Tanta Handbook of Behavioral Sciences for Medical Students

Tanta Handbook of Behavioral Sciences for Medical Students By Staff Members of Neuropsychiatry Department

Tanta Faculty of Medicine

2012/2013

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Contributors Prof Abdu El Dod Prof. El Sayed Gad Prof. Ahmed Mubarak Prof. Mai Essa Prof. Hossam El Sawy Prof. Ehab Ramadan Prof. Mohammed Abdel Hay Dr Adel Badawy Dr Mohammed Seleem

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Contents

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1. Neurobiological basis of behavior 2. Human development across life span

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3. Memory

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4. Thinking and problem solving

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5. Intelligence

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6. Attention

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7. Sensation and perception

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8. Emotions

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9. Learning

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10.Motives

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11. Socio-cultural impact on behavior

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12. Aggression and violence

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13. Personality

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14. Frustration

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15. Conflicts and defense mechanisms

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16.Clinical neuropsychological testing

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17. Admission to hospital

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18. Chronic sickness and disability

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19. Psychological reactions to illness

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20. Human sexuality

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Neurobiological Basis Of Behavior Objective of this chapter: Is to demonstrate that the human behavior is the product of our brain function Historical overview: The notion that the brain is the organ of behavior is an old one. in 19th century Frans J Gall proposed the phrenology theory. According to this theory, brain is the Organs of Mental and Moral Faculties and divided the cerebral cortex into areas representing these faculties as sown in figure 1 Figure 1 Frans

J Gall and phrenology theory

Although the phrenology theory is not accurate but it directs our attention to the facts that brain plays a pivotal role in the production of our behaviors Current status of neurobiology and behavior In recent decades science has developed increasingly sophisticated techniques for investigating the

nervous system. Among the most important tools are the

neurophysiological like evoked potentials (EP) & electro-encephalography (EEG); structural imaging by computerized axial tomography (CAT) scanning and 4

magnetic resonance imaging (MRI); functional imaging as single photo emission tomography (SPECT) and positron emission tomography (PET) scanning.

Scientists often combine these techniques to study brain activity in unprecedented detail.

The recent studies of the functional neuroscience demonstrated that certain brain areas are responsible for particular psychological function. For example, limbic system contributing to emotional experience and expression, frontal lobe for cognition and for motivation, reticular activating system for sleep and in combination with the cerebral cortex it serves for process of attention.

Brain organization and behavior:  The human brain is composed of two hemispheres; left and right. Most functions of the cerebral cortex are represented on both hemispheres. In other words, halves of the occipital lobe are responsible for vision, both halves of the temporal lobes are responsible for hearing, and both halves of the frontal cortex are responsible for planning and decision making.  There is one function that is typically unilateral and found on one hemisphere—language—which is most often located on the left hemisphere.

Human language is separated in the brain into areas for comprehension and speech. Wernicke’s area is responsible for making sense of words that we hear or read, while Broca’s area is responsible for organizing the necessary muscular activities required for speech, such as controlling our lips, tongue, and breathing so that we can make sounds.  In general, anterior (more forward) areas of the cortex are involved with planning and movement, while posterior (near the back) cortical areas are involved with the processing of sensory information. (See Table1 for a description of the general functions of each lobe and other brain regions.)

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Table 1 Brain Areas and Functions Area

Functions

Frontal lobe

Decision-making, reasoning, planning, behavioral inhibition, and personality

Parietal lobe

Sensation and perception of certain senses including touch

Occipital lobe

Sensation and perception of visual information

Temporal lobe

Sensation and perception of auditory information; language comprehension

Limbic system

Emotions, learning and memory, motivation

Hypothalamus

Maintains homeostasis (body temperature, eating, drinking, sleep, metabolism)

Midbrain

Neurotransmitter production

Brainstem

Vital body functions (breathing, regulation of heart rate, consciousness

Cerebellum

Motor coordination and balance, motor learning

Now we shall discuss the frontal lobe and limbic system in some details: Frontal lobe function related to behavior: 1. Ability for initiatives and planning 2. The elaboration of personality traits which are different from one person to another. For example, we all have different likes and dislikes, such as hobbies, different senses of humor and different preferences, such as tastes in art or music.

3. Control of behavior and behavioral inhibition. In other words, certain areas in the frontal cortex are responsible for decision making and acting appropriately based on those decisions. We all know the difference between what is right and wrong. Certain areas of the cerebral cortex, including the frontal cortex, normally suppress certain thoughts, actions, and feelings.

Function of the limbic system • The limbic system is associated with emotion and motivation. • The amygdala is known to attach emotional significance to sensory input.

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• Olfactory stimuli enter the limbic loops via the endorhinal cortex of the parahippocampal gyrus.

•

The limbic system has a direct influence on neuroendocrine, autonomic, and behavior mechanisms, and it also has a role in functions such as fight or flight, homeostasis, self-maintenance, appetite, and sexuality.

Figure 2 Limbic systen

• The limbic system areas are highly interconnected with the rest of the brain, and they likely form a gateway for communication between the cerebral cortex and the hypothalamus.

• This gateway allows for cognitive processes to modify the effect of the limbic system on hypothalamic functions.

These functions showed that the limbic lobe has involvement in olfaction, emotion, and memory.

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Neurochemistry of behavior The neuronal signals are tranasimetted among the previous brain areas by chemical substances called neurotransmitters the role of the most famous transmitters in the behavior is summarized below: 1.

Acetylcholine

Central cholinergic neurons project to widespread areas of the cortex and cholinergic activity is responsible for a wide range of behaviors.

Disruption of cholinergic function can produce amnesia, and anticholinergic drug toxicity, are known to produce delirium and delusions.

Degeneration in the central cholinergic system have been consistently reported in Alzheimer's disease.

Cholinergic excess or hyperactivity has been postulated to play a role in depression and aggressive behaviors.

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2. Dopamine

Dopamine is a neurotransmitter that plays a major role in both motor function and behavior. The major dopamine pathways in the brain are the nigrostriatal, mesolimbic, and mesocortical tracts.

The nigrostriatal tract is also known as the extrapyramidal pathway. Deficiency or blockade of dopamine in this pathway produces parkinsonism symptoms.

An excess of dopamine can produce motor symptoms of dyskinesia, chorea, or tics.

The mesolimbic tract : from the mid brain to limbic system  An excess of dopamine can lead to psychosis, elation or hypomania, and confusion.  Blockade of dopamine receptors in the mesolimbic tract results in a decrease of psychotic symptoms.

Mesocortical tract :from mid brain to cerebral cortex  Decrease dopamine of the mesocortical tract may result in cognitive deficits and an increase in the negative symptoms of psychosis.  Excess may cause obsessions

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3. Serotonin

Brain serotonergic projections are a complex, highly branched system which embrace wide areas of the cortex and limbic system.

Serotonin deficiency has been associated with depression, aggression, and suicide.

Serotonin excess may play a part in anxiety, obsessive-compulsive disorders, and psychotic symptoms.

4. Norepinephrine Central noradrenergic projections arise in the brain stem and project to wide areas of the brain.  Noradrenergic deficits have been linked to depression, dementia, and diminished alertness and concentration.  Increased noradrenergic activity: has been associated with anxiety and aggression.

5. Gamma-amino butyric acid (GABA) GABA is an inhibitory neurotransmitter found in multiple projection and local systems in the brain. Increasing GABA levels can inhibit aggression.

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6. Glutamate Glutamate is the primary excitatory neurotransmitter and its neurotransmission is involved in learning, memory, and the shaping of neuronal architecture (plasticity).

Increased glutamate activity may cause toxicity to the neuron (excito-toxicity) and lead to cell death as in case of Alzheimer’s disease The functions of neurotransmitters are summarized in the following table.

Neurotransmitter Acetylcholine

Decreased Function Memory impairment, delirium, delusions

Increased Function Aggression, depression

Dopamine

Dementia, depression

Psychosis, anxiety, confusion, aggression

Serotonin

Depression, aggression

Anxiety

Norepinephrine

Depression, dementia

Anxiety, aggression

GABA

Anxiety

Reduce anxiety and aggression

Conclusion: The fact that the human behavior is basically a result of the brain function gives us an evidence that not only the normal behavior but also the psychiatric diseases like schizophrenia dementia or depression are caused by abnormal anatomy, physiology or chemistry of the brain. These abnormalities are caused by stressors of the environment, heredity or other brain lesions. This understanding help us to get the fact that mentally ill patient should be treated like other patients and should not be stigmatized and alienated because his disease is produced by the same way of other organic diseases.

References: 1.

Kolb B. & Whishaw I: Fundamentals of Human Neuropsychology Sixth Edition ,

New York, NY :

Worth Publishers,Worth Publishers, 2009 2.

3.

4.

5.

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Stahl SM: Essential Psychopharmacology. Neuroscientific Basis and Practical Applications, Second Edition. New York, NY: Cambridge University Press; 2000 Parsons CG, Danysz W, Quack G. Glutamate in CNS disorders as a target for drug development: an update. Drug News Perspect. 1998;11:523-569 Herrmann N, Lanctot KL. From transmitters to treatment: the pharmacotherapy of behavioral disturbances in dementia. Can J Psychiatry 1997;42 (Suppl 1):51S-64S. Cummings JL, Coffey CE. Neurobiological basis of behavior. In: Coffey CE, Cummings JL, eds. Textbook of Geriatric Neuropsychiatry. American Psychiatric Press;1994 :72-96.

Human development across life span Definition: it is the field of study that examines patterns of growth, change, and stability in behavior (motor, emotional, cognitive, psychosocial,..) that occur throughout the entire life span (from prenatal life to death).

Growth occurs at every period of life, from conception through very old age.

Factors affecting human development: Human development is affected by the interaction of three major systems: the biological system, the psychological system, and the societal system. All the three processes develop and change over one’s life span.

Biological system

Psychological system:-

include:-

The psychological system include

1- Genetic factors

any mental processes central to a

2-Environment resources

person’s ability to make meaning

(nutrition, sunlight)

of experiences and take action (e.g.

3-Environmental toxins

motivation, emotions, perception,

4-Diseases and accidents

learning,…)

5-Life style (eating,

It is affected by:-

sleeping, exercise, drugs)

1-Genetic factors 2-Life experience and education) 3-Self-direction insights (A person can decide to pursue a new interest, learn another language, or adopt a new set of ideas.

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Social system: The societal system includes those processes through which a person becomes integrated into society (e.g. interpersonal relationships, social roles, rituals, family organization, social support, Political and religious, Patterns of economic prosperity, poverty, war, or peace).

Chronological periods of development: there are 8 periods of development 1- Prenatal (from conception to delivery) 2- Infancy (0-2) 3- Preschool/Early Childhood (2-6 years) 4- School Age/Middle Childhood (6-12 years) 5- Adolescence (12-20 years) 6- Early Adulthood (20-40 years) 7- Middle Adulthood (40-65 years) 8- Late Adulthood (above 65 years)

I.

Prenatal Developments:

3 phases A- Germinal stage (first 2 weeks conception): implantation, formation of placenta B- Embryonic stage (2 weeks – 2 months): formation of vital organs and systems C- Fetal stage (2 months – birth): bodily growth continues, movement capability begins, brain cells multiply age of viability

II.

Infancy (0-2 years)

DEVELOPMENTAL MILESTONES: - Infants are born with reflexes that help the infant survive. The senses, except for vision, are fairly well developed at birth.

Gross and fine motor skills develop at a fast pace during infancy and early childhood.

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1- Motor Development: A-Gross Motor 1- 0-6 months: Innate motor reflexes.

2- 6 months: Sits up well and can roll over.

3- 1 year: Walks.

