G oldberger et al. determined in the 1920s, case-control methods, that pellagra was connected to nutritional deficiency. W ithout s pecifying specific nutrients, dietary changes led to drastic reductions of pellagra in institutionalized populations . B rugger's study in 1929 attempted to es timate the prevalence of mental disorders in a defined population (T huringia, G ermany), using a census method. R obert F aris and W arren Dunham investigated the geographical distribution of all patients hos pitalized for the firs t time between 1922 and 1934 in C hicago. T hey found that the rate of schizophrenia decreas ed progres sively with distance away from the center of the 350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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city (from 46 to 13 percent of all admis sions ), leading to the formulation of a number of explanatory proposals.

S ec ond-G eneration S tudies S econd-generation studies were conducted after World War II, taking advantage of the extens ive interes t generated by the perceived frequency of mental in war s ettings and information and instrumentation emerging from profes sional work with such cas es and situations. T hey es tablis hed community s urveys as a tool in ps ychiatric epidemiology. T hey us ed either symptom checklists or relatively uns tructured as basic information-gathering methodology. S ome key studies of this type follow. T he Midtown Manhattan S tudy engaged s pecially social workers to conduct interviews of community res idents and collect s ymptom and other checklis t T he study as sumed that mental illnes s was distributed fundamentally as a continuum from normality and that was anchored adequately by ps ychos ocial impairment dysfunctioning). On the bas is of ps ychiatris ts ' review of collected data, it was found that 23 percent of the was severely psychiatrically impaired. T he S tirling C ounty S tudy in New Y ork ass es sed 1,010 individuals in the community via lay interviewers us ing questionnaire. Additional information was obtained general practitioners and psychiatrists in the area. R es earch ps ychiatris ts then reviewed the obtained us ing the American P sychiatric As sociation's P.658 first edition of the Diagnos tic and S tatis tical Manual of 351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Me ntal Dis orde rs (DS M) as a reference and concluded prevalence of mental disorders was 20 percent. A s tudy of social clas s and mental illnes s in a treated population in New Haven, C onnecticut, was conducted August Hollings head and F rederick R edlich. T hey higher prevalence of mental dis orders in individuals of lower socioeconomic clas ses . T hey als o found that in lower socioeconomic clas ses tended to be treated electroconvuls ive treatment (E C T ) and medication, whereas thos e in higher class es tended to be treated ps ychotherapy.

Third-G eneration S tudies T hird-generation studies have characteris tically used structured interview data aimed at identifying s pecific ps ychiatric disorders, as well as more s ophis ticated statis tical techniques . F undamental to the of survey interviews that were not only more s tructured, but actually s pecific in the lis t of questions to be and s cheduled in the order in which they were was the establishment of ps ychiatric nosologies with explicit inclusion and exclus ion diagnostic criteria (as signment rules to particular categories of ps ychiatric disorders ). T he us e of operational or explicit diagnostic criteria for diagnosis of mental disorders was first proposed by E dward S tengel in his international review of clas sifications. T he earlies t set of explicit diagnostic reported in the scientific ps ychiatric literature was that published by J osé Horwitz and J uan Marconi in 1966 in Latin America for alcohol abuse and thos e by B erner in Aus tria for psychotic disorders. However, the 352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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criteria s ets firs t us ed for the development of fully structured and s cheduled s urvey interviews were those included in DS M-III, which were bas ed on the earlier of J ohn P . F eighner et al. and R obert S pitzer et al. In cours e, the value of psychiatric nos ology developments a new generation of epidemiological findings was reciprocated by the use of population epidemiological res ults for the refinement of psychiatric nosologies . has articulated a promis ing relationship between diagnosis and population epidemiology. Illus tratively, four major epidemiological s tudies corres ponding to this third generation are outlined from a methodological perspective. T he E pidemiological C atchment Area (E C A) s tudy trained lay workers to adminis ter the Diagnostic S chedule (DIS ), a fully s tructured and scheduled instrument aimed at identifying a s et of DS M-III categories , to individuals in several institutional and community s amples in available U.S . s ites. T he National C omorbidity S urvey (NC S ) was aimed at appraising the prevalence of a s et of ps ychiatric in as sociation or not with s ubs tance use dis orders, in a representative U.S . national household sample. It also inves tigated ris k factors for mental illness . G iven its national s cope, this study was able to explore s everal contrasts of interests, s uch as that between urban and rural areas . T his s tudy, as did the preceding one, used trained lay interviewers to administer, in this cas e, the C ompos ite International Interview S chedule (C IDI), a structured and scheduled interview. T his instrument focus ed in identifying DS M-III-R , as well as s ome and tenth revision of the Inte rnational S tatis tical 353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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C las s ification of Dis e as e s and R e late d He alth 10), mental disorders .

F ourth-G eneration S tudies T he firs t three generations of psychiatric studies outlined above have been characterized and differentiated from each other by design and instrumentation variables, but are all s imilar in their on mental disorders . It is pos sible now to elucidate a generation in ps ychiatric epidemiology investigations , which is characterized by a broader focus that certainly includes mental disorders but uses more frameworks, such as both ill and pos itive health, and with meaning, culture, and other interpretative T he emergence of thes e broader s tudies has , in part, heralded by what Arthur K leinman has termed the ne w wave of e thnographie s . Also dis cernible in this array of epidemiological s tudies is their subs tantial interest and involvement in the development and formulation of health policies . F or illustrative purpos es , three recent studies follow. T he B razilian Multicentric S tudy of P s ychiatric combined a highly structured epidemiological cross sectional design with an anthropological interpretation the meaning of ris k factors. A representative s ample of 6,470 adults was s creened for the pres ence of ps ychopathology, with a s ubs ample selected for diagnostic psychiatric interviews with a B razilian DS M-III. T his evolved into a nes ted cas e-control s tudy which all s ubjects positively diagnosed as having a nonps ychotic dis order were cons idered cases and compared to a random sample of thos e not having 354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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evidence of any disorder. T he results sugges ted that gender (and related social proces ses and roles ) has to taken as a fundamental dimens ion. T hey further that any theoretical interpretation of the findings s hould cons ider the fundamental is sue of meaning with a sociocultural matrix. T he National S urvey of Mental Health and W ell-B eing Aus tralia engaged a national population s ample with the C IDI to elicit IC D-10 mental disorders . Of relevance to its consideration as fourth generation is this Australian s tudy also investigated years of life lost, quality of life, and use of mental and general health services . Its impact on the development of national policies s eems to have been cons iderable. T he World Mental Health S urvey (W MH) is a World Health Organization (W HO) initiative that aims to examine the form and frequency, s everity, as sociated disability, and treatment of mental dis orders in more 14 countries. T he novelty of this s tudy is not only the simultaneous application of s imilar ins truments in different countries , but also the as sess ment of social cons equences, burden of disease, and service delivery comprehensive manner. T he initial report of the study edited by R onald C . K es sler and T evfik B edirhan covered a total of 60,559 community adult res pondents from general population s amples in 14 countries (s ix developed, eight developed) in different world regions . T he as sess ments were carried out within the WMH of the W HO C omposite International Diagnostic T he es timated lifetime prevalence of having any WMHdisorder (according to DS M-IV criteria) ranged widely 8.6 percent in S hanghai to 47.3 percent in the United 355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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S tates. At least one-third of the lifetime cas es had a month epis ode. In the United S tates, 33.7 percent of cases were mild, whereas, in Nigeria, 81.6 percent of cases were mild. S erious dis orders were as sociated in countries with substantial disabilities, such as being us ual-role in the pas t year. Although severity of a is strongly related to treatment in all countries, 30 to 53 percent in developed countries and 72 to 83 percent in less developed countries received no health care treatment. T his is not merely a matter of limited res ources , as the number of treated mild and cases s eem to exceed the number of untreated serious cases in all countries . T hese findings put in perspective many pieces regarding the need and utilization of and illness impact on the lives of people and provide us eful insights about the organization of mental health services . F or example, many mental dis orders s eem to in late childhood and adolescence and progres s into serious dis orders with significant social cons equences, which appears to reinforce the need for early clinical interventions . P.659

Purpos es and Us es of E pidemiology In a clas sic paper written in 1955, the B ritish epidemiologist J eremy N. Morris proposed a number of us es for epidemiology. Despite their relatively early formulation, they are widely acknowledged as still relevant. T hey are s ummarized and briefly commented below.

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His torical s tudie s : T his refers to the importance of having a chronological pers pective in the s tudy of health and illness in human populations . T he preceding section on the evolution of general and ps ychiatric epidemiology illus trates the value of appraisals. Also relevant here is the longitudinal depiction of changes in patterns of disease distribution in human populations. C ommunity diagnos is : It has long been that epidemiology furnis hes crucial information on health of a community (i.e., on its diagnos is in a fundamental s ens e). E fforts to conceive community health indices are relevant here (e.g., D. F . 1966). T his application of epidemiology als o has implications for clinical care in terms of situational contextualized clinical diagnosis and of the identification of high-morbidity areas. Apprais al of an individual's health pros pe cts : T his is based on relevant population studies and made on the likelihood of life or death of an as a member of the res earched population. S uch inferences may refer to risk factors , as well as to expectation and life lived with dis abilities . Health s ervice s and ope rational re s earch: S cientific inves tigations on the organization and performance health services are becoming an area of active res earch. F or this, epidemiological methods can be quite helpful—from prevalence s tudies to the as sess ment of need for care to the evaluation of treatment coverage and outcomes. C omple ting the clinical picture : W hen initially 357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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by Morris , this use of epidemiology was best by determining gender and age factors ass ociated with a disease. In mental health, this purpos e is exemplified, in particular, by the of a nosological profile afforded by community surveys , which have been used for development of ps ychiatric clas sifications in IC D-10 and DS M-IV , discuss ed by T im S lade. Ide ntification of s yndrome s : T he use of for the elucidation of different types of “peptic ulcer” and for distinguishing Alzheimer's dis eas e from multiinfarct dementias is illus trative here. Models could be built to as sociate ris k and other factors to signs , s ymptoms, and course to generate nosological hypothes es. More recently, to use ethnographical approaches along with epidemiological methods for elucidating new syndromes, such as ataque de nervios and chips ychos is , that before were neglected as exotic, culture-bound syndromes have begun to emerge. C lue s to caus e s : T here are s ubs tantial indicators us e of epidemiology in clarifying the etiology of clinical problems . E xamples include the of nutritional deficiencies , indus trial cancers , smoking to lung cancer, and occupational T he searching for causes of dis eas e and protective factors for health may lead to better prevention Within the emerging multilevel paradigm, epidemiology is not a “head-counting” activity. It is systemic s cientific activity that ans wers clinical and public health questions with proper analys es of risk factors , outcomes, and other ass ociated variables. 358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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also offers a broader perspective of overall health and health care provision in a s ociety. policy makers and other health stakeholders can epidemiological information as a strategic input for decis ion making on priorities and res ource As epidemiology enters a new “ecological” era, concerned with understanding internal and external connections , investigations formed by a multilevel framework and cons idering a wide array of contributors may become increasingly frequent. E ach of the us es outlined above is applicable to epidemiology. It should be mentioned, however, that, in addition to these seven us es —which rather explicitly to work with illness or pathology—the emerging expansion of the concept of health to include pointedly positive health as pects (i.e., s ocial participation and supports, quality of life) suggests that the inves tigation these aspects will become a s ignificant new use of epidemiology.

ME THODS IN P S YC HIA TR IC E P IDE MIOL OG Y T his s ection reviews the conceptual and procedural that are us ed in epidemiology to fulfill its purposes and goals . F irst, the bas ic cons tructs and parameters in epidemiology and health are considered. K ey and dimensional meas ures and prototypical des igns of epidemiological s tudies are examined next. T he last subs ection outlines the types of ins truments us ed in ps ychiatric epidemiology.

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in E pidemiology Dis eas e, Illnes s , Dis order, and T he terms dis e as e , illne s s , dis order, and s yndrome recognized forms of pathology. Dis e as e and illne s s represent crys tallized or es tablis hed entities of severity and with definite implications for the individual and for public health. Dis e as e is often used with biomedical connotations, referring to a condition with specific etiopathogenesis , whereas illne s s is often used with experiencial and sociocultural connotations . T here however, no wide agreement on these dis tinctions . S yndrome repres ents a condition characterized by a particular symptom profile, the etiology, clinical significance or severity of which is variable. Dis orde r is term midway between a disease or illness and a in terms of cons istency, correlates, and s ignificance. the complexity, intricacy, and variable significance of ps ychiatric conditions included in standard mental and behavioral nosologies, dis order is the term that has preference at the current stage in nosological formulations. Important features of diseases or dis orders of epidemiological interest include (1) cours e of illnes s . refers to the age and mode of onset, the episodic or continuous presentation of illness , and the s table, improving, or worsening progres sion of the illnes s. (2) C omorbidity. T his is a complex and intricate term that refers to the cooccurrence or copresentation of two disorders . It has been argued that comorbidity may sometimes involve two faces of the s ame bas ic clinical condition or cons titute artifactual consequences of a 360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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particular nosological architecture. C omorbidity may place within the domain of mental disorders (e.g., depres sion and alcoholism) and acros s chapters of the (e.g., depres sion and arterial hypertension).

Dis ability F unctioning is an umbrella term that encompass es the bodily functions and personal activities of an individual. Dis ability refers to limitations in functioning that may place at the following different levels. P.660 





B ody level: e.g., brain and nervous s ys tem P ers onal level: e.g., limitations in personal care and daily activities S ocietal level: e.g., restrictions in s ocial and in available s ocial supports

Other Health P roblems O the r health proble ms is the term used in the current 10 to refer to conditions of clinical interes t that are not diseases s e ns o s tricto and may explain presentation to health services for evaluation and care. E xamples acce ntuated pers onality, hazardous us e of s ubs tances , burn-out s yndrome .

R is k F ac tors R is k factors are characteristics , variables, and hazards make it more likely that a given individual will develop a disorder. T hey can res ide within the individual (e.g., 361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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personality and temperament), with his or her family or community (e.g., life events), and with the environment (e.g., certain chemicals ). Us ually, there is an ass umed plaus ible caus al ass ociation between the ris k factor disorder or health problem.

P os itive Health P os itive health is the counterpart of ill health, which, as listed above, includes disease, illness , dis order, and related health problems . P os itive health reflects growing interest in a more comprehens ive concept of health. S uch a concept was already enshrined as “a complete phys ical, social and emotional well-being and not merely the absence of illness ” in the constitution of WHO. P res ently, pos itive health encompass es such as effective pers onal care, good interpers onal occupational functioning, social s upports, and quality of life.

C linic al C are C linical care refers to the array of actions or taking place in health s ervices. B road categories of care include the following: Diagnos is : T his is an evaluative process and formulation conducted by health profes sionals in collaboration with the patient (or cons ulting family, and pertinent members of the community. Illus trative of modern diagnostic concepts and procedures are the recent World P s ychiatric Ass ociation's International G uidelines for Ass es sment (IG DA). 362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T re atme nt: T his refers to the array of profes sional interventions —in cooperation with the consulting person and family—aimed at improving the presented and restoring health. Health promotion: T his refers to a s et of actions at empowering the cons ulting pers on to raise the of his or her health. As s uch, health promotion can regarded as relevant to both public health and care.

C ontext of E pidemiology C ritical as pects of the context of epidemiology include following domains : S ocial environme nt: T his includes human as pects environment at various levels of aggregation (i.e., family, community, nations, and humankind). divers ity and political cons iderations als o play a role in this domain. P hys ical environme nt: T his includes climate, finances , transportation, and other material G e ne tic e ndowme nt: T his includes the genetic illness and health. R ecent analyses of the human genome have pointed out that the express ion of genetic factors is largely influenced by factors . T hese concepts and factors are, of cours e, interrelated. R obert E vans and G reg S toddart offer a modern perspective on thes e interrelations through an schema pres ented in F igure 5.1-1. It reflects the 363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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of the field and outlines the interactive influences of various individual and social factors, as well as health on the various faces of health. T he latter involves or illnes s, health and function, and a sense of well-

FIGUR E 5.1-1 R elationships among s ocial and factors , health care, and the various as pects of health. (F rom E vans R G , S toddart G L. P roducing health, health care. In: E vans R G , B arer ML, Marmor T R , S ome P e ople He althy and O thers Not? T he Health of P opulations . New Y ork: Aldine de G ruyter; with permiss ion.)

K ey C ategoric al and Dimens ional Meas ures in E pidemiology 364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T he meas urement of key variables in epidemiology is guided by the s caling requirements of the type of involved (categorical vers us dimensional), as well as historical and cus tomary considerations .

Meas ures for C ategoric al Variables V ariables that are s tructured in terms of discrete or types (e.g., disorders , inpatient versus outpatient are measured through nominal scaling arrangements , as a s tandardized typology or class ification of S ome of the most frequently us ed measures in this follow: P roportion or pe rce ntage : T his is a widely us ed of frequency for all categorical variables —for percentage of emergency psychiatric evaluations res ult in inpatient admiss ions (as oppos ed to outpatient referrals). P revale nce : T his indicates the proportion of in a given population who have a dis order at a particular point or period in time. It is usually expres sed in percentages. F or point prevalence, time of meas urement is to be s pecified—for percentage of a village's inhabitants who pres ented manifestations of generalized anxiety disorder on 1, 2003. P eriod prevalence is often meas ured by 1month, 6-month, and 1-year intervals —for example, percentage of a village's inhabitants who a s chizophrenic disorder during calendar year Incide nce : T his indicates the proportion of new a dis order that emerge in a population during a specified time interval (us ually 1 year). An 365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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es timation of incidence may be obtained through anamnestic means , whereas a careful appraisal requires two surveys of the population involved— at the beginning and another at the end of the of P.661 interes t. A refined index, described by Olli incidence de ns ity, which deals with poss ible over time and los s at follow-up of individuals in the ris k population and is defined as an average rate over the period of interes t. O dds ratio: T his index involves a comparis on of the presence of a ris k factor for dis eas e in a s ample of diseased subjects and nondis eased controls. In words , it compares the proportion of cas es to noncases in a s ample expos ed to a given risk to proportion of cases to noncases in a nonexpos ed sample.

Meas ures for Dimens ional Variables V ariables that are meas urable with dimens ional s cales informationally more powerful (convey more detailed structured information) and mathematically and statis tically more tractable than yes or no categorical variables . In other words , although categorical are measured in terms of the pres ence or abs ence of variable, dimens ional variables are meas ured in to the extent of their presence—for example, a score of in a 100-point scale. Many variables of epidemiological interest, particularly 366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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those corres ponding to pos itive health (e.g., functioning and quality of life), are meas ured with dimens ional variables .

Meas ures of A s s oc iation Indices of intervariable as sociation or relations hips on the s caling of the variables involved. C ontingency tables are us ed to apprais e the interrelation between categorical variables, and their statis tical significance is expres sed through the chi-square statis tic. P roduct–moment correlation coefficients convey the degree of as sociation between dimens ional variables. can vary from –1, indicating perfectly negative or as sociation, to +1, indicating full s ame-directional as sociation, with 0 express ing no ass ociation at all between the inves tigated variables . P oint biserial correlation coefficient is an adjus ted correlation index designed to meas ure the ass ociation between a binomial variable (e.g., presence versus of a given disorder) and a dimens ional one (e.g., level occupational functioning).

Multivariate A nalys es C omplex s ituations involving several variables as contributors or predictors call for multivariate analys es . S uch analyses are facilitated when the predictor and predicted variables are dimens ionally meas ured. procedures allow the identification of the smalles t and most efficient set of predictors. W hen the predicted variable is categorical, reducible to binomial, it is to use a logistic regres sion model to elucidate a 367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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multivariate predictor.

Des ign of E pidemiologic al S tudies T he most important is sue in designing epidemiological studies involves its population s e tting—that is , a clinic treated population vers us a community or general population. T raditionally, a general population was regarded as always the proper s etting for C linical populations have begun to emerge as an additional proper focus of epidemiological s tudies . T his in line with the enormous significance and cost of care in today's world and with the opportunity that medical centers offer to inves tigate the relations hip between environmental and biological factors of illnes s.

C ros s -S ec tional vers us L ongitudinal P ers pec tives C ros s -sectional versus longitudinal perspectives another crucial des ign is sue in psychiatric Most studies have been cross -sectional in design, reflecting the fact that many des criptive research questions call for s uch designs and that this type of is simpler and les s expensive to conduct. Other questions , including thos e involving etiological hypothes es, the elucidation of a chain of events , and developmental cons iderations , call for longitudinal designs. Longitudinal des igns include cohort and cas e-control studies and us ually involve a time interval between and effect. C ohort s tudie s characteristically engage a sample (cohort) from a well-defined population with a particular expos ure or nonexpos ure status ), 368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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followed up for a specified time to determine whether a particular health outcome emerges. C ohort studies divided into prospective studies and retros pective In the pros pective type, expos ure s tatus is determined the initiation of the longitudinal s tudy; in the type, exposures are determined at a pas t point. C as e control s tudie s engage identified cases of a particular disorder and control s ubjects (thos e without the and follows them up. T his des ign is particularly s uited the study of rare disorders and for the exploration of poss ible ris k factors. C ase-control s tudies are attractive because of their convenience and relatively low cos t. A major limitation is recall bias , es pecially when corroborating information cannot be obtained.

F amily S tudies F amily s tudies represent a significant type of epidemiological s tudy s timulated by the interest aris ing about genetic contributions to the development of disorders . T hese studies examine aggregation of families that may be due to heredity or shared environmental ris k factors. F amily studies may us e population s amples or s amples of cases as certained through probands, including family case-control

Health S ervic es R es earc h Health s ervices research has become a major area of inves tigation, s timulated by the complexity of the organization of clinical s ervices and the magnitude and intricacy of its financing. C haracteris tic of this type of is a naturalis tic approach, which involves appraising proces s and outcome of s ervices in their regular 369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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E pidemiological methods, including descriptions of the types and extent of s ervices provided and the levels of unmet need for service, are applicable to this field. Illus tratively, health s ervices research deals with such as the following: (1) Need: W ho comes to care? C overage of service: W ho gets care? (3) How much res ources are required to meet the need for care? (4) are the outcomes of health care?

L ife S pan S tages R es earc h Life s pan stages res earch address es the complexity of human development by dividing it into three childhood and adolescence, adult development, and age. S tudies on the dis tribution of mental disorders in childhood and adolescence are challenged by the and instability of ps ychopathology during these years. Most epidemiological studies have been conducted adult samples. Attention must be paid to basic features adult development, s uch as res ilience as a protective and levers for health promotion. Old age brings new challenges to the methodology of epidemiological res earch—from meas urement of nosological to late-life risk factors to the role and needs of

C ultural and International C ultural and international frameworks are emerging as fundamental for health studies in general and epidemiology in particular. C ulture pervades and unders tanding of life and health (both ill and as pects ). T he vitality of new res earch in cultural has led to the development of practical tools, such as cultural formulation, 370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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P.662 which may be helpful for clinical care and may als o enhance epidemiological des criptions. T he interactive nature of today's world makes it compelling to cons ider international pers pectives in health at all its levels —governmental (e.g., WHO) and (e.g., W orld P sychiatric As sociation).

E videnc e-B as ed A pproac hes E vidence-based approaches to medicine and have attracted wide attention as efforts to upgrade the solidity and quality of information on which health care public health are bas ed. It is important to place in perspective such efforts , given the complexity of the field. As indicated by s ome of their most authoritative proponents , evidence-based medicine is about individual clinical expertis e and the best external T he need for balancing hard data with informed wis dom extensible to public health policy development.

Ins truments for E pidemiologic al S tudies Ins trument P roperties T he apprais al of the quality and relevance of for meas uring the variables of interes t in epidemiology us ually conducted in terms of their reliability, their or usefulness , and their feas ibility or administrability.

R E L IAB ILITY R eliability refers to the quality of an instrument to yield similar or cons istent results across various 371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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such as time (test–retest reliability) and evaluators (interrater reliability). F or categorical variables, s uch as identification of ps ychiatric dis orders, the most reliability index is the kappa coefficient (κ), the formula which follows: where p ois the proportion of observed agreement and the proportion of chance agreement. F or the not infrequent case of multiple raters multiple categorical diagnos es , an extens ion of the κ been designed and operationalized. F or the reliability or agreement among raters us ing scales, the mos t frequently us ed statis tical index is the intraclas s correlation coefficient.

VAL IDITY V alidity refers to the quality or s trength of an ins trument meas ure the variable or cons truct it is suppos ed to meas ure. In line with this , validity is thought to to the faithfulness , relevance, and usefulness of the instrument to reflect the reality of interes t. validity is regarded as the most fundamental quality of instrument. However, it is not always s imple to validity directly. T he following repres ent common approaches to the es timation of an instrument's C rite rion validity: According to this approach, the validity of a new ins trument is determined by comparing the res ults or meas urements it yields to those obtained with an ins trument of widely relevance and value. F or example, the validity of a depres sion s cale could be es timated by correlating 372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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res ults to those of the Hamilton Depres sion S cale. F ace or conte nt validity: T his is as sess ed by having experts in the field determine the extent to which a new instrument is relevant to its intended purpose covers the informational areas pertinent to that purpos e. Dis criminant validity: Here, an attempt is made to determine if a new instrument is well able to distinguish between s amples of populations presumed to be quite different from each other in instrument's domain or field of application. Illus tratively, the dis criminant validity of a new depres sion s cale could be indicated by the extent which it yields higher scores in a s ample of people than in another sample of healthy C ons truct validity: T his corresponds to the validity of an instrument (i.e., to the extent that it yields res ults consis tent with the theory underlying domain and design. F or example, if it is properly as sumed that an anxiety disorder is s ubs tantially caus ed by environmental s tres s, a new scale to measure the pres ence of that anxiety disorder would be expected to yield high scores among recently exposed to a s erious dis as ter.

FE AS IB IL ITY OR ADMINIS TR AB IL ITY T his evaluative parameter refers to the cas e of use of instrument, as well as low cos t and access ibility.

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T here is a large number and variety of ins truments for evaluation of ps ychopathology and mental disorders . S ome are of a s creening nature. T hese include, first, instruments for detecting the likelihood of an individual having mental disorders (which are us ually bas ed on affective s ymptoms and, in some cas es, other such as social dysfunction). T his type of s creening instrument may be used as the firs t of a two-stage in which they are followed by a s econd in-depth instrument. S econd, s creening instruments may also represent a preliminary attempt at detecting the of a particular dis order, s uch as a depres sive or anxiety disorder. F or the full evaluation of mental disorders , including the identification of specific forms of them, structured or s emistructured interviews —often adminis tered by trained nonclinicians —have become standard in epidemiological s tudies . W ell-trained or psychiatrists , us ing adequate nosologies and criteria, can als o repres ent an adequate approach to ps ychopathological evaluation in epidemiology, the cost of s uch profes sional services and the lower explicitnes s of the proceedings may repres ent limitations and are usually restricted to validation A s election of instruments for general screening and full identification of a substantial s et of mental disorders are pres ented below.

INS TR UME NTS FOR G E NE R AL PS YC HOPATHOLOG IC AL S C R E E NING G e ne ral He alth Q ue s tionnaire (G HQ): T his is one earliest s creening instruments to have received acceptance in a variety of settings. It was 374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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David G oldberg and collaborators . Its complete version is compos ed of 60 items , mostly affective symptoms. S horter versions of 28 and 12 items exis t. Adequate reliability and validity have been documented. S elf-R eporting Q ues tionnaire (S R Q): T his designed as part of a W HO project to s creen for disorders in primary health care settings. It includes items —20 on depres sive and anxiety s ymptoms, on ps ychotic phenomena, one on epileps y, and five related to alcohol abuse—and has been adjusted in length for use in different world s ettings . P ers onal H ealth S cale : T his ins trument, developed J uan Mezzich and ass ociates, is bas ed on an prototypical model for the definition of psychiatric illness and includes 10 items (s ix affective ps ychological and somatic symptoms , three social dys function, and one on global s elfof illnes s and need for clinical care). It can be completed in 2 to 4 minutes and has s everal versions with documented reliability and validity. P.663

INS TR UME NTS FOR FULL PS YC HIATR IC DIS OR DE R S DIS : T his fully structured and s cheduled diagnos tic interview was originally designed to identify a set of DS M-III mental dis orders through interviews 375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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conducted by lay interviewers. It was most prominently applied in the E C A s tudy in five U.S . C IDI: T his structured interview was built on the DIS approach and was extended to identify sets of disorders in DS M-IV and IC D-10. It has been a number of studies, including the U.S . NC S and WMH. S tandardize d C linical As s e s s me nt for (S C AN): T his modular ins trument was built on the tenth edition of the P res ent S tate E xamination (a structured interview for ps ychiatric s ymptoms) and categorical diagnos tic algorithm (C AT E G O). It has us ed in a national s urvey of ps ychiatric morbidity in G reat B ritain. B oth P S E and S C AN were used in Longitudinal S tudies of S chizophrenia. Mini-Inte rnational Ne urops ychiatric Interview T his brief structured diagnos tic interview, recently developed by David S heehan and collaborators , at the identification of a s et of DS M-IV and IC D-10 mental disorders in multicenter clinical trials and epidemiological s tudies . It can usually be less than 30 minutes. It has been validated against C IDI and the S tructured C linical Interview for DS M-

Ins truments for the A s s es s ment of Dis ability and F unc tioning WHO PS YC HIATR IC DIS AB IL ITY AS S E S S ME NT S C HE DUL E T he WHO developed a new version of the Disability Ass es sment S chedule (W HO-DAS II) as a general 376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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of functioning and disability that reflects major life domains and is sensitive to change. T his endeavor on the development of the revis ion of the International C las sification of F unctioning, Disability, and Health and aims to develop a common metric tool that is culturally applicable, psychometrically reliable and valid, and for health s ervices research, s uch as the evaluation of needs and outcomes . W HO-DAS II was conceived as a general health state ass ess ment meas ure that can be for multiple purposes , s uch as epidemiological s urveys , clinical us e, or as a potential description system to contribute to s ummary meas ure of population health. It gives a general s core as well as different profiles on cognition, mobility, s elf-care, interpers onal relations , participation in the community.

INTE R NATIONAL C L AS S IFIC ATION OF FUNC TIONING , DIS AB IL ITIE S AND (IC F) T he International C lass ification of F unctioning, and Health (IC F ) is a major revis ion of the International C las sification of Impairments , Dis abilities, and (IC IDH). T he first edition ass umed that disabilities exclusively from illnes ses. T he s econd considered that disabilities might res ult from the interaction among illness es, the pers on, and the s ocial environment. In disability is conceptualized here as involving at body, personal, and social levels —impairments , limitations , and participation restrictions. An outline of IC F is presented in T able 5.1-2. A checklis t as sess es presence and severity of various functional limitations. F igure 5.1-2 displays the interactions between the 377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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components of the IC F .

Table 5.1-2 An Overview of the C las s ific ation of Func tioning, Dis a (IC F)  

Part 1: Func tioning and Dis ability

 

Part 2: Fac tors

C omponents

B ody functions and structures

Activities and participation

E nvironm factors

Domains

B ody functions and structures

Life areas (tas ks , actions)

E xternal on functi disability

C ons tructs

C hange in body functions (phys iological)

C apacity, executing tas ks in a standard environment

F acilitati hindering of feature phys ical, and attitu

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world  

C hange in body structures (anatomical)

P erformance,   executing tas ks in the current environment

P os itive as pect

F unctional and s tructural integrity

Activities, participation (function)

F acilitato

Negative as pect

Impairment

Activity limitation

B arriers/

 

 

P articipation res triction (disability)

 

F rom W orld Health Organization. Inte rnational C las s ifica and H ealth (IC F ). G eneva: World Health Organization; 2

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FIGUR E 5.1-2 Interactions among the components of International C lass ification of F unctioning, Dis ability and Health. (F rom W orld Health Organization. Inte rnational C las s ification of F unctioning, Dis ability and H ealth G eneva: W orld Health Organization; 2001, with

GL OB AL AS S E S S ME NT OF S C AL E T he G lobal As sess ment of F unctioning S cale combination, social dys function and severity us ing a 100-point scale. It is used to ass ess of DS M-IV and DS M-IV -T R .

Ins truments to A s s es s C ontextual F ac tors : L ife E vents , S tres s ors , S upports ME AS UR ING L IFE E VE NTS 380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T he apprais al of s tres sors and life experiences as contributors to the emergence of mental dis orders represents an intricate challenge. Interesting here is approach of G eorge B rown, which addres ses the definitions of life events, stress , and contextual threat. practical and s imple proposal to evaluate the presence frequent threatening experiences was offered by T erry B rugha et al.

APPR AIS AL OF A S TANDAR D S E T OF C ONTE XTUAL FAC TOR S T his may be attempted using the Z-coded categories of C hapter XXI of IC D-10. As part of the development of multiaxial system for IC D-10, a s chema was des igned the reporting of contextual factors that may influence diagnosis, treatment, and prognos is of mental

Ins truments to A s s es s Quality of Q uality of life as a notion has become increasingly with the recognition that the impacts on health and health care–seeking behavior are often determined not just by s ymptoms and s igns, dis orders , or but also by s ubjective global appraisals of health. T his es pecially important for health conditions that are either recurrent or of a long duration (as is the case with a number of mental P.664 health conditions). T he concept has also gained in the pharmacoeconomic literature. Quality of life can thus be cons idered an operational meas ure of overall health and well-being. 381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T here are a growing number of procedures and tools to as sess health-related quality of life. S ome were for the evaluation of individuals experiencing specific illness es, psychiatric and nonpsychiatric. Others quality of life generically and are most appropriate as of a comprehens ive as sess ment of health status . T he Quality of Life Ins trument (W HOQoL) is noteworthy for broad international anchorage, careful development, wide range of content. T he W HOQoL was developed through an international cross -cultural collaborative to measure people's s elf-perception of their pos ition in in the context of the culture and value s ys tems in which they live and in relation to their goals , expectations , standards , and concerns . It has been extensively us ed is being currently revis ed to reflect new frameworks for meas uring health and health-related outcomes. T he item Quality of Life Index, developed by J uan Mezzich collaborators , is also wide in content (phys ical and emotional well-being, personal and social functioning, social s upports , and personal and spiritual fulfillment) also quite efficient, us ing a culture-informed rating and validated in terms of s everal language versions .

E P IDE MIOL OG IC A L F INDING S ON IL L NE S S A ND HE A L TH T his s ection presents selected recent findings on distribution and patterns of mental disorders , positive as pects of health, clinical care, and health T hese epidemiological res ults are presented principally tabular form.

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As an illustration of findings on distribution of mental disorders in a broad population, R onald K ess ler et al. reported on the lifetime and 12-month prevalence of III-R disorders in a U.S . national household sample 5.1-3). T he lifetime prevalence of any NC S dis order found to be 48.0 percent. Of the broad categories of disorders , substance us e dis order (26.6 percent) was most common, followed by any anxiety disorder (24.9 percent) and any mood dis order (19.3 percent). Of the specific disorders , major depress ion was most (17.1 percent), followed by alcohol dependence (14.1 percent).

Table 5.1-3 L ifetime and 12-Mont Dis orders  

Fem

Male

 

Lifetime

Dis orders

%

12-Mo

(S E )

%

Lifetime

(S E )

%

(S E )

Mood disorders

 

 

 

 

 

 

    Mania

1.6

0.3

1.4

0.3

1.7

0.3

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    Major depres sion

12.7

0.9

7.7

0.8

21.3

0.9

    Dysthymia

4.8

0.4

2.1

0.3

8.0

0.6

    Any mood disorders

14.7

0.8

8.5

0.8

23.9

0.9

Anxiety disorders

 

 

 

 

 

 

    G eneralized anxiety disorder

3.6

0.5

2.0

0.3

6.6

0.5

    P anic disorder

2.0

0.3

1.3

0.3

5.0

1.4

    S ocial phobia

11.1

0.8

6.6

0.4

15.5

1.0

    S imple phobia

6.7

0.5

4.4

0.5

15.7

1.1

    Agoraphobia 3.5 without panic

0.4

1.7

0.3

7.0

0.6

    Any anxiety disorder

0.9

11.8

0.6

30.5

1.2

19.2

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S ubstance disorders

 

 

 

 

 

 

    Alcohol abuse

12.5

0.8

3.4

0.4

6.4

0.6

    Alcohol dependence

20.1

1.0

10.7

0.9

8.2

0.7

    Drug abus e

5.4

0.5

1.3

0.2

3.5

0.4

    Drug dependence

9.2

0.7

3.8

0.4

5.9

0.5

    Any subs tance disorder

35.4

1.2

16.1

0.7

17.9

1.1

Other disorders

 

 

 

 

 

 

    Antis ocial personalitya

4.8

0.5





1.0

0.2

    Nonaffective 0.3 ps ychos is b

0.1

0.2

0.1

0.7

0.2

Any NC S disorder

0.2

27.7

0.9

47.3

1.5

48.7

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NC S , National C omorbidity S tudy; S E , s tandard error. aAntisocial

personality was only as sess ed on a lifetime b

bNonaffective

psychosis : s chizophrenia, s chizophrenifor delus ional disorder, and atypical psychosis. F rom K es sler R C , McG onagle K A, Zhao S , et al.: Lifetim ps ychiatric disorders in the United S tates: results from th P s ychiatry. 1994;51:8–19, with permiss ion. Als o of high interest, the NC S found that 79 percent of ps ychiatrically ill people pres ented with comorbidity involving two or more ps ychiatric disorders . More than of all lifetime disorders occurred in 14 percent of the population. T he figures obtained in the NC S were higher than obtained in the E C A s tudy. F urthermore, lifetime prevalence of “any mental disorder” with the C IDI was found to vary greatly, from more than 40 percent in the U.S . and the Netherlands to 20 percent in Mexico and percent in T urkey. C omplementing the above-mentioned National C omorbidity S tudy in the United S tates , findings from a recent study conducted as part of the W HO World Health S urvey in 12 different settings are presented in T able 5.1-4. C onsiderable variations can be noted countries . Quite consistently, the results obtained in the United S tates tended to be highes t (e.g., 47.3 percent lifetime prevalence of any dis order investigated, and 386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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percent as 12-month prevalence), whereas those in S hanghai, C hina, tended to be the lowes t (e.g., 8.6 percent as lifetime prevalence of any disorder and 4.5 percent as 12-month prevalence).

Table 5.1-4 L ifetime (L T) and 12 C ompos ite Internationa  

Moodb

Anxiety

 

LT

12-Mo

LT

1

 

%

SE

%

SE

%

SE

%

Americas

 

 

 

 

 

 

 

    C olombia

19.5

1.2

9.9

0.8

13.2

0.7

6.2

    Mexico

11.9

0.7

6.9

0.5

10.0

0.7

5.

    United S tates

28.6

0.9

18.2

0.7

21.4

0.8

9.8

E urope

 

 

 

 

 

 

 

    B elgium

13.3

1.9

6.2

1.1

14.4

1.1

5.0

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    F rance

22.0

1.5

9.7

0.9

23.3

1.3

6.4

    G ermany

14.1

1.3

5.9

0.8

10.9

0.8

3.4

    Italy

10.9

0.9

5.0

0.6

10.2

0.6

3.

    Netherlands 15.2

1.0

7.2

0.9

17.5

1.4

4.8

    S pain

10.0

1.0

5.2

0.6

11.6

0.6

4.4

    Ukraine

11.3

1.0

7.4

0.8

16.1

1.2

8.8

Middle E as t and Africa

 

 

 

 

 

 

 

    Lebanon

13.3

1.3

10.9

1.2

11.7

1.0

6.3

    Nigeria

5.8

0.7

3.3

0.4

3.2

0.3

1.0

Asia

 

 

 

 

 

 

 

    J apan

8.4

0.9

4.7

0.8

8.5

0.7

3.0

    P R C

5.9

1.2

3.4

0.7

4.6

0.6

2.7

    P R C S hanghai

3.9

1.0

2.6

0.8

3.7

0.8

1.8

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P R C , P eople's R epublic of C hina; S E , s tandard error. aAnxiety

disorders include agoraphobia, generalized anx disorder, s ocial phobia, and specific phobia. Mood dis or Impulse-control disorders include bulimia, intermittent ex past 12 months of symptoms of three child-adoles cent d defiant disorder). S ubstance disorders include alcohol o met full criteria at some time in their life and who continu currently do not meet full criteria for the dis order. Organ were not us ed. bB ipolar

disorders were not ass ess ed in the E uropean S G ermany, Italy, the Netherlands, and S pain). 3 Intermittent dDrug

explosive dis order was not as sess ed in the

abus e and dependence were not as sess ed in the

F rom W orld Mental Health S urvey C ons ortium: P revalen Organization World Mental Health (W MH) S urveys. J AM One of the most important s ettings for appraising the prevalence of mental disorders is primary health care. David G oldberg and Y ves Lecrubier s tudied s uch prevalence with the C IDI in 15 cities acros s all and found that the prevalence of all mental dis orders varies from 53 percent in S antiago, C hile, to 7.3 S hanghai, C hina, with an average acros s sites of 24 percent. Likewise, depres sive disorder ranged from 30 percent in S antiago to 2.6 percent in Nagas aki, J apan. S ome interesting contrasts acros s continents are 389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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(T able 5.1-5).