4- 18 months: Climbs.

5- 2 years: Runs.

6- 3 years: Jumps, stands on one foot.

B-Fine Motor 1- 0-6 months: Undeveloped.

2- 6 months: Transfers objects from one hand to the other.

3- 1 year: Manipulates objects.

4- 18 months: Uses simple objects, such as spoons and sticks.

5- 2 years: Able to copy a circle, and later a square and triangle.

6- 3 years: Able to copy a cross.

2- Social development: A. Attachment - emotional tie between infant and caretaker. According to attachment theory, an infant’s ability to thrive physically and psychologically depends in large part on the quality of attachment B. Generally, when parents are consistently warm, responsive, and sensitive to their infant’s needs, the infant develops a secure attachment to her parents.

The infant’s expectation that her needs will be met by her caregivers is the most essential ingredient to forming a secure attachment to them.

C. In contrast, insecure attachment may develop when an infant’s parents are neglectful, inconsistent, or insensitive to his moods or behaviors.

3. Erikson’s stages of social development: a- Trust Versus Mistrust: 0 – 1 years of age. Infants must rely on others for care.

Consistent and dependable caregiving and meeting infant needs leads to a sense of trust. Infants who are not well cared for will develop mistrust.

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b- Autonomy Versus Doubt and Shame: 1- 3 years of age. Children are discovering their own independence by learning to walk and to use the bathroom.

Those given the opportunity to experience independence will gain a sense of autonomy. Children that are overly restrained or punished harshly will develop shame and doubt.

Stages of Cognitive developments: Sensorimotor Stage (According to Piaget’s Stage Theory) The infant interacts with the world through sensation and movement. Develops the ability to hold a mental representation of objects

III- Preschool/Early Childhood (2-6 years):After reaching 3 years of age a child should be able to spend a few hours away from the mother in the care of others (e.g., in day care). A child who cannot do this after age 3 suffers from separation anxiety disorder.

Social development:Most notable changes are in peer relationships and types of play.

Solitary play: the child plays with his toys alone.

Parallel play: every child plays indendently from other children in the same group Cooperative play: every child shares other children and cooperates with them.

Erikson’s stages of social development: Stage 3 (3–5 years): Initiative vs. Guilt Children are exposed to the wider social world and given greater responsibility.

During this stage, sense of accomplishment leads to initiative behaviors. whereas feelings of guilt can emerge if the child is made to feel too anxious or irresponsible.

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Cognitive developments: Pre-operational (2–6 years): - The hallmark of preoperational thought is the child’s capacity to engage in symbolic thought. Symbolic thought refers to the ability to use words, images, and symbols to represent the world. Still, the preoperational child understands of symbols remains immature. 2-year-old shown a picture of a flower, for example, may try to smell it.

- Child acquires motor skills but does not understand conservation of physical properties.

- Child begins this stage by thinking egocentrically (the inability to take another person’s perspective or point of view) but ends with a basic understanding of other minds.

- The child tends to see one aspect of the situation or the stimulus.

IV- School children: Motor development: The normal grade school child, 6-12 years of age, engages in complex motor tasks (e.g., plays football...).

Social characteristics: 1. Prefers to play with children of the same sex 2. Identifies with the parent of the same sex 3. Has relationships with adults other than parents (e.g., teachers, group leaders) 4. Demonstrates little interest in psychosexual issues 5. Has internalized a moral sense of right and wrong (conscience) and understands how to follow rules.

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Cognitive characters (Stage of concrete thinking): - Has the capacity for logical thought and can determine that objects have more than one property (e.g., an object can be red and metal).

- Understands the concept of "conservation" This concept involves the understanding that a quantity of a substance remains the same regardless of the size of the container it is in (e.g., two containers may contain the same amount of water even though one is a tall, thin tube and one is a short, wide bowl).

- As the name of this stage implies, thinking and use of logic tend to be limited to concrete reality—to tangible objects and events. For example, an 8-yearold will explain the concept of friendship in very tangible terms, such as, “Friendship is when someone plays with me.”

Social Developments: Stage 4 (5–12 years) Industry vs. Inferiority This is a stage of life surrounding mastery of knowledge and intellectual skills.

Sense of competence and achievement leads to industry. Feeling incompetent and unproductive leads to inferiority.

V- Adolescents:Physical and sexual developments: The main landmark of this stage of development is the puberty and maturation of sexual development:- In girls: the onset of menstruation beginning at age 11 to 12 years. Primary sex characteristics appear (menarche, menstruation and ovulation).

Secondary sex characteristics appear (breasts, pubic hair, wider hips)

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- In boys: the first ejaculation, occurring at age 13 to 14 years. Primary sex characteristics appear (testes and penis growth) and secondary sexual characters (facial and pubic hair, broadened shoulders) start to appear.

- Both has heightened sexual and romantic interest

Cognitive Development: Cognitively – it is the start of formal Operational stage of cognitive development (11 years and up). Youth are capable of abstract reasoning and are interested in abstract issues like justice or equality.

Impulsivity in adolescents: They are more impulsive; adolescents focus more on the short-term than the longterm consequences of their actions.

The findings are also consistent with recent studies linking physical and mental changes: - The region of the brain responsible for controlling impulsive and aggressive behaviors continues to develop into the early 20s.8 - Hormonal changes associated with puberty are related to increases in “reward-sensitivity” and sensitivity to the reactions of others.

Parents and Friends in adolescents:Contrary to what many people think, parent–adolescent relationships are generally positive. In fact, most teenagers report that they admire their parents and turn to them for advice. As a general rule, when parent–child relationships have been good before adolescence, they continue to be relatively smooth during adolescence. Nevertheless, some friction seems to be inevitable as children make the transition to adolescence.

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Adolescents tend to form friendships with peers who are similar in age, social class, race, and beliefs.

Friends often exert pressure on one another to study, make good grades, attend college, and engage in prosocial behaviors. So, although peer influence can lead to undesirable behaviors in some instances, peers can also influence one another in positive ways.

VI- Early Adulthood (20-45): The characters of this stage of life are: - The person started to have his role in society which is well defined.

- Physical development peaks.

- Sense of independence.

What are the main life events at this age?

- Marriage - Having children - Occupation Stage 6 of psychosocial development (Intimacy vs Isolation): - Time for sharing oneself with another person - Capacity to hold commitments with others leads to intimacy - Failure to establish commitments leads to feelings of isolation

VII-Middle adulthood (40-65): The main characters of this stage are power and authority What physiologic functions decrease in men?

Endurance Muscle strength Sexual performance 19

In Female, it is the time of menopause which has the following effects: Lack of menstrual cycles Hot flashes Sexual Dysfunction/Vaginal Dryness Osteoporosis (long-term) According to the psychosocial theory of development, it is the stage 7 generativity vs. Stagnation: - Caring for others in family, friends, and work leads to sense of contribution to later generations - Stagnation comes from a sense of boredom and meaninglessness VIII- Late adult life (above 65 years): The average life expectancy for men in the United States is about 75 years. For women, the average life expectancy is about 80 years. So the stage of late adulthood can easily last for a decade or longer.

Psychosocial changes: Older adults experience ego integrity (The feeling that one’s life has been meaningful) when they look back on their lives and feel satisfied with their accomplishments, accepting whatever mistakes or missteps they may have made.

In contrast, those who are filled with regrets or bitterness about past mistakes, missed opportunities, or bad decisions experience despair—a sense of disappointment in life. Often the theme of ego integrity versus despair emerges as older adults engage in a life review, thinking about or retelling their life story to others.

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Cognitive Changes: Researchers found that general intellectual abilities gradually increase until one’s early forties, then become relatively stable until about age 60. After age 60, a small but steadily increasing percentage of older adults experience slight declines on tests of general intellectual abilities, such as logical reasoning, math skills, word recall, and the ability to mentally manipulate images. But even after age 60, most older adults maintain these previous levels of abilities.

A longitudinal study of adults in their seventies, eighties, and nineties found that there were significant declines in memory, perceptual speed, and fluency.

However, measures of knowledge, such as vocabulary, remained stable up to age 90.

Activity theory of aging—life satisfaction is highest when people maintain level of activity they had in earlier years. Some people in their nineties are healthier and more active than other people who are 20 years younger In general, anxiety about dying tends to decrease in late adulthood.

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MEMORY Storage of memory is done in three ways: 1-Immediate memory (sensory store): information is held for less than a second.

It is more related to attention.

2-Short-term memory (primary memory): Limited to 15-30 seconds. It holds and manipulates information for current use (working memory). It is of limited capacity, holding an average of seven “bits� of information at any one time. This information may be retained for up to several minutes but is lost or replaced by new information if not sustained by repetition. The center of the verbal working memory is in the left hemisphere while the nonverbal in the right hemisphere.

3- Long-term memory (secondary memory): Duration is from few minutes to long decades ago. It is the ability to remember information after a delay interval, during which the individual’s attention is directed away from the target information. It has extraordinary capacity with the potential for holding information without the need for continued repetition.

Types of Memory I- Declarative (explicit) memory: It is directly available for conscious awareness and can be declared (remembered). It is fast and flexible but not reliable and subject to forgetting. Declarative Memory can be divided into: a-Episodic memory: These are information learned at a particular place and time e.g., asking an individual to recall what he ate for breakfast that morning, or what he was doing when he first heard of the explosions of the 11th of September. To 22

recall the target information, the individual must be able to access information regarding the time and place of the original event. b- Semantic memory: refer to general knowledge that is not linked to a particular time or place e.g., asking an individual to define the word “breakfast” or the word “war” or to recall the alphabet. None of these tasks requires recall of where or when the information was learned.

II- Non-declarative (implicit) memory: They are expressed through performance rather than remembering, e.g., skill-related memory and classic conditioning. They are memories that are not available for conscious awareness. They are slow and inflexible, but rapidly expressed by the system involved in learning of that skill.

They are quite reliable and true. Nondeclarative memory can be divided into: 1-Procedural memory: they include behaviors as tying a shoe, riding a bicycle or driving a car. The procedure is automatic and is performed without conscious attention to the mechanics involved.

2-Conditioning: classic conditioning is another type of non-declarative memory.

3-Priming: it is a phenomenon in which previous experience with a stimulus unconsciously facilitates the subject’s ability to later identify those stimuli.

Anterograde Versus Retrograde Memory Anterograde memory refers to the ability to recall or recognize new information or new events, e.g., to learn the way to bathroom or retain events from the day faces or sequences. Retrograde memory refers to the ability to recall or recognize past information or events.

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Recent Versus Remote Memory Retrograde memory is either recent or remote. Recent memory refers to the information acquired recently. They are more disrupted than remote memory.

Remote memory is information or events acquired years before.

Requirements for memory: they are 5 1-Registration: to add new materials to memory stores.

2-Retention: to store knowledge that can be returned.

3-Retrieval: it is the capacity to obtain stored materials from memory.

4-Recall: to remember information into consciousness (no object present).

5-Recognition: feeling of familiarity of object that is present.

Centers of Memory: Three structures are forming the memory center 1- The medial temporal lobe: the hippocampus and the amygdala.

2- The diencephalon: dorsal medial nuclei of the thalamus and the mammillary body.

3- The basal forebrain Strategies to enhance retention and recall: 1-Improve

encoding:

ensure

information

understood,

make

information

meaningful, make information interesting, go into the subject more deeply.

2- Improve storage: rehearse information, repeated learning of a subject.

3- Improve retrieval: encourage frequent recall.

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Theories of forgetting: 1-Trace decay theory: gradual decay of the memory traces.

2-Interference theory: previous learning interferes with recent learning or recent learning interferes with previous learning.

3-Cue-dependent forgetting: information can’t be retrieved due to absence of a suitable cue 4-Repression: conscious effort to forget unpleasant information.

5-Mood-state-dependent forgetting: mood state at retrieval similar to that at learning.

6-Disuse: if the material learnt is not used for a long time, it is liable to forgetting.

Memory span: this means the number of items of specified character that can be correctly reproduced immediately after their first presentation, visual or auditory.

Children 4-6 years have a span of about 4 items, increase to 6-8 items at 18 years. It differs according to intelligence and included in most intelligent tests. Memory span of average persons, 6-8 items is respected and not exceeded in common use e.g. telephone numbers and automobile numbers. If there is a need to increase it, items of different natures are used e.g. letters

Disorders of Memory 1. Decreased or lost (amnesia) which may be: Anterograde: inability to learn new information. Caused by normal aging (cerebral atherosclerosis) and early dementia. Retrograde: amnesia for past events: late

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dementia. Circumscribed: a gap in memory: caused by head trauma (concussion) and dissociative disorders 2. Increased: (hypermnesia) may be normal or occur in hypomania and paranoia 3. Distortion of memory (Paramnesia): a. Confabulation: to fill a gap in his memory by false details. b. Falsification: to add false details to his normal memory. c. DĂŠjĂ vu: disorder of recognition in which new situation is regarded as a previous experience. d. Jamais vu: feeling of strangeness of familiar situation Misnaming of objects: it is momentary loss of memory for words due to faulty retrieval from memory stores.

Types of memory

Declarative Episodic cccccccc cc

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Non-declarative Semantic

Procedural

Conditioning

Priming

THINKING AND PROBLEM SOLVING Definition: Thinking is the manipulation of mental representations of information.

Representations may be words, visual images, sound, data, or any sensory modality. Thinking transforms a particular representation of information into new and different forms in order to answer a question, solve a problem or reach a goal.

The building blocks of thought are mental images and concepts Mental images: Mental images are representations in the mind of an object or event. Every sensory modality may produce corresponding mental image. Some experts see the production of mental images as a way to improve various skills and many athletes use mental imaginary in their training; they visualize themselves playing, hearing the noise, seeing the basket‌.

Concepts (categorizing the world): Concepts are categoriztion of objects, events or people that share common properties. They enable us to organize complex phenomena into simpler more easily used categories (Someone tapping a handheld screen is described as using some kind of computers even if we have never encountered that screen before) Prototypes: They are typical highly representative examples of a concept that correspond to our mental images e.g. a pigeon is a prototype of the concept bird.

Cars and trucks are prototypes of vehicles, but elevators are not. Concepts and prototypes helps physicians make diagnoses by knowing concepts and prototypes of symptoms they learned in medical schools.

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Reasoning: It is the process by which information is used to draw conclusions and make decisions Algorithms and heuristics: An algorithm is a rule that if applied appropriately guarantees a solution to a problem Heuristics: it guides you to a solution. It enhances the likelihood of success but can’t guarantee success e.g., research methodology. (You may follow certain tactics in playing a game, this tactic doesn’t guarantee that it will win, but experience taught you that it will increase the chance of success) Problem Solving: There are 3 steps for problem solving A-Preparation : understanding the problem thoroughly, pay attention to any restrictions. Problems may be well-defined or ill-defined (Well-defined problem as mathematical or jigsaw puzzle and ill-defined problem as bring peace to the middle east region) B-Production: Generating solutions, (common heuristics) 1-The solution may be easy stored in long –term memory 2-Trial and Error: A problem-solving strategy in which several solutions are attempted until one is found that works.

3-Means-ends analysis: Find actions (means) that reduce the gap between the current starting point and goal (ends) 4-Working backward: Start at goal state, move toward starting point 28

5-Searching for analogies: a similarity between the problem, one solved before.

6-Breaking a big problem into smaller problems 7-Insight: a sudden awareness of the relationships among various elements that had previously appeared to be independent of one another C-Judgment: evaluating the solution: To know whether we have been successful and to decide whether alternative solutions is best.

Obstacles to Thinking 1-Overconfidence : Tendency to be more confident than correct 2-Framing: How an issue is framed affect significantly decisions and judgments Example: What is the best way to market ground beef--as 25% fat or 75% lean?

3-Belief Bias: one’s preexisting beliefs to distort logical reasoning.

4- Belief Perseverance: clinging to one’s belief inspite of being discredited Creativity is the ability to generate original ideas or solve problems in novel ways Factors important for creativity: 1-Divergent thinking is the ability to generate unusual response to a question(thinking outside the box). Convergent thinking is the ability to produce responses based on knowledge and logic.

2-Cognitive complexity: preference for complex stimuli and thinking pattern

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Subjective versus objective thinking: Subjective thinking (egocenteric) arises from and is related to the self. Objective thinking is logical not biased, not selfcentered and it deals with realistic external reasonal data.

Autistic versus realistic thinking. Autistic thinking is imaginative, fantastic, unrealistic, wishfulfilling and not directed towards any goal. Realistic thinking is controlled, rational, purposeful, directed and confirming with real facts.

Abstract versus concrete thinking: Abstraction means giving the meaning that stands behind the words or sentences. Concrete thinking means giving the literal meaning of the words or sentences and not going beyond that level. The ability of abstraction is lost in schizophrenics and it is detected by asking the patient to explain any famous proverb (proverb test).

Conscious versus unconscious thinking: Sometimes we think without we know that we do. Sometimes the solution of a problem suddenly comes to mind without we are thinking of or comes after awaking from sleep.

Disorders of thinking I-Disorders of stream:

Hurried stream: as circumstantiality with excessive

unnecessary details and flights of ideas when stream changes from idea to another.

Slow stream as poverty of thought and thought II-Disorders of form as loosening of association, incoherence, word salad and neologism (new language formed by the patient).

III.Disorders of content as delusions (false belief of persecution, reference, influence or grandeur) and obsessions: to compulsory repeat thought or action

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III-Disorders of possession: Thought withdrawal: thoughts are withdrawn from his mind. Thought insertion: someone puts thoughts in his mind. Thought broadcasting: my thoughts are known to others.

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INTELLIGENCE Definition Not many other terms in psychology are so elusive as ‘intelligence’ escaping consensual definitions over more than 100 years of research. Intelligence is the capacity to understand the world, think rationally and use resources effectively when faced with challenges.

Theories of intelligence I.

Two factor theory (Spearman 1927):

Spearman presented a theory of general intelligence known as the two-factor theory. The underlying assumption of this model is that individual differences in a given test can be decomposed into two components. One component is common to all other cognitive tasks—a general factor of intelligence (commonly known as g factor), whereas the other component is specific to each task e.g. music (commonly known as s factor).

II.

Primary Mental Abilities (Thurstone 1938)

He stated that intelligence is formed of independent factors of intelligence that different individuals possess in varying degrees. He opposed the notion of a singular general intelligence. He was able to identify seven distinct factors reflecting:

32

1. Spatial abilities 2. Perceptual speed 3. Numerical capacities 4. Verbal comprehension 5. Word fluency 6. Memory 7. Reasoning abilities.

III.

The Gf-Gc Theory (Cattell 1971, Horn 1982):

This theory distinguishes general fluid from general crystallized abilities General fluid (Gf) abilities reflect the individual’s basic problem solving, reasoning, learning, and selective attention. e.g. if you asked: what's 15% of 270.30 LE. General crystallized (Gc) abilities: reflect the acquired knowledge and their utilization. e.g. if you are asked about the solution to poverty, a task that allows you to draw your past experience and knowledge of the world.

IV.

Multiple Intelligences theory (Gardner 1983)

The theory challenges a traditional notion that linguistic and logical intelligence, typically measured in I.Q. tests are the only intelligence of the brain. It proposes that intelligence is formed of multiple intelligences. Gardner described eight types of intelligences: 1. Linguistic: verbal abilities.

2. Logical-mathematical: mathematical abilities 3. Spatial: ability to visualize objects 4. Musical: ability to appreciate the tonal qualities of sound, compose, and play 5. Bodily-kinesthetic: ability to control movement

6. Interpersonal: ability to understand other people’s feelings and attitudes (social intelligence) 7. Intrapersonal: ability to understand and control his own thoughts and emotions (emotional intelligence).

8. Naturalist: recognizing and classifying phenomena in the environment.

Assessing Intelligence Benefits of intelligence tests These are tests used to measure a person’s level of intelligence. They identify students in need of special attention and diagnose cognitive difficulties.

Moreover, they help people to make optimal educational and vocational choices.

Examples of intelligence tests: Stanford-Binet intelligence test and Wechsler adult intelligence Scale (WAIS) Intelligence Quotient (IQ) Mental age: the average age of the individual who achieves a particular level of performance on a test Intelligence Quotient (IQ): A score that takes into account an individual’s mental and chronological age -IQ = mental age

x 100

chronological age -If a child can solve problems that most other four-year-old can solve, we can say his mental age is 4. If he is also chronologically 4 years old, his IQ would be 100 which is the mean.

-If a 10-year-old obtained a score of 12 and his IQ would be 12/10X100=120. -A 20-years performing at a mental age of 18 has an IQ of 90. -5-years-old performing at a mental age of 3 has an IQ of 60

34

Distribution of IQ scores: (Bell shaped curve of intelligence)

 Average range: 85 to 115  “Gifted” range: 130+  Mentally retarded: < 70

Group differences in intelligence  Rural and Urban: according to educational opportunities and Industrialization  Occupational differences  Race Differences  Sex Differences: boys tend to do better on arithmetic reasoning intelligence Test & or girls better on Vocabulary Tests. Traditional IQ tests have been frequently criticized for being biased in favor of

white middle socioeconomic class Culture-fair tests were developed to avoid questions that depend on particular

cultural background

35

Factors affecting intelligence Heredity provides physical body to develop with certain inherent capabilities while environment provides maturation and training of the individual. Variations in I.Q. were determined to be about 68% by heredity and 32% by environment.

Nature’s influence on IQ (hereditary factors) is evidenced by:  Identical twins reared together are more similar than fraternal twins reared together  Siblings who grow up together are more similar than unrelated individuals who grow up in the same house  Children are more similar to their biological parents than to adoptive parents Nurture’s influence on IQ (acquired factors) includes:  Prenatal care, exposure to alcohol and other toxins, birth complications, malnutrition in the first few months of life all adversely affect mental abilities.

On the other hand, more intellectual stimulation at home, high-quality education, and more time spent in school all improve IQ. Environment of children ages 2 to 4 years appears to be critical since the child normally learns language at this time.

Race and Sex: There is no prominent evidence to show that race is a factor for determining intellectual level. Research studies have shown that there are no significant differences between the sexes. Boys tend to do better on arithmetic reasoning intelligence tests while girls tend to do better on vocabulary Tests

36

Mental Retardation (MR) Incidence: MR occurs in 1-3% of the population.

Definition: It is a disability characterized by significant limitations both in intellectual functioning and in conceptual, social and practical adaptive skills.

Intelligence tests can measure intellectual functioning but not limitations in adaptive skills Classification Mild MR: IQ ranges from 55-69. They constitute 90% of MR. They can be educated with some support, can function independently, and can hold jobs and have families of their own.

Moderate MR: IQ 40-54. They have deficits in language and motor skills. They can be trained and hold simple manual jobs but need moderate supervision and support Severe MR: IQ 25-39, and Profound MR: IQ below 25, are unable to live independently need care for their entire life Causes of Mental Retardation include 1. Hereditary causes 2. Genetic defects: as Down syndrome 3. Environmental: e.g. Inadequate mental stimulation, poor diet, little or no medical care 4. Traumatic brain damage 5. Toxic, e.g. fetal alcohol syndrome 6. Hypoxia

Mental Giftedness: They constitute 2-4%. Their IQ is above 130. They tend to be healthier and more successful than non-gifted 37

ATTENTION Attention is the cognitive process of selectively concentrating on one aspect of the environment while ignoring other things. Attention has also been referred to as the allocation of processing resources.