Table 5.5-1 Prevalenc e of Major Dis orders in Primary Health

C ities

C urrent Alcohol Depres s ion Generalized Dependenc (%) Anxiety (%)

Ankara, T urkey

11.6

0.9

1.0

Athens , G reece

6.4

14.9

1.0

B angalore, India

9.1

8.5

1.4

B erlin, G ermany

6.1

9.0

5.3

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G roningen, the Netherlands

15.9

6.4

3.4

Ibadan, Nigeria

4.2

2.9

0.4

Mainz, G ermany

11.2

7.9

7.2

Manches ter, 16.9 UK

7.1

2.2

Nagasaki, J apan

2.6

5.0

3.7

P aris, F rance

13.7

11.9

4.3

R io de J aneiro, B razil

15.8

22.6

4.1

S antiago, C hile

29.5

18.7

2.5

S eattle,

6.3

2.1

1.5

S hanghai, C hina

4.0

1.9

1.1

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V erona, Italy

4.7

3.7

0.5

Total

10.4

7.9

2.7

F rom G oldberg DP , Lecrubier Y . F orm and frequency of acros s centres. In: Üs tü T B , S artorius N, eds. Me ntal Illn C are : An International S tudy. C hichester, U.K .: J ohn W i permis sion. As an example of international work with specific ps ychiatric disorders , E zra S us ser et al. reported on delineation of acute and trans ient ps ychotic dis orders C handigarh, India. On examining the dis tribution of duration of illnes s for 46 cases of nonaffective acute ps ychos is , they found a bimodal dis tribution of this variable, with 80 percent of the cases lasting less than weeks and 20 percent lasting more than a year. T his supports the nosological s eparation of acute trans ient ps ychos is from s chizophrenia. T he distribution of mental disorders in children and adoles cents in North C arolina was recently reported on E . J ane C ostello et al. Us ing the C hild and Adolescent P sychiatric Ass ess ment (C AP A) as a structured they found that by age 16, one in three adoles cents indications of having a mental disorder. A similar (30 percent) was obtained by K es sler et al. for 15-yearin the NC S . 392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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More broadly, the prevalence of child and adolescence disorders in recent studies across the world are comparatively in T able 5.1-6. T his prevalence varied 23 percent in S witzerland to 13 percent in India.

Table 5.1-6 Prevalenc e of C hild Adoles c ent Dis orders , S elec ted S tudies C ountry

Age

Prevalenc e (%)

E thiopia a

1–15

17.7

G ermany b

12–15

20.7

India c

1–16

12.8

J apand

12–15

15.0

S paine

8, 11, 15

21.7

S witzerlandf

1–15

22.5

US A g

1–15

21.0

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aT ades se

B , et al.: C hildhood behavioural Ambo district, Wes tern E thiopia: I. P revalence es timates. Acta P s ychiatr S cand. 1999;100 97. bWeyerer

S , C as tell R , B iener A, et al.: treatment of ps ychiatric disorders in 3–14-yearchildren; results of a representative field study in small rural town region of T rauns tein, Upper Acta P s ychiatr S cand. 1988;77:290–96. c Indian

C ouncil of Medical R esearch (IC MR ). E pidemiological S tudy of C hild and Adole s ce nt P s ychiatric Dis orders in Urban and R ural Are as . Delhi: IC MR ; 2001.

dMorita

H, S uzuki M, S uzuki S , et al.: P s ychiatric disorders in J apanes e s econdary s chool children. C hild P s ychol P s ychiatry. 1993;34:317–322. e G omez-B eneyto

M, B onet A, C atala MA, et al.: P revalence of mental dis orders among children in V alencia, S pain. Acta P s ychiatr S cand. 357. fS teinhausen

HC , Metzke C W , Meier M, et al.: P revalence of child and adolescent ps ychiatric disorders : the Zurich E pidemiological S tudy. Acta P s ychiatr S cand. 1998;98:262–271.

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gS haffer

D, F isher P , Dulcan MK , et al.: T he Diagnos tic Interview S chedule for C hildren 2.3 (DIS C -2.3): description acceptability, rates, and performance in the ME C A study. J Am C hild Adole s c P s ychiatry. 1996;35:865–877.

P.665

Findings on Dis abilities T he proportion of all disability-adjus ted life years attributed to neuropsychiatric disorders has been found be 12 percent in the G lobal B urden of Diseas e S tudy. 5.1-7 lists the leading caus es of disability-adjus ted life years in all ages and both s exes —unipolar depres sive disorders is in fourth place, and two other behavioral conditions (s elf-inflicted injuries and alcohol us e are included among the top 20 health conditions .

Table 5.1-7 L eading C aus es of Dis ability-Adjus ted L ife Years in Ages , B oth S exes  

Health C onditions

Perc ent

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of Total

1.

Lower res piratory infections

6.4

2.

P erinatal conditions

6.2

3.

Human immunodeficiency virus /acquired immunodeficiency syndrome

6.1

4.

Unipolar depres sive disorders

4.4

5.

Diarrheal diseases

4.2

6.

Is chemic heart dis eas e

3.8

7.

C erebrovascular disease

3.1

8.

R oad traffic accidents

2.8

9.

Malaria

2.7

10.

T uberculos is

2.4

11.

C hronic obs tructive pulmonary disease

2.3

12.

C ongenital abnormalities

2.2

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13.

Meas les

1.9

14.

Iron-deficiency anemia

1.8

15.

Hearing los s, adult-onset

1.7

16.

F alls

1.3

17.

S elf-inflicted injuries

1.3

18.

Alcohol us e dis orders

1.3

19.

P rotein-energy malnutrition

1.1

20.

Osteoarthritis

1.1

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion. Neurops ychiatric conditions account for 31 percent of years of life lived with dis ability. T able 5.1-8 identifies leading caus es of years of life lived with dis ability in all ages and both sexes . F ive of the top 20 health are mental—unipolar depres sive dis order, alcohol us e disorders , schizophrenia, bipolar affective disorder, and Alzheimer's disease and other dementias. T . B . Üs tün as sociates have prepared an update of the initial B urden of Dis eas e S tudy, confirming and extending the 397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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importance of depress ion as a public health problem.

Table 5.1-8 L eading C aus es of Years of Life L ived with All Ages , B oth S exes  

Health C onditions

Perc ent of Total

1.

Unipolar depres sive disorders

11.9

2.

Hearing los s, adult-onset

4.6

3.

Iron-deficiency anemia

4.5

4.

C hronic obs tructive pulmonary disease

3.3

5.

Alcohol us e dis orders

3.1

6.

Osteoarthritis

3.0

7.

S chizophrenia

2.8

8.

F alls

2.8

9.

B ipolar affective dis order

2.5

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10.

Asthma

2.1

11.

C ongenital abnormalities

2.1

12.

P erinatal conditions

2.0

13.

Alzheimer's disease and other dementia

2.0

14.

C ataracts

1.9

15.

R oad traffic accidents

1.8

16.

P rotein-energy malnutrition

1.7

17.

C erebrovascular disease

1.7

18.

Human immunodeficiency virus /acquired immunodeficiency syndrome

1.5

19.

Migraine

1.4

20.

Diabetes mellitus

1.4

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion.

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F urther illustration of significant epidemiological on disabilities is furnis hed by the National S urvey of Mental Health and W ell-B eing in Aus tralia. F igure 5.1-3 health conditions in Aus tralia and their as sociated disability, expres sed as years of life lost through Mental disorders exceeded all the other major health categories in this regard.

FIGUR E 5.1-3 Y ears of life lost through disability (Y LD), Aus tralia, 1996. (F rom Mathers C , V os T , S tevenson C . B urde n of Dis e as e and Injury in Aus tralia. C anberra: Aus tralian Ins titute of Health and W elfare; 1999, with permis sion.)

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Findings on Pos itive As pec ts of T he National S urvey of Mental Health and W ell-B eing Aus tralia included meas urement of well-being at the strong request of cons umers and caregivers. W ellwas apprais ed with the s ingle-item Life S atis faction with 0 percent indicating “terrible” and 100 percent representing “delighted.” T he mean s core for the Aus tralian adult population was 70.4 percent. Men and women had very similar mean scores. W ell-being was higher in people with tertiary education and in thos e owning or purchasing their homes. It was lower in individuals with physical or mental dis orders, depres sion. It was higher in mild us ers of alcohol than was in abs tainers and heavy us ers . Of particular was the existence of a few individuals with current or depress ive disorders who reported high life Quality of life, us ing the S panish version of the Quality Life Index (QLI-S p), was s tudied in a S panis h sample by E s ther Lorente et al. T he mean scores of items of the QLI-S p and the average s core in this community sample composed of 489 men and 70 percent univers ity s tudents and 30 percent having other occupations —is presented in T able 5.1-9. W ithin framework of this 0- to 10-point scale, the average obtained in this community s ample was 6.98 (quite cons istent with the findings of K eith Dear et al. in Aus tralia). T here was not a significant difference in the average s cores of men and women. T he scale item presenting the highest loading on the s ingle factor underlying the scale was “personal fulfillment.” More recently, S aavedra and as sociates studied an adapted version of the QLI-S p on a statis tical s ample of 2,418 401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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households in Lima, P eru, and found a mean average of 7.64, with no highly significant differences among or gender groups .

Table 5.1-9 Quality of L ife in a S panis h C ommunity S ample (489 Men and Women) Quality of L ife Indexa Items

Mean

S tandard Deviation

1. P hys ical well-being

6.58

1.65

2. well-being

6.48

1.74

3. S elf-care/independent functioning

7.31

1.48

4. Occupational

7.48

1.56

5. Interpers onal

7.68

1.56

6. S ocial emotional

7.46

1.81

7. C ommunity support

6.67

1.54

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8. P ersonal fulfillment

6.78

1.76

9. S piritual fulfillment

6.04

1.95

10. G lobal perception of quality of life

7.27

1.65

Average

6.98

1.11

aS core

range: 0 (bad) to 10 (excellent).

F rom Lorente E , Ibáñez MI, Moro M, et al.: Indice calidad de vida: es tandarización y características ps icométricas en una muestra española. S alud Integral. 2002;2:45–50, with permiss ion. P.666 P.667 A s tudy of sociodemographics, self-rated health, and mortality in the United S tates was conducted by P . et al., who analyzed data from the 1987 National E xpenditure S urvey on a representative sample of U.S . civilians. S elf-reported health was measured with the Medical Outcome 20-Item S hort F orm (S F -20) (health perceptions, phys ical function, role function, mental health). P hysical function s howed the greates t 403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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decline with age, whereas mental health increased Women reported lower health for all s cales except role function. G reater income was as sociated with better health, least marked for mental health. C ompared P.668 with whites, blacks reported lower health, whereas reported higher health. Lower s ocioeconomic s tatus being black were factors as sociated with lower health status and higher mortality, women reported health status but exhibited lower mortality, and Latinos reported higher health s tatus and exhibited lower mortality.

Findings on C linic al C are T here is a trend worldwide to diversify the s ettings for mental health care. T he extent and patterns of this are being investigated by the W HO Atlas S urvey on Health R es ources by as king governments to complete questionnaires about mental health resources. T he distribution of ps ychiatric beds per 10,000 population WHO regions is presented in F igure 5.1-4. It shows availability rates are highest in E urope (9.3) and the Americas (3.6) (which includes North America and America) and are quite low (under 1.0) in the res t of the world.

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FIGUR E 5.1-4 P s ychiatric beds per 10,000 population World Health Organization (W HO) regions . (F rom W orld Health Organization. Atlas of Me ntal H ealth R e s ource s W orld 2001. G eneva: World Health Organization; 2001, permis sion.) According to the previous ly mentioned Atlas S urvey, median numbers of ps ychiatris ts per 100,000 are 1.0 worldwide, 9.0 in E urope, 1.6 in the Americas , in the E astern Mediterranean, and under 0.28 in the 405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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the world. T he median numbers of ps ychiatric nurses 100,000 population are 2.0 worldwide, 27.5 in E urope, in the Americas, 1.1 in the W estern P acific, and under the res t of the world. T he median rates of ps ychologists working in mental health are 0.4 worldwide, 3.0 in 2.8 in the Americas , and under 0.2 in the res t of the F inally, the median rates of social workers in mental care are 0.3 worldwide, 2.35 in E urope, 1.9 in the and under 0.4 in the res t of the world. F ocus ing attention on Aus tralia, G avin Andrews et al. as certained the use of the s ervices of different types of health profess ionals for mental problems. T his s tudy documented the predominant roles of general practitioners and even other health profes sionals (including nurses, pharmacists , and welfare above that of psychiatrists , for the care of people experiencing mental disorders (even a large number of these) (T able 5.1-10).

Table 5.1-10 Us e of Profes s ional S ervic es for Mental Problems in Aus tralia, 1997 C ons ultations No Dis order for Mental (%) Problems

Any Dis order (%)

3 Dis orders (%)

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G eneral practitioner onlya

2.2

13.2

18.1

Mental health profes sional onlyb

0.5

2.4

3.9

Other health profes sional onlyc

1.0

4.0

5.7

C ombination of health profes sionals

1.0

15.0

36.4

Any health profes sionald

4.6

34.6

64.0

aR efers

to individuals who had at leas t one cons ultation with a general practitioner in the previous 12 months but did not consult any other type of health profess ional. bR efers

to individuals who had at leas t one cons ultation with a mental health profes sional (ps ychiatris t, psychologist, mental health team) in the previous 12 months but did not consult any other type of health profes sional. 407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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c R efers

to persons who had at least one with another health profes sional (nurse, nonps ychiatric medical s pecialis t, pharmacist, ambulance officer, welfare worker, or counselor) the previous 12 months but did not cons ult any other type of health profes sional.

dR efers

to persons who had at least one with any health profes sional in the previous 12 months. F rom Andrews G , Henderson S , Hall W : comorbidity, dis ability and s ervice utilization: overview of the Aus tralian National Mental Health S urvey. B r J P s ychiatry. 2001;178:145–153, with permis sion. J yrki K orkeila et al. inves tigated the factors predicting readmiss ion to psychiatric hospitals in F inland during early 1990s. T he mos t prominent factors were previous admis sions , long lengths of s tay, and identification of ps ychotic or personality dis orders. T hes e P.669 findings pointed out that, des pite recent emphasis on community care, a continuing need for inpatient for some ps ychiatric patients seems to exist. Illus trating the importance of primary health care for people presenting mental disorders , M. G . R owe et al. found that one in five women and one in ten men 408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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their primary phys icians have been recently depress ed. B ernardo Ng et al., surveying nonpsychiatrist rural C alifornia, documented the need for enhanced postgraduate training on depres sion for primary care phys icians .

Findings on Mental Health Polic y T he WHO Atlas S urvey Minis tries of Health revealed percent of countries in the world have no mental health policies , 30 percent have no national mental health programs, 25 percent have no mental health percent have no s pecific budget for mental health, and percent have no regular mental health training for care personnel. T hese figures are preliminary, and the survey is now being enhanced in collaboration with the World P s ychiatric Ass ociation. Illus trating the value of pointed inves tigations in the complex mental health field to upgrade health and policies , T able 5.1-11 displays the relations hip between women experiencing domestic violence and then contemplating s uicide in eight developing countries in Latin America, Africa, and As ia. In all the s tudy s ites , than twice the percentages of women ever phys ical violence by an intimate partner contemplate committing suicide, as compared to women never experiencing such domestic violence.

Table 5.1-11 R elations hip Domes tic Violenc e and C ontemplation of S uic ide 409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Perc entage of Women Who E ver Thought of C ommitting S uic ide (P T able of C ontents > V olume I > 6 - T heories of P ers onality and P s ychopathology > 6.1: C las P s ychoanalys is

6.1: C las s ic Ps yc hoanalys is W. W. Meis s ner M.D., S .J . P art of "6 - T heories of P ers onality and P sychoanalysis has existed s ince before the turn of the 20th century and, in that s pan of years, has es tablished its elf as one of the fundamental dis ciplines within ps ychiatry. T he science of ps ychoanalys is is the ps ychodynamic unders tanding and forms the fundamental theoretical frame of reference for a variety forms of therapeutic intervention, embracing not only ps ychoanalys is its elf but als o various forms of ps ychoanalytically oriented psychotherapy and related forms of therapy using ps ychodynamic concepts . current efforts are being directed to connecting ps ychoanalytic unders tandings of human behavior and emotional experience with emerging findings of neuros cientific res earch. C onsequently, an informed clear understanding of the fundamental facets of ps ychoanalytic theory and orientation is es sential for student's grasp of a large and s ignificant s egment of current ps ychiatric thinking. One of the difficulties in pres enting s uch a synthetic account is that it must draw its material from more than century of thinking and theoretical development. Although there is more than one way to approach the divers ity of such material, the material in this chapter is 424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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organized along historical lines, tracing the emergence analytical theory or theories over time but with a good deal of overlap and s ome redundancy. B ut there is an overall pattern of gradual emergence, progress ing from early drive theory to s tructural theory to ego object relations and on to s elf-ps ychology, inters ubjectivism, and relational approaches .

R OOTS OF THINK ING P sychoanalysis was the child of S igmund F reud's He put his s tamp on it from the very beginning, and it be fairly said that, although the s cience of has advanced far beyond F reud's wildes t dreams, his influence is still strong and pervasive. In understanding origins of ps ychoanalytic thinking, it is us eful to keep in mind that F reud hims elf was an outstanding product of the scientific training and thinking of his era.

S c ientific Orientation F reud was a convinced empirical s cientis t whose early training in medicine and neurology had been in the progres sive s cientific centers of his time. He s hared the conviction of mos t of the s cientists of his day that law and order and the systematic study of phys ical and neurological process es would ultimately yield an unders tanding of the apparent chaos of mental When he began his study of hys teria, he believed that brain phys iology was the definitive scientific approach that it alone would yield a truly s cientific understanding. With his own increasing clinical experience, F reud was forced to modify that bas ic scientific credo, but it is 425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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significant nonetheles s that he maintained it in one or another form throughout the whole of his long career. own efforts to elaborate a scientific phys iology of phenomena were, in the end, to prove frustrating and disappointing. After abandoning that attempt, contained in the long-lost pages of the P roje ct for a S cie ntific P s ychology (1895), he continued to believe that, the clinical material he dealt with forced him to work on level of ps ychological reflection, there was a close and intimate connection between phys ical and psychical proces ses.

On A phas ia Although a good deal of attention has been paid to F reud's P roje ct as express ing his early model of the more recent attention has been drawn to his important neurological work O n Aphas ia (1891), in which F reud advanced his earliest views of the relation between structure and function in the brain. F ollowing J ohn Hughlings J acks on's emphasis on the complex between thought and language, F reud challenged the prevailing notions of brain localization of function advanced by P ierre B roca, K arl W ernicke, T heodor and others . R ather than thinking in terms of brain à la B roca's speech center, F reud related the functions speech to functional capacities in a widespread visual, acoustic, tactile, and even kines thetic reflecting generalized changes in the functioning of the brain as a whole. T hus, he viewed simple functions , s uch as perception or memory, as phys iologically complex and involving multiple brain systems . In his view, it was the dis ruption in the network that was respons ible for various forms of 426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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rather than des truction of s pecific centers. F ollowing J acks on's differentiation between mind and brain and his concept of functional retrogress ion from higher levels of organization to lower, F reud regarded aphas ia as reflecting retrogress ion to earlier developmental s tates of speech development. He attributed s peech functions to a “zone of language” that was independent of anatomical location, a position that res onated with his later stipulations regarding hysteria which s ymptoms were not related to anatomical lesions but had to do with meaning and symbolization related network of as sociations. In any cas e, the concepts he developed in his s tudy of aphas ia later reemerged in ps ychological theory, specifically, concepts of mental representation, cathexis , s ymbol formation, and word and object representation. T he view of from higher to lower levels of functioning seems to P.702 foreshadow his later doctrine of regress ion, and his comments on forms of paraphas ia read like a draft of the ps ychopathology of everyday life.

The P rojec t T he effort to bridge the chas m between psychological proces ses and neurological mechanis ms reached a intens ity in F reud's attempt to cons truct a “scientific ps ychology”—that is , a psychology bas ed on principles. E arnes tly dedicated to the s cientific ideals of Hermann Helmholtz's approach to phys iology and ps ychology, he conceived the s cheme of elaborating a complete ps ychology that would be bas ed on the 427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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phys icalis tic s upposition of the Helmholtz school. F or nearly 2 years , from 1895 to 1897, F reud s truggled these ideas. F inally, in the white heat of intens e in a period of no more than 3 weeks , he wrote out what known today as the P roje ct. W hen the intensity of his inspiration had begun to wane, F reud became discouraged with what he had written and finally, in disgust, threw it into a des k drawer where it was to for years . In 1898, he wrote in dis couragement and to his friend W ilhelm F lies s that he was “not at all to leave the psychology hanging in the air without an organic basis. B ut apart from this conviction [that there must be s uch a basis] I do not know how to go on, theoretically nor therapeutically, and therefore must behave as if only the ps ychological were under cons ideration.” It was his intention that the P roje ct be des troyed, but after his death, his papers came into hands of thos e who recognized its importance, and it finally published posthumous ly. If it brought F reud's neurological period to a brilliant clos e, it also opened way to the broad vis tas of psychoanalysis and, in important and significant ways, determined the shape ps ychoanalytic principles were to take. F reud's understanding of the principles of mental functioning traditionally formed the core of explanations of how the mental apparatus works and functions, but within the last half century, the central position of thes e principles has come into ques tion. T he P roje ct was on two principal theorems: firs t, the idea that the system was compris ed exclus ively of neurons, by “contact barriers ” (F reud's express ion for s ynaps es); second, a quantitative concept of neural excitation (Qn) 428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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transmitted from cell to cell in the nervous s ys tem and either s tored or discharged, thus accounting for various forms of nervous activity. T he energy in this early was simply a form of quantitative excitation within an open-system neuronal reflex model, but it quickly surplus meaning as a hypothetical substance with hydros tatic properties . Out of these simple elements , in combination with a set of regulatory principles , F reud elaborated his complex and ingenious account of functioning. T he bas ic model used in the P roje ct on a reflex apparatus whose function was withdrawal stimuli, particularly excess ive s timuli, and discharge of accumulated excitation as governed by the cons tancy principle and the neces sity of withdrawing from stimulation in accordance with the unple as ure principle . When F reud finally surrendered his effort to formulate ps ychology in terms of a physical model, he was forced shift to a more s pecifically psychological model of the mental apparatus but without completely abandoning ideas in the P roje ct. His thinking remained tied to the phys icalis tic model of energy s ys tems and their distribution. S urrender of his objective of explaining mental life in terms of phys iological and neurological proces ses was more a compromise than a s urrender. view, the mind pos sess ed certain dynamic properties that the ps ychological model had to be cons tructed according to the dynamic laws and principles inherent current physical theories of the dis tribution and of the flow of energy. Nonetheless , psychic energy was clearly distinct and different from the metabolic energy the brain and referred s pecifically to purpos eful s triving. P sychic energy became the central concept around 429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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F reud erected his economic model of mental P s ychic e nergy was that energy, as sumed to be the mental apparatus deriving from ins tinctual drives, related to affective experience, es pecially anxiety, and modified in various ways by ps ychic s tructures , always with a tendency toward discharge. Although it derived from instinctual drives , it had no specified relations hip phys ical energies ass umed to be operating in corres ponding neural structures. In any case, the concept prevailed that ps ychic energy represented a purely quantitative and nonqualitative capacity for work, which the ps ychic apparatus carried by the transformation, storage, discharge, or delay of discharge of psychic energy. In the clas sic theory, the instinctual drives impose this demand for work on the mind. Not only does the concept of energy as work potential divorce it from the hydros tatic model, but separating the economic principle from connections ps ychic energy removes it from the line of causal in other words , economic principles are not principles efficiency—they are principles of quantitative E fficiency (caus ality, work) belongs to energic factors . However, the regulatory principles, as ess ential to the economic perspective, were originally formulated in of the regulation of ps ychic energies and have been viewed almos t exclus ively in s uch terms ever s ince. may retain s ome validity in economic rather than terms as regulatory principles of how the mental works (T able 6.1-1). Other questions remain regarding place of the drives in relation to the capacity for work or force and whether the drives are the only guarantee of connection between the mind and the phys ical 430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Table 6.1-1 E nergic Princ iples B as ed on the P rojec t R evis ed Princ iple

E xplanation

E ntropy

S igmund F reud: T endency for energy in any physical s ys tem to flow from a region of high energy regions of lower energy; tendency of system toward homogeneity; tendency of s ys tem to spontaneously diminish the of energy available for work.

 

R evised: A revised schema the physical model for ps ychic proces ses in favor of a model bas ed on motivation and tendency of psychic s ys tems to and achieve purpos eful goals .

C ons ervation

F reud: T he s um of forces any isolated (clos ed) system remains cons tant.

 

R evised: T he psychic apparatus not a clos ed s ys tem, but open, does not operate on the bas is of 431

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clos ed-system dynamics. Neuronic inertia

F reud: Neurons tend to dives t thems elves of quantities of excitation. Application of entropy and cons ervation to neuronal activity.

 

R evised: G eneral psychic to resolve s ituations of conflict, tension, affective imbalance (including anxiety, fear, guilt, shame, depres sion) in favor of greater balance and more harmonious integration with other ps ychic s ys tems.

C ons tancy

F reud: T he nervous system tends maintain its elf in a state of tension or level of excitation. to a level of constant excitation is achieved by a tendency to immediate energic discharge (through the path of leas t res is tance).

 

R evised: T endency of ps ychic functions to return to a s tate of res ting potential as contextual stimulus conditions and the 432

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of feedback-regulated conditions the same and related ps ychic systems allow. Nirvana

F reud: T he dominant tendency to reduce, keep cons tant, or remove the internal ps ychic tension due to the excitation of s timuli; the tendency to reduce the level of excitation to a minimum; of constancy principle; expres sed pleas ure principle, ultimately in death ins tinct.

 

R evised: T his principle has no in an economically revised but is replaced by an oppos ite tendency to seek stimulation, to seek complex rather than stimulation.

P leasureunpleasure

F reud: T endency of mental apparatus to s eek pleas ure and avoid unpleasure. Unpleas ure is to the increas e of tension or level excitation, whereas pleas ure is to the release of tension or discharge of excitation. T he pleas ure principle thus follows the economic requirements of

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cons tancy.  

R evised: Indicates the degree of functional satis faction/diss atis faction and efficacy derived from effective/ineffective operation of ps ychic s ys tems; pleasure succes sful transition from to actual operation of the ps ychic function(s ) and achievement of purpos eful and wis hed-for goals .

R eality

F reud: Modification or delay of energic discharge adapting pleas urable dis charge according the demands of reality.

 

R evised: Modification or delay of ps ychic functioning as mutually conditioned by the internal of intra- and inters ys temic within the mental apparatus ; limiting conditions for s pecific functions outside the mind are determined by reality factors.

R epetition

F reud: T endency of ins tinctual forces , as a result of inertial tendencies, to repeat patterns of 434

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discharge even when res ulting in unpleasure.  

R evised: R ather than resulting inertial energic dynamics, may relate to stabilization of functions and s tructural integrations, thus contributing to development and the continual proces s of as similating and accommodating to reality.

F reud used ps ychic energy both as a device to observable phenomena and as a construct in his model the mind. P eople have only begun to appreciate the to which F reud used the neurological and energic terminology of Helmholtz and G ustav F echner as metaphorical devices to express his psychological cons tructs. T he use of s uch metaphors may have us efulnes s, es pecially in expres sing iss ues of conflict development dealt with by ps ychoanalys is — that lend themselves readily to verbal metaphorical hypothes es and les s readily to mathematical quantification. As F reud's viewpoint became ps ychological, his use of concepts of drive and energy became increas ingly metaphorical, as in T hre e E s s ays (1905). P robably after 1900, F reud became aware of the limitations of his theory, es pecially the system and hydraulic aspects of his model, which 435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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prompted further revisions . After his abandonment of P roje ct, he preferred to think of his theories as purely ps ychological, but even s o, the energic ass umptions carried over into s tructural theory.

C ritic is ms of Ps yc hic E nergy All these uncertainties and ambiguities come to roos t in contemporary criticisms of ps ychic energy. T he statements s ummarize the objections and the reas ons critics conclude that the class ic notion of ps ychic can no longer be tolerated in a contemporary ps ychoanalytic theory: P sychic energy is not measurable, so we are tes t any quantitative as sumptions of the theory. T he relationship between neural energies in the and ps ychic energy remains vague and poorly unders tood, and therefore any laws for the transformation of one to the other remain elusive. T he hydraulic analogy is outmoded, and the view of ps ychic energy was based on a simplified view of caus ality and a misleading equation of ps ychic with physiological energy as an explanatory T he model is internally contradictory P.703 and lacks cons is tency; it pres ents a logically closed system that misinterprets metaphor as fact; it tautological renaming of obs ervable ps ychological phenomena in energic terms, which mas querades explanation; it is unable to explain all the relevant data; it tends to lead to a false s ense of 436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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particularly to the extent that it offers ps eudoexplanations that are incons is tent with knowledge of neurophys iology. R ather than serving a bridge between ps ychoanalys is and physiology, es pecially neurophys iology, it becomes a barrier to interdisciplinary communication and integration. T he human organis m is in s ome degree tens ion seeking and maintaining, whereas the energic is based on the principle of tension reduction. P sychic energy comes in multiple forms , s uch as libidinal, aggres sive, narcis sistic, and various of neutralized energies, bound energies, and fus ed energies. T he difficulty here has not so much to do with the varying manifes tation of energies in forms but, rather, with the idea that the differences inherent in the energies themselves . T his objection focus es on the differentiation of the energy its elf, as oppos ed to the idea that various manifestations of ps ychic energy may be determined by the through which they are express ed—qualitative differences would be due to the patterned control, channeling, and mediation of intervening In the analogous cas e of physical energy, the differences of the various forms, s uch as heat and are not attributed directly to energy as s uch but, rather, to the physical channels through which the energy is express ed. B y implication, qualitative differences undercut the idea of the id as chaos cons isting only of energy and its modes of discharge. T here are also problems with the energic metaphor its elf. F reud did not clearly dis tinguis h drive and 437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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energy as biological, phys iological, or ps ychological and connected them almost exclusively with the sexual drive. T he terms share both physical and ps ychological reference: C athexis is both an electrochemical charge and a wish. T his opened door not only to conceptual errors but als o to the of an ess entially nonanalytical model to explain analytical material. If energy s erves as a metaphor for experience, it is merely descriptive and not explanatory; if it stands some neurophys iological function, any explanatory value res ts on dualistic mind–brain as sumptions. T he notion of psychic energy does not meet criteria of accepted scientific method. S pecifically, it internally contradictory and lacks consis tency; it presents a logically clos ed system that metaphor as fact; it involves a tautological observable and experienced psychological phenomena in energic terms that masquerade as explanations ; it is unable to explain all of the data, especially the phenomena of pleasurable tension, exploratory behavior, and s timulus hunger; tends to lead to a false s ense of explanation, particularly ins ofar as it offers ps eudoexplanations are incons is tent with current knowledge of neurophys iology; and it promotes a form of mind– body dualis m—dualistic interactionis m—that P.704 prevents integration of ps ychoanalytic concepts related sciences of the mind and behavior. T he metaphor is given s urplus meaning, which elevates 438 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to an objective phenomenon and introduces circularity, vitiating any verification of drive–energy concepts . T he energic metaphor is incons istent with current neurophys iological unders tanding bas ed on of selective inhibition rather than energy depletion the all-or-none nature of the nervous impuls e rather than fluid dynamics . T he us efulnes s of the energic model for clinical purpos es has been ques tioned. Using a model for qualitative events limits both the range depth of explanation. S uch quantitative trans lation persis ts in the name of presumed objectivity and in belief that it offers a more s cientific view of clinical conceptions . T he drive-discharge model interprets in terms of discharge, thus blurring any distinction between drive and motive. B ut in the clinical libido and s exuality do as sume s ignificant connotations of meaning and motive. E ven if and motive do not exclude quantitative dimens ions , the quantitative cannot s ubstitute for the qualitative. On the basis of such s lender pos tulates , F reud complex and ingenious account of mental functions. He was unable, however, to provide a s atis factory account either defense or cons cious nes s. In both cas es , he embroiled in a continuing regres s in which he s eemed unable to stop. Des pite a variety of ingenious feedback loops that he built into the s ys tem—F reud was many decades ahead of his time in envisioning informational servomechanis ms —he was unable to complete the functioning of his s ys tem without violating the demands 439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of his mechanical principles . He thus introduced into system a major concess ion to vitalis m, an observing T his obs erving ego was able to s ee danger for the mobilization of defens es and was able to s ens e the indication of quality in cons cious experiences. T he ego remained as a sort of primary “willer” and ultimate “knower,” a pers onal center within the theory that could not be reduced to the phys icalistic terms of postulates and that cons equently enjoyed a s ignificant degree of autonomy. One of the persis tent difficulties inherent in the of ps ychic energy is that, because of the original mode which F reud expres sed his economic views, the hypothes is has become overidentified with the of psychic energy. T here is little doubt that theory cannot do without a principle of economics . It is impos sible to express or unders tand matters of quantitative variation, degrees of intensity, levels and intens ity of motivation, or informational communication to explain how individual subjects are able to make choices among conflicting motivations and goals to about the resolution of conflict—or, for that matter, to explain the whole range of affective, motivational, and structural concepts that form the backbone of ps ychoanalytic unders tanding—without invoking the concepts and iss ues of quantity and intens ity that led F reud from the very beginning to postulate an point of view. T he s hifting focus on informational- and communication-based concepts does not escape the for economic governing principles.

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In the decade from 1887 to 1897, F reud turned his attention to the s erious study of the disturbances of his hysterical patients , and, in this period, the beginnings ps ychoanalys is took root. T hese slender beginnings threefold aspect: emergence of ps ychoanalys is as a method of inves tigation, as a therapeutic technique, as a body of scientific knowledge bas ed on an fund of information and basic theoretical propos itions . T hese early res earches flowed out of F reud's initial collaboration with J os eph B reuer and then, from his own independent investigations and developments.

The C as e of Anna O. B reuer was an older phys ician, a distinguished and es tablis hed medical practitioner in the V iennes e community. K nowing F reud's interes ts in hysterical pathology, B reuer told him about the unusual cas e of a woman he had treated for approximately 1.5 years, December 1880 to J une 1882. T his woman became under the pseudonym F räulein Anna O., and s tudy of difficulties proved to be one of the important s timuli in development of ps ychoanalys is . Anna O. was , in reality, B ertha P appenheim, who later became independently famous as a founder of the work movement in G ermany. At the time she began to B reuer, s he was an intelligent and s trong-minded of approximately 21 years of age who had developed a number of hys terical symptoms in connection with the illness and death of her father. T hese symptoms paralysis of the limbs , contractures, anesthesias, visual disturbances , disturbances of speech, anorexia, and a 441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distress ing nervous cough. Her illness was also characterized by two distinct phases of cons cious nes s: relatively normal, but the other reflecting a second and more pathological personality. Anna was very fond of and clos e to her father and with her mother the duties of nurs ing him on his deathbed. During her altered s tates of cons cious nes s, Anna was able to recall the vivid fantasies and intens e emotions s he had experienced while caring for her It was with cons iderable amazement, both to Anna and B reuer, that when s he was able to recall, with the as sociated express ion of affect, the s cenes or circums tances under which her s ymptoms had aris en, symptoms could be made to disappear. S he vividly described this process as the “talking cure” and as “chimney sweeping.” Once the connection between talking through the circums tances of the s ymptoms and the dis appearance the symptoms themselves had been es tablis hed, Anna proceeded to deal with each of her many s ymptoms after another. S he was able to recall that, on one when her mother had been absent, s he had been her father's beds ide and had had a fantas y or which s he imagined that a snake was crawling toward father and was about to bite him. S he s truggled try to ward off the snake, but her arm, which had been draped over the back of the chair, had gone to sleep. was unable to move it. T he paralysis persisted, and unable to move the arm until, under hypnosis, s he was able to recall this s cene. It is easy to s ee how this kind material mus t have made a profound impres sion on It provided convincing demons tration of the power of 442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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unconscious memories and s uppress ed affects in producing hysterical s ymptoms. In the course of the s omewhat lengthy treatment, had become increasingly preoccupied with his and unusual patient and, cons equently, spent more more time with her. In the meanwhile, his wife had increasingly jealous and resentful. As soon as B reuer to realize this, the sexual connotations of it frightened and he abruptly terminated the treatment. Only a few hours later, however, he was recalled urgently to bedside. S he had never alluded to the forbidden topic sex during the cours e of her treatment, but s he was experiencing hysterical childbirth. F reud s aw that the phantom pregnancy was the logical termination of the sexual feelings she had developed toward B reuer in res ponse to his therapeutic efforts. B reuer had been unaware of this development, and the experience was quite unnerving. He was able to calm Anna down by hypnotizing her, but then he left the house in a cold and immediately s et out with his wife for V enice on a second honeymoon. P.705 According to a version that comes from F reud through E rnest J ones, the patient was far from cured and later to be hospitalized after B reuer's departure. It seems ironical that the prototype of a cathartic cure was , in far from success ful. Nevertheles s, the cas e of Anna O. provided an important starting point for F reud's thinking and a crucial juncture in the development of ps ychoanalys is. 443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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S tudies on Hys teria T he collaboration with B reuer brought about publication of “P reliminary C ommunication” in 1893. E s sentially, and B reuer extended J ean C harcot's concept of hysteria to a general doctrine of hys teria. Hys terical symptoms were related to psychic traumata, clearly and directly but als o s ometimes in a s ymbolic disguis e. Obs ervations bas ed on these later cas es es tablis hed a connection between pathogenesis of common hys teria and that of traumatic neurosis; in cases, trauma is not followed by sufficient reaction and thus kept out of cons cious nes s. T hey obs erved that individual hys terical symptoms seemed to disappear when the event provoking them clearly brought to life, with the patient describing the event in great detail and putting accompanying affect words . F ading of a memory or loss of its ass ociated depends on various factors, including whether there been an energetic reaction to the event that provoked affect. T hus, memories can be regarded as traumata have not been sufficiently abreacted. T hey noted that splitting of cons cious nes s, so striking in clas sic cases hysteria as “double cons cious nes s,” is present to at rudimentary degree in every hys teria. T hey des cribed basis of hys teria as a hypnoid s tate—that is , a state of diss ociated cons ciousnes s. T hey believed achieved its curative effect on hys terical s ymptoms by bringing to an end the emotional force of the idea that not been s ufficiently abreacted in the firs t ins tance. It this by allowing strangulated affect to gain dis charge through speech, thus s ubjecting it to as sociative 444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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correction, integrating it with normal cons cious nes s. “P reliminary C ommunication” created cons iderable interes t and was followed in 1895 by S tudie s on which B reuer and F reud reported on their clinical experience in the treatment of hysteria and proposed a theory of hys terical phenomena. F reud's cas e proved to be extremely s ignificant because they formed the original basis for much of his ps ychoanalytic F reud concluded from thes e observations that an experience that had played an important pathogenic together with its subsidiary emotional concomitants, accurately retained in the patient's memory even when apparently forgotten and unrecoverable by voluntary recall. He postulated that repres sion of an idea from cons ciousnes s and exclus ion from any modification by as sociation with other ideas was an ess ential condition development of hysteria. At this early s tage, F reud regarded repress ion as intentional and believed it as the bas is for convers ion of a s um of neural When cut off from more normal paths of ps ychic as sociation, this sum of excitation would find its way all more easily along a deviant path leading to somatic innervation. T he basis for s uch repress ion, he argued, be a feeling of unpleasure derived from the between the idea to be repres sed and the dominant of ideas constituting the ego. Moreover, as one symptom was removed, another developed to take its place. T he illnes s could be even by a person of s ound heredity as the res ult of appropriate traumatic experiences. It should be noted F reud's view was quite different from B reuer's, the origin of hys teria to hypnoid s tates. In F reud's view, 445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the actual traumatic moment, the incompatibility of forces its elf on the ego so that the ego repudiates the incompatible idea. T his reaction brings into being a nucleus for crys tallization of a s eparate psychic group somehow divorced from the ego. T his process res ults the splitting of cons cious nes s characteris tic of acquired hysteria. T he therapeutic process consists in this s plit-off ps ychical group to unite once more with main mas s of cons cious ego ideas . In every cas e of based on sexual traumas , F reud believed that from the presexual period, which produce little or no on the child, can attain traumatic power at a later date memories when the girl or married woman begins to acquire an unders tanding of and exposure to adult life. On the basis of thes e cas es, F reud recons tructed the following s equence of steps in the development of hysteria: (1) T he patient had undergone a traumatic experience, by which F reud meant an experience that stirred up intense emotion and excitation and that was intens ely painful or dis agreeable to the individual; (2) traumatic experience represented to the patient s ome or ideas incompatible with the “dominant mas s of ideas cons tituting the ego”; (3) this incompatible idea was intentionally diss ociated or repres sed from (4) the excitation as sociated with the incompatible idea was converted into s omatic pathways, resulting in hysterical manifes tations and s ymptoms; (5) what was in consciousness was merely a mnemonic symbol only connected with the traumatic event by as sociative links that are frequently enough disguis ed; and (6) if the memory of the traumatic experience can be brought 446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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cons ciousnes s and if the patient is able to releas e the strangulated affect as sociated with it, then the affect is discharged, and s ymptoms dis appear.