Examples include listening carefully to what someone is saying while ignoring other conversations in a room or listening to a cell phone conversation while driving a car. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience. 

Focused attention: The ability to respond discretely to specific visual, auditory or tactile stimuli.



Sustained attention (vigilance): The ability to maintain a consistent behavioral response during continuous and repetitive activity. It is the act of maintaining attention for indefinite time.



Selective attention: The ability to maintain a behavioral or cognitive set in the face of distracting or competing stimuli. Therefore it incorporates the notion of "freedom from distractibility."



Alternating attention: The ability of mental flexibility that allows individuals to shift their focus of attention and move between tasks having different cognitive requirements.



Divided attention: This is the highest level of attention and it refers to the ability to respond simultaneously to multiple tasks or multiple task demands.

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Neural correlates of attention Most experiments show that one neural correlate of attention is enhanced firing. If a neuron has a certain response to a stimulus when the animal is not attending to the stimulus, then when the animal does attend to the stimulus, the neuron's response will be enhanced even if the physical characteristics of the stimulus remain the same.

In a recent review, Knudsen describes a more general model which identifies four core processes of attention, with working memory at the center: 

Working memory temporarily stores information for detailed analysis.



Competitive selection is the process that determines which information gains access to working memory.



Through top-down sensitivity control, higher cognitive processes can regulate signal intensity in information channels that compete for access to working memory, and thus give them an advantage in the process of competitive selection. Through top-down sensitivity control, the momentary content of working memory can influence the selection of new information, and thus mediate voluntary control of attention in a recurrent loop (endogenous attention).



Bottom-up saliency filters automatically enhance the response to infrequent stimuli, or stimuli of instinctive or learned biological relevance (exogenous attention).

39

Factors affecting attention: A)Factors in the stimulus: 1) Intensity of the stimulus: A strong stimulus is more likely to be noticed than a weak one. Bright colors, loud sounds, sweet perfume will attract more attention.

2) Contrast between the stimulus and its background : a black spot in a white field will attract attention more easily.

3) Changeability of the stimulus: A changing stimulus is more easily to be noticed than one that does not change. A flickering light attract our attention more than a steady one.

4) Type of stimulus: It has been shown that pictures attracts more attention than words.

5) Repetition of stimulus: A repeated stimulus is more likely to be noticed than a single one.

6) Combination of stimuli: Stimuli reaching more than one sense organ at the same time attract attention more than a single one stimulating only one sense organ. The television is more attractive than the radio.

7) Strange and unfamiliar objects attract the attention more than common objects.

8) Clarity of the stimulus.

9) Position of stimulus: The ordinary reader will observe the upper half of the newspaper more than the lower half.

B) Factors in the individual: 1) physical health: intact sensory system, so sensory handicap (e.g. defective vision or hearing) interferes with efficient attention.

2) Intelligence: people with superior intelligence can attend more readily than others.

3) Emotional state: When someone is depressed he is less attentive than he is happy.

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4) The interest or set at the moment can affect attention: You always attend to what is going with your interest at the moment. If you wish to buy a certain article and you are prepared to do so it catches your attention in the shop windows you pass by.

Distraction: is the negative aspect of attention.

Causes of distraction: 1) External environmental factors: as noises, inappropriate weather, lack of ventilation.

2) Internal personal factors: A) physical factors: biological needs (e.g. hunger, thirst), fatigue, lack of sleep and physical illness.

B) Psychological factors: i-

Emotional state as depression, fear or anger.

ii-

Lack of interest in certain subject

iii-

Indulgence in day dreams.

iv-

Preoccupation with certain thoughts.

v-

Mental illness e.g. mania

3) Social factors: family troubles, marital disharmony, financial difficulties, occupational maladjustment.

41

SENSATION AND PERCEPTION We use our senses in two almost inseparable processes: One process is sensation, the act of using our sensory systems to detect stimuli present in the environment around us. Once acquired, sensory information must be interpreted in the context of past and present sensory stimuli. This process, which also involves recognition and identification (for example, the realization that you recognize the smell in a restaurant as pizza cooking), is broadly defined as perception.

Sensation and perception are both critical for our interpretation.

So, Perception : is the process of getting to know environment by the use of the senses then giving meaning to this sensation.

Sensation the act of using our sensory systems to detect environmental stimuli.

Sensory receptor cells specialized cells that convert a specific form of environmental stimuli into neural impulses.

Sensory transduction the process of converting a specific form of environmental stimuli into neural impulses.

Absolute threshold the minimal stimulus necessary for detection by an individual.

Difference threshold or just noticeable difference the minimal difference between two stimuli necessary for detection of a difference between the two.

Sensory adaptation the process whereby repeated stimulation of a sensory cell leads to a reduced response.

Bottom-up processing perception that proceeds by transducing environmental stimuli into neural impulses that move onto successively more complex brain regions.

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Top-down processing perception processes led by cognitive processes, such as memory or expectations.

The Chemical Senses: Smell and Taste • Smell, our olfactory sense, converts chemical odorants into neural signals that the brain can use. Taste, our gustatory sense, is closely intertwined with smell. Most flavors are a combination of scents with the five basic tastes we can discern: sweet, salty, sour, bitter, and umami.

• Our tactile sense combines with taste and smell, to help us appreciate, or dislike the textures of foods and to experience temperature and “hot” sensations from capsaicin in spicy foods.

• Taste buds in papillae on the tongue convert chemicals in our food to neural signals the brain can use. Taste receptors and smell receptors are routinely replaced, since they are more vulnerable to damage than other sensory receptors.

• Information about smell goes directly from the olfactory bulb to the olfactory cortex. Areas of the brain that process smells and tastes are plastic, or changeable.

Processing of smells also sometimes overlaps with emotions and memories.

• Our preferred tastes change as we mature from childhood to adulthood, probably from a combination of learning and physical changes in the mouth.

• True disorders of taste are rare; people more frequently lose part or all of their sense of smell. Anosmia can present safety risks and diminish pleasure in life.

The Tactile or Cutaneous Senses:Touch, Pressure, Pain, Vibration • A variety of sensory receptors throughout our bodies convert touch, pressure, or temperature stimuli into neural impulses that our brains can perceive.

• The sensory cortex of the brain maps touch sensations. Especially sensitive or important body parts receive disproportionately large representation in the cortex.

• Pain travels to the brain via both a fast pathway and a slow pathway.

43

• People differ greatly in the perception of pain. Some of the differences are related to culture and gender. Others are individual.

• The gate control theory of pain suggests that certain patterns of neural activity can close a “gate” so that pain information does not reach parts of the brain where it is perceived.

• The inability to feel pain can put people at high risk for injuries.

• People who have lost body parts surgically or through accidents often feel phantom sensations in the missing body part. These may be related to reorganization of the somatosensory cortex after an amputation.

The Auditory Sense: Hearing • The frequency and amplitude of sound waves produce our perceptions of pitch and loudness of sounds.

• When sounds enter the ear, they move the ear drum, which sets in motion the ossicles. The last of these, the stirrup, vibrates the oval window, setting into motion fluid in the cochlea. Hair cells on the basilar membrane in the cochlea transduce movements along the basilar membrane into neural signals the brain can interpret.

• Frequency theory suggests that patterns in the firing rates of the neurons are perceived as different sounds. Place theory suggests that information from different locations along the basilar membrane is related to different qualities of sound.

• Top-down processing lets us use the general loudness of sounds, as well as differences in the signals received from each ear, to determine location of a sound.

• Different pitches are represented in a tonotopic map in the auditory cortex of the brain. Association areas of the cortex help us recognize familiar sounds, including speech.

• The brain integrates information from multiple sensory systems to enable the appropriate recognition and response to stimuli. Some people experience an overlap of sensory systems known as synesthesia.

44

• As young children, we experience a sensitive period during which it is especially easy for us to learn auditory information, including language and music. Some people, particularly those exposed to pure tones during this sensitive period, develop absolute pitch.

• Common hearing problems include hearing loss and deafness, as well as hearing unwanted sounds, such as tinnitus.

The Visual Sense: Sight • Vision is very important to humans, and a great deal of our brain is involved in processing visual information.

• Rods and cones in the retina at the back of the eye change light into neural impulses. Cones provide detailed vision and help us perceive color, while rods provide information about intensity of light.

• The fovea at the center of the retina contains only cones and provides our sharpest vision. We have a blind spot where the optic nerve leaves the retina to carry information to the brain.

• In the brain, visual information is processed through the “what” and “where” pathways.

• Damage to the brain can produce deficits in sensation, as well as abnormal sensory experiences.

• Without adequate visual stimulation through both eyes during a critical period of life, we may not develop binocular vision, a condition known as amblyopia.

• Blind individuals can use other sensory modalities to compensation for the loss of visual information. Learning Braille with touch involves the use of brain areas normally used for vision.

Factors Affecting Perception: 1)Personal factors (factors in the individual): a- Habit, past experiences and familiarity; help perception of things easily.

45

b- Set and expectation; may alter perception of the true stimulus. c- Emotional state; may intensify or decrease the acuity of perception. d- Healthy intact special senses; are important for good accurate perception. e- Aesthetic value; that is the internal attitude and readiness in the person to perceive symmetrical pleasant figures rather than irregular, ugly and unpleasant ones.

2) Factors in the stimulus: a- Figure and background: the more contrast between figure and its background, the more clear and vivid perception. b-Similarity: there is tendency to perceive similar things or stimuli as one group. c-Proximity: there is tendency to perceive nearby things or stimuli together. d- Formation of figure: tendency to perceive a defective unclosed, interrupted, incomplete , asymmetrical and poor figure as if is closed, continuous, complete, symmetrical and goof figure.

Disturbances of perception: a)- Illusions: False perception of real external sensory stimuli.

Causes: 1-Normal: due to i- set and expectation: if some body is waiting an important telephone call he may perceive ringing of the bell of the door as a telephone ring. ii- intense emotions. iii- lack of perceptual clarity.

2-Neurotic: anxiety.

3-Psychotic: accompanying delusions.

4- Delerium. b)-Hallucinations: False perception without the presence of external stimulus. (visual, auditory, olfactory, gustatory and tactile).

Causes: 46

1- Physiological: occur in normal people in the state between sleeping and waking. These are called hypnagogic hallucinations.

2- Pathological hallucinations: i-

Psychiatric diseases: psychoses particularly schizophrenia.

ii-

Organic conditions: toxic states like alcoholism, metabolic states as renal and hepatic failure, and brain lesions like tumors and epilepsy.

References: 1-Psychology around us: Ronald comar and Elizabeth Gould. John Wiley and Sons,Inc. 2011.

2-Behavioual sciences for medical students: Omar Shaheen, Abdou El-Dod, El-Sayed Gad and Ahmed Moubarak. Mona library, 2002.

47

EMOTIONS Dr. Mohamed Ahmed Abd El-Hay

Emotion is a complex state that is easily recognized, though difficult to define, in part because our emotional experiences are so varied and complex.

Emotion researchers define an emotion as "a pattern of response subjectively experienced as strong feeling, usually directed toward a specific object".

The responses include physiological arousal, impulses to action, thoughts and expression of all these.

The specific objects are the goals and needs which could be fundamental such as food, shelter, and survival, or could be more complex like searching for love, ambition to win a prize or to build self respect.