Freud's Tec hnic al E volution One interesting aspect of the S tudie s on H ys te ria is the evolution in F reud's development of technical to the treatment of hys teria. R es ulting from his early interes t in hypnosis , as well as his exposure to techniques both in C harcot's clinic and later at Nancy, F reud began us ing hypnos is extens ively in treating his patients when he opened his own practice in 1887. In beginning, he us ed hypnotic s uggestion to enable patients to rid thems elves of their symptoms . It became quickly obvious, however, that, although patients res ponded to hypnotic s uggestion and tried to treat the symptoms as if they did not exist, the s ymptoms nonetheless reas serted themselves again during the patient's waking experience. B y 1889, then, F reud was s ufficiently intrigued by cathartic method to use it in conjunction with hypnotic techniques as a means of retracing the his tories of symptoms. In his early efforts , he stayed quite close to notion of the traumatic origins of hysterical s ymptoms . C ons equently, the goal of treatment was res tricted to removal of s ymptoms through recovery and of suppres sed feelings with which symptoms were as sociated. T his procedure has since been described “abreaction.” However, as in the case of hypnotic suggestion, F reud was still s omewhat diss atisfied with res ults of this treatment approach. T he beneficial hypnotic treatment s eemed to be transitory; they 447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to las t, or seemed effective, only as long as the patient remained in contact with the phys ician. F reud that alleviation of s ymptoms was in fact dependent in some manner on the pers onal relations hip between patient and phys ician.

F rom Hypnos is to A nalys is F reud had begun to feel that inhibited sexuality may a role to play in production of the patient's s ymptoms. suspicion of a sexual as pect in the treatment of such patients was amply confirmed one day when a female patient awoke from a hypnotic sleep and suddenly her arms around his neck. F reud s uddenly found the same pos ition in P.706 which B reuer had found hims elf during his earlier treatment of Anna O. P erhaps bolstered by B reuer's experience and apparently able to learn from it, F reud not panic or retreat in the face of this sexual advance. R ather, the peculiar obs ervant quality of his mind was to dis engage its elf sufficiently so that this experience could be treated as a s cientific obs ervation. F rom this point on, F reud began to understand that the therapeutic effectivenes s of the patient–phys ician relations hip, which had s eemed so mys tifying and problematic to him until this time, could be attributed in fact to its erotic bas is . T hese obs ervations were to the bas is of the theory of transference that he later into an explicit theory of treatment. In any event, these experiences reinforced his dis satisfaction with hypnotic techniques. He became aware that hypnosis 448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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masking and concealing a number of important manifestations that seemed to be related to the cure or, in s ome cases, to the inability of the patient to achieve a definitive resolution of the neurosis. Later, diss atis faction with hypnosis became more specific in he could see that continued us e of hypnos is precluded further investigation of transference and resis tance phenomena. F reud had also dis covered that many of the patients in private practice were in fact refractory to hypnos is. gradually did he come to recognize that what seemed be his inability to hypnotize a patient might often be due to a patient's reluctance to remember traumatic events. He was able later to identify this reluctance as res is tance. T he vagaries of the hypnotic method did satis fy F reud, and he believed it necess ary to develop approach to treatment that could be us efully applied regardless of whether the patient was hypnotizable. C ons equently, although F reud continued to us e techniques as a bas ic approach to treatment of began to experiment with it and gradually succeeded in modifying the technique.

C ONC E NTR ATION ME THOD One of the patients whom F reud found to be refractory hypnotic technique was E lizabeth von R . F or the first in this cas e, F reud decided to abandon hypnosis as his primary therapeutic tool. He bas ed his decis ion to alter technique on the obs ervation of Hippolyte B ernheim although certain experiences appeared to be forgotten, they could be recalled under hypnosis and then subs equently recalled consciously if the physician were 449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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as k the patient leading ques tions urging reproduction these critical memories. F reud thus evolved his method concentration. T he patient was asked to lie on a couch and close her S he was then instructed to concentrate on a particular symptom and to recall any memories as sociated with it. T he method was substantially a modification of the technique of hypnotic s uggestion. F reud press ed his on the patient's forehead and urged her to recall the unavailable memories. F reud's graphic descriptions of technique carry with them the unavoidable impress ion that he was struggling agains t a force he sensed in the patient and agains t which he found himself battling, as though in hand-to-hand combat. He came slowly, by of this laborious experience, to realize that the is olation certain memory contents was a matter of the operation mental forces generating cons iderable power that kept complex of pathogenic ideas separate from the mass cons cious ideation. T his substantially provided him with the empirical notion of resistance and with the metapsychological perspective of the mind as terms of psychic forces.

FR E E AS S OC IATION T he material presented in such graphic detail in Hys teria reflects dramatically the evolution of F reud's technique in the direction of his more definitive to ps ychoanalys is . He became increas ingly convinced the late 1890s that the process of urging, press ing, questioning, and trying to defeat the resistance offered the patient—all of which were part and parcel of the “concentration” method—rather than facilitating 450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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overcoming of the patient's res is tances , actually with the free flow of the patient's thoughts. P iece by then, F reud gave up the concentration method. this progress ive evolution, the basic principle of ps ychoanalys is—free as sociation—was focus ed and articulated. G radually, F reud surrendered his technique forehead press ure as well as the requirement that clos e their eyes while lying on the couch. T he only remnant of this earlier procedure persisting in the of ps ychoanalys is is the use of the couch. T he of the central principle of ps ychoanalysis was the product of F reud's evolution. T he evolution of F reud's as sociative technique to progres s until it had been perfected. T he continued with increas ing reliance on the patient's capacity to freely manifes t mental contents without suggestive interference on the part of the therapis t. B y end of the 19th century, F reud had more or les s es tablis hed his as sociative technique. He described it the following terms : T his [technique] involves some psychological of the patient. W e must aim at bringing about two changes in him: an increas e in the attention he pays to own psychical perceptions and the elimination of the criticis m by which he normally s ifts the thoughts that occur to him. In order that he may be able to his attention on his self-observation it is an advantage him to lie in a restful attitude and to s hut his eyes. It is neces sary to insis t explicitly on his renouncing all of the thoughts that he perceives . W e therefore tell him that the succes s of the ps ychoanalysis depends on his noticing and reporting whatever comes into his head 451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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not being mis led, for ins tance, into suppres sing an idea because it s trikes him as unimportant or irrelevant or because it s eems to him meaningles s. He must adopt completely impartial attitude to what occurs to him, it is precis ely his critical attitude which is respons ible his being unable, in the ordinary cours e of things , to achieve the des ired unraveling of his dream or idea or whatever it may be. In jus t a few years more, clos ing of the eyes was also abandoned. T hus, free ass ociation became the technique of psychoanalysis . In fact, it was this technique that opened the door to exploration of dreams , which became one of the primary sources of bolstering the nascent psychoanalytic point of view.

Theoretic al Innovations T he theoretical point of view in S tudie s on H ys te ria was relatively complex. B reuer adopted the point of view hysterical phenomena were not altogether ideogenic— that is , that they were not determined s imply by ideas. fact, the phenomena of hysteria may be determined by variety of causes, some brought about by an explicitly ps ychical mechanis m but others without it. Although called hysterical phenomena were not necess arily by ideas alone, their ideogenic as pects were described as hysterical. T he contribution of F reud and B reuer was that they focus ed on investigation of these ideogenic as pects and dis covered s ome of their origins. P articularly, the concept of neuronal excitation, conceived of as s ubject to process es of hydraulic flow discharge as in the P roje ct, was of fundamental in understanding hysteria as well as neurosis in 452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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A careful reading of B reuer's theoretical s ection in of Hys te ria makes it abundantly clear that what he propos ed was a P.707 reworking of the ingenious ideas of F reud's P roje ct, specific application to the explanation of hysterical phenomena. B reuer described two extreme conditions central nervous system (C NS ) excitation, namely, a waking state and the s tate of dreamles s s leep. W hen brain performs actual work, greater cons umption of energy is required than when it is merely prepared to work. T he phenomenon of s pontaneous awakening take place in conditions of complete quiet and without any external s timulus. T his demonstrates that development of ps ychic energy is based on vital of neural elements thems elves . B reuer also provided an explanation of hysterical conversion. His basic explanatory concept—originally propos ed by F rench ps ychiatris ts, particularly P ierre J anet—was the notion of hypnoid states. S uch s tates believed to resemble the basic condition of dis sociation obtaining in hypnos is . T heir importance lay in the that accompanied them and in their power to bring splitting of the mind. T he s pontaneous origin of s uch states through autohypnosis was identifiable relatively frequently in a number of fully developed hysterics. states often alternated rapidly with normal waking E xperience of the autohypnotic s tate was found to be subjected to a more or les s total amnes ia while the was in the waking s tate. Hys terical convers ion seemed take place more eas ily in such autohypnotic s tates than 453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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waking states , similar to more facile realization of suggested ideas in states of artificial hypnos is . Neither hypnoid states during periods of energetic work nor unemotional twilight states were pathogenic. T he reveries, however, filled with emotion and states of arising from protracted affects did s eem to be Occurrence of s uch hypnoid s tates was important in genes is of hysterical phenomena becaus e they made convers ion easier and prevented, by way of amnes ia, the converted ideas from wearing away and losing their intensity. It mus t be said that F reud was not s ympathetic to concept of hypnoid s tates, although, at this s tage, had not been able to bring hims elf to reject it. T he concept, in fact, did not explain very much. T he state was used as an explanation for hysterical s tates, the occurrence and function of hypnoid states were in no way explained or s upported—they were postulated. T he only explanatory attempt made was in terms of a hereditary dis pos ition to such states. T his unproven postulate was one that F reud's scientific could not accept. T he spirit of F reud's treatment of the psychotherapy of hysteria was quite different from that embodied in theoretical treatment. His discus sion of the treatment of hysteria in S tudie s of H ys te ria gives one a good s ens e extent to which F reud had moved away in his own thinking from the somewhat res trictive formulations of P roje ct. He pointed out that each individual hys terical symptom seemed to disappear more or les s when the memory of the traumatic event provoking it brought into cons cious awareness along with its 454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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accompanying affect. It was neces sary that the patient describe such traumatic events in the greates t poss ible detail and be able to expres s verbally the affective experience connected with it. F reud believed that the basic etiology of the acquisition neuros is had to be located in s exual factors. Different sexual influences operated to produce different neurotic disorders . Us ually, the neurotic picture was and purer forms of either hysterical or obs es sional were relatively rare. F reud did not regard all hys terical symptoms as ps ychogenic in origin so that they could all be effectively treated by a ps ychotherapeutic procedure. In the context of his theory and technique at that time, he found that a significant number of patients could not be hypnotized despite an apparently certain diagnosis of hysteria. In these patients, F reud believed he had to overcome a certain ps ychic force in the force that was s et in oppos ition to any attempt to bring the pathogenic idea into cons cious nes s. In the therapy, experienced himself engaging in s ometimes forceful ps ychic work to overcome this intens e counterforce. T he pathogenic idea, however, des pite the force of res is tance, was always clos e at hand and could be by relatively easily acces sible as sociations. T he patient seemed to be able to rid himself or hers elf of s uch turning them into words and des cribing them. Nevertheles s, F reud's experience was that, even in which he was able to surmise the manner in which were connected and could tell the patient before the patient had actually uncovered it, he could not force anything on the patient about matters in which the was es sentially ignorant nor could the therapis t 455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the product of the analys is by arous ing the patient's expectations .

R es is tanc e T he basic question that confronted F reud and B reuer to do with the mechanism that made pathogenic memories unconscious. T he divergence in their points view was not simply a matter of theoretical differences. F reud's own thinking underwent a definite trans ition, the transition seemed to be bas ed primarily on his experience in dealing with his patients . In the he and B reuer had agreed that their hys terical patients undergone traumatic s exual experiences. T hes e experiences were not available to cons cious T hey had als o agreed, at leas t for a time, that recovery these forgotten experiences during an induced state resulted in abreaction and cons equent improvement. F reud discovered that his patients were often quite unwilling or unable to recall the traumatic memories. defined this reluctance of his patients as re s is tance . As clinical experience expanded, he found that, in the majority of patients he treated, resis tance was not a of reluctance to cooperate—that is , the patients engaged in the treatment process and were willing to obey the fundamental rule of free as sociation. T he generally seemed to be well motivated for treatment, frequently enough, it was particularly patients who most dis tres sed by their s ymptoms who s eemed most hampered in treatment by resistance. F reud's was that res is tance was a matter of the operation of forces in the mind, of which the patients themselves 456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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often quite unaware, that maintained the exclus ion cons ciousnes s of painful or dis tres sing material. F reud described the active force that worked to exclude particular mental contents from cons cious awareness re pre s s ion, one of the fundamental ideas of theory.

R epres s ion T he concept of repress ion, together with its related of defens e, came to be the bas ic explanation for phenomena in F reud's thinking. T he notion of reflects one of the basic hypothes es of ps ychoanalytic theory, namely, that the human mind includes in its operation basic dynamic forces that can be s et in oppos ition and that s erve as the source of powerful motivation and defense. F reud described the of repress ion in the following terms : A traumatic experience or a s eries of experiences, us ually of a nature and often occurring in childhood, had been “forgotten” or “repress ed” because of their painful or disagreeable nature; but the excitation involved in stimulation was not extinguished, and traces of it in the uncons cious in the form of repres sed memories . T hese memories could remain without pathogenic until some contemporary event, for example, a love affair, revived them. At this juncture, the s trength the repress ive counterforce was diminis hed, and the patient experienced what F reud termed the return of re pre s s ed. T he original sexual excitement was revived found its P.708

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way by a new path, allowing it to manifes t itself in the of a neurotic s ymptom. T hus , the s ymptom res ults from compromise between repres sed desire and the mass of ideas constituting the ego.” T he whole process repress ion and the return of the repress ed was thus conceived of as involving conflicting forces —that is , the force of the repres sed idea s truggling to expres s itself agains t the counterforce of the ego s eeking to keep the repress ed idea out of consciousness . F reud's development of the notions of repres sion and res is tance was based primarily on his studies of cases conversion hys teria. S pecifically, in s uch cases , he that impulses that were not allowed acces s to cons ciousnes s were diverted into paths of somatic innervation, resulting in such hysterical symptoms as paralysis, blindness , dis turbances of s ens ations , and manifestations. Despite this early emphas is on hysteria as the prototype of repres sion, F reud believed that the basic propos ition that s ymptoms res ulted from compromise between a repress ed impuls e and other repress ing forces could be applied to obs es sivecompuls ive phenomena and even to paranoid ideation. T he logical consequence of this hypothesis was that treatment process during this period focused primarily enabling the patient to recall repres sed sexual experiences , so that the accompanying excitation could allowed to find its way into consciousness and be discharged along with the revivified and previous ly dammed-up affects .

S educ tion Hypothes is and Infantile S exuality 458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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One additional aspect of psychoanalytic theory with s triking clarity from these early researches into hysteria. Invariably, when inquiring into the histories of hysterical patients , F reud found that the repres sed traumatic memories that seemed to lay at the root of pathology had to do with s exual experiences. His became increas ingly focused on the importance of early sexual experiences , us ually recalled in the form sexual s eduction occurring before puberty and often rather early in the child's experience. F reud began to that these seduction experiences were of central importance for understanding the etiology of ps ychoneurosis . Over a period of s everal years, he continued to collect clinical material that seemed to reinforce this important hypothes is . He even went so to dis tinguis h between the nature of the seductive experiences involved in hys terical manifes tations and those involved in obs ess ional neurosis. In the case of hysteria, he believed that the s eduction experience had been primarily pass ive—that is , the child had been the pass ive object of seductive activity on the part of an or older child. In obs ess ive-compuls ive neuros is , he believed the s eduction experience had been active the part of the child. T hus, the child would have actively and aggres sively pursued a precocious s exual What was significant in all of this development was that F reud had taken literally the accounts his patients had given him in the form of forgotten but revived memories of such s exual involvement. T he patients provided him with “tales of outrage” committed by s uch relatives or caretakers as fathers , nursemaids, or uncles. F reud devoted little attention to the role of the child's own 459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychological experience in the elaboration of thes e B ut, little by little, he began to have s ome s econd about thes e s o-called memories . S everal factors contributed to his doubt. F irs t, he had gained additional insight into the nature of pathological process es from clinical experience and his increas ing awarenes s of the of fantasy in childhood. S econd, he simply found it hard believe that there could be s o many wicked and adults in V iennes e s ociety. T he third influence, which undoubtedly was of major significance in this recons ideration, was his own s elf-analysis. As this important proces s of self-analysis progres sed, F reud began to have more and more reason to call the seduction hypothes is into question. During this time, 1893 to 1897, F reud was s till using the combined technique of pres sure and suggestion with relatively as surance. Often, he insisted that patients recall the seduction s cene s o that much of the evidence on which the seduction hypothes is was based was open to the charge of s uggestion. C ons equently, as F reud became more aware of the role of s ugges tion in his technique, doubts about the s eduction hypothesis grew apace. In S eptember 1897, his doubts came to a focus , and he to his good friend F lies s as follows: And now I want to confide in you immediately the great secret that has been slowly dawning on me in the las t months. I no longer believe in my ne urotica [theory of neuros es]. T his is probably not intelligible without an explanation, after all, you yours elf found credible what I was able to tell you. S o I will begin historically [and tell you] where the reasons for disbelief came from. T he continual disappointment in my efforts to bring a single 460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analysis to a real conclusion; the running away of who for a period of time had been mos t gripped [by analysis]; the abs ence of the complete s ucces ses on I had counted; the pos sibility of explaining to mys elf the partial success es in other ways, in the us ual fas hion— was the first group. T hen the s urprise that in all cas es , father, not excluding my own, had to be accus ed of pervers e—the realization of the unexpected frequency hysteria, with precisely the s ame conditions prevailing each, whereas s urely s uch widespread perversions children are not very probable.… T hen, third, the insight that there are no indications of reality in the unconscious, s o that one cannot distinguish between and fiction that has been cathected with affect. [Accordingly, there would remain the s olution that the sexual fantasy invariably seizes upon the theme of the parents .] F ourth, the consideration that in the most reaching psychoses the unconscious memory does not break through, s o that the s ecret of childhood is not disclos ed even in the most confus ed delirium. If thus s ees that the unconscious never overcomes the res is tance of the conscious, the expectation that in treatment the oppos ite is bound to happen, to the point where the uncons cious is completely tamed by the cons cious, als o diminishes. It is obvious that at this period F reud was struggling his own great reluctance to abandon the s eduction hypothes is. T he doubts and the clarifying realization he expres sed to F liess were depress ing. After all, he put in years of effort and had compiled a significant amount of evidence to bolster this s eduction was only with reluctance that he could s urrender it. He 461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sens ed, however, that, in s urrendering the s eduction hypothes is, new poss ibilities for psychological were opened up. In fact, this juncture in the of F reud's thinking was crucial. T he abandonment of seduction hypothes is , with its reliance on actual seduction, forced F reud to turn with new realization to inner fantasy life of the child. It can be s aid, in the real sens e, that this shift from an emphasis on reality factors to an attention to and an unders tanding of the influence of inner motivations and fantas y products marks the real beginning of the ps ychoanalytic movement. In this attempt to distinguish ps ychic reality and fantas y from actual external events ps ychoneurosis from perversion, ps ychoanalys is its elf on a new and highly significant dimens ion. W hat emerged from this shift in direction was a dynamic of infantile sexuality in which the child's own life played the s ignificant and dominant role. T his replaced the more static point of view in which the child represented an innocent victim whos e eroticis m was prematurely disrupted at the hands of uns crupulous adults . P.709 T he turning point was one of extreme significance for F reud hims elf. Increas ingly, he turned his attention to own self-analysis and put increasing reliance on it. He wrote to F liess , “My s elf-analysis is in fact the most es sential thing I have at present and promises to of the greatest value to me if it reaches its end.” More more, he became involved in the s tudy of dreams , all more s o as he developed the technique of free 462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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which provided him with a tool for exploring the as sociative content underlying the dream experience. concerned hims elf ever more s o with the nature of infantile sexuality and with the inner s ources of fantas y and dream content, namely, the uncons cious drives . In recent years, this s o-called abandonment of seduction hypothes is has been s ubjected to severe criticis m on the grounds that it tended to minimize the role of actual s eduction, which looms as a pervasive problem in our contemporary s ociety. B ut in F reud's defens e, it s hould be said that he never denied that seduction was a problem; he knew well enough that it exis ted, but it was not for him a path to deeper unders tanding of the dynamic as pects of ins tinctual infantile sexual life. B y 1897, when the hypothesis of actual s eduction had fallen in the dust at F reud's feet, he could look to a of significant accomplis hments . T he fundamental of psychic determinis m and the operation of a dynamic unconscious were es tablis hed, and concomitantly, a theory of psychoneurosis based on the idea of psychic conflict and the repress ion of disturbing childhood experiences had become clearly established. particularly in the form of childhood sexuality, had been unveiled as playing a significant but previous ly underemphasized or ignored role in the production of ps ychological s ymptoms. More s ignificantly, perhaps , F reud had arrived at a technique, a method of inves tigation, that could be exploited as a means of exploring a wide range of mental phenomena that had previous ly been poorly understood. Moreover, the horizons of psychoanalytic interest had begun to 463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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rapidly. F reud's attention was no longer focus ed on limited forms of ps ychopathology. It had begun to out, reflecting the wide-ranging curios ity and interes ts F reud's mind and to embrace the unders tanding of dreams , creativity, wit, and humor, the everyday experience, and a hos t of other normal and culturally s ignificant mental phenomena. had indeed come to life.

INTE R P R E TA TION OF DR E A MS C urrently, the whole area of sleep and dream activity is one of the most exciting and intens ely studied as pects ps ychological functioning. T he discovery of rapid eye movement (R E M) cycles and the definition of the stages of the sleep cycle have s timulated an intense extremely productive flurry of research activity into the neurobiology of dreaming. A whole new realm of fres h important ques tions has been opened as a result of activity, and ps ychoanalys ts are drawing much closer more comprehens ive unders tanding of the links patterns of dream activity and underlying neurophys iological and ps ychodynamic variables. As is learned about this fascinating and complex question, one comes much clos er to understanding the nature of dream process and the dream experience its elf. In this context, it is difficult to look back and to the uniqueness and originality of F reud's immersion in dream experience. Only when F reud's attention had refocused to the s ignificance of inner fantasy by reason of abandonment of the s eduction hypothesis and in the context of his developing the technique of as sociation, did the s ignificance and value of the 464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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inves tigation of dreams impres s on him. F reud became aware of the s ignificance of dreams in his experience his patients when he realized that, in the process of as sociation, his patients frequently reported their along with the ass ociative material that seemed with them. He dis covered little by little that dreams had definite meaning, although that meaning was often hidden and disguis ed. Moreover, when he encouraged patients to as sociate freely to the dream fragments , he found that what they frequently reported was more connected with repres sed material than ass ociations to events of their waking experience. S omehow, the content s eemed to be closer to the uncons cious and fantas ies of the repress ed material, and dream material seemed to facilitate dis clos ure of this content.

Theory of Dreaming T he rich complex of data derived from F reud's clinical exploration of his patients' dreams and the profound insights derived from his ass ociated investigation of his own dreams were distilled into the landmark publication in 1900 of T he Inte rpre tation of Dre ams . B asing his on thes e data, F reud presented a theory of the dream paralleled his analys is of psychoneurotic symptoms. viewed the dream experience as a cons cious an uncons cious fantas y or wish not readily access ible cons cious waking experience. T hus, dream activity cons idered one of the normal manifestations of unconscious process es. T he dream images represented uncons cious wis hes or thoughts disguis ed through a proces s of symbolization 465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and other distorting mechanisms. T his reworking of unconscious contents constituted the dream work. postulated the exis tence of a “cens or,” pictured as guarding the border between the unconscious part of mind and the precons cious level. T he censor exclude uncons cious wis hes during conscious s tates during regres sive relaxation of sleep, allowed certain unconscious contents to pas s the border, yet only after transformation of uncons cious wishes into dis guised experienced in the dream contents by the s leeping subject. F reud as sumed that the cens or worked in the service of the ego—that is , as s erving the s elfobjectives of the ego. Although he was aware of the unconscious nature of the process es, he tended to the ego at this point in the development of his theory more restrictively as the s ource of cons cious process es reasonable control and volition. It s hould not be that, even in S tudie s on Hys teria, repres sion was s till envis ioned in intentional and volitional terms. F reud's deepened appreciation of the unconscious dimens ion these proces ses led him to view the ego as in some unconscious, one of the reasons for his formulation of structural theory in 1923.

A nalys is of Dream C ontent F reud's view of dream material was that it contained content that has been repress ed or excluded from cons ciousnes s by defens ive activities of the ego. T he dream material, as cons cious ly recalled by the simply the end result of uncons cious mental activity place during sleep. F reud believed that the ups urge of unconscious material was s o intense that it threatened interrupt s leep its elf so that he envis ioned one function 466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the cens or was to act as a guardian of s leep. Ins tead of being awakened by these ideas , the s leeper dreams. F rom a more contemporary viewpoint, it is known that cognitive activity during sleep has a great deal of S ome cognitive activity follows the description that provided of dream activity, but much of it is more realistic and more consis tently organized along logical lines. T he dreaming activity that F reud analyzed and described is probably more or less as sociated with stage 1 R E M periods of the s leep–dream cycle. T he called manifes t dream that embodies the experienced content of the dream, which the s leeper may or may be able to recall after waking, is the product of dream activity. Uncons cious thoughts and wishes that in view threatened to awaken the sleeper were des cribed “latent dream content.” P.710 F reud referred to uncons cious mental operations by latent dream content was transformed into the manifes t dream as the dre am work. In the proces s of dream interpretation, he was able to move from the manifest content of the dream by way of ass ociative exploration arrive at the latent dream content that lay behind the manifest dream and that provided it with its core In F reud's view, there were a variety of s timuli that dreaming activity. T he contemporary unders tanding of dream process , however, s uggests that dreaming takes place more or les s in conjunction with the patterns of central nervous activation that characterize certain phases of the sleep cycle. What F reud believed be initiating stimuli may in fact not be initiating at all but 467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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may be merely incorporated into the dream content, determine to that extent the material in the dream thoughts. S timuli could aris e from various sources.

NOC TUR NAL S E NS OR Y S TIMUL I A variety of s ens ory impres sions, such as pain, hunger, thirst, or urinary urgency, may play a role in dream content. T hus, ins tead of disturbing one's s leep leaving a warm bed, a s leeper who is in a cold room who urgently needs to urinate may dream of voiding, and returning to bed. F reud's view would have been that the activity of dreaming preserved and safeguarded the continuity of sleep. It is known now, however, that the function of dreaming is cons iderably more complex and cannot be regarded simply as preserving sleep, although there is still room for this proces s to be counted among the dream functions.

DAY R E S IDUE S One of the important elements contributing to s haping the dream thoughts is the residue of thoughts and and feelings left over from experiences of the day. T hes e res idues remain active in the unconscious like sensory s timuli, can be incorporated by the s leeper into thought content of the manifest dream. T hus, day res idues could be amalgamated with unconscious drives and wis hes deriving from the level of instincts. T he amalgamation of infantile drives with elements of the day's residues effectively disguises the infantile impuls e and allows it to remain effective as the driving force behind the dream. Day res idues may in thems elves be quite s uperficial or trivial, but they 468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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significance as dream ins tigators through unconscious connections with deeply repress ed instinctual drives wis hes .

R E PR E S S E D INFANTILE DR IVE S Although these various elements may be determining as pects of the thought content of the dream the es sential elements of the latent dream content from one or several impulses emanating from the repress ed part of the uncons cious . In F reud's s chema, ultimate driving forces behind dream activity and dream formation were the wis hes , originating in drives , from an infantile level of ps ychic development. T hese drives took their content s pecifically from oedipal and oedipal levels of psychic integration. T hus, nocturnal sens ations and day res idues played only an indirect determining dream content. A nocturnal stimulus , however intens e, had to be as sociated with and with one or more repres sed wis hes from the to give rise to the dream content. T his point of view some revis ion because it s eems that, in s ome phas es nighttime cognitive activity, the mind is able to proces s res idues of daytime experience without much indication connection with unconscious repres sed content. in phases of cognitive activity during sleep that bear stamp of dreaming activity as F reud described and it, this ess ential link to the repres sed probably s till some validity.

S ignific anc e of Dreams Once F reud's attention had definitively shifted to the of inner process es of fantasy and dream formation, the 469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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study of dreams and the process of their formation became the primary route by which he gained acces s unders tanding uncons cious proces ses and their In T he Inte rpre tation of Dre ams , he maintained that dream s omehow repres ents a wish fulfillment. He bolstered this hypothes is with a cons iderable amount documentation, including exhaus tive analysis of his dreams . T here is a more general tendency today to view the activity as express ing a broader spectrum of proces ses, keeping the as pect of wish fulfillment as among the dimens ions of dream activity but not as an absolute principle, as it s eemed to be in F reud's T he manifest dream content may represent imaginary fulfillment of a wish or impulse from early childhood, before such wis hes have undergone repres sion. In childhood, and even later in adulthood, however, the acts to defend its elf agains t unacceptable instinctual demands of the unconscious. W is h fulfillment in the proces s is usually quite obs cured by the extensive distortions and disguis es brought about by the dream work so that it often cannot be readily identified on a superficial examination of the manifest content.

Dream Work T he theory of the nature of dream work became the fundamental description of the operation of proces ses —the bas ic mechanis ms and the manner of operating—that s tands even today as an unsurpas sed foundational account of uncons cious mental T he focus of F reud's analysis was on the proces s by unconscious latent dream thoughts were disguis ed and 470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distorted in s uch a fashion as to permit their express ion and translation into conscious manifes t content of the dream. However, these unconscious process es , part of fruit of his inves tigation, found ready application and extrapolation not only to understanding the formation of neurotic s ymptoms but als o, more broadly, to a whole range of unconscious productivity. T he theory of dream work consequently became the basis for a wideanalysis of uncons cious operations that found in F reud's s tudy of everyday experiences, as well as creativity, jokes, and humor, and a variety of culturally based activities of the human mind. As pects of the work are as follows.

R epres entability T he basic problem of dream formation is to determine how it is that latent dream content can find a means of representation in the manifes t content. As F reud s aw it, the state of s leep brought with it relaxation of and, concomitantly, latent uncons cious wis hes and impulses were permitted to press for dis charge and gratification. B ecaus e the pathway to motor expres sion was blocked in the s leep state, thes e repres sed wis hes impulses had to find other means of representation by of mechanis ms of thought and fantasy. Activity of the dream censor provided continual res is tance to of thes e impulses, with the result that the impulses had be attached to more neutral or “innocent” images to be able to pass the scrutiny of cens orship and be allowed cons cious expres sion. T his dis placement was made poss ible by s electing apparently trivial or ins ignificant images from residues of the individual's current ps ychological experience and linking thes e trivial 471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dynamically with latent uncons cious images, on the bas is of s ome res emblance that allowed links to be established. In the proces s of facilitating economic express ion of latent unconscious contents at the same time, maintaining the distortion that was es sential for uncons cious contents to es cape the repress ing action of the censor, the dream work us ed a variety of mechanisms, making it pos sible for more images to represent repres sed infantile components. T hese mechanis ms included symbolis m, dis placement, condensation, projection, and s econdary revision. P.711

S YMB OL IS M S ymbolis m is a complex process of indirect that in the ps ychoanalytic us age has the following connotations : A s ymbol is repres entative of or s ubs titute for some other idea from which it derives a secondary significance that it does not poss es s itself. A s ymbol represents this primary element by a common element that thes e ideas s hare. A s ymbol is characteris tically sensory and concrete nature, as oppos ed to the idea it repres ents , which may be relatively abs tract and complex. A s ymbol provides a more condens ed express ion of the idea represented. S ymbolic modes of thought are more primitive, both ontogenetically and phylogenetically, and repres ent 472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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forms of regres sion to earlier stages of mental development. C ons equently, symbolic tend to function in more primary process or regress ed conditions : in the thinking of primitive peoples, in myths, in s tates of poetic inspiration, particularly, in dreaming. A s ymbol is thus a manifes t express ion of an idea is more or less hidden or s ecret. T ypically, the us e the symbol and its meaning are unconscious. T hus , symbols tend to be used s pontaneous ly, and unconsciously. T he use of s ymbols is a sort of secret language in which instinctually determined content can be reexpress ed as other images ; for example, money can s ymbolize feces , or windows symbolize the female genitals . Many questions still pers is t about the origins of proces ses; the s tage of development in which they become organized; the extent to which they require altered states of consciousness , such as the sleep their implementation; and the degree to which symbolic expres sion is related to underlying conflicts . C urrent formulations regard the symbolic function as a uniquely human trait involved in all forms of human mental from the most primitive expres sion of infantile wishes to the most complex creative process es of literary, religious , and s cientific thinking.

DIS PL AC E ME NT T he mechanis m of dis place me nt refers to the transfer amounts of energy (cathexis ) from an original object to subs titute or symbolic representation of the object. 473 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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B ecaus e the s ubs titute object is relatively neutral—that less inves ted with affective energy—it is more to the dream cens or and can pass the borders of repress ion more easily. T hus, whereas s ymbolism can taken to refer to the substitution of one object for displacement facilitates dis tortion of unconscious through transfer of affective energy from one object to another. Des pite the transfer of cathectic energy, the of the uncons cious impulse remains unchanged. F or example, in a dream, the mother may be represented visually by an unknown female figure (at leas t one who less emotional significance for the dreamer), but the content of the dream nonetheless continues to derive from the dreamer's unconscious instinctual impulses toward the mother.

C ONDE NS ATION C onde ns ation is the mechanism by which s everal unconscious wis hes , impuls es, or attitudes can be combined into a single image in the manifest dream content. T hus , in a child's nightmare, an attacking may come to represent not only the dreamer's father may als o repres ent s ome aspects of the mother and some of the child's own primitive hostile impuls es as T he converse of condens ation can als o occur in the work, namely, an irradiation or diffusion of a s ingle wis h or impulse that is distributed through multiple representations in the manifest dream content. T he combination of mechanisms of condens ation and provides the dreamer with a highly flexible and device for facilitating, compress ing, and diffus ing or expanding the manifest dream content, which is 474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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from latent or unconscious wishes and impulses.

PR OJ E C TION T he proces s of projection allows dreamers to rid thems elves of their own unacceptable wis hes or and experience them as emanating in the dream from other people or independent sources. Not s urprisingly, figures to whom these unacceptable impuls es are in the dream often turn out to be those toward whom subject's own unconscious impulses are directed. F or example, the individual who has a s trong repres sed to be unfaithful to his wife may dream that his wife has been unfaithful to him; or a patient may dream that she has been sexually approached by her analyst, although is reluctant to acknowledge her own repress ed wishes toward the analyst. S imilarly, the child who dreams of a destructive monster may be unable to acknowledge his her own destructive impulses and the fear of the power to hurt the child. T he figure of the monster cons equently is a res ult of both projection and displacement.

S E C ONDAR Y R E VIS ION T he mechanis ms of symbolism, dis placement, condensation, and projection are all characteristic of relatively early modes of cognitive organization in a developmental s ens e. T hey reflect and expres s the operation of the primary process . In the organization of the manifest dream content, however, primary-proces s forms of organization are supplemented by a final that organizes the absurd, illogical, and bizarre aspects the dream thoughts into a more logical and coherent 475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he distorting effects of symbolis m, displacement, and condensation thus acquire a coherence and rationality are necess ary for acceptance on the part of the more mature and reasonable ego through a process of secondary revis ion. S econdary revision thus us es intellectual proces ses that more closely resemble organized thought proces ses governing rational s tates cons ciousnes s. It is through secondary revision, then, the logical mental operations characteris tic of the secondary process are introduced into and modify work.

AFFE C TS IN THE DR E AM WOR K In the process of dis placement, condens ation, or projection, as F reud hypothesized, the energic component of the ins tinctual impulses is s eparated its repres entational component and follows an independent path of expres sion in the form of affects or emotions . T he repress ed emotion may not appear in manifest dream content at all, or it may be experienced a considerably altered form. T hus , for example, hostility or hatred toward another individual may be modified into a feeling of annoyance or mild irritation in the manifest dream express ion, or it may even be represented by an awareness of not being annoyed— is , a conversion of the affect into its absence. T he affect may poss ibly be directly transformed into an oppos ite in the manifes t content, for example, as when repress ed longing might be represented by a manifes t repugnance or vice vers a. T hus, the viciss itudes of and the transformation by which latent affects are disguis ed introduce another dimens ion of dis tortion into the content of the manifes t dream. T he vicis situdes of 476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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affect, then, take place in addition to and in parallel proces ses of indirect repres entation that characterize viciss itudes of dream content.

R egres s ion In the seventh theoretical chapter of T he Interpre tation Dreams , F reud provided a model of the ps ychic as he understood it at the turn of the 20th century. Not only was the model a description of the functioning of dreaming mind, but it als o repres ented a broader conceptualization of the ps ychic apparatus as it in both pathological and normal human experience, P.712 as he had formulated previously in the P roje ct. It clear that the economic model, on which F reud had expended such intense effort in the 1890s and had seemingly abandoned in frus tration, had come back to reass ert itself, now in a new language and in a different setting. T he lines of continuity and parallels between model of the mind in the P roje ct and the model of the seventh chapter could not be appreciated until the manus cript of the P roje ct was rediscovered after death. T he model was an elaborate construction bas ed on a notion of a stimulus –res ponse mechanis m. In normal waking experience, s ens ory input is taken into the receptor end of the apparatus and then process ed in a number of mnemonic s ys tems of increasing degrees of elaborateness and complexity. After varying degrees of proces sing, the impuls e is s ubs equently dis charged through the motor effector apparatus . In the dream 477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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motor effector pathways are blocked so that, instead of discharge through motor s ys tems, excitation is forced move in a backward or regress ive direction through the mnemonic s ys tems and back toward s ens ory systems . During waking hours, the path leading from levels of the apparatus through precons cious to levels is barred to the dream thoughts by activity of the cens or. In sleep, however, this pathway is again made more available becaus e res is tance of the censor is diminis hed in s leep. C onsequently, uncons cious and their instinctual determinants could press to through the perceptual apparatus, as is particularly the case in hallucinatory dream experiences. T hus , dreams could be des cribed as having a regres sive character. C ons is ting specifically of the turning back of an idea the sensory image from which it was originally derived, regress ion is an effect of the resistance opposing of psychic energy ass ociated with the thought into cons ciousnes s along the normal path. R egress ion is contributed to by simultaneous attraction exercised on thought by the presence of ass ociated memories in the unconscious. In dreams , regress ion is further facilitated by diminution the progres sive current flowing from continuing s ensory input during waking hours. R egress ion, as F reud is es sentially a regres sion to the originating s ource of impres sion in the revers al he describes within the apparatus, but it also is a regres sion in time. F reud distinguished s everal forms of regres sion, namely, a topographical regress ion involving a regress ion in cons cious to unconscious s ys tems within the mental model; a temporal regres sion according to which the 478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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mental proces s refers back to older ps ychical particularly thos e deriving from an infantile level of development; and formal regress ion, in which more primitive methods of expres sion and repres entation the place of the more normal ones . “All these three of regres sion,” F reud commented, “are, however, one bottom and occur together as a rule; for what is older in time is more primitive in form and in psychical lies nearer to the perceptual end.”

P rimary and S ec ondary P roc es s P erhaps the most central aspect of the functioning of mental model, clos ely related to the formulations of the P roje ct, has to do with F reud's notions of the primary secondary process es. T o begin with, the impulses and instinctual wishes originating in infancy serve as the indis pensable nodal force for dream formation. T he energic conception of these drives follows the bas ic economic principles laid down by the P roje ct (T able T hey are elevated states of psychic tens ion in which energy is constantly s eeking discharge according to cons tancy principle and the pleas ure principle. T he tendency to discharge, however, is oppos ed by ps ychic s ys tems. T hus , F reud envisioned two fundamentally different kinds of ps ychic process es involved in the formation of dreams . One of these proces ses tends to produce a rational organization of dream thoughts , which was of no les s validity in terms contact with reality than normal thinking. However, another s ys tem—the firs t psychic s ys tem in F reud's schema—treats the dream thoughts in a bewildering irrational manner. He believed that a more normal train 479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thought could only be s ubmitted to abnormal psychic treatment if an uncons cious wis h, derived from infancy and in a s tate of repres sion, had been transferred to it. res ult of the operation of the pleas ure principle, the firs t ps ychic s ys tem is incapable of bringing anything disagreeable into the context of the dream thoughts. It unable to do anything but wish. Operating in with the demands of this primary system, the system can only cathect an unconscious idea if it can inhibit any development of unpleasure that may have proceeded from the coming to awarenes s of that idea. Anything that may evade that inhibition is equivalently inacces sible to the s econd s ys tem, as well as to the because it is promptly eliminated in accordance with unpleasure principle. T he ps ychic proces s derived from the operation of the system is referred to as primary proce s s . T he process res ulting from the inhibition impos ed by the s econd system is referred to as the s e condary proce s s , and it reflects the operation of the s ys tem of inhibition and sketched in the P roje ct. T he s econdary s ys tem thus and regulates the primary s ys tem in accordance with principles of logic, rationality, and reality. Among the wis hful impulses derived from infantile impulses, there some whos e fulfillment is a contradiction of the and ideas of secondary process thinking. T he these wishes can no longer generate an affect of but is unpleasurable. T his formulation, it s hould be forms the bas is for F reud's later elaboration of the principle, as oppos ed to the reality principle. T he secondary process organization of preconscious aimed at avoiding unpleas ure, at delaying instinctual 480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discharge, and at binding mental energy in accordance with the demands of external reality and the subject's moral principles or values . T hus, functioning of the secondary process is closely connected with the reality principle and is governed, for the mos t part, by the dictates of the reality principle.

Topographic al Theory B eginning with abandonment of the s eduction with the concomitant turning of F reud's interes ts to proces ses of fantas y and dream formation, and ending with publication of T he E go and the Id in 1923, in which F reud propounded his s tructural model of the psychic apparatus, F reud's thinking was cas t largely in terms of topographical theory.

B as ic As s umptions T here were a number of as sumptions underlying thinking that s erved as lines of continuity between stages of his investigations and helped him to organize thinking in terms of success ive models of the mental apparatus. T he firs t as sumption was that of determinism,” according to which all ps ychological including behaviors , feelings , thoughts, and actions, caus ed by—that is , are the end res ult of—a preceding sequence of causal events . T his ass umption derived F reud's Helmholtzian convictions and repres ented application of a bas ic natural science principle to ps ychological unders tanding; but it was also reinforced F reud's clinical observation that apparently hysterical s ymptoms , which had been previous ly attributed to s omatic etiology, could be relieved by 481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relating them to past, apparently repress ed, T hus, apparently arbitrary pathological behavior could tied to a caus al psychological network. T he second ass umption is that of “unconscious ps ychological process es.” T his ass umption derived cons iderable amount of evidence gathered through the us e of hypnosis , but it was als o cons olidated by experience of the free ass ociating of his patients past experiences to awarenes s. T he uncons cious which s urvived and was able to influence present experience, was found to be governed by s pecific regulatory P.713 principles, for example, the pleas ure principle and the mechanisms of primary proces s that differed radically those of cons cious behavior and thought process es . the unconscious process es were brought within the of psychological understanding and explanation. T he third as sumption was that “unconscious conflicts ” between and among psychic forces formed basic elements at the root of ps ychoneurotic difficulties . T his ass umption related to F reud's experience of and the drive to repres sion in his patients . T he full realization of this aspect of psychic functioning came with awarenes s that the reports of patients represented not memories of actual experiences but, rather, unconscious fantas ies . T he ass umption of uncons cious forces accounted for the process that created those fantas ies and brought them into conscious ness during as sociation. It als o accounted for the agency that the coming to cons cious nes s of s uch fantasies . T his 482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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counterforce that clas hed with the sexual drives and diverted them into fantas ies or s ymptoms was related the function of censorship as developed in the dream theory and, later, to the operation of ego instincts that were set in opposition to the s exual ins tincts . T he final ass umption of the topographical theory was there exis ted “ps ychological energies ” that originated in instinctual drives . T his as sumption was derived from observation that recall of traumatic experiences and accompanying affect resulted in dis appearance of symptoms and anxiety. T his sugges ted, therefore, that displaceable and transformable quantity of energy was involved in the psychological process es res ponsible for symptom formation. F reud originally ass umed that this quantity was equivalent to the affect, which became dammed up or strangulated when it was not expres sed and, thus , was trans formed into anxiety or conversion s ymptoms . After he had developed his of ins tinctual drives, this quantitative factor was of as drive energy (cathexis ). As noted previous ly in discuss ion of the P roje ct, the ass umption of psychic energies s erved F reud as an important heuristic T he us efulnes s of the metaphor and its necess ity as a as sumption of analytical theory have been ques tioned found wanting.

Topographic al Model F reud's thinking about the mental apparatus at this was bas ed on the class ification of mental operations contents according to regions or s ys tems in the mind. T hese systems were des cribed neither in anatomical spatial terms but, rather, were s pecified according to 483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relations hip to cons cious nes s. T he topographical has ess entially fallen into disfavor because of its limited us efulnes s as a working model of psychoanalytic largely because it has been s urpas sed and s upplanted the structural theory. T he topographical viewpoint, however, is still useful for clas sifying mental events descriptively by quality and degree of awarenes s. a tendency currently to revive aspects of the model of the mind in viewing mental process es as descriptively more or less cons cious or unconscious, than as reflecting operation of a mental structure as in systemic unconscious of clas sic metapsychology.

C ons c ious nes s T he cons cious system is that region of the mind in perceptions coming from the outside world or from the body or mind are brought into awarenes s. Internal perceptions can include intros pective observations of thought proces ses or affective states of various kinds . C ons cious nes s is, by and large, a subjective the content of which can only be communicated by language or behavior. It has also been regarded ps ychoanalytically as a s ort of superordinate s ens e which can be s timulated by perceptual data impinging the C NS . It was as sumed that the function of cons ciousnes s used a form of neutralized psychic called atte ntion cathe xis . T he nature of cons cious nes s was described in les s F reud's early theories , and certain aspects of are not yet completely unders tood and are actively debated by ps ychoanalys ts. F reud regarded the system as operating in close as sociation with the 484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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preconscious. T hrough attention, the s ubject can cons cious of perceptual s timuli from the outside world. F rom within the organis m, however, only elements in preconscious are allowed to enter consciousness . T he of the mind lies outside awareness in the uncons cious . B efore 1923, however, F reud als o believed that cons ciousnes s controlled motor activity and regulated qualitative distribution of psychic energy.

P rec ons c ious T he preconscious s ys tem consists of thos e mental proces ses, and contents that are, for the mos t part, capable of reaching or being brought into cons cious awarenes s by the act of focus ing attention. T he quality preconscious organizations may range from realityoriented thought s equences or problem-solving with highly elaborated secondary proces s s chemata all way to more primitive fantasies, daydreams , or dreamimages, which reflect a more primary proces s T hus, it s tands over and agains t unconscious which the trans formation to consciousness is accomplis hed only with great difficulty and by dint of expenditure of cons iderable energy in overcoming the barrier of repress ion. T he preconscious has been amplified by recent neuros cientific study of memory. An es sential between episodic memory and procedural memory. E pisodic memory deals with pas t events in the experience that are us ually autobiographical or in content. Other memories , however, have more to do with skills and habitual patterns of behavior, as, for example, riding a bike, driving a car, playing the piano, 485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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grammatical rules, s ocial norms of politeness and etiquette, and so forth. T hes e are as pects of normal living and behavior that people rarely, if ever, think about—people just do them, but the procedures are embedded in our memories and are readily applied without any effort to recall them. In fact, any effort to them more than likely only interferes with their T hese memory s ys tems, along with others that can be differentiated, are apparently s erved by different neural circuits and have different connections with and behavior.

Unc ons c ious Uncons cious mental events , namely, thos e not within cons cious awarenes s, can be des cribed from several viewpoints . One can think of the unconscious descriptively, that is , as referring to the s um total of all mental contents and proces ses at any given moment outside the range of cons cious awarenes s, including preconscious. One can als o think of the uncons cious dynamically, as referring to thos e mental contents and proces ses are incapable of achieving cons cious nes s becaus e of operation of a counterforce of cens ors hip or T his repres sive force or “countercathexis ” manifests in ps ychoanalytic treatment as res istance to T he unconscious mental contents in this dynamic cons ist of drive representations or wishes that are in meas ure unacceptable, threatening, or abhorrent to the intellectual or ethical s tandpoint of the individual. T his res ults in intraps ychic conflict between the repress ed forces and the repress ing forces of the mind. W hen 486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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repress ive countercathexis weakens, this may result in formation of neurotic s ymptoms. T he symptom is thus viewed as ess entially a compromise between forces . T hese uncons cious mental contents are als o organized on the basis of infantile P.714 wis hes or drives and strive for immediate discharge, regardless of the reality conditions . C onsequently, the dynamic unconscious is believed to be regulated by the demands of primary process and the pleas ure F inally, there is a s ys temic sense of the unconscious referring to a region or system within the organization the mental apparatus that embraces the dynamic unconscious and within which memory traces are organized by primitive modes of as sociation, as by the primary proces s. T his s ys temic view of the unconscious is cons idered, in a specifically sens e, as a component subsystem within the topographical model and in the s tructural theory is attributed to the id. C ons equently, the systemic unconscious can be described in terms of the following characteristics in F reud's view: Ordinarily, elements of the systemic unconscious inacces sible to consciousness and can only cons cious through acces s to the preconscious, excludes them by means of cens ors hip or R epress ed ideas, consequently, may only reach cons ciousnes s when the cens or is overpowered ps ychoneurotic symptom formation), relaxes (as in dream s tates), or is fooled (in jokes). 487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he unconscious s ys tem is exclusively ass ociated primary process thinking. T he primary process has its principal aim facilitation of wis h fulfillments and instinctual dis charge. C ons equently, it is intimately as sociated with—and functions in terms of—the pleas ure principle. As s uch, it disregards logical connections , permits contradictions to coexis t simultaneously, recognizes no negatives, has no conception of time, and repres ents wis hes as fulfillments . T he unconscious s ys tem als o uses primitive mental operations that F reud identified in the operation of the dream proces s. Moreover, the quality of motility, characteristic of primary process thinking and of unconscious energy, is als o linked to the capacity for creative thinking. Memories in the uncons cious have been divorced their connection with verbal s ymbols. F reud discovered in the cours e of his clinical work that repress ion of a childhood memory could occur if energy was withdrawn from it and, especially, if the verbal energy was removed. W hen the words are reconnected to the forgotten memory traits (as ps ychoanalytic treatment), it becomes recathected and can thus reach cons cious nes s once more. T he content of the uncons cious is limited to wis hes seeking fulfillment. T hes e wishes provide the force for dreams and neurotic s ymptom formation. has already been noted that this view may be overs implified. T he unconscious is clos ely related to the ins tincts . this level of theory development, the instincts are cons idered to consist of s exual and s elf488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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(ego) drives. T he unconscious is believed to mental representatives and derivatives , particularly the sexual instincts.

Dynamic s of Mental Func tioning F reud conceived of the ps ychic apparatus , in the of the topographical model, as a kind of reflex arc in the various s egments have a spatial relationship. T he cons ists of a perceptual or sensory end through which impres sions are received; an intermediate region, cons isting of a s torehous e of unconscious memories ; motor end, closely ass ociated with the preconscious, through which instinctual dis charge can occur. In early childhood, perceptions are modified and s tored in the form of memories . According to this theory, in ordinary waking life, the mental energy as sociated with uncons cious ideas discharge through thought or motor activity, moving the perceptual end to the motor end of the apparatus . Under certain conditions, such as external frus tration or sleep, the direction in which energy travels along the revers ed, and it moves from the motor end to the perceptual end instead of the other way around. It tends to reanimate earlier childhood impres sions in earlier perceptual forms and res ults in dreams during or hallucinations in mental disorders . T his reversal of normal flow of energy in the ps ychic apparatus is the “topographical regress ion” discuss ed previously. F reud s ubs equently abandoned this model of the mind a reflex arc, he retained the central concept of and applied it later in s omewhat modified form in the theory of neurosis . T he theory states that libidinal 489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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frus tration res ults in revers ion to earlier modes of instinctual dis charge or levels of fixation, which had previous ly determined by childhood frustrations or excess ive erotic s timulations. F reud called this kind of revers ion to instinctual levels of fixation libidinal or ins tinctual re gres s ion.

Framework of Ps yc hoanalytic R epres s ed vers us R epres s ing T hroughout his long lifetime and in the course of many twis tings and turnings of the theoretical developments his thinking, F reud's mind was dominated by a to des cribe many as pects of mental functioning in contrasting polarities; s ome of the primary polarities that of subject (ego) vers us object (outer world), versus unpleas ure, and activity versus pas sivity. T he fundamental and dominant dualism is between the and contents of the mind viewed as repres sed and unconscious and those forces and mental agencies res ponsible for the act of repress ing. Although the persis tence of such bas ic dualis m in ps ychoanalytic thinking has clear advantages and undoubtedly helps unders tand some fundamental as pects of the mind, should not forget that s uch paradigms may prove to be overly res trictive. T here is real ques tion in the current of psychoanalysis as to whether s ome of these basic dimensions may not, in fact, be limiting the of ps ychoanalytic theory to grow apace with the expanding horizons of both clinical experience and experimental, es pecially neuroscientific, exploration. historical role and the present vitality of the bas ic ps ychoanalytic dualism, however, s hould not be undervalued because they provide a powerful tool for 490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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unders tanding and treating clinical pathology.

INS TINC TUA L THE OR Y All human beings have s imilar ins tincts . T he actual discharge of these ins tinctual impuls es is organized, directed, regulated, or even repres sed by functions of individual ego, which mediates between the organism the external world. Historically, F reud's exploration of instincts in ps ychoanalys is preceded his development structural theory and his concern with ps ychology of ego.

C onc epts of Ins tinc ts One of the firs t problems to be dealt with in considering the theory of ins tincts is what is meant by the term “instinct.” T he problem is made more complex by the variation in usage between a primarily biological and F reud's primarily psychological concept. T he difficulties are als o compounded by the complexities in F reud's own us e of the term. T he term “instinct” was introduced primarily by students of animal behavior, P.715 referring generally to a pattern of s pecies -specific based mainly on potentialities determined by heredity was therefore considered to be relatively independent learning. T he term was applied to a great variety of behavior patterns, including patterns described in such terms as a maternal ins tinct, a nes ting instinct, or a migrational instinct. S uch usage resis ted success ful phys iological explanation and tended to introduce a strong teleological connotation, thus implying some 491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of purposefulness , as in the concept of a s elfinstinct. F reud adopted this us age unques tioningly, but validity has been ques tioned even by strong of ins tinctual theory among animal behaviorists , for the line between instinctual and learned behavior has become increas ingly more complex and debatable. dichotomy of nature/nurture can no longer be simplis tically or rigidly maintained. T hus , instinctually derived patterns of behavior are s een to be modifiable in the interes ts of adaptation. E thologis ts cons equently prefer to s peak s imply of s pecies -typical behavior patterns that are based on innate equipment that mature and develop or are elicited through a degree of environmental interaction. F reud, of cours e, took as the bas is of his thinking the concept of instinct, but in adopting it for his purposes, transformed it. Actually, F reud's own formulation of the notion of ins tinct underwent contextual modification s o that he actually offered a variety of definitions . P erhaps most cogent was the following: “An ‘instinct’ appears to as a concept on the frontier between the mental and somatic, as the ps ychical repres entative of the s timuli originating from within the organis m and reaching the mind, as a meas ure of the demand made upon the for work in cons equence of its connection with the It is immediately evident that the bas ic ambiguity in the concept of instinct between biological and as pects continued to influence F reud's thinking about instinctual drives and remains latent in s ubs equent ps ychoanalytic usage of the term. F reud hims elf varied the emphasis he placed on one or another aspect of concept s o that s ubsequent discus sions of the concept 492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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instinct in psychoanalysis have varied similarly emphasis on biological aspects and emphasis on ps ychological as pects .

Theory of the Ins tinc ts When F reud began his investigation into the nature of unconscious drives, he s trove cons is tently to base ps ychoanalytic theory on a firm biological foundation. of the mos t important of his attempts to link and biological phenomena came when he bas ed his theory of motivation on instincts. F reud viewed ins tincts a class of borderline concepts that functioned between mental and organic s pheres. C ons equently, his use of term “instinct” is not always consistent because it emphasizes either the psychic or biological aspect of term in varying degrees in varying contexts. then, libido refers to the s omatic proces s underlying the sexual instinct, and at other times , it refers to the ps ychological representation its elf. T hus , F reud's quite divergent from the Darwinian implications of the term “instinct,” which imply innate, inherited, unlearned, and biologically adaptive behavior. T he cleares t formulation of the notion of instinct is as a concept of functions between the mental and the s omatic realms ps ychic representative of stimuli, which come from the organism and exercise their influence on the mind. they are a meas ure of the demand made on the mind work as a result of its connection with the body.

C harac teris tic s of the Ins tinc ts F reud ascribed to ins tinctual drives four principal characteristics : s ource, impetus , aim, and object. In 493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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general, the s ource of an ins tinct refers to the part of body from which it arises, the biological substratum gives ris e to the organis mic s timuli. T he source, then, to a s omatic proces s that gives rise to s timuli, which represented in the mental life as drive repres entations affects. In the case of libido, the s timulus refers to the proces s or factors that excite a specific erotogenic T he impe tus or pre s s ure be hind the drive is a economic concept referring to the amount of force or energy or demand for work made by the instinctual stimulus . T he aim is any action directed toward or tens ion releas e. T he aim in every instinct is which can only be obtained by reducing the s tate of stimulation at the s ource of the ins tinct. T he object is person or thing that is the target for this s atis factionseeking action and that enables the instinct to gain satis faction or dis charge the tens ion and thus gain the instinctual aim of pleasure. F reud commented that the object was the mos t characteristic of the instinct becaus e it is only to the extent that its characteris tics make satis faction poss ible—a view that has been s ignificantly revised in light of object relations . At times, the s ubject's own may s erve as an object of an instinct as , for example, masturbatory activity. Although this early view of the instinctual object long held s way in ps ychoanalytic thinking, it has come under some serious criticis m C ons iderably more weight is put on the significance of objects of libidinal attachment, particularly by object relations theoris ts. Increas ingly, it has become that the ps ychoanalytic concept of instincts is unles s it includes and derives from a context of object 494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relatednes s. Moreover, it cannot be said s imply that the objects of infantile drives are the mos t variable characteristic of the instinct becaus e attachment to the primary objects , particularly the mothering object, is of utmos t s ignificance developmentally.

C ONC E P T OF L IB IDO T he ambiguity in the term ins tinctual drive is reflected in us e of the term libido. B riefly, F reud regarded the instinct as a ps ychophysiological process that had both mental and phys iological manifes tations . E ss entially, us ed the term libido to refer to “the force by which the sexual instinct is repres ented in the mind.” T hus, in its accepted sense, libido refers s pecifically to the mental manifestations of the s exual ins tinct. F reud recognized early that the sexual instinct did not originate in a or final form, as represented by the stage of genital primacy. R ather, it underwent a complex process of development at each phase of which the libido had specific aims and objects that diverged in varying from the s imple aim of genital union. T he libido theory thus came to include all of these manifestations and complicated paths they followed in the course of ps ychos exual development.

INFANT S E XUAL ITY It had long been s upposed, as one of the favored analytical lore, that F reud's belief on infantile sexuality cons tituted an as sault on the cherished ideas of 19thcentury and V ictorian thinking and that he was violently attacked for his views of the erotic life of young seems, however, that his significant contribution, the 495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T hre e E s s ays on the T heory of S e xuality, came to light a revolutionary work but as part of a flood of literature dealing with s exual problems . F reud had become convinced of the relationship sexual trauma, in both childhood traumata and the of psychoneuros is, and disturbances of sexual as related to the s o-called actual neuros es —that is , hypochondriasis, neurasthenia, and anxiety neuroses. F reud originally viewed these conditions as related to misuse P.716 of sexual function. T hus , for example, he believed neuros is to be due to inadequate dis charge of s exual products, leading to the damming up of libido that was then converted into anxiety. Als o, he attributed neuras thenia to excess ive masturbation and a in available libidinal energy. In any case, these studies F reud to an awareness of the importance of s exual in the etiology of ps ychoneurotic s tates.

PAR T INS TINC TS F reud described the erotic impulses arising from the pregenital zone as compone nt or part ins tincts . T hus , kiss ing, s timulation of the area s urrounding the anus , even biting the love object in the course of lovemaking examples of activities as sociated with these part T he activity of component instincts or early genital excitement may undergo displacement, as, for the eyes in looking and being looked at (s coptophilia), may consequently be a s ource of pleas ure. Ordinarily, these component ins tincts undergo repres sion or 496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a restricted fashion in s exual foreplay. More young children are characterized by a polymorphous pervers e s exual disposition. T heir total sexuality is relatively undifferentiated and encompass es all of the instincts. In the normal course of development to adult genital maturity, however, thes e part instincts are presumed to become s ubordinate to the primacy of the genital region.

A ggres s ion and E go Ins tinc ts T he aggres sive drives hold a peculiar place in F reud's theory. His thinking about aggres sion underwent a evolution. E arly in his thinking, his attention had been preoccupied by the problems posed by libidinal drives . was quite aware of the aggress ive components often expres sed in the operation of libidinal factors, but he not long avoid taking explicit account of the more destructive aspects of ins tinctual functioning. Undoubtedly, also, the horrors and des tructiveness of World W ar I made a s ignificant impres sion on him s o he began to realize more profoundly the s ignificance of destructive urges in human behavior. B y 1915, F reud arrived at a dualistic conception of the instincts as divided into sexual instincts and ego He recognized a sadis tic component of the sexual but this s till lacked a s ound theoretical basis. Oral, and phallic levels of development all had their sadis tic components. Devoid of any manifes t eroticism and covering a wide range from s exual perversions to of cruelty and des tructiveness , the s adis tic as pects certainly had different aims from the more s trictly Increasingly, F reud s aw the s adis tic component as 497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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independent of the libidinal and gradually segregated it from the libidinal drives. Moreover, impulses to control, tendencies toward the acquis ition and exercis e of and defens ive trends toward attacking and des troying manifested a strong element of aggres siveness . It then, that there was s adism as sociated with the ego instincts as well as with the libidinal ins tincts . F reud again followed the dualistic bent of his mind and postulated two groups of instinctual impulses, two qualitatively different and independent sources of instinctual impulses with different aims and modalities . With the publication of T he E go and the Id in 1923, gave aggress ion a s eparate s tatus as an instinct with a separate s ource, which he pos tulated to be largely the skeletomus cular s ys tem, and a separate aim of its namely, des truction. Aggres sion was no longer a component instinct nor was it a characteris tic of the instincts; it was an independently functioning instinctual system with aims of its own. T he elevation of aggress ion to the s tatus of a s eparate instinct, on a par with sexual instincts, dealt a severe to any lingering romantic notions of the es sentially or exclusively benign nature of man. Aggress ion and destructiveness were seen as inherent qualities of nature such that aggres sive impuls es were elicited whenever an individual was sufficiently thwarted or abused. F reud's new formulation als o drew attention to the specific role of aggres sion in forms of as well as to understanding of the developmental proces ses through which aggress ion could be normally integrated and controlled. It s hould be noted that aggres sion remains a problem 498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalytic thinking even today. Although a great has been learned about the operation and vicis situdes aggres sion s ince F reud originally struggled with it, still a great deal that remains to be learned about its nature, its origins , and the conditions that produce and unleas h it as well as the developmental factors that contribute to its pathological deviations and to its more cons tructive integration in the realm of human functioning. S ome more recent revis ions of aggress ion it les s in terms of des tructive or s adistic aims but more broadly as a capacity for effective action in the face of obstacles or opposition-embracing capacities for and s elf-as sertion and as related to patterns of rather than as a biologically determined drive force.

L ife and Death Ins tinc ts When F reud introduced his final theory of life and instincts in B eyond the P le as ure P rinciple in 1920, he what can now be seen as an inevitable and logical next step in the evolution of the instinct theory he had been developing. It was nonetheles s a highly s peculative attempt to extrapolate the directions in which his theory was taking s hape to the broad realm of principles. One can recall that F reud's thinking about instincts always casts its s hadow in a dual modality. In beginning, he had dis tinguished s exual and ego T his dis tinction provided the bas ic dichotomy for the explanation of ps ychological conflict and the unders tanding of psychoneurosis. T he introduction of the life and death ins tincts must be seen in the cours e of this development and as the inherent duality of instinctual theory to the level of 499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ultimate and final biological principle. F reud had not divorced his notion from the underlying economic principles derived from principles of entropy and cons tancy. T he constancy principle was extended to Nirvana principle, the objective of which was ces sation all s timuli or a state of total rest. It was only a small, subs equent s tep that led F reud from the formulation of Nirvana principle to the death ins tinct, or T hanatos. postulated that the death ins tinct was a tendency of all organisms and their component cells to return to a total quies cence—that is , to an inanimate state. In opposition to this instinct, he set the life ins tinct, or referring to tendencies of organic particles to reunite of parts to bind to one another to form greater unities, in sexual reproduction. In F reud's view, the ultimate destiny of all biological matter, driven by the inexorable tendencies of all life to follow principles of entropy and cons tancy (with the exception of the germ plasm), was return to an inanimate state. He believed that the dominant force in biological organisms had to be the death ins tinct. In this final formulation of life and death instincts, the instincts were cons idered to represent abstract biological principles, which transcended the operation of libidinal and aggres sive drives. T he life death ins tincts repres ented the forces underlying and aggres sive ins tincts . C ons equently, they general trend in all biological organis ms . Needles s to s ay, F reud's extravagant s peculation has subjected to severe criticis m. It is impos sible to argue a general biological principle exis ts merely on the basis clinical observation. If the inherent destructivenes s of some states of psychopathology can permit the 500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of P.717 destructive forces operating in the individual psyche, it no means points to the exis tence of inherent and biologically determined forces of self-destructive However one regards the argument as a biological speculation, for thes e thinkers , it has little relevance as ps ychological speculation. On the contrary, the life and death ins tincts are alive and flourishing in K leinian and F rench analytical circles . T he school of analysts the lead of Melanie K lein constitute the most significant group of ps ychoanalytic theorists who embrace the instinct. K leinian analysis bases a considerable portion its unders tanding of intrapsychic process es on the operation of the life and death ins tincts . In K lein's work with severely dis turbed children, she ascribed the manifestations of aggress ive instincts in s uch children the operation of the death instinct. T his point of view seems to collapse the intervening s teps in the of ins tinctual theory and makes almost any of des tructive aggres sion a direct expres sion of the instinct. Although contributions of K lein and her to the psychopathology of childhood dis turbances are significant, other s chools of analytical thinking have not followed their lead in this conceptualization of the instincts.

NA R C IS S IS M A ND THE DUA L THE OR Y T he concept of narcis sism holds a pivotal pos ition in development of psychoanalytic theory. It was F reud's 501 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dawning realization of the importance of narcis sism led him to important modifications in his unders tanding libido and his instinct theory. At the s ame time, F reud's examination of narciss is m and its related clinical phenomena led to an increasing concern with the and functions of the ego. It mus t be said that the introduction of and focus on narcis sis m have had broad implications and reverberations in psychoanalytic since F reud's day. T he whole problem of narcis sism remains difficult and problematic for psychoanalys is . problem of pathological narcis sis m remains a focus of active interest, thinking, and clinical concern even T he problem has s pecial relevance with regard to forms of character pathology, which are relatively to therapeutic intervention. F reud observed that in cases of dementia praecox (s chizophrenia), libido appeared to have been from other people and objects and turned inward. He concluded that this detachment of libido from external objects might account for the loss of reality contact s o typical of these patients. He s peculated that the libido had then been reinves ted and attached to the patient's own ego, res ulting in megalomaniacal and s uggesting that this libidinal reinves tment found expres sion in their grandios ity and omnipotence. F reud also became aware at the same time that was not limited to these ps ychotic manifes tations . It also occur in neurotic and, to a certain extent, even in “normal” individuals under certain conditions . He noted, for example, that in s tates of phys ical illness and hypochondriasis, libidinal cathexis was frequently withdrawn from outs ide objects and from external 502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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activities and interests. S imilarly, he s peculated that, in sleep, libido was withdrawn from outs ide objects and reinvested in the pers on's own body. T hus, he believed could be that the hallucinatory intens ity of the dream experience and the intensity of the emotional quality of the dream might res ult from the libidinal cathexis of fantas y repres entations of the people who compos ed dream images . F reud also appealed to the basically narcis sistic form of object choice in perversions, particularly homosexuality. T he introduction of narcis sism into his theory played a significant role because it required that he reconcile his theory of libido with what now s eemed to be a libidinal force operating within the ego. F reud originally thought the reinvestment of libido as directed to the ego as T his formulation has given rise to a considerable in the understanding of narciss istic libido. A decis ive reorganization of the concept of narciss is m was by Heinz Hartmann when he pointed out that it was accurate to regard narciss is tic libido as attached not to ego as such but to the s elf. T he ego, as an intraps ychic cons truct, is oppos ed to the self as related to external objects extraps ychically. T he proper opposition, then, between object libido and narciss is tic libido is that the former is attached to object repres entations, whereas latter is attached to s elf-representations. T his important shift in the unders tanding of narcis sis m has opened an area of theoretical reconsideration that is still very flux and has introduced into psychoanalytic thinking the concept of s elf as an important, albeit as -yet-ill-defined, intraps ychic s tructural component.

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Narc is s is m and the C hoic e of L ove Objec t R eference was made earlier to the crucial role of early object relations hips in later choice of love objects. found that a deepened unders tanding of the of narcis sis m made it eas ier to unders tand the basis for choice of certain love objects in adult life. A love object might be chos en, as F reud put it, “according to the narcis sistic type,” that is , because the object res embles subject's idealized self-image (or fantasized s elfP os sibly the choice of object might be an “anaclitic in which cas e the object might res emble someone who took care of the s ubject during the early years of life. In summary, the concept of narcis sis m occupies a and pivotal pos ition in ps ychoanalytic theory. W ith the introduction of the concept of narcis sism, it became obvious that the concept of the “individual” and the individual's “body” and “ego” could no longer be us ed interchangeably. It became clear that further unders tanding and advances in psychoanalytic theory depended on a clearer definition of the concept of self its more adequate delineation from the concept of ego. Attempts to implement s uch understanding have into focus the ambiguities in the concept of the ego and have underscored the need for the s ys tematic study of development, structure, and functions. Attention to narcis sistic phenomena has als o enlarged the unders tanding of a variety of mental disorders as well various normal psychological phenomena. T hese are dis cuss ed in relation to treatment iss ues .

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P S YC HOL OG Y T he topographical theory was ess entially a trans itional model in the development of F reud's thinking and an important function in providing a framework for development of his bas ic ins tinct theory. However, the problems inherent in the topographical theory once again, the need for a more systematic concept of ps ychic s tructure. T he main deficiency of the topographical model lies in its inability to account for extremely important characteristics of mental conflict. T he firs t important problem was that many of the mechanisms that F reud's patients us ed to avoid pain or unpleasure and that appeared in the form of res is tances during psychoanalytic treatment were thems elves not initially access ible to consciousness . drew the obvious conclus ion that the agency of repress ion, therefore, could not be identical with the preconscious because this region of the mind was , by definition, easily access ible to consciousness . T he problem was that he found that his patients frequently exhibited an uncons cious need for punis hment or an unconscious s ens e of guilt. According to the model, however, the moral agency making this demand was allied with the P.718 antiinstinctual forces available to cons cious nes s in the preconscious level of the mind.

From Topographic al to S truc tural Pers pec tive T he germination of the shifting currents of F reud's 505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thinking finally came to fruition in his abandoning the topographical model and replacing it with the structural model of the psychic apparatus in T he E go and the Id. introduction of the structural hypothesis initiated a new era in psychoanalytic thinking. T he structural model of mind, or the “tripartite theory” as it is often called, is comprised of three distinct entities or organizations the ps ychic apparatus—the id, the ego, and the T he terms have become s o familiar and the tendency hypos tas ize them so great that it is well to bear in mind their nature as scientific cons tructs. T he terms are theoretical cons tructs that have as their primary the specific groups of mental functions and operations that they are intended to organize and integrate into higher-order s ys tems. E ach refers to a particular mental functioning, and none of them expres ses or represents the sum total of mental functioning at any time. Although they are often s poken of as though they functioned as quasiindependent systems , they are, nonetheless , ultimately coordinated aspects of the operation of the mental apparatus representing mental actions of the person. Attribution of agency to any one them is a form of misplaced concretenes s because actions and functions are bas ically thos e of the thems elves . Moreover, unlike such phenomena as sexuality or object relations, id, ego, and superego are empirically demonstrable phenomena in themselves must be inferred from the observable effects of the operations of specific psychic functions .

His toric al Development of E go Ps yc hology 506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he evolution of the concept of ego within the of the historical development of psychoanalytic theory parallels to a large extent the s hifts in F reud's view of instincts and can be divided into four phases. T he first phase ended in 1897 and coincided with the of the early ps ychoanalytic formulations . T he s econd phase extended from 1897 to 1923, thus s panning the development of psychoanalys is proper. T he third from 1923 to 1937, saw development of F reud's theory the ego and the gradual emergence to prominence of ego in the overall context of the theory. P arallel to this development was the evolution of F reud's thinking anxiety. F inally, the fourth phas e, coming after F reud's death, saw the emergence and s ys tematic a general psychology of the ego as well as a s hifting of focus from the operation of ego functions themselves the broader social and cultural contexts within which ego developed and functioned.

F irs t P has e: E arly C onc epts of the In the initial phase, the ego was not always precisely defined. R ather, it referred to the dominant mass of cons cious ideas and moral values that were dis tinct impulses and wis hes of the repress ed unconscious. ego was concerned primarily with defense, a term soon replaced with the notion of repress ion, so that repress ion and defens e were regarded as the neurophys iological jargon of the P roje ct, the ego described as “an organization… whos e presence with pas sages of quantity (of excitation).” T ranslating into the language of psychology, the ego was regarded an agent defending against certain ideas that were unacceptable to consciousness . T hese ideas were 507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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be primarily sexual in nature and were initially believed have been engendered by premature s exual trauma real s eduction. P resumably, becaus e memory of s uch trauma led to arous al of unpleas ant and painful affects , they evoked a defens ive res ponse and repress ion of original thought content. T his repres sion, however, led damming up of energy and the consequent production anxiety. F unctioning of this “early ego” was to a degree because its primary purpos e was to reduce tension and thus avoid unpleas ant affects connected sexual thoughts , but in the process of repress ion, it seemed to evoke an equally unpleasant affect s tate, anxiety.

S ec ond P has e: His toric al R oots of P s yc hology During the years preceding publication of T he E go and Id, analysis of the ego as such received little direct attention becaus e F reud was concerned primarily with instinctual drives —their repres entatives and transformations. C onsequently, references to defens e defens ive functions were much les s frequent. T he clarification of these concepts required further of the ego, its functions , and the nature of its It was during this s econd phase that F reud grappled these problems and gradually approached the more definitive res olution provided by the s tructural theory. T he ego's relations hip to reality is particularly relevant this connection. As noted earlier, the concept of a secondary process implies the ability to delay instinctual drives in accordance with demands of reality. T he capacity for delay was later to be as cribed 508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the ego. T he progres sion from pleasure principle to principle in childhood involves a similar capacity to “postpone gratification” and thereby conform to the requirements of the outside world. F inally, if neither the preconscious nor the ego instincts were s olely respons ible for repress ion or cens ors hip, was repress ion to be achieved? F reud tried to ans wer question by pos tulating that ideas are maintained in the unconscious by a withdrawal of libido or energy In the manner characteristic of unconscious ideas , however, they cons tantly renew their attempt to attached to libido and thus reach cons cious nes s. C ons equently, the withdrawal of libido must be repeated. F reud described this process as “countercathexis .” Again, however, if such is to be cons is tently effective agains t uncons cious must be permanent and must its elf operate on an unconscious basis. Understanding of ps ychic s tructure, specifically of the ego, which could perform this complicated function, was clearly called for and cons tituted s till another indication of the need for the development of ego psychology. T hus , the way was pointed toward the third phas e, wherein the ego was delineated as a s tructural entity and s eparated from the instinctual drives .

Third P has e: F reud's E go With publication of T he E go and the Id, the phase of introduction and development of F reud's own theory of the ego was accomplis hed. T he ego was pres ented as structural entity, a coherent organization of mental proces ses and functions, primarily organized around 509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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perceptual-cons cious system, but it also included structures res ponsible for res is tance and uncons cious defens e. T he ego at this s tage was relatively pass ive weak. Its functioning was s till a res ult of press ures from id, s uperego, and reality. T he ego was the rider on the id's hors e, more or less obliged to go the id wished to go. T he as sumption remained that the ego was not only dependent on forces of the id but was somehow genetically derived and differentiated out of id. F reud had yet to recognize any real development of ego comparable to the phases of libidinal development. During this period, the view of the ego underwent transformation. S ome of the details of this development took place in connection with F reud's theory of anxiety. Inhibitions , S ymptoms , and Anxie ty in 1926, F reud repudiated the conception of ego as subservient P.719 to the id. S ignal anxiety became an autonomous for initiating defense, and the capacity of the ego to pass ively experienced anxiety into active anticipation underlined. Here, too, the relatively rudimentary conception of the defens ive capacity of the ego was enlarged to include a variety of defens es that the ego at its dis pos al and could us e in the control and id impulses . Moreover, elaboration of F reud's of the reality principle introduced a function of that allowed the ego to curb ins tinctual drives when prompted by them led to real danger. T he effect of this trans formation of his theory of the ego was threefold. F irs t, it brought the ego into prominence a powerful regulatory force respons ible for integration 510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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control of behavioral res pons es . S econd, the role of was brought to center stage in the theory of ego functioning. It had been banished to the wings in the preceding quarter century, but concern with the function of the ego again brought it back to E ven s o, the conception of adaptation here was rudimentary and limited to the ego's capacity to avoid danger. T he notions that F reud was evolving during phase provided the foundation for the later concept of autonomy of the ego, as developed by later theoris ts. F inally, it was toward the end of this period that F reud finally made explicit the as sumption of independently inherited roots of the ego that were quite independent the inherited roots of the ins tinctual drives. T his formulation was taken over by Hartmann and s erved as the bas is for his notion of primary ego autonomy, which cons equently s timulated the developments of the fourth phase.

F ourth P has e: S ys tematization of P s yc hology If the third phase can be thought of as culminating in F reud's work on the defense mechanis ms of the ego, fourth phas e can be s een as taking its initiation from publication of Hartmann's work on the ego and adaptation. Hartmann's work primarily focused on two as pects of F reud's later notions of the ego, namely, the autonomy of the ego and the problem of adaptation. Dis cus sion of the apparatuses of primary autonomy the bas is for a doctrine of the genetic roots of the ego a development of the notion of epigenetic maturation. Hartmann's treatment of adaptation als o brought the adaptational point of view into focus in such a way that 511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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has become generally acceptable as one of the basic metapsychological as sumptions of ps ychoanalytic Although this development of thinking about the ego an important advance, many psychoanalys ts began to that it created an imbalance in the theory and that, by increasingly focus ing on the mechanical and as pects of ego functioning, it left a picture of functioning and dys functioning that s eemed relatively mechanistic and inhuman. Moreover, there developed widening s plit between the id, the vital s tratum of the mind and the dynamic s ource of ps ychic energies, and nonins tinctual, nondynamic structural apparatuses of ego. C onsequently, the id increas ingly came to be the source of ins tinctual energies —the image of the seething cauldron—without the repres entational or directional qualities that s o long characterized F reud's views of the instincts and their functions. T he other extremely important as pect of the fourth is reemergence of the importance of reality in its and most profound meanings as a significant ps ychoanalytic thinking. T his is in many ways a direct extrapolation of Hartmann's thinking about adaptation because the adaptive functioning of the organis m has directly to do with fitting in with the requirements of external reality and adaptively interacting with the environment, not only the inanimate but als o the and s ocial environment.