48

Emotions are transitory, with relatively well-defined beginnings and endings.

This is in contrast to moods, which have less specific causes and last for longer periods of time.

The Functions of Emotions Psychologists identified several important functions that emotions play in our daily lives. Among the most important of those functions are the following:  Making life interesting: life would be considerably less satisfying, and even dull, if we lacked the capacity to feel and express emotion. Thus emotions make life interesting.  Preparing us for action. Emotions act as a link between events in our environment and our responses. For example, if you saw an angry dog charging toward you, your emotional reaction (fear) would be associated with physiological arousal of the sympathetic nervous system, the activation of the “fight-or-flight” response.  Shaping our future behavior. For example, your emotional response to unpleasant events teaches you to avoid similar circumstances in the future.  Helping us interact more effectively with others. We often communicate the emotions we experience through our verbal and nonverbal behaviors. These behaviors can act as a signal to observers, allowing them to understand us better what we are experiencing and to help them predict our future behavior.

Emotional process (Components of emotions) A- Arousal: While the physiological changes associated with emotions are triggered by the brain, they are carried out by the endocrine and autonomic nervous systems.

49

For example; in response to fear or anger, the brain signals the pituitary gland to release a hormone called ACTH, which in turn causes the adrenal glands to secrete cortisol, which triggers what is known as the fight or-flight response, (that prepare the body for action in dangerous situations).

During fight or-flight response, the heart beats faster, respiration is more rapid, the liver releases glucose into the bloodstream to supply added energy, fuels are mobilized from the bodyâ&#x20AC;&#x2122;s stored fat, and the body generally goes into a state of high arousal. The pupils dilate, perspiration increases while secretion of saliva and mucous decreases, hairs on the body become erect, and the digestive system slows down as blood is diverted to the brain and skeletal muscles. These changes are carried out with the aid of the sympathetic nervous system. When the crisis is over, the parasympathetic nervous system returns things to their normal state.

Moderate levels of arousal increase efficiency levels by making people more alert.

However, intense emotions, either positive or negative, interfere with

performance because central nervous system responses are channeled in too many directions at once. The effects of arousal on performance also depend on the difficulty of the task at hand; emotions interfere less with simple tasks than with more complicated ones.

B- Appraisal (Cognitive control of emotion) 1. Cognitive interpretation (appraisal) of events with respect to personal needs and goals play a large role in human emotion.

2. Negative and positive appraisals are the most basic type made.

C- Expressive behavior 1. Smiling, crying, running, shouting, change in facial expression, body language and vocal qualities convey the person's emotions.

50

2. There are similarities in the expression and interpretation of basic emotion around the world.

D- Affective aspect Subjective experience of feelings (e.g., being afraid, angry, depression, happy, etc.).

Neuroanatomy of emotions • Specific brain regions have specific roles in emotional expression and experience. Areas of the brain that play an important role in the production of emotions include the reticular formation, the limbic system, and the cerebral cortex.

• The reticular formation, within the brain stem, receives and filters sensory information before passing it on the limbic system and cortex.

• The limbic system includes the hypothalamus, which produces most of the peripheral responses to emotion through its control of the endocrine and autonomic nervous systems; the amygdala, which is associated with fear and aggressive behavior; the hippocampus; and parts of the thalamus.

• the amygdala appears to be very involved in the perception (as opposed to the expression) of fear; lesioning the amygdala leaves a person unable to perceive fearful emotions from others, although these patients have no problems matching the appropriate emotion with a sentence or in expressing various emotions using facial expression upon request • The frontal lobes of the cerebral cortex receive nerve impulses from the thalamus and play an active role in the experience and expression of 51

emotions. fMRI has revealed that the lateral aspects of the frontal lobes as most associated with positive emotions, whereas the medial aspects of the frontal lobes are most associated with negative emotion â&#x20AC;˘ The right hemisphere is more involved in perception of emotion, specifically facial expression and prosody (melody of speech that conveys sincerity, sarcasm, etc.)

Classification of emotions Emotions are described in terms of feeling, e.g., fear, anger, joy, grief, and sadness. Most language contains many words and descriptive phrases associated with emotions. However, no consensus was reached with attempts to classify emotions into basic categories. This may be due to cultural differences.

All accounts about emotion agree that emotions can be classified along two broad dimensions; the degree of pleasantness and degree of arousal. ď&#x201A;ˇ

Pleasant- unpleasant dimension: Some emotions such as fear are

clearly unpleasant (also called negative), and others such as joy are clearly pleasant (also called positive). ď&#x201A;ˇ

Degree of arousal dimension: Some emotions such as anger and joy

are associated with high level of arousal; others such as sadness are associated with decreased energy.

Measuring Emotion The judgment of emotion is largely a subjective matter, (this is true both for a person experiencing an emotion and for someone else who is judging that person's experience.

52

Several different indicators can be used to identify the emotion expressed and the level of arousal and feelings being experienced. These indicators include: 1. Observation of behavior: observed behavior such as facial expression, gestures, and postures can be used to understand the emotion being expressed.

2. Recording physiologic changes: changes in heart rate, blood pressure, breathing pattern, pupillary dilatation, blood flow to the periphery, and electrodermal activity are often interpreted as indicator of emotions.

3. Self-reports of emotional experience: this could be achieved through direct inquiry of emotion experience or through the administration of either formal scales, such as Hamilton depression rating scale. Personal reports often include written or spoken descriptions of feelings.

4. Projective technique: e.g., Rorschach test.

53

LEARNING Learning is acquiring new or modifying existing knowledge, behaviors, skills, values, or preferences and may involve synthesizing different types of information.

The ability to learn is possessed by humans, animals and some machines.

Types of learning: I- Non-associative learning: behavior change as a result of presentation of one stimulus repeatedly. It also describes learning which has no association with reward or punishment. Common examples include: A- Habituation.

B- Sensitization.

C- Observational learning (Modeling).

II- Associative learning: Learning that occurs when a connection or pairing is made between a particular stimulus and a particular response.

I- Non-associative learning A- Habituation A person first responds to a stimulus, but if it is neither rewarding nor harmful the person reduces subsequent responses, i.e., there is a progressive diminution of behavioral response probability with repetition stimulus.

B- Sensitization Sensitization is the progressive amplification of a response following repeated administrations of a stimulus. An everyday example of this mechanism is the repeated tonic stimulation of peripheral nerves that will occur if a person rubs his arm continuously. After a while, this stimulation will create a warm sensation that 54

will eventually turn painful. The pain is the result of the progressively amplified synaptic response of the peripheral nerves warning the person that the stimulation is harmful.

C- Observational learning (Modeling) Observational learning is learning through observing the behavior of another person (called a model). Observational learning plays an important role in countless types of everyday behavior, including aggression. The skills and rituals acquired by each generation are passed on this way, not through deliberate training. This type of learning is more efficient and faster than operant learning.

Observational learning is important in many aspects of life, including work; for example, it can be used in training programs designed to help workers interact more effectively with people from different cultural backgrounds.

Modeling can be used to learn a medical procedure and to then teach it to others.

Like the well-known description of learning in medicine, see one, do one, teach one.

Studies have shown that modeling can be used to ease fear in people undergoing medical procedures. For example, before having an endoscopy, a patient is instructed to view a videotape of another patient comfortably undergoing the same procedure while successfully using relaxation and other coping strategies. When the patient himself then undergoes the procedure, he is relaxed and comfortable.

II- Associative Learning (conditioning) is the process by which an element is taught through association with a separate, pre-occurring element. Two major types are described: A. Classical conditioning (respondent learning) Classical conditioning is a form of learning first described by Ian Pavlov, in which an association is formed between one stimulus and another.

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• Neutral stimulus is a stimulus that currently does not produce a response the response of interest when it is presented.

• Unconditioned stimulus is any stimulus that automatically (without being learned) produces a response (e.g., the odor of food).

• Unconditioned response is the response made to the unconditioned stimulus (e.g., salivation in response to the odor of food).

• Conditioned stimulus is a previously neutral stimulus that has now been conditioned to produce a response (e.g., the sound of the lunch bell).

• Conditioned response is the response made to the conditioned stimulus (e.g., salivation in response to the lunch bell).

Further Concepts that Apply to Classical Conditioning • Generalization: conditioned response is given to stimuli that are similar to the conditioned stimulus; [(e.g., a fire bell) that resembles a conditioned stimulus (e.g., the lunch bell) causes a conditioned response (e.g., salivation)].

• Discrimination: conditioned response not given to stimuli that are dissimilar to the conditioned stimulus.

• Extinction: If the conditioned stimulus is presented repeatedly without being followed by the unconditioned stimulus, the conditioned response will diminish or cease • Spontaneous Recovery: Following extinction, the conditioned response will spontaneously re-appear after a delay B. Operant conditioning In operant conditioning or trial and error learning, learning occurs because of the consequences to the individual of a previous behavior. Although a behavior may 56

have occur randomly at first, the consequence, occurring immediately after the behavior, determines whether the behavior continues, i.e., operant conditioning is a type of learning in which a voluntary response is strengthened or weakened, depending on its favorable or unfavorable consequences. The likelihood that a behavior will occur is increased by reinforcement and decreased by punishment.

Operant conditioning is distinguished from classic conditioning in that operant conditioning

uses

reinforcement/punishment

to

alter

an

action-outcome

association. In contrast classic conditioning involves strengthening of the stimulusoutcome association. So when teaching an individual a response, you need to find the most potent reinforcer for that person. This may be a larger reinforcer at a later time or a smaller immediate reinforcer.

Factors affecting operant conditioning: A- Reinforcement: is the stimulus that increases the probability that a prior behavior will occur again.  Positive reinforcement is the introduction of a rewarding or positive stimulus that results in an increase in a preceding response.  Negative reinforcement is the removal of an aversive stimulus that lead to an increase in the probability that a preceding response will occur again in the future.

B. Punishment is the stimulus that decreases the probability that a prior behavior will occur again.  Positive punishment weakens a response through the application of an unpleasant stimulus  Negative punishment consists of the removal of something pleasant 57

Schedules of Reinforcement  Continuous reinforcement: Behavior that is reinforced every time it occurs  Partial reinforcement: Behavior that is reinforced some but not all of the time  Fixed-ratio schedule: Reinforcement is given only after a certain number of responses  Variable-ratio schedule: Reinforcement occurs after a varying number of responses rather than after a fixed number  Variable-interval schedule: Time between reinforcements varies around some average rather than being fixed  Fixed-interval schedule: Provides reinforcement for a response only if a fixed time period has elapsed, overall rates of response are relatively low Factors affecting learning: I. Personal Factors: 1- Age: it can influence the capability of learning; a child can not learn the things what elders can learn and an aged person will have difficulty to learn modern ways of knowledge.

2- Intelligence: learning is generally easier among those with higher degrees of intelligence 3- Attention: Attention is very important factor which influence learning, if a person does not pay attention towards how to learn a specific knowledge, skill or experience, he can not learn easily 4- Motivations: strong motives help learning. Psychologists and educators also recognize that learning is best when the learner is motivated to learn.

External rewards are often used to increase motivation to learn. Motivation aroused by external rewards is called extrinsic motivation. In other cases, 58

people are motivated simply by the satisfaction of learning. Motivation that results from such satisfaction is called intrinsic motivation. This type of motivation can be even more powerful than extrinsic motivation.

5- Emotional state and mental health: anxiety and depression impair the process of learning.

6- Physical health: sensory deprivations (i.e., blindness, deafnessâ&#x20AC;Ś..) and physical health could affect learning.

II.

External Factors 1- Methods of learning: every individual has its own learning preference that he responds more to it, thus the method used in learning affect the process of learning.