S truc ture of the Ps yc hic Apparatus F rom a structural viewpoint, the ps ychic apparatus is divided into three groups of functions des ignated as id, ego, and s uperego and dis tinguis hed by their different 512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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functions . T he id is the locus of the instinctual drives under domination of primary process . It operates according to dictates of the pleas ure principle, without regard for the limiting demands of reality. T he ego, however, represents a coherent organization of whos e task is to avoid unpleasure or pain by oppos ing regulating the dis charge of instinctual drives to conform demands of the external world. T he regulation of id discharges is also contributed to by the third structural component of the psychic apparatus, the s uperego, contains the internalized moral values, prohibitions , standards of the parental imagoes .

Id F reud s eparated the ins tinctual drives in his tripartite theory into a separate compartment, the vital stratum of the mind, and in s o doing reached the culminating point of the evolution of his theory of ins tincts . In contrast to concept of the ego as an organized, problem-solving capacity, F reud conceived of the id as a completely unorganized, primordial reservoir of energy, derived the instincts , and under the domination of primary proces s. It was not, however, s ynonymous with the unconscious because the structural viewpoint was in that it demons trated that certain functions of the ego, specifically certain defenses against uncons cious instinctual pres sures, were unconscious; for the most the superego also operated on an uncons cious level.

E go T he cons cious and precons cious functions typically as sociated with the ego—for example, words, ideas, or 513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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logic—do not account entirely for its role in mental functioning. T he dis covery that certain phenomena that emerge most clearly in the psychoanalytic treatment setting, s pecifically repress ion and res is tance, both as sociated with the ego, could themselves be pointed out the need for an expanded concept of the as an organization retaining original clos e relations hip cons ciousnes s and to external reality and yet variety of unconscious operations in relationship to and their regulation. Once the s cope of the ego had thus broadened, cons cious nes s was redefined as a quality that, although exclusive to the ego, cons titutes only one of its qualities or functional as pects rather separate mental s ys tem its elf, as in the topographical model. No more comprehens ive definition of the ego is than the one F reud himself provided toward the end of career in O utline of P s ychoanalys is : Here are the principal characte ris tics of the e go. In cons equence of the pre-es tablis hed connection sens e and perception and muscular action, the ego voluntary movement at its command. It has the tas k of self-preservation. As regards external events, it that task by becoming aware of s timuli, by storing up experiences about them (in the memory), by avoiding excess ively strong s timuli (through flight), by dealing moderate s timuli (through adaptation) and finally by learning to bring about expedient changes in the world to its own advantage (through activity). As internal events, in relation to the id, it performs that by gaining control over the demands of the ins tinct, by deciding whether they are to be allowed satisfaction, by 514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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postponing that s atisfaction to times and circums tances favourable in the external world or by s uppress ing their excitations entirely. It is guided in its activity by cons ideration of the tension produced by stimuli, these tens ions are present in it or introduced into it. P.720 T hus, the ego controls the apparatuses of motility and perception, contact with reality, and, through of defense, inhibition of primary instinctual drives .

OR IG INS OF THE E G O If the ego is defined as a coherent s ys tem of functions mediating between ins tincts and the outs ide world, one must concede that the newly born infant has no ego or, best, the mos t rudimentary of egos. Nonetheles s, the neonate certainly has a rather complex array of intact capacities and both sensory and motor functions . however, little coherent organization of thes e s o that must say that the ego is at bes t rudimentary. Developmental ego ps ychology is then faced with the problem of explaining the process es that permit modification of the id and the concomitant genes is of ego. F reud believed that the modification of the id occurs as res ult of the impact of the external world on the drives. P res sures of external reality enable the ego to energies of the id to do its work. In the proces s of formation, the ego seeks to bring the influences of the external world to bear on the id, substitute the reality principle for the pleasure principle, and thereby to its own further development. In s ummary, F reud 515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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emphasized the role of ins tincts in ego development particularly, the role of conflict. At first, this conflict is between the id and the outside world, but later, it is between the id and the ego itself.

DE VE L OPME NT OF THE E G O T he proces ses by which the internal world is built up by which s tructure is consolidated within the self are referred to under the heading of internalization. F orms internalization—incorporation, introjection, and identification—are various ly connected with of the ego. Incorporation was originally conceived of as an activity derived from and based developmentally on the oral phas e and was considered as a genetic precurs or identification. However, even though incorporation fantas ies are often as sociated with internalizing they are by no means identical and may be quite independent. S ome authors envision incorporation as mechanism of primary identification, aimed at a primary union between ones elf and the maternal object. Incorporation as a mechanism of internalization seems involve a primitive oral wis h for union with an object. union has a quality of totality and globalization so that the internalization of the object, the object loses all distinction and function as object. T he external object is completely ass umed into the pers on's inner world. Incorporation is thus operative in infantile or relatively regress ive conditions. Introje ction is perhaps the mos t central process in development of the s tructural apparatus involving ego and s uperego. Introjection was originally des cribed by 516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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F reud in Mourning and Melancholia as a process of narcis sistic identification in which the lost object is introjected and thus retained as a part of the internal structure of the psyche. F reud later applied this mechanism to the genes is of s uperego, making introjection the primary internalizing mechanism by parental imagoes were internalized at the close of the oedipal phas e. T he child tried to retain gratifications derived from thes e object relations hips , at least in through the proces s of introjection. B y this mechanis m, qualities of the person who was the center of the gratifying relationship are internalized and as part of the organization of the s elf. F reud referred to internalized product as a pre cipitate of abandoned cathe xis . Ide ntification has often been confused with introjection, partially becaus e the two proces ses were treated in an overlapping and s omewhat interchangeable fashion by F reud. T here are, nonetheless , grounds for maintaining distinction between them. Ide ntification is , properly speaking, an active s tructuralizing proces s that takes within the s elf by which the s elf cons tructs the inner cons tituents of regulatory control on the bas is of elements derived from the model. W hat cons titutes the model of identification can vary considerably and can include introjects, structural aspects of real objects , or even value components of group structures and group cultures. T he process of identification is specifically an intras ys temic structuralizing activity attributed to the functions of the s elf, related to its synthetic function, affecting structural integration in all parts of the ps ychic apparatus, including superego. 517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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FUNC TIONS OF THE E G O T he ego comprises an organization of functions that in common the task of mediating between ins tincts and the outside world. T hus , the ego is a subsystem of the personality and is not s ynonymous with the s elf, the personality, or character. Any attempt to compile a complete list of ego functions has to be relatively Invariably, the list of basic ego functions s uggested by various authors differs in varying degrees. T his is limited to s everal functions generally conceded to be fundamental to ego operation.

C ontrol and R egulation of Ins tinc tual Development of the capacity to delay immediate discharge of urgent wis hes and impulses is ess ential if ego is to ass ure the integrity of the individual and fulfill role as mediator between id and outside world. Development of the capacity to delay or pos tpone instinctual dis charge, like the capacity to tes t reality, is clos ely related to the progres sion in early childhood pleas ure principle to reality principle.

R elation to R eality F reud always regarded the ego's capacity for relations hip to the external world among its principal functions . T he character of its relationship to the world may be divided into three components : (1) the of reality, (2) reality testing, and (3) the adaptation to reality.

S ens e of R eality T he sens e of reality originates simultaneous ly with the 518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of the ego. Infants firs t become aware of reality of their own bodily s ens ations . Only gradually do they develop the capacity to dis tinguis h a reality their own bodies .

R eality Tes ting R eality te s ting refers to the ego's capacity for objective evaluation and judgment of the external world, which depends first on primary autonomous functions of the ego, s uch as memory and perception, but then also on relative integrity of internal structures of s econdary autonomy. Under conditions of internal s tres s, in which regress ive pulls are effectively operating, introjective as pects of inner psychic structure can tend to dominate and, thus, become s usceptible to projective dis tortions that color the individual's perception and interpretation the outside world. B ecause of the fundamental of reality tes ting for “negotiating” with the outside world, its impairment may be ass ociated with severe mental disorder.

A daptation to R eality Adaptation to re ality refers to the capacity of the ego to the individual's resources to form adequate solutions based on previously tested judgments of reality. It is poss ible for the ego to develop not only good reality tes ting, with perception and grasp, but als o to develop adequate capacity to accommodate the individual's res ources to the s ituation thus perceived. Adaptation is clos ely allied to the concept of mastery, both in res pect external tasks and to the instincts. It should be distinguished from adjustment, which may entail 519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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accommodation to reality at the expense of certain res ources or potentialities of the individual. T he adaptation to reality is closely related to P.721 the defens ive functions of the ego. T he mechanism may s erve defensive purposes from one point of view simultaneously s erve adaptive purposes when viewed from another perspective. T hus, in the obs ess ivecompuls ive person, intellectualization may s erve important inner needs to control drive impulses, but by the same token, from another perspective, the activity its elf may s erve highly adaptive functions in dealing with the complexities of external reality.

Objec t R elations hips T he capacity for mutually s atisfying relations hips is one the fundamental functions to which the ego contributes , although s elf–other relations hips are more properly a function of the whole person, the s elf, of which the ego functional component. S ignificance of object and their disturbance—for normal psychological development and a variety of ps ychopathological were fully appreciated relatively late in the clas sic ps ychoanalys is . T he evolution in the child's for relations hips with others , progres sing from to social relations hips within the family and then to relations hips within the larger community, is related to capacity. Development of object relations hip may be disturbed by retarded development, regress ion, or conceivably by inherent genetic defects or limitations in the capacity to develop object relations hips or 520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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impairments and deficiencies in early caretaking relations hips . T he development of object relations hips clos ely related to the concomitant evolution of drive components and the phas e-appropriate defens es that accompany them.

Defens ive F unc tions of the E go As was pointed out previous ly, in his initial formulations and for a long time thereafter, F reud cons idered repres sion to be virtually s ynonymous with defens e. More specifically, repres sion was directed primarily agains t the impulses, drives, or drive representations and, particularly, agains t direct of the sexual instinct. Defense was thus mobilized to instinctual demands into conformity with demands of external reality. W ith development of the structural view the mind, the function of defens e was ascribed to the Only after F reud had formulated his final theory of however, was it poss ible to study the operation of the various defense mechanis ms in light of their in res pons e to danger s ignals . T hus, a s ys tematic and comprehensive study of ego defens es was only presented for the first time by Anna F reud. In her class ic monograph T he E go and the Me chanis ms of De fe ns e , s he maintained that whether normal or neurotic, uses a characteris tic repertoire of defens e mechanisms but to varying On the basis of her extensive clinical s tudies of she described their ess ential inability to tolerate instinctual stimulation and discus sed proces ses the primacy of s uch drives at various developmental stages evoked anxiety in the ego. T his anxiety, in turn, 521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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produced a variety of defens es. W ith regard to adults, ps ychoanalytic investigations led her to conclude that, although res is tance was an obstacle to progress in treatment to the extent that it impeded the emergence unconscious material, it als o cons tituted a us eful information concerning the ego's defensive operations.

G enes is of Defens e Mec hanis ms In the early s tages of development, defens es emerge res ult of the ego's s truggles to mediate press ures of and the requirements and s trictures of outs ide reality. each phas e of libidinal development, as sociated drive components evoke characteris tic ego defens es . T hus, example, introjection, denial, and projection are mechanisms as sociated with oral-incorporative or oralsadis tic impulses, whereas reaction formations, s uch shame and disgust, us ually develop in relation to anal impulses and pleas ures . Defens e mechanisms from phases of development pers is t side by s ide with thos e later periods. W hen defens es ass ociated with phases of development tend to predominate in adult over more mature mechanisms, such as s ublimation repress ion, the personality retains an infantile cast.

C las s ific ation of Defens es T he defens es used by the ego can be categorized according to a variety of clas sifications, none of which inclusive or takes into account all of the relevant Defenses may be class ified developmentally, for in terms of the libidinal phase in which they aris e. T hus, denial, projection, and distortion are as signed to the stage of development and to the correlative narciss is tic 522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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stage of object relations hips. C ertain defens es , such as magical thinking and regres sion, cannot be categorized in this way. Moreover, certain bas ic developmental process es , such as introjection and projection, may als o s erve defens ive functions under certain s pecifiable conditions. T he defens es have also been clas sified on the bas is of particular form of psychopathology with which they are commonly ass ociated. T hus, the obs es sional defens es include isolation, rationalization, intellectualization, and denial; however, defens ive operations are not limited to pathological conditions. F inally, the defens es have clas sified as to whether they are simple mechanisms or complex, in which a single defens e involves a or compos ite of s imple mechanis ms . T able 6.1-2 gives brief clas sification and description of s ome of the bas ic defens e mechanisms mos t frequently us ed and mos t thoroughly inves tigated by ps ychoanalys ts.

Table 6.1-2 C las s ific ation of Defens e Mec hanis ms Narcis s is tic Defens es P rojection

P erceiving and reacting to unacceptable inner impulses and their derivatives as they were outside the s elf. On 523

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ps ychotic level, this takes the form of frank delus ions about external reality, usually persecutory, and includes perception of one's own feelings in another with subs equent acting on the perception (ps ychotic delus ions). Impuls es may from id or s uperego (hallucinated recriminations). Denial

P sychotic denial of external reality, unlike repres sion, perception of external reality more than perception of internal reality. S eeing, but refusing to acknowledge what one s ees , or hearing, and negating what is actually are examples of denial and exemplify the clos e of denial to s ens ory Not all denial, however, is neces sarily ps ychotic. Like projection, denial may in the service of more or even adaptive objectives. Denial avoids becoming of some painful aspect of

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reality. At the psychotic level, the denied reality may be replaced by a fantas y or delus ion. Dis tortion

G ross ly res haping external reality to suit inner needs , including unrealistic megalomaniacal beliefs, hallucinations , wis h-fulfilling delus ions, and using feelings of delus ional superiority or entitlement.

Immature Defens es Acting out

T he direct expres sion of an unconscious wis h or impulse action to avoid being of the accompanying affect. T he unconscious fantas y, involving objects , is lived out impulsively in behavior, thus gratifying the impulse more than the prohibition against it. On a chronic level, acting out involves giving in to impulses to avoid the tens ion that 525

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from postponement of expres sion. B locking

An inhibition, usually temporary in nature, of affects es pecially, but pos sibly also thinking and impuls es . It is clos e to repress ion in its but has a component of arising from the inhibition of the impulse, affect, or

Hypochondrias is

T ransformation of reproach toward others aris ing from bereavement, lonelines s, or unacceptable aggres sive impulses into s elf-reproach somatic complaints of pain, illness , and so forth. R eal may als o be overemphasized exaggerated for its evas ive regress ive poss ibilities . T hus, res ponsibility may be guilt may be circumvented, instinctual impuls es may be warded off.

Introjection

In addition to the developmental functions of proces s of introjection, it als o

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serves s pecific defensive functions . T he introjection of loved object involves the internalization of of the object with the goal of clos enes s to and cons tant presence of the object. cons equent to separation or tension arising out of ambivalence toward the is thus diminished. If the is a los t object, introjection nullifies or negates the los s taking on characteristics of object, thus, in a sens e, internally preserving the E ven if the object is not los t, internalization usually a s hift of cathexis , reflecting a significant alteration in the object relations hips . Introjection of a feared object serves to avoid anxiety internalizing the aggres sive characteristic of the object thereby putting the under one's own control. T he aggres sion is no longer felt as coming from outs ide but is taken within and us ed

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defens ively, thus turning the subject's weak, pass ive into an active, s trong one. clas sic example is “identification with the aggres sor.” Introjection can also be out of a s ens e of guilt which the s elf-punis hing introject is attributable to the hostile, destructive of an ambivalent tie to an object. T hus, the s elf-punitive qualities of the object are over and establis hed within one's s elf as a s ymptom or character trait, which represents both the and the preservation of the object. T his is als o called ide ntification with the victim. P as siveaggres sive behavior

Aggress ion toward an object expres sed indirectly and ineffectively through pass ivity, masochism, and turning agains t the s elf.

P rojection

Attributing one's own unacknowledged feelings to others ; it includes severe

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prejudice, rejection of through s uspicious ness , hypervigilance to external danger, and injus tice P rojection operates correlatively to introjection, such that the material of the projection is derived from the internalized configuration of the introjects . At higher levels of function, projection may the form of misattributing or misinterpreting motives , attitudes, feelings, or of others. R egress ion

A return to a previous s tage development or functioning to avoid the anxieties or involved in later s tages. A return to earlier points of fixation embodying modes of behavior previous ly given up. T his is often the res ult of a disruption of equilibrium at a later phas e of development. T his reflects a basic tendency achieve ins tinctual or to es cape ins tinctual by returning to earlier modes

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and levels of gratification later and more differentiated modes fail. S chizoid fantasy

T he tendency to use fantasy and to indulge in autis tic retreat for the purpos e of conflict res olution and gratification.

S omatization

T he defens ive conversion of ps ychic derivatives into bodily symptoms; tendency to react with somatic rather than ps ychic manifes tations . Infantile s omatic responses replaced by thought and during development (desomatization); regress ion earlier somatic forms or res ponse (resomatization) res ult from unres olved and may play an important in ps ychophysiological reactions .

Neurotic Defens es

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C ontrolling

T he excess ive attempt to manage or regulate events or objects in the environment in the interes t of minimizing anxiety and s olving internal conflicts.

Dis placement

Involves a purposeful, unconscious s hifting from one object to another in the of solving a conflict. Although the object is changed, the instinctual nature of the impulse and its aim remain unchanged.

Dis sociation

A temporary but dras tic modification of character or sens e of pers onal identity to avoid emotional dis tres s; it includes fugue states and hysterical convers ion

E xternalization

A general term, correlative to internalization, referring to the tendency to perceive in the external world and in external objects components of one's own pers onality, including instinctual impuls es , conflicts,

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moods , attitudes , and s tyles thinking. It is a more general term than projection, which is defined by its derivation from and correlation with specific introjects . Inhibition

T he unconscious ly limitation or renunciation of specific ego functions , s ingly in combination, to avoid anxiety aris ing out of conflict with ins tinctual impuls es , superego, or environmental forces or figures.

Intellectualization

T he control of affects and impulses by way of thinking about them instead of experiencing them. It is a systematic excess of thinking, deprived of its affect, to agains t anxiety caused by unacceptable impulses.

Is olation

T he intraps ychic s plitting or separation of affect from content res ulting in of either idea or affect or the displacement of affect to a

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different or substitute content. R ationalization

A justification of attitudes, beliefs, or behavior that might otherwis e be unacceptable by an incorrect application of justifying reasons or the invention of a convincing fallacy.

R eaction formation

T he management of unacceptable impulses by permitting express ion of the impulse in antithetical form. T his is equivalently an expres sion of the impulse in negative. W here instinctual conflict is pers is tent, reaction formation can become a character trait on a basis , usually as an aspect of obses sional character.

R epress ion

C ons is ts of the expelling and withholding from cons cious awarenes s of an idea or It may operate either by excluding from awareness was once experienced on a cons cious level (s econdary

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repress ion) or by curbing and feelings before they have reached cons cious nes s (primary repres sion). T he “forgetting” of repress ion is unique in that it is often accompanied by highly symbolic behavior, which suggests that the repress ed not really forgotten. T he important dis crimination between repres sion and the more general concept of defens e has been discus sed. S exualization

T he endowing of an object or function with s exual significance that it did not previous ly have, or a less er degree, to ward off anxieties connected with prohibited impulses.

Mature Defens es Altruis m

T he vicarious but cons tructive and instinctually gratifying service to others . T his mus t 534

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distinguished from altruistic surrender, which involves a surrender of direct or of instinctual needs in favor of fulfilling the needs of others to the detriment of the self, with vicarious s atis faction being gained through introjection. Anticipation

T he realis tic anticipation of or planning for future inner discomfort: implies overly concerned planning, and anticipation of dire and dreadful poss ible outcomes .

Asceticism

T he elimination of directly pleas urable affects to an experience. T he moral element is implicit in s etting values on s pecific pleas ures . Asceticism is directed against all “base” pleas ures cons ciously, and gratification derived from the renunciation.

Humor

T he overt express ion of without pers onal discomfort immobilization and without

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unpleasant effect on others . Humor allows one to bear, yet focus on, what is too terrible to be borne, in to wit, which always involves distraction or dis placement away from the affective is sue. S ublimation

T he gratification of an whos e goal is retained but whos e aim or object is from a socially objectionable one to a s ocially valued one. Libidinal sublimation involves desexualization of drive impulses and the placing of a value judgment that subs titutes what is valued by the superego or s ociety. S ublimation of aggres sive impulses takes place through pleas urable games and Unlike neurotic defens es , sublimation allows instincts to be channeled rather than dammed up or diverted. in sublimation, feelings are acknowledged, modified, and directed toward a relatively significant pers on or goal s o

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that modest ins tinctual satis faction res ults. S uppres sion

T he cons cious or decis ion to pos tpone attention to a cons cious impuls e or conflict.

Adapted from V aillant G E . Adaptation to L ife . Little, B rown; 1977; S emrad E . T he operation of defens es in object los s. In: Moriarity DM, ed. T he of L ove d O nes . S pringfield, IL: C harles C . 1967; and B ibring G L, Dwyer T F , Huntington DS , V alens tein AA: A s tudy of the ps ychological principles in pregnancy and of the earlies t child relationship: Methodological cons iderations . P s ychoanal S tud C hild. 1961;16:25.

S ynthetic F unc tion T he s ynthetic function of the ego refers to the ego's capacity to integrate various aspects of its functioning. involves the capacity of the ego to unite, organize, and bind together various drives, tendencies , and functions within the personality, enabling the individual to think, feel, and act in an organized and directed manner. the synthetic function is concerned with the overall organization and functioning of the ego in the selfand cons equently mus t enlis t the cooperation of other 537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and nonego functions in its operation. Although the synthetic function subserves adaptive functioning in the ego, it may als o bring together forces in a way that, although not completely adaptive, an optimal s olution for the individual in a particular at a given moment or period of time. T hus , the of a s ymptom that repres ents a compromis e of tendencies, although unpleasant in some degree, is nonetheless preferable to yielding to a dangerous instinctual impuls e or, conversely, trying to s tifle the impulse completely. Hysterical convers ion, for combines a forbidden wis h and the punis hment for it a physical s ymptom. On examination, the s ymptom turns out to be the only poss ible compromise under the circums tances .

A utonomy of the E go Although F reud only referred to “primal, congenital ego variations ” as early as 1937, this concept was greatly expanded and clarified by Hartmann. Hartmann a bas ic formulation about development that the ego id differentiate from a common matrix, the so-called undifferentiated phase, in which the ego's precurs ors inborn apparatuses of primary autonomy. T hese apparatuses are rudimentary in nature, pres ent at birth, and develop outs ide the area of conflict with the id. area Hartmann referred to as a “conflict-free” area of functioning. He included perception, intuition, comprehension, thinking, language, certain phases of motor development, learning, and intelligence among functions in this conflict-free sphere. E ach of these functions , 538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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P.722 P.723 however, might als o become involved in conflict secondarily in the course of development. F or example, aggres sive, competitive impulses intrude on the impuls e learn, they may evoke inhibitory defens ive reactions on part of the ego, thus interfering with the conflict-free operation of these functions .

P rimary A utonomy With the introduction of the primary autonomous functions , Hartmann provided an independent genetic derivation for at leas t part of the ego, thus es tablis hing it an independent realm of psychic organization that was totally dependent on and derived from the instincts . T his was an ins ight of major importance because it laid the foundations for the emerging doctrine of ego autonomy and meant that the analys is of ego development would have to cons ider an entirely new set of variables quite separate from thos e involved in instinctual

S ec ondary A utonomy Hartmann obs erved that the conflict-free sphere derived from s tructures of primary autonomy can be enlarged that further functions could be withdrawn from the domination of drive influences . T his was Hartmann's concept of s econdary autonomy. T hus, a mechanism arose originally in the s ervice of defense agains t drives may in time become an independent s tructure, that the drive impuls e merely triggers the automatized 539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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apparatus. T hus, the apparatus may come to serve functions than the original defensive function, for example, adaptation or s ynthes is . Hartmann referred to this removal of s pecific mechanis ms from drive as a process of change of function.

S uperego T he origins and functions of the superego are related those of the ego, but they reflect different viciss itudes . B riefly, the s uperego is the las t of the structural components to develop, resulting in F reud's analysis from resolution of the oedipal complex. It is concerned with moral behavior based on uncons cious behavioral patterns learned at early pregenital stages development. F requently, the superego participates in neurotic conflict by allying its elf with the ego and thus impos ing demands in the form of conscience or guilt feelings. Occasionally, however, the superego may be allied with the id agains t the ego. T his happens in severely regres sed reaction, in which functions of the superego may become s exualized once more or may become permeated P.724 by aggres sion, taking on a quality of primitive (us ually anal) destructivenes s.

HIS TOR IC AL DE VE L OPME NT In a paper written in 1896, F reud described ideas as “s e lf-re proaches which have re-emerged from re pre s s ion and which always relate to some s e xual act was performed with pleas ure in childhood.” T he activity 540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a s elf-criticizing agency was also implicit in F reud's discuss ions of dreams, which pos tulated existence of a “cens or” that did not permit unacceptable ideas to enter cons ciousnes s on moral grounds . He first dis cuss ed concept of a special s elf-critical agency in 1914, that a hypothetical s tate of narcis sis tic perfection in early childhood; at this stage, the child was his or her own ideal. As the child grew up, admonitions of others self-criticis m combined to destroy this perfect image. compens ate for this los t narciss ism or to recover it, the child “projects before him” a new ideal or ego-ideal. It at this point that F reud s ugges ted that the psychic apparatus might have still another structural special agency whos e task it was to watch over the make s ure it was measuring up to the ego-ideal. T he concept of the superego evolved from thes e of an ego-ideal and a s econd monitoring agency to its preservation. Again in 1917, in Mourning and Me lancholia, F reud of “one part of the ego” that “judges it critically and, as were, takes it as its object.” He s uggested that this which is s plit off from the res t of the ego, was what is commonly called cons cie nce . He further s tated that this self-evaluating agency could act independently, could become “diseased” on its own account, and s hould be regarded as a major institution of the self. In 1921, referred to this self-critical agency as the ego-ide al and held it res ponsible for the s ens e of guilt and for the reproaches typical in melancholia and depres sion. At point, he had dropped his earlier distinction between ego-ideal, or ideal s elf, and a s elf-critical agency, or cons cience. 541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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In 1923, however, in T he E go and the Id, F reud's the superego again included both these functions—that the s uperego repres ented the ego-ideal as well as cons cience. He als o demonstrated that operations of superego were mainly uncons cious . T hus, patients were dominated by a deep sense of guilt lacerated thems elves far more hars hly on an unconscious level they did conscious ly. T he fact that guilt engendered by superego might be eas ed by suffering or punishment apparent in the case of neurotics who demonstrated an unconscious need for punis hment. In later works, elaborated on the relations hip between ego and superego. G uilt feelings were ascribed to tens ion these two agencies , and the need for punis hment was expres sion of this tens ion.

OR IG INS OF THE S UPE R E G O In F reud's view, the s uperego comes into being with res olution of the Oedipus complex. During the oedipal period, the little boy wishes to poss es s his mother, and little girl wis hes to pos ses s her father. E ach must, contend with a substantial rival, the parent of the same sex. T he frustration of the child's pos itive oedipal this parent evokes intense hostility, which finds not only in overt antagonistic behavior but also in thoughts of killing the parent who stands in the way with any brothers or sisters who may also compete for love of the desired parent. Quite unders tandably, this hos tility on the part of the is unacceptable to parents and, in fact, eventually unacceptable to the child as well. In addition, the boy's sexual explorations and masturbatory activities may 542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thems elves meet with parental disfavor, which may be unders cored by real or implied threats of castration. T hese threats and, above all, the boy's obs ervations women and girls lack a penis convince him of the castration. C onsequently, he turns away from the situation and its emotional involvements and enters the latency period of ps ychosexual development. He renounces the sexual express ions of the infantile G irls , when they become aware of the fact that they penis (in F reud's terms , they have “come off badly”), to redeem the los s by obtaining a penis or a baby from father. F reud pointed out that, although the anxiety surrounding castration brings the Oedipus complex to end in boys, in girls it is the major precipitating factor. renounce their oedipal s trivings, first, because they fear the loss of the mother's love and, second, because of disappointment over the father's failure to gratify their wis h. T he latency phas e, however, is not s o well girls as it is in boys , and their pers istent interest in relations is expres sed in their play; throughout grade school, for example, girls “act out” the roles of wife and mother in games that boys s crupulous ly avoid. T his the bas ic outline of F reud's theory of the superego.

E VOL UTION OF THE S UPE R E G O What, indeed, is the fate of the object attachments up with res olution of the Oedipus complex? F reud's formulation of the mechanis m of introjection came into play here. During the oral phase, the child is entirely dependent on the parents. Advancing beyond this the child must abandon these earlies t s ymbiotic ties the parents and form initial introjections of them, which, 543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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however, follow the anaclitic model—that is , they are characterized by dependence on the parents . T hus, diss olution of the Oedipus complex and the abandonment of object ties led to rapid acceleration of introjection process . T hese introjections from both parents became united formed a kind of precipitate within the self, which then confronted other contents of the ps yche as the T his identification with the parents was based on the child's s truggles to repres s ins tinctual aims that were directed toward them, and it was this effort of that gave the s uperego its prohibiting character. It is for this reas on, too, that the s uperego res ults, to such a extent, from introjection of the parents' own s uperegos. Y et, becaus e the s uperego evolved as a result of of ins tinctual desires, it had a clos er relation to the id did the ego itself. Its origins were more internal; the originated to a greater extent in relation to the external world and was its internal repres entative. F inally, throughout the latency period and thereafter, child (and later the adult) continues to build on these identifications through contact with teachers , heroic figures , and admired people, who form the s ources of child's moral standards, values , and ultimate and ideals. T he child moves into the latency period endowed with a superego that is, as F reud put it, “the to the Oedipus complex.” Its structures at firs t might be compared to the imperative nature of demands of the before it developed. T he child's conflicts with the continue, of cours e, but now they are largely internal, between his or her own ego and superego. In other the s tandards , res trictions , commands, and 544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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impos ed previously by the parents from without are internalized in the child's s uperego, which now judges guides behavior from within, even in the abs ence of the parents .

C UR R E NT INVE S TIGATIONS OF THE S UPE R E GO E xploration of the s uperego and its functions did not with F reud, and such s tudies remain of current active interes t. R ecent interes t has focus ed on the between superego and ego-ideal, a distinction that periodically revived and abandoned. At pres ent, the s upe re go refers primarily to a self-critical, prohibiting agency bearing a close relationship to aggres sion and aggres sive identifications . T he ego-ideal, however, is a kinder function, bas ed on a transformation of the abandoned perfect state of narcis sism, or s elf-love, exis ted in early childhood and has been integrated with positive elements P.725 of identifications with the parents . In addition, the of an ideal object—that is , the idealized object choice— has been advanced as dis tinct from the ideal self. theoris ts regard the ego-ideal as an aspect of s uperego organization derived from good parental imagoes . A s econd focus of recent interes t has been the contribution of the drives and object attachments in the pre-oedipal period to the development of the superego. T hes e pregenital (es pecially anal) the superego are generally believed to provide s ome of the very rigid, strict, and aggres sive qualities of the 545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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superego. T hes e qualities s tem from projection of the child's own sadis tic drives and primitive concept of based on retaliation, which is attributed to the parents during this period. T he hars h emphasis on absolute cleanliness and propriety that is sometimes found in rigid individuals and in obsess ional neurotics is based some extent on this s phincter morality of the anal One result of these developments is that the between oedipal dynamics and s uperego development have been s ignificantly diluted in the s ense that preoedipal s uperego precurs ors and pre-oedipal s uperego functions are better unders tood on one hand, and postoedipal adaptive integrations, especially with ego functions , on the other hand, have modified the unders tanding of s uperego functions .

P S YC HIC DE VE L OP ME NT— INTE G R A TION OF P HA S E S A ND OB J E C T As his clinical experience increased, F reud was able to recons truct to a certain degree the early s exual experiences and fantasies of his patients . T hese data provided the framework for a developmental theory of childhood s exuality, which, in the subs equent cours e of ps ychoanalytic developmental exploration based on observation of childhood behavior, has been widely corroborated, accepted, and elaborated by theoris ts . T hese views have been s ubjected to cons iderable revis ion and development, as well as and rejection, in ens uing years . P erhaps an even more important source of information that contributed to F reud's thinking about infantile s exuality was his own analysis, begun in 1897. He was gradually able to 546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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memories of his own erotic longings in childhood and conflicts in relations hip to his parents, related to his oedipal involvement. R ealization of the operation such infantile s exual longings in his own experience suggested to F reud that these phenomena might not res tricted only to the pathological development of neuros es, but that es sentially normal individuals might undergo similar developmental experiences. T he progres sive integration of psychos exual developments and object relations has been further elaborated in phases of instinctual development, Margaret Mahler's separation-individuation process , and E rik E rikson's epigenetic s equence.

Phas es of Ps yc hos exual T he earlies t manifes tations of infantile s exuality aros e relation to bodily functions that were bas ically such as feeding and development of bowel and bladder control. T herefore, F reud divided these stages of ps ychos exual development into a s ucces sion of developmental phas es, each of which was believed to build on and s ubsume accomplis hments of the phases —namely, the oral, anal, and phallic phases . oral phase occupied the first 12 to 18 months of the infant's life; next, the anal phas e, until approximately 3 years of age; and, finally, the phallic phase, from approximately 3 to 5 years of age. F reud postulated that, in boys , phallic erotic activity es sentially a preliminary stage for adult genital activity. contrast to the male, whos e principal s exual organ remained the penis throughout the course of ps ychos exual development, the female had two 547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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erotogenic zones , the clitoris and the vagina. F reud believed that the clitoris was preeminent during the infantile genital period but that erotic primacy after puberty was transpos ed to the vagina. R ecent sexual inves tigations have cas t some doubt on a s upposed transition from clitoral to vaginal primacy, but many analysts retain this view on the basis of their clinical experience. T he ques tion for the time being remains unresolved. F reud's basic s chema of the psychosexual s tages was modified and refined by K arl Abraham, who further subdivided the phas es of libido development, dividing oral period into a s ucking and biting phas e and the anal phase into a des tructive-expulsive (anal sadis tic) and a mastering-retaining (anal erotic) phase. F inally, he hypothes ized that the phallic period cons is ted of an phase of partial genital love, which was designated as true phallic phas e, and a later, more mature genital F or each of the stages of psychosexual development, F reud delineated s pecific erotogenic zones that gave to erotic gratification. T able 6.1-3 provides an overview current, more or les s tentative, views on ps ychosexual development.

Table 6.1-3 S tages of Development Oral S tage 548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Definition

E arlies t s tage of development in which the infant's needs , perceptions, and modes of expres sion are primarily centered mouth, lips, tongue, and other organs related to the oral zone.

Des cription

Oral zone maintains dominance in ps ychic organization through approximately the first 18 mos of Oral s ensations include thirs t, hunger, pleasurable tactile stimulations evoked by the nipple its s ubs titute, and s ensations to swallowing and s atiation. Oral drives cons is t of two components: libidinal and aggres sive. S tates of oral tension lead to s eeking for gratification, as in quiescence at of nurs ing. Oral triad cons is ts of to eat, sleep, and reach that relaxation that occurs at the end of sucking jus t before ons et of s leep. Libidinal needs (oral erotis m) predominate in early oral phase, whereas they are mixed with more aggres sive components later (oral sadis m). Oral aggres sion biting, chewing, s pitting, or crying. Oral aggres sion connected with

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primitive wis hes and fantas ies of biting, devouring, and destroying. Objectives

E stablish a trusting dependence nursing and s ustaining objects , es tablis h comfortable express ion and gratification of oral libidinal needs without excess ive conflict or ambivalence from oral s adistic wis hes .

P athological traits

E xces sive oral gratifications or deprivation can res ult in libidinal fixations contributing to traits. S uch traits can include excess ive optimism, narciss ism, pess imism (as in depres sive or demandingness . E nvy and jealousy often as sociated with oral traits.

C haracter traits

S uccess ful resolution of oral phas e res ults in capacities to give to and receive from others without excess ive dependence or envy, capacity to rely on others with a sens e of trus t as well as with a of self-reliance and self-trus t. Oral characters are often excess ively dependent and require others to

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give to them and look after them are often extremely dependent on others for maintaining self-es teem.

Anal S tage Definition

S tage of ps ychos exual prompted by maturation of neuromuscular control over sphincters, particularly anal sphincters, permitting more voluntary control over retention or expulsion of feces .

Des cription

P eriod extends roughly from 1–3 of age, marked by recognizable intens ification of aggress ive drives mixed with libidinal components in sadis tic impulses. Acquisition of voluntary s phincter control as sociated with increas ing shift pass ivity to activity. C onflicts over anal control and s truggles with parents over retaining or expelling feces in toilet training give rise to increased ambivalence together struggle over separation, individuation, and independence. 551

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Anal e rotis m refers to s exual in anal functioning, both in precious feces and presenting as a precious gift to the parent. s adis m refers to express ion of aggres sive wishes connected with discharging feces as powerful and destructive weapons. T hes e often displayed in fantasies of bombing or explosions . Objectives

Anal period is marked by striving independence and s eparation from dependence on and control of parents . Objectives of sphincter control without overcontrol (fecal retention) or los s of control (mess ing) are matched by to achieve autonomy and independence without excess ive shame or self-doubt from los s of control.

P athological traits

Maladaptive character traits , often apparently inconsistent, derive anal erotis m and defenses against Orderliness , obs tinacy, willfulnes s, frugality, and are features of anal character. defens es agains t anal traits are

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effective, anal character reveals of heightened ambivalence, lack of tidiness , mess iness , defiance, and s adomas ochis tic tendencies. Anal characteristics and defens es typically s een in obs es sivecompuls ive neuros es. C haracter traits

S uccess ful resolution of anal provides bas is for development of personal autonomy, a capacity for independence and personal without guilt, a capacity for s elfdetermining behavior without a sens e of shame or s elf-doubt, a of ambivalence and a capacity for willing cooperation without either excess ive willfulnes s or selfdiminution or defeat.

Urethral S tage Definition

T his s tage not explicitly treated by S igmund F reud but s erves as transitional s tage between anal phallic stages . It s hares s ome characteristics of anal phase and some from subs equent phallic 553

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Des cription

C haracteris tics of the urethral often s ubs umed under phallic Urethral e rotis m, however, refers pleas ure in urination as well as pleas ure in urethral retention analogous to anal retention. is sues of performance and control are related to urethral functioning. Urethral functioning may als o have sadis tic quality, often reflecting persis tence of anal s adistic urges . Loss of urethral control, as in enures is , may frequently have regress ive s ignificance that reactivates anal conflicts.

Objectives

Is sues of control and urethral performance and loss of control. clear whether or to what extent objectives of urethral functioning differ from thos e of anal period.

P athological traits

P redominant urethral trait is competitivenes s and ambition, probably related to compens ation for shame due to loss of urethral control. T his may be start for development of penis envy, related to feminine s ens e of shame and inadequacy in being unable to

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male urethral performance. Als o related to iss ues of control and shaming. C haracter traits

B es ides healthy effects analogous those from anal period, urethral competence provides s ens e of and s elf-competence bas ed on performance. Urethral is area in which s mall boy can and try to match his father's more adult performance. R esolution of urethral conflicts s ets stage for budding gender identity and subs equent identifications .

Phallic S tage Definition

P hallic s tage begins s ometime during 3rd yr and continues until approximately end of 5th yr.

Des cription

P hallic phas e characterized by primary focus of s exual interests, stimulation, and excitement in genital area. P enis becomes organ principal interes t to children of both sexes, with lack of penis in 555

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being considered as evidence of castration. P hallic phas e with increase in genital accompanied by predominantly unconscious fantas ies of sexual involvement with opposite-sex parent. T hreat of cas tration and related anxiety connected with over mas turbation and oedipal wis hes . During this phase, oedipal involvement and conflict are es tablis hed and consolidated. Objectives

T o focus erotic interest in genital area and genital functions . T his foundation for gender identity and serves to integrate residues of previous stages into predominantly genital-sexual orientation. E stablishing oedipal s ituation es sential for furtherance of subs equent identifications s erving basis for important and enduring dimensions of character organization.

P athological traits

Derivation of pathological traits phallic-oedipal involvement are sufficiently complex and subject to such a variety of modifications so

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that it encompas ses nearly the of neurotic development. Iss ues, however, focus on cas tration in males and penis envy in females . P atterns of identification from res olution of oedipal complex provide another important focus of developmental distortions . of castration anxiety and penis defens es agains t them, and of identification are primary determinants of the development human character. T hey also and integrate res idues of previous ps ychos exual stages so that or conflicts deriving from preceding stages can contaminate and oedipal resolution. C haracter traits

P hallic s tage provides foundations for emerging s ens e of sexual of a s ens e of curios ity without embarrass ment, of initiative guilt, as well as a s ens e of mastery not only over objects and people in environment but also over internal proces ses and impuls es. of the oedipal conflict gives rise to internal s tructural capacities for regulation of drive impulses and

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their direction to constructive ends . T his internal s ource of regulation is the superego, bas ed on identifications derived primarily parental figures.

Latency S tage Definition

S tage of ins tinctual relative quies cence or inactivity of s exual drive during period from res olution of the Oedipus complex until pubes cence (from approximately yrs of age until approximately 11– yrs of age).

Des cription

Ins titution of superego at close of oedipal period and further maturation of ego functions allow cons iderably greater degree of control of ins tinctual impuls es. S exual interes ts generally believed be quiescent. P eriod of primarily homos exual affiliations for both and girls as well as a sublimation libidinal and aggres sive energies energetic learning and play exploring environment, and 558

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becoming more proficient in with world of things and people around them. P eriod for development of important skills. R elative s trength of regulatory elements often gives rise to of behavior that are somewhat obses sive and hypercontrolling. Objectives

P rimary objective is further integration of oedipal and cons olidation of sex-role and s ex roles . R elative quies cence and control of ins tinctual impuls es allow for development of ego apparatuses and mas tery of s kills . F urther identificatory components may be added to the oedipal ones basis of broadening contacts with other s ignificant figures outside family (e.g., teachers , coaches , other adult figures ).

P athological traits

Danger in latency period can aris e either from lack of development of inner controls or excess of them. Lack of control can lead to inability to sufficiently sublimate energies in interes t of learning and of skills; exces s of inner control,

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however, can lead to premature clos ure of personality development and precocious elaboration of obses sive character traits . C haracter traits

Latency period frequently regarded as period of relatively unimportant inactivity in the developmental schema. More recently, greater res pect has been gained for developmental process es in this period. Important cons olidations additions are made to basic postoedipal identifications and to proces ses of integrating and cons olidating previous attainments in ps ychos exual development and es tablis hing decis ive patterns of adaptive functioning. T he child can develop a sense of industry and capacity for mastery of objects and concepts that allows autonomous function and a sense of initiative without risk of failure or defeat or a sens e of inferiority. T hes e are all important attainments that need to be further integrated, ultimately as the es sential basis for a mature life of satis faction in work and love.

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Genital S tage Definition

G enital or adoles cent phas e from onset of puberty from 11–13 of age until young adulthood. C urrent thinking tends to s ubdivide this s tage into preadoles cent, early adoles cent, middle adoles cent, adoles cent, and even periods.

Des cription

P hysiological maturation of of genital (s exual) functioning and attendant hormonal systems leads intens ification of drives, particularly libidinal drives . T his produces a regress ion in pers onality organization, which reopens of previous s tages of development and provides opportunity for reres olution of conflicts in context of achieving a mature sexual and adult identity. Often referred to as a s e cond individuation.

Objectives

P rimary objectives are ultimate separation from dependence on attachment to parents and es tablis hment of mature, 561

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noninces tuous, heterosexual relations . R elated are achievement mature sense of personal identity and acceptance and integration of adult roles and functions that new adaptive integrations with expectations and cultural values . P athological traits

P athological deviations due to inability to achieve s ucces sful res olution of this s tage of development are multiple and complex. Defects can arise from whole s pectrum of psychosexual res idues becaus e developmental tas k of adolescence is in a s ense a partial reopening and reworking reintegrating of all of thes e as pects of development. P revious unsuccess ful resolutions and fixations in various phas es or of psychosexual development produce pathological defects in the emerging adult personality.

C haracter traits

S uccess ful resolution and reintegration of previous ps ychos exual stages in adoles cent genital phas e set s tage normally fully mature pers onality with

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capacity for full and satis fying potency and a self-integrated and cons istent s ense of identity. T his provides bas is for capacity for s elfrealization and meaningful participation in areas of work, love, and in creative and productive application to s atis fying and meaningful goals and values.

Development and Objec t R elations C urrent theories in ps ychoanalytic psychiatry have increasingly on the importance for later of early disturbances in object relationships —that is , a disturbance in the relations hip between the child's and the significant objects in the environment, the mothering object. F rom the very beginning of the child's development, F reud regarded the s exual instinct “anaclitic” in the sense that the child's attachment to feeding and mothering figure was based on the child's utter phys iological dependence on the object. T his view the child's earliest attachment s eems consis tent with F reud's understanding of infantile libido developed on basis of his insight, acquired early in his clinical that s exual fantasies of even adult patients typically centered on early relationships with their parents . In event, throughout his descriptions of libidinal phases of development, F reud made constant reference to the significance of children's relationships with crucial 563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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in their environment. S pecifically, he pos tulated that the choice of a love object in adult life, the love relationship its elf, and object relations hips in other s pheres of and activity depend largely on the nature and quality of the child's object relations hips during the earliest years life.

Objec t R elations during P regenital P has es At birth, the infant's respons es to external stimulation relatively diffus e and dis organized. E ven so, as recent experimental res earch on neonates has indicated, the infant is quite responsive to external stimulation, and patterns of res pons e are quite complex and relatively organized, even s hortly after birth. E ven neonates of a hours of age respond s electively to novel s timuli and demonstrate remarkable preferences for complex, as compared with simple, patterns of s timulation. T he res ponses to noxious and pleas urable stimuli are also relatively undifferentiated. E ven so, sensations of cold, and pain give ris e to tens ion and a corresponding need to seek relief from painful s timuli. At the life, however, the infant does not res pond s pecifically to objects as objects . A certain degree of development of perceptual and cognitive apparatus es is required, as as a greater degree of differentiation of s ens ory P.726 P.727 impres sions and integration of cognitive patterns, babies are able to differentiate between impres sions 564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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belonging to thems elves and thos e derived from objects. C ons equently, observations and inferences on data derived from the first 6 months of life mus t be interpreted in the context of the child's cognitive functioning before self–object differentiation. In thes e first months of life, human infants are cons iderably more helpless than any other young mammals . T heir helples snes s continues for a longer than in any other s pecies. T hey cannot survive unless are cared for, and they cannot achieve relief from the painful disequilibrium of inner phys iological states help of external caretaking objects . Object relations hips the most primitive kind only begin to be established an P.728 infant firs t begins to gras p this fact of experience. In the beginning, an infant cannot dis tinguis h between its own lips and its mother's breas ts, nor does an infant initially as sociate s atiation of painful hunger pangs with presentation of the extrins ic breast. B ecaus e the infant aware only of its own inner tension and relaxation and unaware of the external object, longing for the object exis ts only to the degree that the disturbing s timuli and longing for satiation remains unsatis fied in the absence of the object. W hen the s atisfying object appears , and the infant's needs are gratified, longing disappears. G radually, but als o rather quickly, the becomes aware of the mother herself, in addition to her breast, as a need-satis fying object.

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T his experience of unsatis fied need, together with the experience of frus tration in the absence of the breas t need-satis fying release of tension in the presence of breast, forms the bas is of the infant's firs t awarenes s of external objects . T his firs t awarenes s of an object, the ps ychological s ens e, comes from longing for something that is already familiar and for something actually gratified needs in the pas t but is not available in the pres ent. T hus, it is basically the infant's hunger in this view that in the beginning compels recognition of the outside world. T he first primitive reaction to objects, putting them into the mouth, then becomes unders tandable. T his reaction is consistent the modality of the infant's first recognition of reality, judging reality by oral gratification, that is, whether something will provide relaxation of inner tens ion and satis faction (and s hould thereby be incorporated, swallowed) or whether it will create inner tens ion and diss atis faction (and cons equently s hould be s pit out). E arly in this interaction, the mother s erves an important function, that of empathically res ponding to the infant's inner needs in such a manner as to become involved in proces s of mutual regulation, which maintains the homeostatic balance of the infant's physiological needs and proces ses within tolerable limits . Not only does this proces s keep the child alive, but it sets a rudimentary pattern of experience within which the child can build elements of a basic trust that promote reliance on the benevolence and availability of caretaking objects . C ons equently, the mother's administrations and res ponsiveness to the child help to lay the mos t rudimentary and es sential foundation for subsequent 566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of object relations and the capacity for entering the community of human beings. As differentiation between the limits of self and object gradually es tablis hed in the child's experience, the becomes acknowledged and recognized as the s ource gratifying nouris hment and, in addition, as s ource of erotogenic pleas ure the infant derives from sucking on breast. In this s ens e, s he becomes the first love object. quality of the child's attachment to this primary object is the utmos t importance, as developmental and theoris ts have demonstrated. F rom the oral phas e the whole progress ion in psychosexual development, its focus on success ive erotogenic zones and as sociated component ins tincts , reflects the quality of child's attachment to the crucial figures in the environment as well as the strength of feelings of love hate, or both, toward these important people. If a fundamentally warm, trusting, secure, and affectionate relations hip has been es tablis hed between mother and child during the earlies t s tages of the child's career, least theoretically, the stage is s et for development of trus ting and affectionate relationships with other human objects during the course of life.

ANAL PHAS E AND OB J E C TS During the oral s tage of development, the infant's role not altogether pas sive becaus e, caught up as it is in a proces s of mutual interaction, the infant makes its own contribution to eliciting certain res ponses from the mother. T he activity, however, is more or les s and dependent on such phys iological factors as level of activity, irritability, or res ponsivenes s to stimuli. 567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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speaking, however, the infant's control over the feeding res ponses is relatively limited. C ons equently, primary onus remains on the mother to gratify or the demands of the infant. In the trans ition to the anal period, however, this changes s ignificantly. T he child acquires a greater of control over behavior and particularly over sphincter function. Moreover, for the firs t time during this period, demands are placed on the child to relinquish some of freedom by reason of expectations to accede to parental demands to use the toilet for evacuation of and urine. However, the primary aim of anal eroticis m enjoyment of the pleasurable s ens ations of excretion. S omewhat later, s timulation of the anal mucos a retention of the fecal mas s may become a s ource of more intense pleasure. Nonetheles s, at this stage of development, the demand is placed on the child to regulate gratification, to surrender some portion of the gratification at the parent's wis h, or to delay according to a s chedule es tablis hed by the parent's It can be readily s een that one of the important as pects the anal period, therefore, is that it s ets the stage for a contest of wills over when, how, and on what terms the child achieves gratification.

PHAL L IC PHAS E AND OB J E C TS T he pass age from anal to phallic phas e marks not only transition from pre-oedipal to beginnings of the oedipal level of development but also marks completion of the work of s eparation individuation and, in the normal of development, achievement of object cons tancy. T he oedipal s ituation evolves during the period extending 568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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from the third to the fifth year in children of both s exes.

Oedipus C omplex In the normal course of development, the so-called pregenital phas es are regarded as primarily autoerotic. P rimary gratification derives from s timulation of erotogenic zones , whereas the object serves a although s econdary and ins trumental, role. A shift begins to take place in the phallic phas e in which phallus becomes the primary erotogenous zone for sexes, thus laying a foundation for and initiating a s hift libidinal motivation and intention in the direction of objects. T he phallic phas e sets the s tage for the fundamental task of finding a love object, a dynamic moves to another level of progres sion in establis hing relations of the oedipal period and beyond to more mature adult object choices and love relationships . T he phallic period is also a critical phase of development for the budding formation of the child's own sense of identity—as decis ively male or female—based on the child's discovery and realization of the significance of anatomical s exual differences . T he events as sociated the phallic phas e also set the stage for the predis pos ition to later psychoneuroses. F reud used the term O e dipus complex to refer to the intense love relations hips , together with their as sociated rivalries, hostilities , and emerging identifications , formed during this period between the child and parents.

C as tration C omplex T here is s ome differentiation between the s exes in the pattern of development. F reud explained the nature of 569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discrepancy in terms of genital differences. Under circums tances , he believed that, for boys , the oedipal situation was resolved by the castration complex. S pecifically, the boy had to give up his strivings for his mother becaus e of the threat of castration—castration anxiety. In contrast, the Oedipus complex in girls was evoked by reason of the cas tration complex, but unlike boy, the little girl was already cas trated, and as a turned to her father as bearer of the penis out of a disappointment over her own lack of a penis . T he little was thus more threatened by a los s of love than by castration fears. P.729

The B oy's S ituation In boys, development of object relations is relatively complex than for girls becaus e the boy remains to his firs t love object, the mother. T he primitive object choice of the primary love object, which develops in res ponse to the mother's gratification of the infant's needs , takes the s ame direction as the pattern of choice in res ponse to opposite-sex objects in later life experience. In the phallic period, in addition to the attachment to and interes t in the mother as a source of nouris hment, he develops a strong erotic interes t in her and a concomitant desire to pos sess her exclus ively sexually. T hes e feelings us ually become manifest at approximately 3 years of age and reach a climax at 4 years of age. With appearance of the oedipal involvement, the boy begins to show his loving attachment to his mother 570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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as a little lover might—wanting to touch her, trying to in bed with her, proposing marriage, expres sing wis hes replace his father, and devis ing opportunities to s ee naked or undres sed. C ompetition from s iblings for mother's affection and attention is intolerable. Above however, the little lover wants to eliminate his arch mother's husband. His wishes may involve not merely displacing or s upers eding father in mother's affection eliminating him altogether. T he child understandably anticipates retaliation for his aggress ive wis hes toward father, and thes e expectations in turn give rise to a anxiety in the form of the “castration complex.” T his s omewhat simplified picture of the res olution of Oedipus complex is cons iderably more complex in the actual cours e of development. Usually, the boy's love his mother remains a dominant force during the period infantile sexual development. It is known, however, that love is not free of some admixture of hostility and that child's relations hip with both parents is to some degree ambivalent. T he boy als o loves his father, and at times when he has been frustrated by his mother, he may her and turn from her to seek affection from his father. Undoubtedly, to some degree, he loves and hates both parents at the same time. In addition, F reud's of an es sentially bisexual basis of the nature of the complicates matters further. On the one hand, the boy wants to pos sess his mother and kill the hated father On the other hand, he als o loves his father and seeks approval and affection from him, whereas he often to his mother with hos tility, particularly when her demands on her husband interfere with the of the father–son relations hip. T he ne gative O e dipus 571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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complex refers to those situations in which the boy's for his father predominates over the love for the and the mother is relatively hated as a dis turbing in this relations hip.

The G irl's S ituation Understanding of the little girl's more complex oedipal involvement was a later development. B ecause it could be regarded as equivalent to the boy's development, it raised a number of questions that proved to be more difficult. F reud could not get beyond viewing female sexual development as a variant of male development. S imilar to the little boy, the little girl forms an initial attachment to the mother as a primary love object and source of fulfillment for vital needs . F or the little boy, mother remains the love object throughout his development, but the little girl is faced with the tas k of shifting this primary attachment from the mother to the father to prepare herself for her future sexual role. was bas ically concerned with elucidating the factors influenced the little girl to give up her pre-oedipal attachment to the mother and to form the normal attachment to the father. A s econdary ques tion had to with the factors that led to the diss olution and of the Oedipus complex in the girl s o that paternal attachment and maternal identification would be the for adult s exual adjus tment. T he girl's renunciation of her pre-oedipal attachment to the mother could not be satisfactorily explained as res ulting from ambivalent or aggress ive characteristics the mother–child relationship, for s imilar elements influenced the relations hip between boys and the 572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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figure. F reud attributed the crucial precipitating factor to anatomical differences between the s exes—specifically the girl's discovery of her lack of a penis during the period. Up to this point, exclusive of cons titutional differences and depending on variations in parental attitudes in relating to a daughter in comparis on to a the little girl's development parallels that of the little F undamental differences , however, emerge when s he discovers during the phallic period that her clitoris is inferior to the male counterpart, the penis . T he typical reaction of the little girl to this dis covery is an intens e sens e of los s, narcis sis tic injury, and envy of the male At this point, the little girl's attitude to the mother changes. T he mother had previous ly been the object of love, but now s he is held res ponsible for bringing the girl into the world with inferior genital equipment. T he hostility can be s o intens e that it may persist and color future relations hip to the mother. W ith the further discovery that the mother also lacks the vital penis, the child's hatred and devaluation of the mother becomes even more profound. In a desperate attempt to compens ate for her “inadequacy,” the little girl then to her father in the vain hope that he will give her a or a baby in place of the mis sing penis . Obvious ly, the F reudian model of feminine development has undergone, and is currently cons iderable revis ion. T he charge has been made, and justifiably so, that masculine phallic-oedipal was the primary model in F reud's thinking and that feminine development was viewed as defective by comparis on. F reud saw women as basically weak, dependent, and lacking in conviction, s trength of 573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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character, and moral fiber. He believed thes e defects the res ult of failure in the oedipal identification with the phallic father because of female castration. T he internalization of aggres sion was both cons titutionally determined and culturally reinforced. T hese concepts must now be regarded as obs olete. hypothes es of a pass ive female libido, arrest in ego development, incapacity for s ublimation, and s uperego deficiencies in women are outdated and inadequate. Differences in male and female ego and s uperego development may be defined, but there are no grounds for judging one to be s uperior or inferior to the other. are simply different. As Harold B lum obs erved: development cannot be des cribed in a s imple reductionism and overgeneralization. F emininity cannot be predominantly derived from a primary masculinity, disappointed maleness , masochistic resignation to fantas ied inferiority, or compens ation for fantas ied castration and narcis sistic injury. C astration reactions penis envy contribute to feminine character, but penis envy is not the major determinant of femininity.” T he adequate conceptualization and unders tanding of feminine ps ychology and its development are still very much in process . T here is much that is poorly and much more that is hardly unders tood at all. C urrent res earch has given partial s upport to and convincing refutation of F reud's ideas. C urrent views emphasize role of primary femininity and conflicts in identification with the mother as determining the course of development of feminine gender identity rather than the outmoded views of castration anxiety and penis envy. It clear in all this that F reud was s imply wrong about 574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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this whole area, but much of what he des cribed may simply expres sed what he was able to observe in the women of his time and reflected the influence of toward women in his society and culture. T imes however, and the culture and the place of women in it have changed and are changing. T o that extent, are different, and much of their ps ychology is different, too. P s ychoanalytic unders tanding must inevitably lag behind these changing patterns of ps ychological experience, but a new view of feminine development functioning is gradually emerging.

Mahler's S eparation–Individuation Proc es s A utis tic P has e Mahler has conceptualized the proces s of development terms of phas es of s eparation and individuation. T he phase of development s he describes is the autis tic P.730 “During the first few weeks of extrauterine life, a s tage absolute primary narcis sism, marked by the infant's awarenes s of a mothering agent, prevails. T his is the we have termed normal autism. It is followed by a dim awareness that need s atis faction cannot be by oneself, but comes from somewhere outside the T he tas k of the autis tic phas e is the achievement of homeostatic equilibrium of the organis m within the new extramural environment, by predominantly phys iological mechanisms.” T o the external obs erver, newborn infants s eem to 575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to their mothers in a condition of unique dependence res ponsiveness . T his relations hip is , however, at leas t first, purely biological bas ed on phys iological reflexes ordered to the fulfillment of basic biological needs. It is only as babies ' egos begin to develop, along with the organization of perceptual capacities and memory which allow for the initial differentiation of self and that infants can be s aid to experience s omething of themselves, to which they can relate, as satis fying inner needs. T his dawning awareness of the external object is a mos t s ignificant s tate in the psychological development of children and involves not only cognitive and perceptual developments but also goes hand in with the organization of rudimentary infantile drives and affects in relation to emerging object experiences . T he emergence of the psychological need-satis fying relations hip to the object or part-object occurs during oral phase of libidinal development. It should be noted, however, that the notion of the oral phas e of and the concepts of need-satis fying relationships are equivalent. T he oral phas e is primarily concerned with libidinal development and stress es predominance of oral zone as the main erotogenic zone. T he concept of need-satis fying relationship, however, is not concerned directly with iss ues of drive development but, rather, the characteristics of object involvement and object relations hip.

S ymbiotic P has e T his awareness signals the beginning of normal “in which the infant behaves and functions as though and his mother were an omnipotent s ys tem—a dual 576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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within one common boundary.” T he symbiotic phas e is described as a “hallucinatory or delusional omnipotent fusion with the representation of the mother and, in particular, the delusion of a common boundary between two phys ically s eparate individuals.” T hese boundaries become temporarily differentiated only in state of “affect hunger” but disappear again as a result need gratification. Only gradually does the child form more s table part-images of the mother such as breas ts, face, or hands . C ons equently, the object is recognized separate from the s elf only at moments of need so that, once the need is satis fied, the object ceases to exis t— the infant's (s ubjective) point of view—until a need arises . Moreover, from the infant's perspective, the relations hip is not to a specific object (or part-object) rather to a function of the object s atisfying the need the pleas ure accompanying that function. It is only the specific object—that is , the whole object—becomes important to the child as the need-satis fying function it performs that one can regard the child's development moving beyond the level of need-satis fying toward the attainment of object constancy. T hus, it is useful to distinguish between need as a s tage of development in object relations hips , to but not s ynonymous with the oral phas e of libidinal development, and need s atisfaction as a determinant in object relations hips at every level of development. T he satis faction of various kinds of psychological needs continues to play a role at all levels of object but the satis faction of s uch needs cannot be used as a distinguishing characteris tic of the specific stage of satis fying object relations hips. As objects become 577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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increasingly differentiated in the child's experience, representations achieve increasing ps ychological complexity and value in a context of increasingly and s ubtle needs for a variety of input from objects. Development of object constancy implies a constant relations hip to a specific object, but within that relations hip, the wish for s atis faction of needs and the actual s atis faction of thos e needs may still be a component of the object relationship.

S eparation and Individuation HATC HING During this period, the child with effort gradually differentiates out of the symbiotic matrix. T he first behavioral s igns of such differentiation s eem to aris e at approximately 4 or 5 months of age at the high point of the s ymbiotic period. T he firs t stage of this proces s of differentiation is described as “hatching” from the symbiotic orbit: In other words , the infant's attention, which during the months of symbios is was in large part inwardly focus ed in a coenesthetic vague way within the orbit, gradually expands through the coming into being outwardly directed perceptual activity during the child's increasing periods of wakefulnes s. T his is a change of degree rather than of kind, for during the s ymbiotic the child has certainly been highly attentive to the mothering figure. B ut gradually that attention is with a growing s tore of memories of mother's comings and goings, of “good” and “bad” experiences ; the latter were altogether unrelievable by the self, but could be 578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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“confidently expected” to be relieved by mother's minis trations.

PR AC TIC ING As the child's differentiation and separation from the mother gradually increase, there is a move to the or “practicing” subphase of s eparation–individuation. practicing period can be us efully divided into an early practicing period and a practicing period proper. T he practicing phas e begins with the infant's earlies t ability move physically away from the mother by locomotion, that is , crawling, creeping, climbing, and ass uming an upright sitting position. Moving away from the s afe protective orbit of the mother has its risks and uncertainties , however. In the early practicing phas e, is frequently a pattern of vis ually “checking back to mother” or even crawling or paddling back to her to or hold on as a form of “emotional refueling.” T he practicing period proper is characterized by the attainment of free upright locomotion. It is marked by three interrelated developments that contribute to the continuing process of s eparation and individuation. are (1) rapid bodily differentiation from the mother, (2) es tablis hment of a s pecific bond with her, and (3) and functioning of autonomous ego-apparatuses in connection and dependence on the mothering figure.

R APPR OC HE ME NT As this testing of the freedom of individuation by approximately the middle of the s econd year of life, child enters the third s ubphas e of rapprochement: He now becomes more and more aware, and makes 579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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greater and greater us e, of his physical separatenes s. However, s ide by side with the growth of his cognitive faculties and the increasing differentiation of his life, there is als o a noticeable waning of his previous imperviousness to frus tration, as well as a diminution of what has been a relative obliviousness to his mother's presence. Increas ed separation anxiety can be first this cons is ts mainly of fear of object loss , which is be inferred from many of the child's P.731 behaviors . T he relative lack of concern about the presence that was characteris tic of the practicing subphase is now replaced by s eemingly constant with the mother's whereabouts, as well as by active approach behavior. As the toddler's awareness of separateness grows —stimulated by his maturationally acquired ability to move away phys ically from his and by his cognitive growth—he seems to have an increased need, a wish for mother to share with him one of his new skills and experiences , as well as a need for the object's love. T he crisis in the rapprochement phase is particularly of s eparation anxiety. T he child's wishes and des ires to separate, autonomous , and omnipotent are tempered an increas ing awarenes s of the need for and on the mother. Ambivalence is characteris tic of the phase of the rapprochement subphase. T here is a between the child's need to use the mother as a extension, as having her magically fulfill wis hes , and realization that, with the child's increas ing the mother becomes less available and more distant. 580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the mother's availability and the reass urance of her continuing love and support become all the more important.

OB J E C T C ONS TANC Y As developments of the rapprochement phase are gradually realized, the child enters the fourth and final phase of s eparation and individuation, namely, the of consolidation of individuality and the beginnings of emotional object cons tancy. At this s tage, there are significant developments in the s tructuralization and integration of the ego as well as definite signs of internalization of parental demands reflecting the development of s uperego precursors . Attainment of object cons tancy marks a transition from the stage of need-satis fying relationships to a more ps ychological involvement with objects . Object implies a capacity to differentiate between objects and maintain a meaningful relations hip with one specific object regardless of whether needs are being satis fied. S uch object cons tancy als o implies s tability of object cathexis and, s pecifically, the capacity to maintain emotional attachments to a particular object in the face frus tration of needs and wis hes in regard to that object. T his achievement als o implies the capacity to tolerate ambivalent feelings toward the object and the capacity value that object for qualities that it pos ses ses over beyond the functions that it may s erve in satis fying and in gratifying drives . T o summarize, it can be said that the notion of object cons tancy implies involvement of a number of s pecific elements that are central to further emergence of the 581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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meaningful capacity for relationships with objects. elements include perceptual object cons tancy; the capacity to maintain drive attachment to a s pecific regardless of whether it is pres ent; the capacity to both loving and hostile feelings toward the s ame object to maintain a loving relationship with the object in the face of hostile and destructive impuls es ; the capacity to maintain significant emotional attachment to a s ingle specific object; and, finally, the capacity to value the for qualities and attributes that it pos ses ses in itself, in virtue of its own uniqueness as individually and exis ting, and as independent of any need-satis fying function it may serve.

E riks on's E pigenetic S equenc e: Ins tinc tual Zones and Modes of E go Development E rikson made a major contribution to the concept of development in his study of the relations hip between ins tinctual zones and the development of modalities of ego functioning. E rikson's theory links as pects of ego development with the epigenetic timetable of instinctual ps ychos exual development by postulating a parallel relations hip between specific of ego or ps ychos ocial development and specific libidinal development. During libidinal development, particular erotogenic zones become loci of stimulation development of particular modalities of ego functioning. T he relationship between zones of ins tinctual and their corres ponding modalities of ego functioning is easily s pecifiable in pregenital levels of development, E rikson projects this basic modality of relationship, 582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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extending it to the limits of the life cycle. T he firs t modality of development is related to the oral phase, s pecifically to s timulus qualities of the oral T his early s tage is called the oral-re s piratory-s e ns ory and it is dominated by the firs t oral-incorporative mode, which involves the modality of “taking in.” Other modes are als o operative, including a second oralincorporative (biting) mode, an oral-retentive mode, an oral-eliminative mode, and, finally, an oral-intrus ive T hese modes become variably important according to individual temperament but remain subordinated to the first incorporative mode unless the mutual regulation of the oral zone with the providing breast of the mother is disturbed, either by a los s of inner control in the infant defect in reciprocal and res pons ive nurturing behavior the part of the mother. T he emphas is in this stage of development is placed on the modalities of “getting” “getting what is given,” thus laying the necess ary ego groundwork for eventually “getting to be a giver.” T he second s tage, also focus ed on the oral zone, is marked biting modality becaus e of the development of teeth. phase is marked by development of interpersonal patterns, centered in the s ocial modality of “taking” and “holding” onto things. S imilarly, with the advent of the anal-urethral-muscular stage, the “retentive” and “eliminative” modes become es tablis hed. E xtens ion and generalization of these over the whole of the developing mus cular s ys tem the 18- to 24-month-old child to gain some form of selfcontrol in the matter of conflicting impulses s uch as “letting go” and “holding on.” When this control is disturbed by developmental defects in the anal-urethral 583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sphere, a fixation on modalities of retention or can be es tablis hed that can lead to a variety of disturbances in the zone itself (s pas tic), in the muscle system (flabbiness or rigidity), in obses sional fantas y (paranoid fears ), and in s ocial spheres (attempts at controlling the environment by compulsive E rikson laid out a program of ego development that reached from birth to death: T he individual pass es the phases of the life cycle by meeting and resolving a series of developmental ps ychos ocial crises . T hese phases of the life cycle and their respective accomplis h s everal things. F irs t, they make it clear that development is open ended and never finished. T he capacity to success fully resolve any one crisis depends on the degree of resolution of the preceding cris es. One can form a mature and integral sens e of identity only to the extent that one has meaningful s ens e of trus t, autonomy, initiative, and indus try. S ucces sful resolution at any level lays the foundation for engaging in the next developmental S econd, they clarify the relation between the various phases of development and earlier phas es of libidinal development. T he latter had been the bas ic of earlier efforts of ps ychoanalysis, but E rikson's developmental s chema gave a better unders tanding of way in which earlier libidinal developmental residues carried along in the cours e of growth and were built later developmental efforts of the ego. P s ychoanalysis not previously had the conceptual tools to deal with this problem, particularly in regard to the pos tadoles cent phases of the life cycle. F inally, E rikson's treatment of crises as s pecifically ps ychos ocial brought into focus 584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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fact that the development of the ego was not merely a matter of intrapsychic vicis situdes dealing with the economics of inner psychic energies. It was that, but it was also a matter of the interaction and “mutual regulation” between the developing human organis m significant people in its environment. E ven more it is a matter of mutual regulation evolving between the growing child and the culture and traditions P.732 of society. E riks on has made the s ociocultural integral part of the developmental matrix out of which personality emerges .

Trus t vers us Mis trus t T he crisis of trus t vers us mis trus t is the first crisis the infant must face. It takes place in the context the intimate relations hip between infant and mother. infant's primary orientation to reality is erotic and on the mouth. T he primary locus for s ignificant contact with reality, therefore, is oral. T he typical situation in the infant experiences oral eroticism is the feeding relations hip. Depending on the quality of experience feeding contacts , the child learns to accept what is by the warm and loving mother, to depend on that mother, and to expect that what she provides will be satis fying. T he importance of the child–mother here s hould not be underes timated. T he child's oral orientation is largely biologically determined; the mother's feeding orientation is not only a product of biological factors but als o of a complex proces s of development in which her sense of identity as a female 585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and as a mother plays a vital part. Any defect in her identity, thus , has important cons equences for the of the interaction between herself and her child. S uccess ful resolution of this initial phase of interaction entails a dis pos ition to trus t others , basic trust in capacity to receive from others and to depend on them entrus t oneself), and a sense of s elf-confidence. Uns ucces sful res olution of this cris is results in the these same qualities and relative dominance of such oppos ite qualities as mis trust and lack of confidence. C ons equently, the des ignations “basic trust” and “basic mistrust” stand for a complex of personality factors characterizing s ucces sful or uns ucces sful resolution of first cris is .

A utonomy vers us S hame and S elfT he second s tage of psychosexual development is eroticism. B iologically, this stage is marked by a fuller s tool and maturation of the neuromuscular to a point sufficient to allow control of s phincter governing retention and releas e of waste materials . Likewise, the anal zone becomes a source of erotic stimulation through pleasurable sensations of retaining releas ing. P sychos ocially, this period is marked by emergence in the child of self-awarenes s as a separate independent unit. G rowing mus cular control is accompanied by increasing capacity for autonomous expres sion and s elf-regulation, which typically centers problems of s phincter control of the s o-called anal T he ego thus enters into interactions of ass ertivenes s other wills in the s ocial environment, particularly with parents . S uccess fully resolved, the cris is of autonomy 586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the foundation for a mature capacity for self-as sertion self-expres sion, a capacity to res pect the autonomy of others , an ability to maintain s elf-control without los s of self-es teem, and a capacity for rewarding and effective cooperation with others . T he corres ponding defect lays the foundation of fals e autonomy that must feed on the autonomy of others by domination and excess ive demands or of an exces sive rigidity that can be in the fragile autonomy of the compuls ive (anal) personality. Inability to achieve bas ic autonomy implies the lack of s elf-es teem reflected in a sense of shame the lack of s elf-confidence implied in s elf-doubt.

Initiative vers us G uilt When the child enters the play age, the maturing reaches a developmental s tage in which the serving functions of locomotion and language are sufficiently organized to permit facile use. T he motor equipment has reached a sufficient level of to permit not merely performance of motions but a ranging experimentation in locomotion. T he child to “tes t the limits ” of this new-found capability. T he activity becomes vigorous and intrusive. A s imilar crys tallization of function occurs in the us e of language, which becomes an exciting new toy calling for experimentation and the s atis faction of curios ity. T he child's mode of activity is marked by intrus ion: intrus ion into other bodies by physical attack, into other's by activity and aggres sive talking, into s pace by locomotion, and into the unknown by active curiosity. this activity is accompanied by a growing sexual and a development of the prerequisites of s pecifically masculine or feminine initiative, which are conditioned 587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of a phallic eroticism. If the cris is of initiative is success fully resolved, positive res idues are provided for development of conscience, sens e of respons ibility and dependability, s elfand a certain independence in the mature personality. stage is therefore crucial for the formation of the based on the introjection of authoritative, and parental, prohibitions . T he uns ucces sful resolution provides the bas is for the harsh, rigid, moralistic, and punis hing s uperego that serves as the dynamic source basic s ens e of guilt.

Indus try vers us Inferiority T he period of infantile (phallic) s exuality and the period adult s exuality (puberty) are s eparated by the so-called latency period in which the child's interest is generally diverted to other matters. T he child takes a step up the level of imaginative exploration and play to a level which participation in the adult world is foreshadowed. Wes tern culture, children are sent to school, where begin to learn skills that will equip them to take their places one day in adult society. T heir interests turn to doing and making things; in general, they become involved in developing the neces sary technology for living. T hey are drawn away from home and its close as sociations and plunged into the matrix of the s chool system. T hey learn the reward s ys tems of the school society and as similate the values of application and diligence. T hey als o ass imilate the implicit cultural of work and productivity. T hey achieve a sense of the pleas ure of work, of the satisfaction of a task accomplis hed, and of the merit of pers everance in 588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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enterprises . In other words, normally developing add to their evolving personality a s ens e of industry. danger at this stage is that a lack of s ucces s in meeting demands of the s chool society and inability to res olve ps ychos ocial crisis produce a sense of inadequacy and inferiority.

Identity vers us Identity C onfus ion T he pass age to adolescent years is marked by an period of phys iological growth and sudden maturation genital organs . T he ps ychos exual phas e of puberty is accompanied on the psychos ocial level by a kind of organization or crys tallization of the residues of the preceding formative phas es. T he developmental preparations for participation in adult life mus t now to take a more or less definitive s hape, s o the must begin to experiment with es tablis hing a future role and function within adult s ociety. T he adolescent mus t develop a confident sense of s elf-awarenes s the ability to maintain inner samenes s and continuity on the confidence that this awareness is matched by samenes s and continuity of his or her meaning to T his particular ps ychosocial crisis is therefore vulnerable and s ens itive to s ocial and cultural T he context of the cris is is specifically interpersonal, such, its s ucces sful res olution becomes all the more tenuous and problematic. In a s pecial sense, achieving sens e of pers onal identity requires an awareness of the context of relations to reality within which the self forms and maintains its own proper identity. P.733 589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Intimac y vers us Is olation T he status of adulthood is marked on the ps ychos exual level by achievement of genital maturity. On the ps ychos ocial level, this development is paralleled by es tablis hment of s ignificant interpers onal relations hips that complement the previously formed identity in the social s phere. T ypically, the emerging sexual drive on another individual of the opposite s ex as its object. elements of s exual identification, which are ess ential as pects of personal identity, are naturally expres sed as es tablis hed by the standards of inters ex behavior of the society and culture. T he intimate ass ociation of male female in a clos e interpers onal union is thus an of their own identities as well as a culturally approved institution (marriage). T his fact does not mean that the sexual act is the only path to a s ens e of intimacy. F rom point of view of pers onality development, the crucial element is the capacity to relate intimately and meaningfully with others in mutually s atis fying and productive interactions . T he pattern of s uch selfrelations depends in large meas ure on the identity one accepted as his or her own. T he inability to achieve a success ful res olution of this ps ychos ocial crisis res ults in a sense of personal T he incapacity to es tablis h warm and rewarding relations hips with others is but a reflection of the to realize a s ecure and mature s elf-acceptance. Interpersonal relations hips become strained, s tiff, or formal. E ven if a façade of pers onal warmth can be there is a rigidly maintained inner wall that is never breached, a wall defended by intellectualization, 590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distancing, and s elf-absorption.

G enerativity vers us S tagnation “G enerativity” points to a primary concern with es tablis hing and guiding the s ucceeding generation (through genes and genitality). In E riks on's terms , “G enerativity, as the instinctual power behind various forms of s elfles s ‘caring,’ potentially extends to man generates and leaves behind, creates and (or helps to produce).” It mus t also be recognized, however, that other areas of altruistic effort cannot be excluded. P erhaps “productivity” or “creativity” are terms. S uch creativity can as sume a myriad of forms , on the native endowment of the person; but realized generativity is als o determined to a large extent by the identity the individual has accepted and by the extent which one is capable of interacting maturely and cooperatively with others . C onsequently, success ful res olution of this crisis depends closely on the degree succes s achieved in the res olution of the preceding of identity and intimacy. Moreover, true generativity has its goal enrichment of the lives of others ; it involves a direct concern with the welfare of others, exclusive of concern over self-interes t.

Integrity vers us Des pair Integrity marks the culmination of development of the personality in E rikson's s chema. It means acceptance oneself and all aspects of life and integration of thes e elements into a stable pattern of living. It implies the experience of and adjus tment to the trials and troubles 591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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life as well as to its rewards and joys. C ons equently, exis tence holds no fear; the ego has res igned its elf to acceptance of life itself and to acceptance of the end of that life in death. Integrity thus repres ents the fully developed personality in its mos t mature selfT he inability to achieve ego integration res ults often in kind of despair and an unconscious fear of death: T he life cycle, given to every human as his or her own, has been accepted. T he person who does not achieve is doomed to live in basic s elf-contempt. T he parallel lines of development and their interrelation are indicated in T able 6.1-4.