2- Previous learning help in acquisition of new materials. Psychologists and educators recognize that new learning can benefit from old learning because learning one thing helps in learning something else. This process is called transfer of training.

3- Nature

of

knowledge:

If

knowledge

is

interesting

in

nature,

any individual can learn it more efficiently.

4- Environmental factors; weather, noise, light etc. may impair or facilitate learning process.

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MOTIVATION DEFINITION A motive is an internal state, (physiological or psychological arousal) that arouses direct, and maintains behavior towards a goal.

Explaining Motivation: A lot of psychological theories were put to explain why a person is motivated to do certain behavior, these include:

Instinct Approaches: According to instinct approaches to motivation, people and animals are born preprogrammed with sets of behaviors essential to their survival. Those instincts provide the energy that channels behavior in appropriate directions. Hence, sexual behavior may be a response to an instinct to reproduce, and exploratory behavior may be motivated by an instinct to examine oneâ&#x20AC;&#x2122;s territory.

Drive-Reduction Approaches: Drive-reduction approaches suggest that a lack of some basic biological requirement such as water produces a drive to obtain that requirement (in this case, the thirst drive).

According to this approach, a drive is the motivational tension, or arousal, that energizes behavior to fulfill a need. Many basic drives, such as hunger, thirst, sleep, and sex, are related to biological needs of the body or of the species as a whole. These are called primary drives. Primary drives contrast with secondary drives, in which behavior fulfills no obvious biological need. In secondary drives, prior experience and learning produce needs. For instance, some people have 60

strong needs to achieve academically and professionally. We can say that their achievement need is reflected in a secondary drive that motivates their behavior.

We usually try to satisfy a drive by reducing the need underlying it. For example, we eat when we feel hungry. If the weather turns cold, we put on extra clothing or raise the setting on the thermostat to keep warm. If our bodies need fluids to function properly, we experience thirst and seek out water.

Arousal Approaches: Arousal approaches seek to explain behavior in which the goal is to maintain or increase excitement. According to arousal approaches to motivation, each person tries to maintain a certain level of stimulation and activity. This model suggests that if our stimulation and activity levels become too high, we try to reduce them.

But, if levels of stimulation and activity are too low, we will try to increase them by seeking stimulation.

People vary widely in the optimal level of arousal they seek out, with some people looking for especially high levels of arousal. For example, people who participate in risky sports, high-stakes gamblers, and criminals who pull off high-risk robberies may be exhibiting a particularly high need for arousal.

Incentive Approaches: Incentive approaches to motivation suggest that motivation stems from the desire to obtain valued external goals, or incentives. In this view, the desirable properties of external stimuli â&#x20AC;&#x153;whether grades, money, affection, food, or sexâ&#x20AC;?, account for a personâ&#x20AC;&#x2122;s motivation. For example, when a delicious dessert appears on the table after a filling meal, its appeal has little or nothing to do with internal drives or the maintenance of arousal. Rather, if we choose to eat the dessert, such behavior is 61

motivated by the external stimulus of the dessert itself, which acts as an anticipated reward.

Cognitive Approaches: Cognitive approaches to motivation suggest that motivation is a product of peopleâ&#x20AC;&#x2122;s thoughts, expectations, and goals; (their cognitions). For instance, the degree to which people are motivated to study for a test is based on their expectation of how well studying will result in a good grade.

Cognitive theories of motivation draw a key distinction between intrinsic and extrinsic motivation. Intrinsic motivation causes us to participate in an activity for our own enjoyment rather than for any concrete reward that it will bring us. In contrast, extrinsic motivation causes us to do something for money, a grade, or some other concrete reward. For example, when a physician works long hours because he loves medicine, intrinsic motivation is prompting him; if he works hard to make a lot of money, extrinsic motivation underlies her efforts.

Maslowâ&#x20AC;&#x2122;s Hierarchy: Ordering motivational needs Maslowâ&#x20AC;&#x2122;s model places motivational needs in a hierarchy and suggests that before more sophisticated, higher-order needs can be met, certain primary needs must be satisfied. A pyramid can represent the model, with the more basic needs at the bottom and the higher-level needs at the top (see Figure 1 ). To activate a specific higher-order need, thereby guiding behavior, a person must first fulfill the more basic needs in the hierarchy.

The basic needs are primary drives: needs for water, food, sleep, sex, and the like.

To move up the hierarchy, a person must first meet these basic physiological needs. Safety needs come next in the hierarchy; Maslow suggests that people need 62

a safe, secure environment in order to function effectively. Physiological and safety needs compose the lower-order needs.

CLASSIFICATION OF MOTIVES I- Physiologically based motives Basic physiological motives are concerned with the following needs: A- Survival needs: Directed towards the survival of individual e.g. hunger, thirst.

B- Biological needs: Directed towards the survival of species e.g. sex and motherhood motives.

C- Emergency needs: Related to the welfare of the organism and to deal with the environment, e.g., ď&#x201A;ˇ Escape and fear (on facing danger e.g. withdrawal reflex)

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 Combat and anger (civilized man modifies these motive to be

socially accepted)  Objective motive; exploration, manipulation, curiosity to deal with

the environment.  Others (mastery, chase)

Characteristics 1. Innate motives (Present since birth; it is a good positive criteria; its absence

did not exclude innate nature, e.g., sex motive which is not present since birth).

2. Universal: present in all individual 3. Homeostatic (leads to satisfaction).

4. Permanent: once present always present 5. Learning has a role in influencing the way in which the biological innate

motives are expressed (combination of motives).

II- Psychologically-based motives These motives are not rooted in biology, but are learned and acquired a- Achievement motives Determined by one’s need to attempt and succeed at task and to achieve a standard of success and excellence. b- Power motives Some people want to excel and to be in control of others. c- Affiliation motives The need to be with others, to work, to form friendship etc. d- Competency motives To be able to cope effectively with the challenges of every day life. e- The need for recognition f- The need for dominance 64

g- The need for affection and love. h- Social motives  General social motives: motives shared by a group of people.  Cultural social motives: depends on the individual culture and education.  Individual social motive: may according to each person’s environment,

family and occupation etc.

Characteristics 1- Not universal it depends on  Attitude: tendency to behave in certain manner toward an object.  Interests: attention directed towards certain purpose.  Purpose: goal set through purposive action.

2. Non homeostatic 3. Learned and acquired through direct learning, vicarious learning and cognition.

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SOCIO-CULTURAL IMPACT ON HUMAN BEHAVIOR Human behavior beside its genetic basis can be strongly shaped through socio-cultural factors. These factors can affect human behavior through its strong impact on issues like identity, personality development, value system, cognitive and emotional development.

A human society is a group of people related to each other through persistent relations, sharing the same geographical territory, subject to the same political authority. Human societies are usually composed of small units (families, tribes, groupsâ&#x20AC;Ś.etc) who share a distinctive culture.

Culture is the set of shared attitudes, values, goals, and practices that characterizes any society.

I-Impact of family on human behavior Family can be described as the unique unit of any given society.

1-Family structure: Any given family is composed of parents and siblings who are in a state of communication and has its boundaries which allow a degree of interaction with the surroundings. Accordingly there might be: - single-parent family: one of the two parents is absent due to death, travel or desertion - nuclear family: original family of the individual (his parents and siblings) - family of procreation: the individualâ&#x20AC;&#x2122;s procreated family (his wife/her husband and offspring) - Extended family: living with grandfather or grandmother and sometimes with uncles or aunts.

- Abnormal communicative style: between members of the same family. No communication (isolation and living of the family members apart from each

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others) or bad communication (interpersonal insults) can negatively affect the homogeneity of the family atmosphere.

- Abnormal family boundaries: the best is the translucent boundary which allows the family to preserve its own identity and values and at same time to interact with the surrounding world for its benefit. Sometimes the boundary is opaque as in conditions of family isolation which permits no communication with the surroundings. Also, sometimes the boundary is transparent which causes complete family dissolution and loss of family identity.

2-Family function: the role of the family as a whole or the roles of its members in a given society. It should have a positive role going towards proper upbringing, education and effective sharing in the society development.

3-Family stresses: broken homes, financial stresses, health problems and legal problems in the family may have its effect on the family members.

II- Impact of society on human behavior Social Psychology is the field of psychology that is concerned with how others influence the thoughts, feelings and behaviors of the individual. Social psychologists focus on the person or individual not on the group per se (which is more likely to be the concern of sociology).

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Social psychology

Sociology

1. Central focus on individual

1. Focus on group/society

2. Variations in behavior believed to 2. Variations in behavior believed to be due to peopleâ&#x20AC;&#x2122;s interpretation of be due societal-based problems as social stimuli and differences in poverty, crime, and deviance. personality.

3.

Observational

and

the

3. Experimentation as the primary correlational studies as the primary research

method,

correlational

followed

studies,

and

by method,

followed

by

then Experimentation.

observation.

Any individual in a given society can influence and be influenced by his society. People in the same society are in a state of continuous interaction. There are different forms of these interactions which have a great impact on human behavior.

Attitude: An attitude is a relatively stable and general evaluative (i.e. with or against) disposition (tendency) directed toward some object. It consists of feelings, behaviors and beliefs. Attitude can predict personâ&#x20AC;&#x2122;s actions and reactions.

Attitude is formulated throughout life by learning and can be based on either correct or wrong assumptions. Changing attitude (and assumptions) is one of the basic aims in cognitive behavioral therapy. Attitude whether positive or negative can be biased. Stereotypy, prejudice, discrimination and stigma are all examples of biased negative attitudes. On the other hand interpersonal attraction is an example of biased positive attitudes.

Stereotypes: are the perceptions, beliefs, and expectations a person has about members of some group. There is false assumption that all members of a group share the same characteristics.

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Prejudice: Stereotyping often leads to prejudice, which is a negative attitude, or a cluster of negative beliefs, toward an individual based simply on his or her membership in some group. Prejudice leads to discrimination which finally is the basis of stigma formation.

Interpersonal attraction: we like people who like us, who are near to us, who similar to us, who physically attract us. Intimacy: Refers to sharing which is inmost with others. In intimate relationships we psychologically expand our selves by acting as if all or some aspects of our partner are part of our own selves. People will think about and respond toward intimate ones as they do about themselves (a friend is, as it were, a second self).

Attribution: how can we attribute our actions either to internal personal or external environmental factors.

Social norms: The agreed rules of the society which guides and directs our social actions. Violating these social norms may be the basis for the psychopathic personality.

Social conformity: it is to change our behavior to be consistent with the behavior of other people in the society. Social conformity may sometimes be a sort of authority obedience.

Social pressure: the pressure the society can do to change individualâ&#x20AC;&#x2122;s behavior e.g. certain societies can do social pressure on the smokers to stop smoking through a certain social rejection for smokers. The opposite can occur when one starts to smoke or use drugs under the effect of peer pressure in certain societies.

Social isolation: Especially in immigrants and minority groups, this tendency for isolation may also the result of issues like discrimination and prejudice.

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Social facilitation and social interference: is improved or impaired performance due to the presence of others.

Social learning: Learning may be intentional or unintentional. Modeling, positive and negative re-enforcements (through social rewarding and punishment strategies) are all ways of how the behavior of an individual can be influenced by the society.

III- Impact of culture on human behavior Culture can be defined as the set of shared attitudes, traditions, values, goals, and practices that characterizes a society. Cultural psychology is the study of how individualâ&#x20AC;&#x2122;s psyche can be affected by variations in these cultural domains.

Cultural psychology is distinct from cross-cultural psychology in that the cross-cultural psychologists generally use culture as a means of testing the universality of psychological processes rather than determining how local cultural practices shape psychological processes. So whereas a cross-cultural psychologist might ask whether Piaget's stages of development are universal across a variety of cultures, a cultural psychologist would be interested in how the social practices of a particular culture shape the developmental processes in different ways.