Table 6.1-4 Parallel L ines of Dev Ins tinc tual Phas es

S eparation– Individuation

Objec t R elations

Ps yc hos

Oral

Autism, symbios is

P rimary narcis sism, needsatis fying

T rus t/mi

Anal

Differentiation, practicing, rapprochement

Needsatis fying, object cons tancy

Autonom doubt

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P hallic

Object cons tancy, Oedipal complex

Object cons tancy, ambivalence

Initiative

Latency





Indus try/

Adoles cence G enitality, secondary individuation

Object love

Identity/i confusio

Adulthood



Intimacy generati integrity/

Mature genitality

C urrent C ons iderations In recent years , a fres h current has entered the of analytical developmental theory. In s ome degree reacting to the work of F reud and Mahler, on the bas is observational s tudies of very young infants , the view of infant emerged as active, s urprisingly well organized at the very beginning of life, and as attuned to and interactive with the mothering figure in complicated and quite sophis ticated ways. P articular objections to approach to s eparation–individuation focus ed on her of pathological terms (autism, s ymbiosis) to des cribe developmental phas es of normal infants and the fact her extens ive observations were often too overlaid with 593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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metapsychological terms that obs cured the boundary between fact and theory. T he work of Daniel S tern particularly pres ented a different view of the infant and focus ed attention on other important aspects of development that had been treated only tangentially in previous studies. S tern's observations brought into clearer focus the affective and interactional matrix between mother and child and directed attention more specifically to the emergence of a s ens e of self than had previous ly been available. T o begin with, S tern's baby was calm, alert, cognitively well organized, and highly res ponsive to interactive with the mother. T he extent to which the was preadapted to s timuli from the mother and active eliciting certain res ponses from the mother, whether caretaking or affective, cast a different light on early of development. T he relation between mother and child proved to be more active and interactive than had previous ly been appreciated. Also following in the wake Heinz K ohut's s elf–selfobject views and the developments that arose from them, much of the of mother–child interaction was cast in terms of the relational and intersubjective models of relating. S tern centered his interest on study of a subjective sense of separately from s tudy of the ego, which had held stage in Mahler's view. Whether such a separate s elf is neces sary or whether the s eparation–individuation proces s and object relations theory already covered ground remain debatable ques tions. C ertainly, Mahler's concentration on the sense of identity and selfcannot be P.734 594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discounted, but S tern emphas ized inters ubjective relatednes s, sugges ting “a deliberately s ought s haring experiences about events and things.” All these interactions, including the highly intimate bodily interchanges between mother and child, are steeped in affective res onances. S tern carefully traced the of a core s ens e of s elf out of increasingly complex and s elf–other experiences , es pecially with the mother, taking place within an intens ely affective ambiance leading to development of an affective core in self-experience. T his proces s leads ultimately to es tablis hing a degree of libidinal self-cons tancy sens e of self as relatively integrated and independent, relatively durable and s table, as differentiated from but involved in complex relationships , and as an active agent capable of causing effects and influencing the surrounding environment. Whether and to what extent this approach to development of the s elf and its affective resonances is contradictory to the Mahlerian s chema or is open to eventual integration remains a s ubject of debate. the at times oppos itional s tance that advocates of one the other view ass ume, the potential exists for these pers pectives in the hope of deepening the unders tanding of the complexities of human development. C ritics have pointed out that these approaches may be looking at children in different contexts of obs ervation—the S tern baby in periods of relatively calm and unconflicted interaction with the mother, Mahler's baby in contexts of greater conflict separation. It may be that the obs ervations of both 595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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are valid enough and need to be brought together to accomplis h a more complete view of the developing infant. C ertainly S tern's focus on the emergence of the adds a fres h direction of inquiry more congruent with evolving theoretical concepts of the self in

OB J E C T R E L A TIONS THE OR Y One of the important developments in psychoanalysis , which emerged more or less in parallel to the evolution ps ychoanalytic ego psychology, is object relations Only gradually over the years have these parallel and somewhat independent courses of theoretical development converged into complementary rather oppos itional pers pectives . T he development of class ic ps ychoanalytic theory through elaboration of a ego ps ychology has led inexorably in the direction of better understanding of the adaptive functions of the particularly the close involvement between the ego and reality in its functioning and development. One dimension of the problem of reality in ps ychoanalytic theory is the whole question of object relations . T he integration of thes e complementary currents of thinking provides a more comprehens ive basis for about the mind as it functions not only intrapsychically interpersonally in its relation to others as important sources of the s ocial environment of the human

Origins T he origins of the object relations view can bes t be from the contribution of K lein. K lein's theorizing based its elf on F reud's later instinct theory, primarily on the death ins tinct as the main theoretical prop of her 596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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metapsychology. W orking primarily with very young children, she des cribed instinctual dynamics in the firs t years of life. Driven by the death ins tinct, the child was compelled to rid him- or hers elf of intolerable, impulses (predominantly oral) and to project them externally. T he earliest recipient of thes e projected impulses was the mother's breast, which provided satis fying nourishment and satiation (good breas t) but often deprived and did not s atis fy (bad breast). At this stage, the images of the breast are part-objects that infant had yet to combine into a single whole object, mother. E arly frustration of oral needs, even in the firs t of life, reinforced these trends s o that the bad breas t became a pers ecutory object that was hated, feared, envied. E xperience of the bad breas t and its ass ociated persecutory anxiety formed the earlies t developmental stage in K lein's theory: the paranoid-schizoid position. bad breast withheld gratification and thus stimulated child's primitive oral envy, provoking s adistic wis hes to penetrate and destroy the mother's breasts and body. boys , these primitive des tructive impulses gave rise to fear of retaliation (bas ed in part on projection) in the of castration anxiety; in girls, the primitive envy was expres sed in envy of the mother's breast during the developmental phas e and later was transformed into envy during the genital phas e. K lein held that by the of weaning, the child was capable of recognizing the mother as a whole object poss es sing good and bad qualities . B ut the combination of good and bad qualities a s ingle object—previous ly separated in part-objects— created a dilemma: Des tructive attacks on the bad 597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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also des troyed the good and needed object. T his prevented the child from unleas hing aggres sive agains t the object and lay the basis for the depres sive position, in which aggres sion was turned against the rather than against the object. T he guilt ass ociated with destructive wishes against the object was the precursor cons cience. K lein's emphas is in the child's developmental fell on the proces ses of introjection and projection, from basic instinctual drives, and their interactions with the important and primary objects of the child's early experience. P rojection of des tructive s uperego permitted acceptance of good introjects (internalization good objects ), thus alleviating the underlying paranoid anxiety. T he projected s uperego elements were later reintrojected to become the agency of guilt and early forms of obsess ional behavior. T he K leinian emphasis good and bad introjects concentrated on vital relations hips to objects at the earlies t level of child development, and the delineation of the internal structuring of the child's inner fantasy world in terms of the viciss itudes of these introjects , or internal objects , provided the basis and the rudimentary content for an object relations view of development. T hus K lein's “inner world” was peopled by internal that were either good or bad and with whom the individual was involved in intrapsychic interactions and struggles that were in many ways as real as thos e on with the real objects outside the person. In fact, saw external object relations as derived from and influenced by projective content derived from the object relations . K lein has been generously criticized 598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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her almost blind interpretation of all forms of destructive intent as manifes tations of the death for her inability to distinguish among the various kinds intraps ychic content (lumping object representations , representations, internal objects , fantas ies, and structures of various kinds together indiscriminately treating them in a unitary fas hion), for her tendency to subs titute theoretical inferences for observations , and, finally, for her marked tendency to predate the of intraps ychic organizations that are generally thought other theorists to be achieved only in later stages, for example, locating the origin of the superego the firs t year of life rather than in resolution of the situation in latency. In any case, K lein's observations and formulations had tremendous impact, particularly in bringing into prominence the role of aggres sion in pathological development, in making theoris ts of development much more aware of the early developmental precurs ors of structural entities, and particularly in providing the rudiments and foundations for an emergent theory of object relations . Wilfred B ion extended and applied K lein's ideas, developing the ramifications of the notion of projective identification—a process , originally described by K lein, which a subject dis places a part of the s elf into an and then identifies with that object or elicits a res ponse the object corres ponding to qualities of the projection. B ion applied this notion to a wide range of psychotic cognitive operations . He developed the metaphor of “container” P.735 599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and the “contained” to expres s the manner in which projective identification occurs , es pecially in the of mother–child and analyst–patient interaction. T he child/patient projects toxic or des tructive contents onto the mother/analys t, who, in turn, absorbs, modifies , or “contains ” it so that it becomes available in more form for s ubs equent reinternalization by the res ulting in a healthier modification of the child/patient's pathogenic introjects. B ion als o contributed s ignificantly to the understanding of group process es by demonstrating the “basic as sumptions ” that operate on unconscious emotional level in therapeutic groups and expres sed in patterns of fight-flight, pairing, and dependence.

E G O A ND OB J E C TS B eginning around 1931, R onald F airbairn s hifted the emphasis in his thinking specifically to the problem of analysis. F airbairn's contribution was to bring personal object relations into the center of the theory. Whereas ego in F reudian theory had been regarded as a modification of the id, developed s pecifically for the purpos e of impulse control and adaptation to the demands of reality, F airbairn conceived of the ego as core phenomenon of the psyche. R ather than an organization of functions , he conceived of it more specifically as embodying a real s elf—that is , as the dynamic center or core of the personality. Ins tead of basing his theory on the ins tinctual drives as the basic concept, F airbairn shifted the emphasis to the ego and everything in human ps ychology as specifically an 600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ego functioning. With this reorientation, there came a parallel of the instinctual pers pective. T he libido or instincts in general, rather than mechanisms for energic discharge, were regarded as ess entially object seeking. zones were not the primary determinants of libidinal but, rather, channels that mediated the primary relations hips with objects, particularly with relationships with objects that had been internalized during early life under the press ure of deprivation and frustration. E go development itself was characterized by a process whereby an original state of infantile dependence, on a s ymbiotic union with the maternal object, was abandoned in favor of a s tate of adult or mature dependence based on differentiation between self and object. T hus, F airbairn conceptualized the proces s in terms of the vicis situdes of relations with objects rather than the viciss itudes of ins tinctual T he basis for much of F airbairn's theorizing is his experience with s chizoid patients . He contrasted the dilemma of the s chizoid with that of neurotic patients whom he felt clas sic ps ychoanalytic theory was bas ed. saw that the schizoid was not primarily concerned with control of threatening impulses toward s ignificant but that the is sue for this kind of patient was es sentially that of having an ego capable of forming object at all. T he relations hip to objects presented a difficulty, because of dangerous impulses arising in connection them, but becaus e the ego was weak, undeveloped, infantile, and fragile. In the s truggle to overcome this weaknes s, the schizoid's impulses became antisocial. T hus, object relations theory in its bare es sentials 601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a number of bas ic points that differentiate it from theory. F irs t, the ego is conceived of as whole or total birth, becoming s plit or los ing inner unity as a result of early bad experiences in object relations hips, in relation to the mothering object. T his point differs radically from the clas sic theory, according to which the ego begins as undifferentiated and unintegrated and achieves unity through the course of development. S econd, libido is regarded as a primary life drive of the ps yche, the energic source of the ego's s earch for relatednes s with good objects , which is ess ential for growth. T hird, aggress ion is regarded as a natural defens ive reaction to frustration of the libidinal drive rather than s pecifically as an independent instinct. the structural ego pattern that emerges when the ego unity is lost involves a pattern of ego s plitting and formation of internal ego–object relations . T he shift in emphas is toward the primacy of the environment and the influence of objects on the cours e development has es tablis hed a definite trend in ps ychoanalytic thinking and has been advanced in the work of B ritish theoris ts, among whom the work Michael B alint and Donald W innicott stands out. particularly has emphas ized the importance of early interactions between mother and child as determining factors in the laying down of important components of ego development. C urrently, there is ample room for overlap and integration in the approaches and formulations of both object relations theorists and more clas sic ps ychoanalytic ego theorists . S uch integration advanced to the point that they are generally regarded forming at least complementary as pects of a common 602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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theory, if not a more comprehens ive and unified theory such. B oth B alint and W innicott were concerned with levels early developmental failure that were es sentially preoedipal, were manifested in forms of pers onality that are more primitive and more difficult to treat than us ual neurotic disorders , and s eemed to involve critical as pects of the relationships with objects early in the of development and corres pondingly do not fit well with clas sic ps ychoanalytic s tructural theory with its basic on is sues of intraps ychic conflict. B alint envisioned s everal layers of psychological functioning in analysis. T he first is the familiar genital centering on triadic relations hips and concerned specifically with intrapsychic conflicts . T hese conflicts quality of relationships were usual and familiar material most analytical proces ses and could be treated by use adult language in verbal interpretations . T here was, however, a s econd, deeper level in which the meaning of words no longer had the same impact, and interpretations were no longer perceived as meaningful the patient. T his was the level of preverbal experience. referred to this level of impairment in object relations as the bas ic fault. B alint recognized that at this level of preverbal experience any attempt to address or the child's experience in adult language is bound to fail. P roblems arose in analysis when efforts were made to interpret events from this preverbal level in adult or secondary process terms. B alint dis tinguis hed between forms of regress ion that described as benign and malignant. T he benign was more or les s an extension of the basic notion of 603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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us ual analytic regress ion to a level of primitive with primary objects. S uch a regres sion was gradual, tempered, and modulated according to the patient's capacity to tolerate and productively integrate the res ulting anxiety. During this regress ion, the analyst's empathic res ponsivenes s and recognition made it for the patient to withstand this uns tructured and to keep the anxiety within manageable limits . At level of the bas ic fault, the lost infantile objects can be mourned, and the quality of the relationship with them was open to reworking so that the patient's basic as sumptions governing his or her interaction with the internal and external object world could be reformed. During phas es of benign regres sion to this preverbal pregenital level of object relationship in the analysis, analyst could usually provide an adequate degree of empathic acceptance and recognition, rather than verbalized interpretations, of this level of the patient's unstructured and regres sive experience, without any need to es cape or subvert this level of experience through interpretation. B alint felt that the dynamics at level are more primitive than can be adequately in terms of conflict because they derive from the bas ic form of dual relations hip involved in early mother–child interaction—that is , the basic fault. In contras t, malignant regres sion tends to be and extreme; the ego is prematurely overwhelmed by traumatic and unmanageable anxiety. P.736 T his anxiety prevented any effective reworking of fundamental disturbances in object relations hips, re604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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creating and reinforcing the basic fault, rather than creating the conditions for its therapeutic revis ion. At even deeper level, beyond the reach of analytic lay the area of creativity; that is, an idiosyncratic, uncommunicable, and objectless area that lies beyond conventional express ion. R egress ion to the level of the bas ic fault was a quite different and distinct phenomenon than the more usual oedipal regres sions experienced in the analysis of neurotics . In the oedipal regress ion, the aim was gratification of infantile instinctual wishes. R egres sion the level of the basic fault, however, sought a basic recognition by the therapist, as well as protective and cons ent to express the inner core of creativity that at the heart of the patient's being and accounts for the capacity to become ill or well. B alint used the notion of primary love at this deepes t level to describe libido from a frus trating object in the effort to certain inner harmony in which it becomes pos sible to recover the conditions of early care and tranquility. He referred to a “harmonious interpenetrating mix-up” to describe this early, almos t undifferentiated interaction the infant and environment. T he analogy he used was of breathing air; the organism cannot exis t without air, air and the organis m are seemingly ins eparable, but cutting off the supply of air reveals both the organism's need for it and the dis tinction between air and the organism. In terms of primary love as it came to bear in analysis, then, the patient would s eek a basic form of recognition from the analys t, as he had from significant objects in the patient's early life experience. Winnicott als o was concerned with the earlies t phase 605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the mother–child relationship and the importance of he des cribed as “good-enough mothering” for the personality development. T he cours e of development involved movement from an early stage of total or absolute dependence toward a more adult phase of relative independence. As he saw it, the inherited potential for growth was s trongly influenced by the of maternal care. T his potential for development is affected even from the moment of conception. E ven before birth, the child becomes inves ted by a strong narcis sistic cathexis that allows the mother to identify the child and to become empathically attuned to the child's inner needs, as if the child were—and indeed extension of her own s elf. W innicott called this early prenatal involvement of mother and child in the womb a primary mate rnal preoccupation. T his set the stage for development of a holding relations hip in which the mother becomes sensitively attuned to the infant's and s ens itivities and is both phys ically and emotionally res ponsive to them, thus providing a phys ical, phys iological, and emotional ambiance, protection, and security for the absolutely dependent infant. As the infant moves from this early stage of absolute dependence toward a more relative dependence, awarenes s of personal needs and of the exis tence of mother as a caretaking object grows. T he optimal relations hip at this s tage involves a continuation of protective holding, along with an optimal titration of gratification and frus tration. As a result of this optimally attuned relationship between the patterning of infantile drives and initiatives and their harmonious fitting in with maternal s ens itivities and res ponsivenes s, there is a 606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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developing s ens e of reliable expectation that the needs will be satisfied without the threat of excess ive withdrawal of the mothering object and without the threatening, overwhelming, and s hort-circuiting of the infant's initiatives as a res ult of excess ive maternal impingements. In the course of normal development, this allowed for emergence of a certain omnipotence from which the gradually retreats with the experiences of tolerable degrees of frus tration by and s eparatenes s of the object. Although the mother continues her holding at phase, she must yet allow enough s eparation between herself and the developing infant to permit expres sion the baby's needs and initiatives that form the rudiments an emerging s ens e of self. If she is too distant, too unrespons ive, or not s ufficiently present, anxiety arises is accompanied by the fading of the infant's internal representations of her. T he transition from a phas e of abs olute dependence to one of relative dependence represents a crucial development in the capacity for object relations . It is accompanied by a critical transition from total to the capacity for objectivity in the perception of and relation to objects. T he transition from s ubjectivity to objectivity is accomplished by development of transitional phenomenon, expres sed in the firs t the emergence of trans itional objects . T hese objects the child's first object poss es sions that are perceived separate from the emerging self—the firs t “not me” poss ess ions. F rom the study of infant behavior, argued that the transitional object was a substitute for maternal breas t, the first and mos t s ignificant object in 607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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environment to which the infant related. T he object exis ts in an intermediate realm contributed to by the external reality of the object (the mother's and by the child's own s ubjectivity. T his intermediate realm is at once both subjective and objective without being exclusively either. Winnicott referred to this realm as the re alm of illus ion, intermediate area of experience that embraced both and external reality and may be retained in areas of functioning having to do with such imaginative as creativity, religious experience, and art. In its form, however, the transitional object commonly experienced in childhood development may take the of a particular object, a blanket, a pillow, or a favorite or teddy bear to which the child becomes intens ely attached and from which it cannot be s eparated without stirring up severe anxiety and dis tres s. Attachment to object is an immediate displacement from the figure of mother and represented an important developmental step, insofar as it allows the child to tolerate increasing degrees of separation from the mother, us ing the transitional object as a substitute. T he mother participates in this intermediate transitional realm of illus ion by her res pons iveness to the infant's to continually create her as a good mother. In her sens itivity and res ponsiveness , s he functions as a enough mother. However, her inability to provide such adequate mothering, either by exces sive withdrawal or excess ive intrusion and control, may result in of a false self in the child bas ed on compliance with the demands of the external environment, a condition that reflects a developmental failure and results in a variety 608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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often s evere character pathologies. When s uch patients are s een as adults , they are neurotic nor ps ychotic but s eem to relate to the world through a compliant s hell that is not quite real to them to the analys t. T hey are often mistrustful without being specifically paranoid, they appear withdrawn and disengaged and s eem able to relate only by means of protective s hell, which s eems apparently obsess ive compliant but which s eparates and isolates them from meaningful contacts with their fellows , even as it their only bas is for relations hip. T hese dis turbed personality types reflect a bas ic impairment in very object relations , particularly in the mutuality and res ponsiveness of very early mother–child interaction. Infants who developed in the direction of a false self have not experienced the security and mutual of such a relationship. S uch mothers are empathically of contact with the child and react largely on the basis their own inner fantas ies, narciss is tic needs, or conflicts. T he child's s urvival depends on the capacity adapt to this pattern of the mother's respons e, which is gross ly out of phase with the child's needs . T his es tablis hed a pattern of gradual training in compliance with whatever the mother was capable of offering, than s eeking out and finding what is needed and C ons equently, the child's needs, ins tinctual impulses, wis hes , and initiatives , instead of becoming a guide to s atis fying growth experiences and enlarging capacities to interact meaningfully with objects, from the very beginning a threat to the harmony of the relations hip with the mother, who remains to effective feedback from the child. 609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Winnicott's attempts to formulate principles of for such basically impaired patients built on the model good-enough mothering. T his called for a capacity for holding, for empathic res ponsiveness , and for a P.737 capacity for creatively playful exchange that allowed patient's capacities for growth to emerge and flouris h, permitting expansion of the patient's authentic sense of self, which remains hidden behind the external facade false-self compliance.

A TTA C HME NT THE OR Y Another more recent development in the study of relations hips with objects has taken the form of attachment theory. Attachment theory takes its origin in the work of J ohn B owlby. In his s tudies of infant attachment and s eparation, B owlby pointed out that attachment cons tituted a central motivational force and that mother–child attachment was an ess ential medium human interaction that had important consequences for later development and personality functioning. Attachment theoris ts have s tudied patterns of early attachment and related them to patterns of adult interaction with s ignificant objects. Us ing the Adult Attachment Interview (AAI), developed by Mary Main others , they document the nature of internal working models of early attachment relations. B oth attachment theoris ts and object relations theorists emphasize the significance of the mother's empathic respons ivity to infant needs for s elf-development and relatedness , the importance of the mother–child involvement for 610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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personality development, and the role of the mother as catalys t for age-appropriate development. S tudy of infant respons es in the S tranger S ituation, an arrangement for obs erving the quality of parent–child interaction and the effects of s eparation, led to of four categories of infant behavior: secure, avoidant, res is tant, and disorganized-disoriented. T hes e patterns could be related to attachment attitudes in adults on basis of the AAI. S ecure infants were related to s ecure relatively autonomous patterns of attachment and interaction in adults , avoidant infants were ass ociated an adult pattern of dis mis sing relationships as or s ignificant, resis tant infants connected with a preoccupied adult s tance in which s ubjects were preoccupied with past attachments often with angry or fearful emotions, and the disorganized-disoriented related to an unres olved and dis organized pattern in adults s uggesting more severe dis turbance in self– relations . T hese findings provide an extension and specification of an object relations approach as well as providing specific empirical and observational methods more detailed study of the development of object relations from childhood to adulthood.

P S YC HOL OG Y OF THE S E L F Over the las t two s core and more of years , the concept the self has been emerging with increasing emphasis definition as a central notion in the deepening ps ychoanalytic unders tanding of the organization and functioning of the human psyche. Although the regarding the unders tanding of the s elf are s till very in flux, and the place of the notion of the s elf in 611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalytic theory remains tentative and uncertain, is sues address ed by the ps ychology of the self seem to of sufficient significance and to have gained a more or permanent place in psychoanalytic thinking s o that a cons ideration of thes e iss ues is warranted in this presentation. T he is sues to which a self-ps ychology addres ses itself by no means new to psychoanalys is . P art of the stems from the ambiguity in F reud's use of the term standing ambiguous ly both for the ego as part of the mental apparatus, a s tructural agency, and for the experiential subjective and personal sense of s elf. T he decis ion of the editors of the E nglish S tandard E dition translate Ich to the term “ego” tended to s hift the of the term toward the more impersonal structural of agency and away from the more s ubjective implications. T here are pas sages where it is quite clear F reud uses the G erman term s e lbs t as s ynonymous the term Ich, referring to the s ubjectively experienced self—the person as such. T his unres olved ambiguity and the progres sive s hift in implications of the term ego have left a certain vacuum ps ychoanalytic metapsychology. T his deficit has been attacked by a number of thinkers as reflecting a lack of personal ego or a s ens e of s elf-as -agent in theory. P artly in an attempt to deal with this is sue, the notion of the self has been focused by various analytic thinkers in a variety of contexts . K ohut's development self psychology has been a major s timulus to renewed interes t in the self. T he self psychology movement came into prominence largely as the res ult of K ohut's efforts in the late 1960s, 612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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there was a his tory of development of a self-concept in ps ychoanalys is well before that. Development of a of the self in the context of the structural theory was stimulated by Hartmann's distinction between ego and self, terms that had been left ambiguous by F reud: T he was an intrapsychic organization of functions , whereas self was cas t in terms of a s elf-representation that then became the object of narciss istic libido but als o was specifically connected with object relations . In these the ego was related to and interactive with other intraps ychic s tructures , for example, superego, and the was concerned with object relations and self–object interactions. T his distinction also clarified the differentiation of object-libido and narciss istic libido because the self was the repository for secondary narcis sism and, as s uch, distinct from the ego. Hartmann's distinction between the ego and the s elf the self in representational terms . T he s elf was conceptualized either as a complex repres entation, organized and synthesized as a function of the ego or, later theorists , in structural terms as a more complex supraordinate integration of the tripartite structures is , embracing the tripartite entities as s ubordinate subs tructures ). T he former view regarded the self as the repres entational world, whereas the latter ass igned to the realm of internal ps ychic s tructure. T he of emphas is and formulation regarding these two perspectives remain a pers istent problem in developing cons istent concept of the self.

K ohutian S elf Ps yc hology S elf ps ychology, as a s eparate movement within 613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalys is, takes its origin from contributions of and his followers. K ohut linked the origin of the s elf to narcis sism, viewing the s elf as the result of a s eparate of narcis sis tic development that progres ses through a series of archaic narciss istic structures toward a mature and cohesive s elf-organization. K ohut argued that narcis sism went through a separate of development independent from object libido and object relations . In his view, the original primary differentiates in the course of development and in res ponse to laps es in parental empathy into two configurations, the grandiose self and the idealized parental imago. T he grandios e s e lf involves an and exhibitionis tic image of the self that becomes the repository for infantile perfection; the ide alize d parental imago, in contrast, trans fers the previous perfection to admired omnipotent object or objects. F urther normal development of the grandios e self leads to more forms of ambition, s elf-es teem, s elf-confidence, and pleas ure in accomplis hment. T he idealized parental likewise becomes integrated into the ego ideal with the mature values, ideals , and s tandards it repres ents. P athological pers istence of the grandiose self results in intens ification of grandios ity, exhibitionis m, shame, depres sion, hypochondriacal concerns, and of P.738 self-es teem. Loss of the idealized object or the object's love can res ult in narcis sis tic imbalance, the individual vulnerable to depress ion, depletion, poor self-es teem, failure of ideals and values , and even 614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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fragmentation. K ohut bases his s elf ps ychology on the need, both the cours e of development and during the cours e of for empathic interaction with s e lfobje cts . T he original selfobject is the mother or caretaking person who empathic res ponse to s elfobject needs in the infant in form of love, admiration, acceptance, joyful warmth, and respons ivenes s, communicating a sense valued and cherished exis tence to the child. Human continue to s eek objects to fulfill these basic s elfobject needs throughout life. F ailures to fulfill such needs can res ult in the formation of pathological psychic and patterns of behavior during development and pathological character s tructures during adult life. (T his analysis comes close to W innicott's views on goodmothering.)

E volving C onc epts of the S elf T he direct line of development of the notion of the s elf ps ychoanalys is, as previously discus sed, is best traced to Hartmann's effort to clarify the ambiguity latent in F reud's use of the term Ich. Hartmann distinguis hed from the s elf by ass igning the res pective terms to frames of explanatory reference. T he ego referred to specific intraps ychic agency whose frame of reference action was within the intrapsychic s tructure and in to other intraps ychic entities , for example, s uperego id. T he self, in contrast, had its proper frame of relations hip to objects . T hus formulated, the notion of self came to be regarded as roughly equivalent to the concept of the person as s uch. In an effort to clarify the theoretical implications of the 615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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early thinkers , following Hartmann's lead, came to the self in repres entational terms —that is , as referring the self-representation, which was then regarded as a subordinate function of the ego. Another point of view, however, sees the s elf as a s tructural organization, envis ioned as a fourth focus of organization in addition the tripartite entities or as a s upraordinate organization, including the tripartite s tructures and perhaps structural as pects. P art of the difficulty is that the notion of the self can be looked at from a variety of perspectives. T he s elf can seen as agent, or as object, or even in locational terms res pect to questions of what is inside or outside of the mind or the ps ychic s tructure and what it might mean parts of the s elf to be internalized or externalized. T he representational view of the s elf seems to lend its elf clearly to a view of the s elf as object, that is , as what cognitively and experientially gras ped of the s elf as an object of inner experience. S uch an experienced s elfobject must have repres entational qualities to be cognitively relevant. B y the s ame token, the s tructural perspective seems to be mos t congruent with the view the s elf-as -agent, as a s ource of psychic integration activity, and as s ynonymous with the originating s ource personal action and awareness . T he s tructural as pect the self-as -agent, with particular reference to its of conscious s ubjectivity, comes clos est to s atisfying demand for a “personal ego” in the theory. T he theory of the s elf remains at this juncture uncertain and very much in flux. However the ultimate conceptualization may be res olved, it s eems apparent the ps ychology of the s elf will continue to gain a 616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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permanent place in ps ychoanalytic thinking and theory. is poss ible to specify s ome of the theoretical gains of emerging role of the s elf-concept: T he self as a theoretical construct provides a focus formulating and unders tanding the complex integrations of functional process es that involve combinations of functions of the respective component agencies . T his has specific application such complex activities as affects, in which all of ps ychic s ys tems s eem to be in one way or other represented; complex s uperego integrations in such formations as value s ys tems; and other complex interactions of ps ychic s ys tems that fantas y production, drive-motor integration, or cognitive-affective proces ses. T here is room here cons iderable reworking and refocusing of traditional ps ychoanalytic ways of looking at and ps ychic phenomena in terms of the s elf as a system. T he self-concept provides a more specific and less ambiguous frame of reference for the articulation of self–object interrelations hips and interactions , including the complex areas of object relations and internalizations . T he emergence of a self-concept provides a locus the theory for articulating the experience of the personal s elf, either as gras ped intros pectively and reflectively or experienced as the originating source personal activity. T his s ens e of the self-as -subject provides a place within the theory for an account of subjectivity and s ubjective meaning. 617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T his approach raises an important metapsychological is sue; namely, the relations hip between the organization of the s elf and the tripartite entities . T he organization of the s elf and the organization of tripartite entities cannot be s imply identified. T he s elforganization operates at a different level of psychic organization than do the s tructural entities; moreover, structural entities in the strict theoretical s ens e are unders tood to be organizations of specific functions . concept applies not only to the ego as such but als o to superego and the id. Although the theory at various attributes more or les s personalized, metaphors to the operation of thes e s tructures , their theoretical intelligibility is nonetheles s given in terms of the organization of s pecific functions attributed to the res pective s tructures.

R elational and Inters ubjec tive Approac hes T hese more recent approaches to understanding the analytical interaction derive from a form of epistemology in which transference was regarded as res ulting from the interaction of analys t and patient. cons tructivist view contras ts with the more objectivist view of ego ps ychology and object relations . T he attention is focused on the here-and-now interaction the patient rather than on the inner dynamics of the patient's mental life and experience. T his effects a s hift from a one-person to a two-person ps ychology in which the ongoing interactions , whether cons cious or unconscious, between the participants are central, and transference and countertransference are regarded as 618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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mutually cocreated by both. T his approach was further developed into a view of analytical interaction in inters ubjective and relational terms. T he self ps ychological emphasis on s elf– transference has encouraged movement away from cons iderations of the analyst's stance as neutral or observational, ques tioning the analyst's subjectivity, authority, and capacity to know any objective reality the patient. On these terms, pers onality development is dependent on the interpersonal field insofar as ps ychic is continually being remodeled in terms of both past present relations hips and not determined by fixed patterns deriving from pas t unconscious conflicts . T he concept of personality as developing within a relational matrix calls for a central focus on the intersubjective within the relations hip between analys t and patient. It is this aspect of the analytical situation that is explored interpreted in the interest of bringing about personal growth in the patient. T he analyst's technical neutrality and objectivity are rejected in this approach as illus ory little more than express ions of the analys t's position. Within a s elf–selfobject or intersubjective relation, neutrality is precluded as P.739 potentially traumatizing and destructive to potential cons olidation of the self. An inevitable cons equence of these approaches is that they do away with the notion of the unconscious and undercut any sense of transference as reflecting unconscious aspects of the patient's inner psychic life because trans ference is anew in the pres ent analytical interaction. 619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Ps yc hology of C harac ter T he development of the concept of character in ps ychoanalys is has drawn increasingly clos er to the that are latent in a ps ychology of the s elf. C haracter come to s tand for a unique combination of the components of the individual's psychic organization reflects the basic elements of that person's personality organization and style. T he implications of the concept character, then, lie much clos er to the framework of the personality functioning as a whole, rather than to ps ychic agencies . T he concept of character can vary widely in meaning, depending on whether it is us ed in a moralistic, sociological, or general s ens e. Application of the in ps ychoanalysis has remained res trictive despite the that theoretical propos itions concerning the meaning of character have undergone an evolution that parallels evolution in ps ychoanalytic theory, particularly in the theory of the ego. During the period when F reud was developing his ego theory, he noted the relations hip between certain character traits and particular ps ychos exual components. F or example, he that obstinacy, orderlines s, and pars imonious nes s as sociated with anality. He noted that ambition was related to urethral eroticis m and that generos ity was related to orality. He concluded, in his paper on and Anal E roticism,” that permanent character traits represented “unchanged prolongations of the original instincts, or sublimation of thos e instincts, or reactionformations against them.” In 1913, F reud made an important distinction between 620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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neurotic s ymptoms and character traits : Neurotic symptoms come into being as a result of failure of repress ion, the return of the repress ed; character traits their exis tence to the succes s of repress ion or, more accurately, of the defens e s ys tem, which achieves its through a persistent pattern of reaction formation and sublimation. Later, in 1923, with increas ed of the phenomenon of identification and the formulation of the ego as a coherent s ys tem of functions , the relations hip of character to ego development came into sharper focus . At this point, F reud obs erved that the replacement of object attachment by identification (introjection), which s et up the los t object inside the also made a significant contribution to character formation. A decade later, in 1932, F reud emphasized particular importance of identification (introjection) with the parents for the construction of character, with reference to superego formation. S everal of F reud's disciples made important to the concept of character during this period. A major share of K arl Abraham's efforts were devoted to the inves tigation and elucidation of the relations hip oral, anal, and genital eroticism and various character traits. Wilhelm R eich made an important contribution to the ps ychoanalytic unders tanding of character when he described the intimate relations hip between resistance treatment and character traits of the patient's R eich's obs ervation that res is tance typically appeared the form of thes e s pecific traits anticipated Anna later formulation concerning the relationship between res is tances and typical ego defens es. T he development of psychoanalytic ego psychology 621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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led to an increasing tendency to include character traits among the properties of the ego, s uperego, and egoIt s hould be noted, however, that character is not synonymous with any of these properties . the emphasis has been extended from an interes t in specific character traits to a cons ideration of character its formation in general. P sychoanalys is has come to regard character as the pattern of adaptation to and environmental forces , which is typical or habitual given individual. T he character of a person is from the ego by virtue of the fact that it refers largely to directly obs ervable behavior and s tyles of defense, as as of acting, thinking, and feeling. T he clinical value of concept of character has been recognized by and ps ychoanalys ts and has become a meeting ground the two disciplines. T he formation of character and character traits res ults the interplay of multiple factors. Innate biological predis pos itions play a role in character formation in its instinctual and ego fundaments . T he interactions of forces with early ego defenses and with environmental influences, particularly the parents, constitute the major determinants in the development of character. V arious early identifications and imitations of objects leave their lasting s tamp on character formation. T he degree to which the ego has developed a capacity tolerate delay in drive dis charge and to neutralize instinctual energies , as a result of early identifications defens e formation, determines the later emergence of such character traits as impulsiveness . F inally, a authors have s tres sed the particularly clos e ass ociation between character traits and the development of the 622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ideal. T he development of the ego-ideal must be unders tood in the context of the developmental viciss itudes of narciss is m. It is in this respect that the ps ychoanalytic concept of character begins to parallel more common us e of the term characte r in a s omewhat moral sense. T he exaggerated development of certain character traits at the expense of others may lead to character dis orders later in life. At other times , s uch distortions in the development of character traits can produce a vulnerability in personality organization or a predis pos ition to ps ychotic decompensation.

C L A S S IC P S YC HOA NA L YTIC TR E A TME NT C ertain aspects of the therapeutic technique that F reud developed and that were later expanded by his are closely related with ps ychoanalytic theory. One of distinctive as pects of the ps ychoanalytic approach to treatment in general is its cons is tent attempt to therapeutic us ages and approaches with the unders tanding of psychic functioning available from ps ychoanalytic theory. In its origins and clinical application, ps ychoanalys is is uniquely a theory of

Analys is vers us Analytic al Ps yc hotherapy One of the chronically recurring is sues among analys ts whether and to what extent psychoanalys is is distinguishable from ps ychotherapy. T here are distinguishing features between them as more or les s forms: the us e of couch in analysis, not in therapy; free as sociation as a primary method in analysis, not in 623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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intens ive and long-term s cheduling in analys is , not in therapy; emphasis on neutrality, abstinence, and interpretation on the part of the analyst in analys is, not therapy; and the central focus on transference and countertransference in analysis , not in therapy. Over years , however, forms of psychotherapy have evolved modifying all of these criteria and res ulting in a of psychotherapeutic interventions , ranging from ps ychoanalys is at one end to diluted forms of ps ychotherapy at the other. T he dis tinction between explorative vers us supportive therapy parallels this continuum s o that many variants of the analytical have aris en in which both components are us ed in degrees . S ome of this variation has come about by of the expans ion of P.740 analytical techniques to the widening scope of ps ychopathology and the corres ponding challenge of adapting analytical techniques to these patient needs. Another factor, however, has been the rejection of traditional analytical approaches and methods accompanying rejection of more traditional analytical theories. One conclus ion is that better means for determining what patients are better served by what forms of therapy needs to be developed.

Analytic al Proc es s S ome of the origins of F reud's approach to treatment been cons idered, particularly in the development of his basic techniques of free as sociation and in his growing awarenes s and interpretation of the trans ference. In 624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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es sence, modern ps ychoanalytic treatment procedures differ from thos e that F reud originally developed in one fundamental respect. E arly in his approach to therapy, F reud believed that recognition by the phys ician of the patient's unconscious motivations, the communication this knowledge to the patient, and its comprehens ion the patient would of its elf effect a cure. T his was his doctrine of therapeutic insight. F urther clinical however, has demonstrated the fallacy of these expectations . S pecifically, F reud found that his discovery of the unconscious wis hes and his ability to impart thes e to the patient s o that they were accepted and were ins ufficient. S uch ins ight might permit clarification the patient's intellectual apprais al of problems , but the emotional tensions for which the patient sought were not effectively alleviated in this way. T his led to a s ignificant breakthrough. F reud began to that the succes s of treatment depended on the ability to unders tand the emotional significance of an experience on an emotional level and depended on the patient's capacity to retain and use that insight. In that event, if the experience recurred, it elicited another reaction; it was longer repress ed, and the patient would have undergone a ps ychic economic change. F reud's formula for this process was: “Where id was , there ego be.” F reud thus elaborated a treatment method that minimal importance to the immediate relief of to moral s upport from the therapist, or to guidance. T he goal of ps ychoanalys is was to pull the neuros is out by roots, rather than to prune off the top. T o accomplis h 625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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it was necess ary to break down the pregenital, deep crys tallization of id, ego, and s uperego and bring underlying material near enough to the surface of cons ciousnes s s o that it could be modified and reevaluated in light of reality. T his method the clas sic ps ychological treatment from more ps ychodynamic forms of psychotherapy. T he patient is unaware of the repress ion of the forces conflict and the ps ychic mechanisms of defens e the us es . B y isolating the bas ic problem, the patient has protected her- or himself against what s eems, from the patient's view, to be unbearable suffering. No matter it may impair functioning, the neurosis s eems preferable to the emergence of unacceptable wis hes ideas . All the forces that permitted the original are thus mobilized once again in the analys is as a res is tance to this threatened encroachment on territory. No matter how much the patient may cons ciously with the therapist in the analys is, and no matter how painful the neurotic symptoms may be, the patient automatically defends agains t reopening of old wounds with every s ubtle resource of defense and res is tance available. In dis cuss ing the analytical proces s, one must clarify basic distinction between the analytical proces s and analytical s ituation. T he analytical proce s s refers to the regress ive emergence, working through, interpretation, and res olution of the trans ference neurosis. T he s ituation, however, refers to the s etting in which the analytical process takes place, specifically the relations hip between patient and analyst bas ed on the therapeutic alliance. 626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he regress ion induced by the analytical situation (instinctual regres sion) allows for a reemergence of infantile conflicts and thus induces formation of a transference neuros is . In the class ic transference the original infantile conflicts and wishes become on the pers on of the analyst and are thus and relived. In the analytical regres sion, earlier infantile conflicts are revived and can be s een as a the repetition compulsion. R egres sion has a dual from one point of view, it is an attempt to return to an earlier state of real or fantasy gratification, but from another point of view, it can be seen as an attempt to master previous traumatic experience. T he regres sion the analytical s ituation and the development of transference are preliminary conditions for the mas tery unresolved conflicts. T hey can also represent and unconscious wis hes to return to an earlier s tate of narcis sistic gratification. T he analytical process must its elf out in the face of this dual potentiality and tension. If the analytical regress ion has a des tructive potentiality (ego regres sion) that mus t be recognized and guarded agains t, it also has a progres sive potentiality for and reworking infantile conflicts and for achieving a reorganization and consolidation of the pers onality on a more mature and healthier level. As in any crisis, the risk of regres sive deterioration mus t be agains t the promise of progres sive growth and T he therapeutic importance of the criteria of can be easily recognized becaus e patients who are to achieve the progres sive potentiality of the analytical regress ion cannot be expected to realize a good therapeutic res ult. T he determining element within the 627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analytical s ituation against which the regress ion must balanced and by which the destructive or cons tructive potential of the regres sion can be meas ured is the therapeutic alliance. A firm and stable alliance offers a buffer against exces sive (ego) regres sion and also basis for pos itive growth.

The A nalytic al R elation T he analytical or therapeutic relation is compounded of least three components that are coexistent, mutually interacting and influencing, and intermingled at all in the analytical process . Although cons tantly to influence the patterns of interaction between analyst and patient and determining the cours e of the proces s, they can be us efully distinguished in that they point to differentiable is sues and aspects of the therapeutic proces s and call for different therapeutic res ponses and interventions . T hey are the trans ference and countertransference, the therapeutic alliance, and real relation.