Cultural identity: Sometimes also called social identity. It is an enduring and deep system of traditions, values and customs. Economic, political and ideological differences lead to cultural diversities and inequalities. Construction of such identity over generations is the basis for ethnic and racial determination.

The definition of certain concept might differ from culture to another e.g. individual sense of power in western cultures is achieved through autonomy and independence and individuation is the main theme there in such cultures. On the other hand, in far eastern cultures such individual sense of power is believed to be achieved through inter-personal dependence and group conjoint work is the main theme there in such cultures.

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Cultural change and culture shock: is the difficulty people have adjusting to a new culture that differs markedly from their own (as in immigration).

Phases of culture shock: 1. Honeymoon phase: During this period, the differences between the old and new culture are seen in a romantic light, wonderful and new. For example, in moving to a new country, an individual might be fascinated by the new culture and love the new foods, the pace of the life, the people's habits, the buildings and so on.

2. Negotiation phase: After some time (usually three months but sometimes sooner or later, depending on the individual), differences between the old and new culture become apparent and may create anxiety, frustration and anger as one continues to experience unfavorable events that may be perceived as strange to one's cultural attitude.

Language barriers, differences in public hygiene, traffic safety, food accessibility and quality may heighten the sense of disconnection from the surroundings.

3. Adjustment phase: Again, after some time (usually 6 to 12 months), one starts to be accustomed to the new culture and develops routines. One becomes concerned with basic living again, and things become more "normal". One starts to develop problem-solving skills and begins to accept the culture.

4. Mastery phase: One becomes able to participate fully and comfortably in the new culture. Mastery does not mean total conversion; people often keep many traits from their earlier culture, such as accents and languages. It is often referred to as the biculturalism stage. Reverse culture shock: it is the same features of culture shock mentioned before but which occur upon returning back to home country after being away for a long period (for years).

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AGGRESSION AND VIOLENCE Aggression is any form of behavior with intention to harm others.

Aggressive behavior may be either verbal (insults) or physical (violence). It may be directed towards human, animals or even towards properties (e.g. destroying cars, shops, furniture….etc). Aggression also can be expressed in other ways.

Jokes and rumors are alternative ways to express aggression in some instances.

Rape is a form of aggression but expressed sexually. Some consider issues like emotional neglect (e.g. husband/wife, parent/offspring), coercion, retaliation and intimidation are all forms of aggression.

Instrumental versus hostile aggression: when aggression is meant for certain purpose (to gain something or to escape from certain punishment), it is called instrumental (i.e. aggression is used as an instrument to achieve certain goal). On the other hand, if aggression is just an expression of anger and has no goal except causing injury to the victim, is called hostile aggression.

Determinants of aggression I- Biological determinants:  Brain areas which are responsible for modulating aggressive behavior are cerebral cortex, limbic system, amygdale and hypothalamus. Brain lesions in such areas may lead to aggressive behavior.  Chromosomal factors: people with XYY chromosomes are liable to be tall, below average intelligence, more likely to be engaged in criminal behavior.  Endocrinal factors: testosterone is believed to be the cause of differences in aggression in males than females. Thyroid hormone is associated with increase tendency for aggression while estrogen is believed to decrease aggression level.

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 Neurotransmitters: serotonin, dopamine, nor epinephrine (NE), Dopamine (DA) and Gama-Amino-Butyric Acid (GABA) are all neurotransmitters believed to be involved in the modulation of aggressive acts.

II- Psychosocial determinants: Aggression can be explained by many psychosocial mechanisms  Aggression can be an innate instinctive drive as that demonstrated as a part of Thanatos drive (drive for death and destruction), Eros drive (drive for life and survival), combat drive.  As a part of certain defense mechanisms (displacement, projection, repression).  As an end product of a faulty parent-child relationship (as in cases of punitive parent) or morbid family atmosphere (broken homes, financial troubles, bad interpersonal communication style).  Social learning (bandura’s view): aggression could be a learned behavior through modeling with positive re-enforcements. When a person learns how to behave in an aggressive manner and sees that this behavior is always rewarded by the society, he will adopt aggression as an optimal mode of behavior in such society. Presenting aggressive models through media has great impact in reducing the sensitivity towards aggressive models which finally remove the individual’s inhibitions towards such behavior and he himself will imitate such behavior without any feeling of remorse.

III-

Situational determinants:

Aggression could be a response to a certain situational incident  Frustration: frustration is one of the strong psychological determinants of aggression specially when perceived as unreasonable.

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 Direct provocation: as a response to pain, humiliation, loss of faith, deprivation from the basic needs...etc  Environmental factors: e.g. crowd, noise, heat, air pollution  Heightened physiological response: as in states of arousal (vigorous exercise, anxiety, sexual arousal).

Terrorism  It is a worldwide problem  It is a form of aggressive violent behaviour against civilians causing actual or threatened death or serious injury, or eliciting intense fear and horror.

This is usually due to political aim.

Types of terrorism: 1- State terrorism: Terroristic actions undertaken by the authority towards civilians of the same country e.g. Genocide (authority seeks to wipe out minority group in its territory).

2-

International terrorism: Violence in another countries by action e.g. Nuclear bombs Hiroshima & Nagasaki.

3- Non-state terrorism: a) Anti-state terrorism: Terroristic actions undertaken by a group against civilians of a state, usually for political reasons. Most antistate terrorists see themselves as revolutionaries or freedom fighters. b) Intra-state terrorism: Terroristic actions undertaken by a group against another group of civilians.

4 -Patterns of Terrorism: Bombing (suicide & non-suicide), bio-terrorism, assassinations, hostage taking and sky jacking 74

PERSONALITY Definition Personality is the dominant impression that an individual makes on us (e.g. a person may be regarded as aggressive or outgoing or suspiscious).

It is the total individualâ&#x20AC;&#x2122;s habits, thoughts, attitudes, expressions and his philosophy of life It is described in terms of traits which are described as a pair of opposites: cheerful/ depressed, worm/ cold, intelligent/foolish Type and trait approaches to personality Type theory: regards people as discrete categories that are qualitatively different from other types.

Trait theory: differences between people are quantitative rather than qualitative. Differences between people are therefore based on the extent to which they possess the specified trait (e.g. extroversion-introversion dimension) Structure of the personality Freud suggested that 3 elements form the personality 1-The id 2- The ego 3-The super ego 1-The Id (Pleasure) It is present from the moment of birth. The role is the pleasure. It is the seat of all instincts. The id demands that the instincts be satisfied but if not satisfied, energy builds up and the baby cries. It includes sex and aggression. If strong it may lead to irresponsible, selfish, pleasure seeking individual (antisocial personality)

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2- The Ego (Reality) It develop at the age of one year. It establishes the relationship with the external world (reality principle). The infant no longer demands unreasonably on the caretaker (the aim of the ego is to ensure that instincts are satisfied but at the real time and place). The ego is capable to divert his energy into other behaviour. Without the ego, toilet training will not be possible. The individuals with strong ego have flexibility in handling various life stresses. If the ego is week it will be unable to tolerate the stresses 3- The Super ego (Morality) It develops between the age of 3-5 years. It sustains the moral and social values of parents and culture. It is the supervisor of the ego and of the inner unconscious tendencies, so it is the repressing part of the personality. It criticizes the ego and causes pain to it when it accept impulses from the id. If the superego is severe and inflexible it sill result into fear which will lead to rigid, unhappy, anxious and neurotic personality: obsessional personality.

Mind is divided into three parts Conscious mind contains things that occupy oneâ&#x20AC;&#x2122;s current attention Preconscious mind contains things that arenâ&#x20AC;&#x2122;t currently in consciousness, but can be accessed Unconscious mind contains memories, urges, and conflicts that are beyond awareness Role of the Unconscious Mind It contains memories, urges that are forbidden or dangerous (more on this later).

These are kept from consciousness, but can still cause problems. Example: Prior traumatic experience can cause irrational anxiety. Dreams express contents of unconscious mind 76

Personality Development, Stages of Psychosexual Development First year: Oral stage Pleasure comes from sucking, putting things in mouth. Fixation at this stage can cause overeating, smoking, nail-biting, sarcastic, argumentative, dependent and gullible.

Second year: Anal stage Pleasure comes from retaining or passing feces. The parents teach the child how to control his sphincters. Fixation at this stage can cause excessive neatness or excessive messiness, mean, cruel, untidy, destructive, hot-tempered Ages 3 to 5: Phallic stage Pleasure comes from self-stimulation of genitals. The child becomes curious about the sex difference between males and females. Erotic feelings directed toward opposite-sex parent. Fixation here can cause relationship, sexual problems; also Oedipus or Electra complex, hysteric symptoms Ages 5 to puberty: Latency period Sexual

feelings

suppressed;

energy

directed

towards

school,

social

relationships. He becomes to be interested in heroes of cinema, TV and history.

He identifies and takes the morals of his parents, Shouldnâ&#x20AC;&#x2122;t be left to the servant Adolescence: Genital stage He becomes interested in the same sex and chooses his friends from the same sex. The adolescent is concerned with other peopleâ&#x20AC;&#x2122;s opinion about him. Mature sexual relationships with opposite sex. Must be met with permissive, understanding and instructive attitude from parents Adulthood The mature person can establish intimate and loving relation with the opposite sex. Can care for a family 77

I-Physique and personality Kletchmer classified personality into: A) Pykinic: Short, Fatty, thick necked, rounded person (manic-depression) B) Athenic: thin, tall, long extremities (schizophrenia) C) Athletic: muscular strong person (paranoia) D) Dysplastic

II- EMBRYOLOGICAL CLASSIFICATION (SHELDON) Endomorphic Personality: (highly developed internal organs and weak external structure) which is allied to Kretchmer’s pyknic type and has Viscertonic characteristics (sociable, relaxed enjoys eating).

Mesomorphic personality: (well developed bones ,muscles and connective tissue), which is allied to kretchmer’s asthletic type and has Somatotonic characteristics (energetic, competitive action oriented).

Ectomorphic Personality:(delicacy all over the body) which is allied to Kretchmer’s

asthenic type and has cerbrotonic characteristics (antisocial,

hypersensitive, secretive).

Dysplastic Personality: which is allied to Kretchmer’s Dysplastic type

III-TRAIT

CLSSIFICATION

(EXTROVERSION-INTROVERSION

DIMENSION) (K. Jung) The Introvert :Those individuals are shut in, with-drawn, asocial, shy, sensitive, suspicious, anxious about the future, day dreamers, interested in details, fond of mental activities and reserved The Extravert :Those individuals who are outgoing, sociable, don’t care about criticism, kind hearted, optimistic, practical and expressive emotionally .

The Ambivert :These are individuals mid-way between the first two 78

ASSESSMENT OF PERSONALITY INTERVIEW METHOD :This is classic method in medical practice .

CASE STUDY METHOD :This is gathering of all available information from infancy, childhood, adolescence to maturity, with a full account of the family, personal, past and present history .

FREE ASSOCIATION AND DREAM INTERPRETATION : This method is used psychoanalysis to reveal deeper parts of the personality.

The patient relaxes both physically and mentally and talks about whatever comes to his mind. During this time, the therapist is trying to understand what is behind his talk.

OBJECTIVE METHOD Rating scales: A list of questions is given to the subject to measure the degree of a certain trait, e.g., irritability has the following degrees: 1) never gets irritable, 2) very occasionally irritable, 3) irritable in appropriate circumstances, 4) irritable most of the time, 5) almost always irritable.