TR ANS FE R E NC E T hrough free as sociation, hidden patterns of the mental organization that may be fixated at immature levels and refer to events or fantas ies in the patient's private experience are brought to life and activated in relation with the analyst. In the s imples t model of transference, the analyst is gradually invested with emotions us ually ass ociated with significant figures in past. T he patient dis places or projects feelings directed toward thes e earlier objects onto the analys t, then becomes alternately a friend or enemy, one who 628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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nice or frustrates needs and punishes, or one who is or hated as the original objects were loved or hated. Moreover, this tendency pers is ts so that, to an extent, the patient's feelings toward the analys t feelings toward the specific people being talked about more accurately, those about whom the patient's unconscious is talking. T his transference object acts as lens through which the patient views the analyst, him or her in the image of the trans ference As unresolved childhood attitudes and feelings emerge and begin to function as fantasized projections toward analyst, he P.741 or s he becomes for the patient a phantom compos ite figure repres enting various important people in the patient's early environment or objects represented in or her inner world. T hos e earlier relations hips are reactivated with s ome of their original affective vigor, expos ing in some degree the roots of the patient's disturbance. T he concept of transference has cons iderable elaboration over time, res ulting in multiple variants, broadening its connotations to include every emotional connection to the analyst, and extending the transference model to encompas s the widening range ps ychopathology addres sed by ps ychoanalys is . in transference and their des criptions are contained in T able 6.1-5. Unders tanding trans ferences requires exploration of mechanisms involved in their formation their dynamic interactions . T he bas ic mechanisms by which trans ferences are effected—displacement, projection, and projective identification—are des cribed 629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T able 6.1-6.

Table 6.1-5 Trans ferenc e Libidinal transferences    F ollow the class ic model and us ually in milder forms as pos itive trans fe rence re actions but can the form of more intens e and disturbing erotic trans fe rences . T hey are derivatives of phalliclibidinal impulses and may be permeated by pregenital influences. T hey may occur with varying degrees of intens ity and in mild forms not even require interpretation if they contribute and s upport the therapeutic relation. S igmund recommended that they call for interpretation only when they begin to serve as a res is tance. Aggress ive transferences    T ake the form either of negative or more pathological paranoid transferences . Negative trans fe rences are seen at all levels of ps ychopathology but may predominate in s ome borderline patients who tend to s ee the relations hip in terms of power and victimization, regarding the therapist as omnipotent and whereas the patient experiences him- or hers elf helpless , weak, and vulnerable. However, 630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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transferences are identifiable in varying degrees all analyses and usually require specific and interpretation. T ransferences of defense    Oppos ed to trans fe rences of impuls e ; defense agains t impuls es finds its way into the rather than the impuls es themselves. In this form transference, attention shifts from drives to the defens ive functioning so that trans ference is no longer merely repetition of instinctual cathexes includes as pects of ego functioning as well. T ransference neuros is    Involves the re-creation or more ample of the patient's neurosis enacted anew within the analytical relation and at leas t theoretically as pects of the infantile neurosis. T he neuros is usually develops in the middle phase of analysis, when the patient, at firs t eager for improved mental health, no longer cons is tently displays s uch motivation but engages in a continuing battle with the analys t over the desire attain some kind of emotional satisfaction from analyst so that this becomes the most compelling reason for continuing analys is. At this point of the treatment, the transference emotions become important to the patient than alleviation of dis tress 631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sought initially, and the major, unresolved, unconscious problems of childhood begin to dominate the patient's behavior. T hey are now reproduced in the trans ference, with all their pentup emotion.    T he trans ference neurosis is governed by three outstanding characteris tics of ins tinctual life in childhood: the pleas ure principle (before effective reality testing), ambivalence, and repetition compuls ion. E mergence of the transference is us ually a s low and gradual process , although in certain patients with a propens ity for trans fe rence re gre s s ion, particularly more hysterical patients , elements of transference and trans ference may manifes t thems elves relatively early in the analytical process . One situation after another in life of the patient is analyzed and progress ively interpreted until the original infantile conflict is sufficiently revealed. Only then does the transference neuros is begin to s ubs ide. At that termination begins to emerge as a more central concern.    C ontemporary opinion is divided as to its importance and centrality, whether it forms to the extent F reud believed, and whether it is for success ful analysis —for some, it remains an es sential vehicle for analytical interpretation and therapeutic effectivenes s; for others , it may never

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develop or, to the extent that it does , may play a central role in the proces s of cure. T ransference psychosis    Occurs when failure of reality testing leads to of self–object differentiation and diffus ion of self object boundaries . T his may reflect an attempt to fus e with an omnipotent object, investing the s elf with omnipotent powers as defense agains t underlying fears of vulnerability and T ransference psychosis may als o include transference elements in which fusion carries the threat of engulfment and loss of self that may precipitate a paranoid trans fe rence re action. Narciss is tic transferences    C larified by Heinz K ohut (1971) as variations of patterns of projection of archaic narcis sistic configurations onto the therapist. T hey are based projections of narciss istic introjective both s uperior and inferior—the superior form reflecting narcis sistic s uperiority, grandiosity, and enhanced self-es teem, and the inferior oppos ite qualities of inferiority, self-depletion, and self-es teem. T he therapist comes to represent, in K ohut's terms , either the grandios e s elf in mirror trans fe rences or the idealized parental imago in ide alizing trans fere nce s . In idealizing 633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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all power and s trength are attributed to the object, leaving the subject feeling empty and powerles s when s eparated from that object. with the idealized object enables the subject to regain narcis sis tic equilibrium. Idealizing transferences may reflect developmental disturbances in the idealized parent imago, particularly at the time of formation of the ego by introjection of the idealized object. In some individuals , narciss istic fixation leads to development of the grandiose self. R eactivation analysis of the grandiose s elf provides the bas is formation of mirror trans ferences, which occur in three forms : archaic merge r trans fe rence , a les s archaic alter-ego or twins hip trans fe rence , and trans fe rence in the narrow s e ns e . In the most merger trans ference, the analyst is experienced as an extension of the subject's grandios e s elf thus, becomes the repos itory of the patient's grandiosity and exhibitionism. In the alter-ego or twinship transference, activation of the grandios e self leads to experience of the narciss is tic object similar to the grandiose self. In the most mature of mirror transference, the analyst is experienced a s eparate pers on but, nonetheles s, one who becomes important to the patient and is accepted by him or her only to the degree that he or s he is res ponsive to the narcis sistic needs of the reactivated grandios e s elf.

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S elfobject transferences    R epres ent extens ions of the s elf-ps ychology paradigm beyond merely narcis sis tic T he selfobject involves investment of the s elf in object s o that the object comes to serve a s elfsustaining function that the self cannot perform its elf—either in maintaining fragile s elf-cohes ion in regulating self-es teem. T he other is, thus , not experienced as an autonomous and separate or agency in its own right but as pres ent only to serve the needs of the self. T ransference in this reflects a continuing developmental need that satis faction in the analytical relation.    S elfobject trans ferences reflect the underlying need s tructure the patient brings to the relations hip bas ed on the predominant pattern of selfobject deprivation or frus tration and the corres ponding seeking for the appropriate form of selfobject involvement. T hes e configurations been described as the unders timulated s e lf, the overs timulate d s elf, the overburdene d s elf, and fragme nting s e lf. Other des criptions of s elfobject need translate patterns of trans ference based on narciss is tic dynamics into the of the relationship between self and s elfobject, as mirror-hungry pers onalities and ideal-hungry personalities . V ariations on the mirroring transference theme include the alter-ego–hungry

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personality, the merger-hungry personality, and, contrast, the contact-shunning pers onality. In transferences derived from s uch pers onality configurations, the clas sic meaning of has undergone radical modification. R ather than displacements or projections from earlier object relational contexts, the patient brings to bear a based in his or her own currently deficient and defective character s tructure—a need to the object in a dependent relationship to or s tabilize his or her own ps ychic integration. T ransitional relatedness    T his transference model is based on Donald Winnicott's notion of the trans itional object. T ransference in more primitive character is regarded as a form of trans itional obje ct which the therapist is perceived as outside the but is inves ted with qualities from the patient's archaic s elf-image. T he transference field in this is envis ioned as a transitional s pace in which the transference illus ion is allowed to play itself out. T ransference as psychic reality    R eflects the need of each participant in analysis draw the other into a s tance corres ponding to his her own intrapsychic configuration and needs as reflection of the individual subject's psychic 636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T his regards the clas sic view of transference, on dis placement or projection from past objects, inadequate, res ulting in further diffus ion of of trans ference as equivalent to the individual's capacity to create a meaningful world or to inform the world with meaning. In this rendition, transference becomes equivalent to the patient's ps ychic reality s o that any dis tinction between the meanings given to reality and the meanings inherent in transference are lost. T ransference in these terms becomes all-encompas sing, and whatever dis tinguishing and dynamic s ignificance may have had fades into obscurity. In this form of transference, there does not s eem to be any definable mechanis m at work other than involved in the subject's psychic reality. T he view of his or her environment and his or her impres sion of objects of his or her experience, including the analytical object, are from ordinary cognitive and affective proces ses characterizing his or her involvement and res ponsiveness to the world about him or her. T ransference as relational or intersubjective    T he relational or intersubjective view of transference as emerging from or cocreated by subjective interaction between analyst and analysand transforms transference into an interactive phenomenon in which individual

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intraps ychic contributions from either participant are obs cured. T rans ference in this sense is not anything individual to or intrapsychically derived from the patient but is based on the pres ent ongoing interaction between analys t and patient coconstructing trans ference. On these terms , analysis of transference has little to do with past derivatives and everything to do with the ongoing relation with the analyst, primarily in the form of interpersonal enactments . T ransference in this is no longer a one-person phenomenon but a two-person transference–countertransference interaction. T he s upposition is that there is no thing as trans ference without countertrans ference and no such thing as countertransference without transference. T he patient is thus relieved of any burden of a pers onal dynamic unconscious reflecting developmental viciss itudes and of a life history. T ransference is created anew in immediacy of present analytical interaction as the product of mutual influence and communication between analys t and analysand, probably relying some form of mutual projective identification to sustain the interactive connotation.

Table 6.1-6 Trans ferenc e Mec hanis ms 638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Dis placement    T he basic mechanis m of class ic transference paradigms in which an object representation from any level or combination of levels of the subject's developmental experience is dis placed the representation of the new object, namely, the analyst, in the therapeutic relations hip. Dis placement is the bas ic mechanis m for based transferences , both positive and erotic, as as for aggress ive and es pecially negative transferences . B y and large, displacement transferences tend to play a more dominant role neurotic disorders in which phallic-oedipal (and to less er degree pre-oedipal) dynamics tend to play dominant, although not exclus ive, role. P rojection    P rocess by which qualities or characteristics of self-as -object, us ually involving introjections or representations, are attributed to an external and the subs equent interaction with the object is determined by the projected characteris tics. the analyst/object may be s een as sadis tic—that as poss ess ing the sadis tic character of the analysand/s ubject, an aspect of the s ubject's s elf is denied or dis owned by the subject. P rojection tends to play a more prominent, although again 639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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exclusive, role in formation of transferences in primitive character dis orders but can be found in variously modified forms throughout the s pectrum of neuroses. B ecause projections derive primarily from the configuration of introjects cons tituting patient's s elf-as -object, the effect of projective or externalizing transferences is that the image of therapist comes to repres ent part of the patient's own s elf-organization rather than simply an object representation.    P rojections derived from destructive introjects provide the basis for both negative and paranoid transference reactions . T hos e based on the victim/introject res ult in the patient relating to the therapist as his or her victim and him- or hers elf as suming a hos tile or s adistic pos ition as a destructive aggress or or victimizer to the victim. T hen again, projection based on the aggres sor/introject results in the patient relating the therapist as an aggres sor and him- or herself as suming a weak, vulnerable, or mas ochis tic in which he or she becomes a pass ive and victim to the therapist's des tructive aggress ion. S imilar patterns can take place around is sues involving introjective configurations of narcis sistic s uperiority and inferiority.    However, projective dynamics in s elfobject transferences seem to involve more than

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projections becaus e these forms of transference tend to draw the analyst into meeting the pathological needs of the s elf. If anything is projected, it is an infantile wis hed-for imago, one lacking earlier in the patient's experience, as , for example, an empathic and idealized parental On the other hand, trans itional transferences , despite their considerable overlap with s elfobject phenomena, tend to involve a more explicit projective element as the s elf-related contribution the transitional experience. P rojective identification    T he concept of projective identification was first propos ed by Melanie K lein, arguing that the projection of impuls es or feelings into another person brought about an identification with that person bas ed on attribution of one's own qualities that other. T his attribution served as the bas is for sens e of empathy and connection with the other. these terms, projective identification was a taking place solely in the mind of the one    P rojective identification is often appealed to as mechanism of trans ference, or more exactly transference–countertransference interactions , particularly in K leinian usage. C onfus ion arises the failure to clearly distinguish between and projective identification. T he notion of

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projective identification added to the bas ic of projection the notes of diffusion of ego boundaries , a los s or diminis hing of self–object differentiation, and inclusion of the object as part the self.    Later elaborations of the notion of projective identification transformed it from a one-body to a two-body phenomenon, describing interaction between two s ubjects , one of whom projects something onto or into the other, whereon the introjects or internalizes what has been projected. Ins tead of the projection and introjection taking place in the same s ubject, the projection now place in one and the internalization in the other. latter usage has led to extensive extrapolation of concept of projective identification to apply to object relations of all s orts , including T he emphasis in K leinian transference is les s on influence of the pas t on the pres ent but rather the influence of the internal world on the external in here-and-now interaction with the analys t.

P.742

C OUNTE R TR ANS FE R E NC E If the patient is capable of trans ference in the analytical interaction, the analyst is correspondingly capable of 642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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countertransference, meaning that the analys t engages the interaction with his or her own burden of elements coming from his or her own developmental past or elements that may be activated in the course of his or interaction with the patient, es pecially in res pons e to patient's transference. Originally, countertransference a matter of a res ponse in the analys t's unconscious affecting his or her view of and reaction to the patient, recent views tend to see it as encompas sing the total affective res ponse of the analyst to the patient, whether cons cious or unconscious, and as reflecting more res ponses arous ed in the present interaction with the patient than influences coming from the analyst's pas t experience or uncons cious . When patient transference and analys t countertransference are caught up in an interaction, res ult is a transference–countertransference E arly views of countertrans ference saw it as interfering the work of the analys is , as it may often do, but recent revis ions have emphas ized the contributions to more effective analytical work arising from attention to and of countertrans ference res pons es in the course of an analysis. C ountertrans ference has thus become as inevitable and not necess arily destructive to the analytical process . T he author's opinion is that it is insofar as it reveals unconscious factors that would otherwis e remain hidden but that therapeutic and effect cannot be achieved through countertransference as s uch but only through the us e made of it from the vantage point provided through the therapeutic alliance. If the therapis t finds him- or herself annoyed at a patient, it is not therapeutically 643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to express or act out the annoyance on the patient. it is useful to analyze the s ources of the anger in his or past experience and find a cons tructive way to deal in relation to the patient.

THE R APE UTIC AL L IANC E T he therapeutic alliance is bas ed on the one-to-one collaborative relations hip that the patient establishes in interaction with the analyst. T his interaction deals with those aspects of the therapeutic relation that enable patient and analyst to engage meaningfully and productively in the analytical process with the objective achieving therapeutic benefit for the patient. T he terms the alliance are negotiated between analyst and obviously, not any terms of their working together do only thos e that can predictably contribute to or s et the stage for their effectively working together. T he alliance these terms includes at least the following elements : empathy, trust, autonomy, respons ibility, authority, freedom, hones ty, and neutrality. All these elements pertinent to the role of the patient in analysis as to the analyst. T he therapeutic alliance allows a s plit to take place in patient's ego—that is , the observing part of the ego can ally its elf with the analyst in a working relations hip, which allows it to gradually identify with the analys t in analyzing and modifying defens es put up by the defensive ego against internal danger situations . Maintenance of this therapeutic s plit, well as the relationship to the analyst involved in the therapeutic alliance, requires maintenance of s elf– differentiation, tolerance and mastery of ambivalence, 644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the capacity to dis tinguish fantasy from reality in the relations hip. In many analyses, consequently, the requires work and effort to es tablis h and can thus one of the objectives of the analytical work. In no cas e the alliance be taken for granted P.743 or ass umed because the propens ity of all patients to various s ubtle forms of misalliance is pervas ive. If they not carefully looked for and attuned to, s uch can easily dis tort the cours e of an analys is and only become apparent when they reach a point of cris is or impas se. In more severely dis turbed pers onalities, a greater tendency to dis ruptions of the alliance rather than mis alliances , which can destroy an analytical and often require extreme efforts to salvage the Maintenance of the therapeutic alliance requires that patient be able to differentiate between the more and the more infantile as pects of the experience in relations hip to the analyst. T he therapeutic alliance a double function. On one hand, it acts as a s ignificant barrier to excess ive regress ion of the ego in the proces s; on the other hand, it s erves as a fundamental as pect of the analytical s ituation, against which the feelings, and fantas ies evoked by the transference can be evaluated, meas ured, and interpreted. In many pathological conditions —some character neuroses, borderline pers onalities , and more s evere neurotic disorders —it may be difficult to maintain a clinical distinction between therapeutic alliance and the transference neuros is . T he therapeutic alliance derives from the mobilization 645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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specific ego resources relating to the capacity for relations and reality tes ting. T he analyst mus t direct attention toward eliciting the patient's capacity to es tablis h s uch a relations hip that is able to withstand inevitable distortions and regres sive as pects of the transference neuros is . It is inevitable that the features of the therapeutic alliance be carefully and unders tood and ultimately integrated with the analysis of the trans ference neuros is. T his point is particularly and graphically displayed in the analysis of hysterical patients . T he initial transference neuros is of patients tends to pres ent primarily oedipal material, but analysts have learned to appreciate the importance of underlying oral factors in the genes is of many disorders . In the terminal stages of analys is of these patients, it becomes increasingly clear that res olution oedipal conflicts depends on the s uccess ful analys is of earlier conflicts stemming from the pregenital level of development. S pecifically involved are conflicts , us ually an oral level, that are related to achieving early object relations and the acceptance of reality and its T hese elements, however, are s pecifically thos e that the developmental basis of the therapeutic alliance.

R E AL R E L ATION R eality pervades the analytical relationship. On one there is the reality of the pers onalities and of analys t and analysand; on the other, there are the realities of time, place, and circums tance external to analytical s etting but constantly influencing the course the analytical relation. T hese include realities of the location of the analyst's office, the phys ical the furniture and decorations in the room, the 646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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geographical location itself, and even how the analys t dress es; they all have their effects in the analytical and influence how the P.744 patient experiences the pers on of the analyst. T he surrounding circums tances that create the framework the analytical effort—the patient's financial s ituation, marital s tatus, and job demands ; arrangements for payment of the fee; whether the patient has ins urance what kind; what kinds of press ures are pus hing the into treatment; accidental factors such as illness , interfering obligations —are reality factors extrinsic to analysis but exercis ing significant influence on the analytical relations hip and how it is es tablis hed and maintained. T he most important and central reality for the patient is the person of the analys t. E very analys t has his or her cons tellation of personal characteris tics, including manneris ms , style of behavior and speech, habits of gender, way of going about the task of managing the therapeutic s ituation, attitudes toward the patient as a human being, prejudices , moral and political views , and personal beliefs and values. T hes e are all relevant of one's real exis tence and personality as a human T hey are realities that play a role in the therapeutic relations hip and are entirely dis tinct from transference countertransference. In terms of the analytical process , none of this is lost on the patient who is observant of and s ensitive to the smallest details of the analyst's real pers on. T he same considerations operate from the s ide of the analyst in relation to the patient. 647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Tec hnic al A s pec ts T he analytical technique is always adapted to the idios yncras ies of the patient's developmental needs , and defens ive cons tellation. Analytical do not stand in is olation but are part of a living, proces s that is intended to induce and achieve internal ps ychic growth.

FR E E AS S OC IATION T he corners tone of the psychoanalytic technique is free as sociation. T he patient is encouraged to use this as far as pos sible throughout the treatment. T he function of free as sociation, besides obvious ly content for the analys is , is to help to induce the regress ion and relatively pass ive dependence with es tablishing and working through the trans ference neuros is . T hus, free ass ociation is conjoined with the techniques that induce such regres sion, namely, lying the couch, not being able to see the analyst, and conducting the analysis in an atmos phere of quiet and res tful tranquility. One als o cannot simply regard the proces s of free as sociation as s omething that takes place in is olation the patient. In fact, the proces s is more complex, more difficult to conceptualize, and increasingly mus t be the context of and in reference to the more relations hip between analyst and patient. T he patient's free as sociating is a function of the more basic relations hip. Moreover, it is increasingly clear from a contemporary perspective that much more is required patient than s imply free as sociating. It is not enough for 648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the patient to lay back and allow s elf-surrender to a position of pass ive dependency within the analytical relations hip without at the same time being able to mobilize basic ego res ources in the service of mastery, gaining insight, mobilizing executive and synthetic capacities, and, ultimately, being able to as sume a less pass ive and more active and autonomous function the analytical relations hip. Obviously, there is a in the mobilization of thes e capacities in the patient, varies from phas e to phase of the analytical process .

R E S IS TANC E T he most conscientious efforts on the part of the say everything that comes to mind are never succes sful. No matter how willing and cooperative the patient may be in attempting to free ass ociate, the res is tance are apparent throughout the course of every analysis. T he patient paus es abruptly, corrects him- or herself, makes a slip of the tongue, s tammers , remains silent, fidgets with s ome part of clothing, asks irrelevant questions , intellectualizes , arrives late for finds excus es for not keeping them, offers critical evaluations of the rationale underlying the treatment method, s imply cannot think of anything to s ay, or even cens ors thoughts that do occur and decides that they banal or uninteres ting or irrelevant and not worth mentioning. T he development of resis tance in the analysis is quite automatic and independent of the patient's will as the development of the transference itself. T he s ources of res is tance are just as uncons cious as sources of transference. T he emotional forces, however, that give 649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to resistance us ually are defending against thos e producing the trans ference. T hus, res is tances tend to emerge more in the middle phase of the analys is, in regress ive emergence of the trans ference is a central concern. T he analys is becomes a recurring field of between the tendencies toward transference and those toward res is tance, manifes ted by the involuntary inhibition of the patient's efforts to ass ociate freely. T his inhibition may las t for moments or days or may pers is t through the whole course of the analys is . R es istance may take place in all phases of the its quality and significance are different depending on analytical task at hand. In any case, the patient's enables the analys t to evaluate and become familiar the defens ive organization of the patient's ego. In this the pattern of resistance not only offers valuable information to the analys t but also offers a channel by which the patient can be approached therapeutically. T he significance of this basic conflict is clear. It is a repetition of the very same s exuality–guilt conflict that originally produced the neuros is its elf. T ransference may be a form of resistance, in that the wis h for gratification in the analys is can circumvent and es sential goals of treatment. C onsequently, the res is tance, particularly trans ference res is tance, is one the analyst's primary functions . It als o accounts in cases for the extended time period required for ps ychoanalytic treatment. No matter how s killful the analyst, res is tance is never absent. In the light of relational and intersubjective on the analytical proces s, the concept of resistance fallen out of favor in that any s uch phenomenon is a 650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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byproduct of the interaction between analyst and T here is, then, no resistance coming from the patient rather is contributed by both participants . R es is tance only be dealt with by examining the interaction caus ing and not by interpretation of the patient's defens es . T his point of view remains highly controvers ial.

INTE R PR E TATION Interpretation is the chief tool of the analys t in efforts to reduce uncons cious res is tance. As mentioned earlier, the early stages of the development of psychoanalytic therapeutic techniques, the sole purpos e of was to inform the patient of his or her unconscious Later, it was des igned to help the patient understand res is tance to s pontaneous self-awarenes s. In current ps ychoanalytic practice, the analyst's function as interpreter is not limited to s imply paraphrasing the patient's verbal reports but, rather, to indicating at appropriate moments what is not reported or is implicit what is reported. C ons equently, as a general rule, analytical interpretation does not produce immediate symptomatic relief. On the contrary, there may be a heightening of anxiety and an emergence of further res is tance. If a correct interpretation is given at the proper time (mutative interpretation), the patient may react either immediately or after a period of emotional s truggle which new as sociations are offered. T hese new as sociations often confirm the validity of previous interpretations and add s ignificant additional data, thus disclos ing motivations and experiences of the patient of which the analys t could not previously have been 651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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G enerally s peaking, P.745 it is not so much the analyst's insight into the patient's ps ychodynamics that produces progress in the analys is it is the patient's ability to gain this insight the analyst can facilitate this proces s by reducing unconscious resis tance to s uch self-awarenes s appropriate, carefully timed interpretation. T he most effective interpretation is timed so that it is given by the analyst in s uch a way as to meet the emerging, if and half formed, awarenes s of the patient. T hus , the analyst mus t gauge the capacity of the patient at any given moment to hear, as similate, and integrate the content of a given interpretation. Another important as pect of interpretations is that they cannot be s een in isolation from the total context of the analytic situation and the analytic proces s. An interpretation, both as given by the analys t and as received by the patient—and that includes elements of both transference neurosis and therapeutic alliance— takes place within the context of the therapeutic relations hip. T hus, the giving and receiving of interpretations are cloaked with a series of meanings unavoidably influence both the capacity of the patient accept and integrate interpretations and the analys t's sens e of offering and providing such interpretations. E xperience has s hown that, at best, the therapeutic benefits produced by virtue of the analyst's unilaterally provided insights are only temporary. T hose interpretations are most effective and of lasting therapeutic value that are arrived at by the delicate 652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dialectic arising from the mutually facilitated and awarenes s of both patient and analyst.

MODIFIC ATIONS IN TE C HNIQUE S T here are no shortcuts in psychoanalytic treatment. P sychoanalytic treatment typically extends over a of years and requires interminable patience on the part both analyst and patient. R igid adherence, however, to fundamental principles of psychoanalytic technique is impos sibility. F or example, the immediate situation may be s o serious for the patient that the must pay commons ens e attention to its practical implications. T hose patients whose early childhood extraordinarily deficient in love and affection so that have a basic developmental defect in their capacity for one-to-one relations hip and, consequently, in their capacity to sus tain a therapeutic alliance must be given more s upport and encouragement than usually by strict ps ychoanalytic technique. T he analyst's role in the early s tages of analysis in to es tablis h the therapeutic alliance is of particular importance. As noted, with the primitive patients, the es tablis hing of a therapeutic alliance can be the more significant aspect of the treatment proces s and can persis t as a problem through most of the analys is. es tablis hing the therapeutic alliance for mos t patients is significant aspect of the analytic process . T he nature and the degree of the analys t's active intervention in the opening hours of analys is are s till matters of considerable dis cuss ion and controversy. transference neuros is us ually develops only gradually, that attempts at premature interpretation in the early 653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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hours may not be productive and may even be counterproductive. T his has tended to foster the us e of prolonged silences , lack of responsivenes s, rigidity, relative lack of participation in the analys is on the part the analyst, as if any reference to the analytic situation to the pers on of the analyst or to the patient's feelings about the analys t was to be taken as contrary to developing a transference interpretation and, thus, to avoided. Often, however, s erious problems in the subs equent s tages of analysis of the transference can due to a failure to es tablis h a meaningful alliance in the initial s tages of treatment. T hus, suitable interventions the analyst in the early stages of treatment can help patient in es tablishing such a meaningful therapeutic alliance. P atients who are more borderline or very narciss is tic es tablis h a strong personal tie and strong feelings of attachment and relations hip with the analys t before can develop sufficient interes t and motivation for treatment. Moreover, s uch a s trong object tie with the analyst for these more primitive patients is an absolute neces sity if the destructive effects of excess ive are to be avoided. Development of sufficient trust is es sential for these patients if they are to establish any meaningful alliance. T hes e are difficult problems, because experience also sugges ts that every deviation from analytic technique that such special conditions compel tends to prolong the length of treatment and to cons iderably increase its viciss itudes and problems. S uch modifications in analytical technique us ually go under the heading of “parameters ,” and they remain a cons iderable source of dis cus sion and controversy 654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analytical therapis ts. A significant trend today is the increasing tendency of analys ts to treat more difficult complex cases ; thus , the neces sity for introducing modifications in various aspects of the treatment corres pondingly increas es . As a res ult, what might previous ly have been thought of as parameters are increasingly accepted as valid technical practices . T he res olution of such difficulties in as sess ing and modifications of techniques mus t ultimately rest on the basis of clinical experience.

R es ults of Treatment T he therapeutic effectivenes s of ps ychoanalys is problems in its evaluation. Impartial and objective are handicapped in attempts to apprais e therapeutic res ults by the fact that s o many patients state that they have been analyzed when no s uch procedure was, in undertaken or when it was undertaken by s omeone us ed the title of analys t and who had little of analytical s cience and technique. Other patients been in analysis only for a very short time and then discontinued treatment on their own initiative or were advis ed that they were not suitable candidates for analytical treatment. E xcept for ps ychoanalys ts thems elves , profes sionals, as well as lay people, demonstrate varying degrees of confusion as to what ps ychoanalys is is and what it is not. No analyst can ever eliminate all the personality and neurotic factors in a given patient, no matter how thorough or success ful the treatment. Mitigation of the rigors of a punitive s uperego, however, is an es sential criterion of the effectivenes s of treatment. 655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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do not us ually regard alleviation of s ymptoms as the significant aspect in evaluating therapeutic change. absence of a recurrence of the illnes s or a further need ps ychotherapy is perhaps a more important index of value of ps ychoanalys is . T he chief bas is of evaluation, however, remains the patient's general adjus tment to life—that is , the capacity for attaining reas onable happines s, for contributing to the happines s of others, ability to deal adequately with the normal viciss itudes stress es of life, and the capacity to enter into and mutually gratifying and rewarding relationships with people in the patient's life. More s pecific criteria of the effectivenes s of treatment include the reduction of the patient's uncons cious; neurotic need for s uffering; reduction of neurotic inhibitions; decreas e of infantile dependency needs ; an increas ed capacity for respons ibility and for relations hips in marriage, work, and social relations. important criteria are the capacity for pleas urable and rewarding sublimation and for creative and adaptive application of the patient's own potentialities . T he most important criterion of the s ucces s of treatment, the releas e of the patient's normal potentiality, which been blocked by neurotic conflicts, for further internal growth, development, and maturation to mature personality functioning. Des pite the methodological difficulties and complexities outcome s tudies , extens ive empirical evaluations from number of centers P.746 have demons trated the effectivenes s and relative 656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of psychoanalysis and ps ychoanalytic therapy for appropriately s elected cases in the ps ychoneurotic conditions, pers onality disorders , and forms of s elfpathology. T herapeutic outcomes have been more guarded in cas es of ps ychosomatic illness , more levels of personality dis order, and ps ychoses .

S UG G E S TE D C R OS S T he ps ychoanalytic perspective is relevant to virtually every chapter of this book. Of particular interes t are the discuss ion of E riks on in S ection 6.2, other schools in S ection 6.3, and approaches derived from ps ychology and philosophy in S ection 6.4. Neurodevelopmental theory of s chizophrenia is S ection 12.5. P s ychological treatments of mood are covered in S ection 13.9; anxiety dis orders in 14; personality dis orders in C hapter 23; psychoanalys is ps ychoanalytic ps ychotherapy in S ection 30.1; of psychotherapy in S ection 30.11; and psychotherapy with the elderly in S ection 51.4h.

R E F E R E NC E S B alint M. P rimary L ove and P s ycho-Analytic New Y ork: Liveright; 1965. B lum HP : Mas ochis m, the ego ideal, and the of women. J Am P s ychoanal As s oc. 1976;24 Diamond D, B latt S J : Attachment res earch and ps ychoanalys is. 1. T heoretical considerations . 2. implications. P s ychoanal Inquiry. 1999;19:4–5. 657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Diamond D, B latt S J , Lichtenberg J : Attachment res earch and ps ychoanalys is . 3. F urther reflections theory and clinical experience. P s ychoanal Inquiry. 23(1). E rikson E H. C hildhood and S ocie ty. New Y ork: 1963. E rle J B , G oldberg DA: T he cours e of 253 analyses selection to outcome. J Am P s ychoanal As s oc. 2003;51:257. F airbairn W R D. P s ychoanalytic S tudies of the London: R outledge and K egan P aul; 1972. *F enichel O. T he P s ychoanalytic T he ory of Y ork: Norton; 1945. F reud A. T he ego and the mechanisms of defense. T he W ritings of Anna F re ud. V ol II. 1936. New Y ork: International Universities P res s; 1975. F reud S . O n Aphas ia: A C ritical S tudy. New Y ork: International Universities P res s; 1953. *F reud S . T he S tandard E dition of the C omple te P s ychological W orks of S igmund F re ud. 24 V ols. Hogarth P ress ; 1953–1974. *G reenberg J R , Mitchell S A. O bje ct R e lations in P s ychoanalytic T he ory. C ambridge, MA: Harvard 658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Univers ity P res s; 1985. Meis sner WW . Inte rnalization in P s ychoanalys is . Y ork: International Universities P res s; 1981. *Meiss ner W W. T he T he rape utic Alliance . New Y ale Univers ity P res s; 1996. Meis sner WW . T he E thical Dile mma of Dialogue . Albany, NY : S tate University of New Y ork P res s; 2003. Mitchell S A. R elational C once pts in P s ychoanalys is . C ambridge, MA: Harvard Univers ity P ress ; 1988. *Moore B E , F ine B D. P s ychoanalys is : T he Major New Haven, C T : Y ale Univers ity P res s; 1995. R ichards AD, T ys on P : T he psychology of women: P sychoanalytic perspectives. J Am P s ychoanal 1996;44. R izzuto AM, Meis sner WW , B uie DH. T he Dynamics Human Aggres s ion: T heore tical F oundations , Applications . New Y ork: B runner-R outledge; 2004. S chafer R . As pects of Inte rnalization. New Y ork: International Universities P res s; 1968. S hapiro T , E mde R N: R esearch in psychoanalys is : P roces s, development, outcome. J Am P s ychoanal 1993;41[S uppl]. 660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 7 - Diagnosis and P s ychiatry: E xamination of the P s ychiatric P s ychiatric Interview, H is tory, and Mental S ta tus E xa mination

7.1: Ps yc hiatric Interview, His tory, and Mental S tatus E xamination E kkehard Othmer M.D., Ph.D. S ieglinde C . Othmer Ph.D. J ohann Philipp Othmer M.D. P art of "7 - Diagnos is and P s ychiatry: E xamination of P sychiatric P atient"

INTR ODUC TION Goal of the C linic al Ps yc hiatric Interview T he goal of the initial diagnostic clinical psychiatric interview is to collect s pecific, detailed information 15 topics . T hese topics cons titute the ps ychiatric evaluation. Acquiring the databas e of information for these 15 topics enables the interviewer to make compatible with the revis ed fourth edition of Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV five axes and to develop a treatment plan acceptable to the patient: I. Identifying data. T he patient's name, s ex, age, marital s tatus, and vital s igns. 662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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II. C hief complaint. T he chief complaint in the patient's own words . Alternatively, signs of dis ordered functioning observed by the interviewer. III. Informants . A list of all informants, their reliability, level of cooperation; also previous hospital records , available. S uch informants are es sential in circums tances that prevent the patient from adequate information. C hoos ing the right s et of informants is more important than having a great number of informants. IV . R eas on for admiss ion or cons ultation. T he referral source; in case of hos pitalization, statement of status —voluntary versus involuntary—and the why hos pitalization is the safest and least environment for treatment. V . His tory of pres ent illnes s. E arly manifestations and recent exacerbations of all ps ychiatric disorders present (Axis I and II); review of diagnoses and treatments given by other providers. V I. P sychiatric dis orders in remis sion. P s ychiatric presently in remiss ion, es pecially substance abus e disorders ; ps ychiatric disorders firs t diagnosed in childhood and adolescence and their treatments . V II. Medical his tory. All medical dis orders past and and their treatments and childhood disorders that involve the central nervous system (C NS ). F or pregnancy status —es pecially if on psychotropics or expecting the us e of ps ychotropics and precautions agains t pregnancy and concomitant treatment. On all patients, but particularly in liais on work, the medical history includes the 663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interrelation of medical and ps ychiatric conditions. V III. S ocial history and premorbid pers onality. E arly developmental history. Description of premorbid personality as baseline for patient's best level of functioning. Impact of Axis I and II dis orders on patient's life. T he patient's psychosocial and environmental conditions predisposing to, precipitating, perpetuating, and protecting against ps ychiatric disorders. P remorbid vers us morbid functioning. P resent s upport s ys tem. IX. F amily history. P sychiatric history of first-degree relatives , including treatment respons e as a genetic predisposition for the patient. X. Mental s tatus examination. Appearance, cons ciousnes s, psychomotor functions , s peech, thinking, affect, mood, s ugges tibility, and thought content; cognitive functions, such as orientation, memory, intelligence, and executive functions; and judgment. XI. Diagnos tic formulation. S ummary of biological, ps ychological, and s ocial factors contributing to the patient's ps ychiatric disorder. XII. Differential diagnos is . Dis cuss ion of diagnos tic based on overlapping symptomatology. XIII. Multiaxial psychiatric diagnos is . Information on all axes . XIV . Ass ets and s trengths . Inventory of patient's knowledge, interes ts , aptitudes, education, and employment status to be us ed in the treatment XV . T reatment plan and prognos is . Account of 664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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ps ychopharmacological, ps ychological, and s ocial treatment modalities planned, frequency of visits, list of providers ; discharge criteria if inpatient. How does the interviewer get comprehensive, clinically significant, reliable, and valid information to cover points in a restricted time frame of 20 to 90 minutes? acquire the communication skills needed for this task, interviewer has to mas ter the range between disordercentered and patient-centered interviewing s tyles and apply them to the four components of the interview: rapport, techniques , mental s tatus, and diagnos ing.

Dis order-C entered vers us P atientC entered Interviewing S tyles P sychiatric interviewing is a s pecial form of human communication. T he interviewer asks the patient to disclos e complaints , s hare problems, and reveal According to the difficulties that the patient experiences with this reques t, the interviewer shifts the focus disorder-centered and patient-centered interviewing. Dis order-centered interviewing is bas ed on a atheoretical model of ps ychiatric dis orders called the me dical P .795 mode l, which is the official model s upported by the American P s ychiatric Ass ociation (AP A) and the W orld Health Organization (W HO) codified in DS M-IV -T R and the International C lass ification of Dis eas es (IC DT his framework views ps ychiatric disorders as s imilar medical dis orders, using criteria for diagnos is as 665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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identifiable clus ters of occurrences from a res tricted of symptoms , s igns, and behaviors that caus e and mortality. E ach disorder can be differentiated from other psychiatric disorders ; each has a typical natural history, often occurs in increased frequency in firs trelatives , with specific comorbidities, and with predictable treatment respons es . Whereas the an infectious dis order is established by tests that determine the pres ence or absence of a specific agent, tes ts confirming the etiology of a diagnosis in ps ychiatric disorders are not available. E xcept for the presence of es tablis hed or s us pected genetic etiology is incomplete. S pecific genetic les ions or susceptibilities, perhaps arising through multifactorial genetic factors, which form the basis of the current paradigm of the etiology of psychiatric disorders , to be determined. T he triggers for ps ychiatric disorders remain a mys tery, as do the triggers for the onset of infectious diseas es and medical conditions . R is k present in more people than actually develop the T o establish a psychiatric diagnosis based on this descriptive medical model, the interviewer chooses proven, s ymptom-oriented, open-ended ques tions with relatively narrow s cope followed up by closed-ended, nonleading ques tions centering on the dis order. P rerequisites for this style are the knowledge of the IV -T R criteria and the 15 topics to be covered. T his disorder-centered interview style works for mos t cooperative patients , patients whose communication are not impaired by their Axis I and II dis orders or their defens e mechanisms. Disorder-centered interviewing driven by the patient's help-seeking behavior. 666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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for dis order-centered interviewing can be acquired the firs t few years of training. In contras t, patient-centered interviewing is bas ed on intros pective model, which emphas izes the individuality the patient's experience. T his model attends to the intraps ychic battle of conflicts . It is s ens itive to the patient's educational, emotional, intellectual, and social background, the personality, and the individual cons tellations tracing their arrival to individual circums tances and the individual's unique respons e (cognitive-behavioral model). One example of the intros pective model is the ps ychodynamic model. Interviewing based on the psychodynamic model uses nonstructured, open-ended ques tions with a broad encouraging free as sociation. T he ps ychodynamic posits the etiology of psychiatric s ymptoms as to often unconscious inter- and intrapersonal conflicts . explores and interprets behaviors and s equences of answers . In this model, the interviewer strives to help patient overcome self-defeating intra- and interpersonal conflicts. T he prerequis ite for s uch an interview is the interviewer's experience and unders tanding of coping styles, the knowledge of how Axis I and II disorders interfere with the doctor–patient interaction (transference), and how to manage such interference. S witching to the patient-centered s tyle may become neces sary if the patient puts up res is tance and and becomes difficult to interview. T o acquire in patient-centered interviewing is a lifelong endeavor, training for excellence in most s ports. T he disorder-centered and patient-centered styles do not exclude each other. T hey are end points 667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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continuum. T he interviewer's mobility and flexibility in gliding between the two extremes determine the efficiency, reliability, validity, and quality of data T he degree of the patient's impairment determines