Questionnaire: A list of questions is given to the subject and he is asked to respond by YES or NO or by FALSE or TRUE. An example of such questionnaire is present in Minnesota Multiphasic Personality Inventory (MMPI Projective techniques: Rorschach test: Ten standard inkblots are printed on large cards and the subject is told to report on the ideas associated with the picture.

Thematic Apperception Test: 20 standard cards showing a picture from which the patient is asked to make up a story.

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Frustration Frustration is an emotional state that occurs when a person is faced with an obstacle that interferes with satisfaction of a desire, need, or a goal.

Certain situations may be frustrating to some people but not to others, this is because of differences in people's desires and goals.

Frustration can occur in not only in human being but also in other animals, e.g., a rat in a maze subjected to electric shock when he tries to eat a piece of cheese will finally be frustrated and sop trials to eat it.

Causes of frustration: In every day life, we are subjected to a lot of obstacles which may interfere with satisfying our wishes. These obstacles could be summarized as follow: 1. Physical environment: bad weathers, floods, rough unpaved roads; are examples of physical factors that could limit the person's ambitions with resultant frustration.

2. Social factors: every society has its norms and standards which ought to be followed by persons living in that society. The limits imposed by these norms and standards led to interference with the needs and desires of some people resulting in frustration in those people.

3. Personal factors: psychical handicapping (e.g., blindness or deafness, limb paralysis, or speech difficulties) may represent a barrier to goal satisfaction.

4. The person's choices: making decisions may reveal bad choices which led to choosing bad options or leaving good one. This situation could lead to frustration 80

Factors determining behavior following frustration 1. Motive strength: interference of highly motivated person results in stronger reaction than a mildly motivated one.

2. Previous learning: previous experience helps the person to learn alternative ways of responding to frustration, resulting in low frustration. On the contrary, a particular situation may be considered not acceptable and result in high level of frustration.

3. Frustration tolerance: people vary in their reaction to frustrating situation. Some people cope easily with frustrating situations while others got disorganized in frustrating situation.

4. Specific situations: when there is a chance to escape or avoid a problem and when there is other alternative is available, frustration will be less that that will develop in reverse situations.

Reaction to frustration: 1) Psychomotor hyperactivity: the person develops an increase in inner tension associated with restlessness, trembling, clenching fists.

2) Aggression: Any response made with the intention of harming a person, animal, or object. Aggression may be direct or displaced: a) Direct aggression: aggression is directed to the individual or object which is the source of frustration. b) Displaced aggression: Redirecting aggression to a target other than the source of oneâ&#x20AC;&#x2122;s frustration; i.e., rather than aggression is directed to the individual or object which is the source of frustration, aggression is 81

directed to another individual or object, which acts as a scapegoat. This usually occurs because of inability to react directly against the source of frustration. Breaking a cup of glasses whenever frustrated is an example.

3) Social withdrawal: sometimes the people withdraw from his social surroundings as a reaction to frustrating situations. This passive reaction may result from failure of aggressive reaction to satisfy their needs or inability to express aggressively due to any reason.

4) Fantasy: when people find it difficult to solve their problems in real world, they resort to imagination and day dreaming.

5) Stereotyped behavior: instead of flexibility and striking out in new directions to solve problems, people tend to exhibit repetitive fixed pattern of behavior, the way to their goal is blocked.

6) Regression: it means return to more primitive mode of behavior that characterizes younger age.

7) Physiological responses: stress especially chronic one, had been accused to

result or share in the occurrence of many physical symptoms, e.g., peptic ulcer, bronchial asthma, hypertension, and skin eruptions.

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CONFLICT AND DEFENSE MECHANISM Conflict Conflict arises in situations where two or more needs or goals compete and cause the person to be pulled in different directions with sense of discomfort Types of conflict Approach versus approach conflicts Avoidance versus avoidance conflict Approach versus avoidance conflict Double or multiple approach-avoidance conflict Approach versus approach conflicts People are attracted equally to two desirable but incompatible goals.

Examples two job offers of equal description, salary, or promotions.

A girl who has two extremely attractive suitors whom she must choose one.

It is easy to resolve: Both are pleasant options and the result will be pleasant.

As the person is nearer to one goal, its attractiveness increases and that of the other goal decreases.

This approach is rarely encountered Avoidance versus avoidance conflict When a person is affected by two aversive situations, moving away from one, approaches the other Examples A young lady may be in conflict with respect to marrying unloved person or becoming a spinster The student who doesnâ&#x20AC;&#x2122;t like to study but doesnâ&#x20AC;&#x2122;t want to fail 83

It’s very difficult to resolve: Both are aversive and the result is aversive As one situation is approached, its aversive nature becomes more apparent Depression will result Approach versus avoidance conflict The person is attracted to and repelled by one option “bitter sweet situation”.

An appealing career may require a lot of education.

A luxurious car is costy.

In order to marry a man she loves, she has to accept an intolerable mother in law.

Double or multiple approach-avoidance conflict Two goals each have good and bad points The best example is the girl who has two extremely attractive suitors whom she must choose one.

Or a young woman who has to choose between working as house keeper which is dull but with good income, or attending college with expensive education but meaningful career Other types Conflict between two incompatible biological needs e.g. sex motive and fear of venereal diseases Conflict between biological motives and conscience: sex motive and religious restrictions Conflict between two self-constructive needs: to get wealth or continue a scientific career.

Conflict between two duties: a husband conflicting between his duty as a bread winner and as a companion to his wife and children..

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Adjustment and defense mechanism

These are means to adjust to various life conditions Direct coping “conscious defense mechanism” to deal directly with anxietyproducing situation: doing something to overcome, change or avoid it.

Defensive coping “Unconscious defense mechanism”: defending against anxious feelings without trying to deal directly with anxiety provoking situation. It distorts one’s perception of the situation to make it less threatening

Goals of defense mechanisms 1- overcoming obstacles.

2- reduction of inner tension 3- Avoiding psychic pain 4- Self-defense.

5- Achievement of certain goals 6-Adjustment to the environment

Conscious defense mechanism 1. Removal of obstacle 2. Changing the way to the same goal 3. Changing the goal itself and putting a substitute 4. Put a compromise 5. Compensation If the effort required is beyond the capacity of the individual or the use of conscious mechanisms causes anxiety not decreasing it. They are used normally, but if they operate in excess they may cause maladjustment 85

Unconscious defense mechanism Repression Rationalization Sublimation Compensation Reaction formation Displacement Identification Projection Introjection Denial Undoing Regression Fantasy Dissociation 1-Repression It is the automatic transformation of thoughts from the conscious awareness to the unconscious where it is unavailable for conscious recall.

It is the most widely known.

It is the automatic forgetting of unpleasant thoughts.

Resistance is maintaining repression Suppression: it is conscious control of wishes and unacceptable acts that is prevented from being revealed.

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2- Rationalization It is to hide from oneself and others the actual motive for his behavior.

Examples: Failing to get a job is rationalized that a job has many bad features People deceive themselves by pretending that a bad situation is really good “sweet lemon strategy” or the good one is really bad “the sour grapes strategy”

3- Sublimation The consciously unacceptable instinctual drives find expression in socially acceptable forms.

The sex drives could be expressed in writing poems or letters.

4- Compensation One attempts to cover or balance real or fancied defects by extraeffort to excel in a different activity. Examples: a backwarded students may put an extraeffort to excel in sports or social activities to be famous in school.

5-Reaction formation Is to show the opposite attitudes and feelings of those possessed unconsciously.

Example: a mother may be overprotective of a child whom she unconsciously rejects 6- Displacement An emotional feeling is transferred from its actual object to a substitute. A teacher may deal hardly with the students, not because of their bad behavior but because manager of school treated him badly.

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7- Identification It plays a healthy role in child development and in enjoyment of life.

It is the mechanism by which an individual enhances self-esteem through feeling, in fantasy or in actual life as if he was another person with whom he identifies himself.

Examples: on reading stories we identify ourselves with the hero

8- Projection To find in others the feelings and ideas he actually possess

9- Introjection Loved or admired objects are symbolically taken into oneself. It plays a role in personality development.

10-Denial When people deny reality, they ignore or refuse to acknowledge the existence of unpleasant experience (of which they are fully aware) to protect themselves.

When emotions are so powerful that they become frightening, one may deny these emotions.

Bereaved persons are often unable to cry or say they have no emotions at all.

11-Undoing To cancel out or nullify an event or actions previously done by certain counteraction.

When a child deliberately hits his brother he runs hugging and kissing him. He tries to convince himself that nothing hurts him.

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12-Regression If a child developed trauma at any stage of development, he will be fixated there He develops normally but if he faces any future trauma, he may regress to the developmental stage where he fixated It is a return to a more primitive mode of behavior the person may be trying to return to a period of past security.

A big child may cry or seek parental care to get love and affection. This is called retrogressive regression.

A person may loose his control and start fist fighting (primitivation of behavior)

13-Fantasy It is imaginary sequence of events or mental images which act to resolve emotional conflict through unreal solution. This occurs in day dreams.

14-Dissociation Portion of the personality which is the source of stress may be eliminated.

Examples: somnambulism.

Drawbacks of unconscious defense mechanisms 1-Using defense mechanisms excessively results in unreal problem-solving.

2-The person is deceiving himself rather than deceiving others.

3-Distortion of reality 4-The person will not be aware of his personality defects and he will not correct them.

5-Maladjustment.

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Clinical Neuropsychological Testing Aim of the test: -Designed to measure specific aspects of a personâ&#x20AC;&#x2122;s intelligence, thinking or personality -Intelligence testing is necessary to establish the degree of mental retardation.

How they are administered -They are administered by well trained in their use and interpretation.

-They are standardized against normal subjects. Their responses are tabulated in a normal distribution pattern against which new subjects are compared.

The test should be valid and reliable.

-Reliability assesses the reproducibility of results.

-Validity assesses whether the test measures what it supposed to measure.

TYPES OF PERSONALITY TESTS 1-Objective tests: -They specifically use pencil-and-paper tests.

-They yield numerical scores easily subjected to mathematical or statistical analysis e.g., Minnesota Multi-Phasic Personality Inventory (MMPI).

Minnesota Multi-Phasic Personality Inventory (MMPI) -It is the most widely used -It consists of more than 500 statements to which the subject must answer true or false or cannot say.

-The test was initially thought to be a diagnostic tool, but now it is used to describe the personality pattern.

-A single high score on one scale is not an indication of a disorder.

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2-Projective tests: -They present ambiguous stimuli that force the person to project their own psychological and emotional factors into the test situation: e.g. Thematic Apperception Test (TAT), the Draw-a-Person test, the Rorschach test, and Sentence Completion Test.

Rorschach test -A standard test of 10 inkblots: 5 are black and white and the other 5 are coloured.

-The cards are shown to the patient in a particular order and the psychologist record the patientâ&#x20AC;&#x2122;s verbatim response and the total time spent in each card.

-The test material serves as a screen upon which the subject projects his fears, aggressions and attitudes.

Thematic Apperception Test -TAT consists of a series of pictures that contain persons.

-There is ambiguity in each picture.

-The patient constructs a story.

-An important aspect of the story is the hero with whom the person identify and they attribute their wishes and conflicts -Their stories reflect their own approaches to organization, sequence, vocabulary, and style.

Sentence completion test Word-association technique Draw-a-person test.

INTELLIGENCE TESTING -In 1905 Alfred Binet introduced the concept of the mental age (average intellectual level of a particular age.

-The intelligence quotient (IQ) is the ratio of mental age to chronological age multiplied by 100 to eliminate the decimal point.

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-An IQ of 100 or average results when the chronological age and mental age are equal.

Wechsler Adult Intelligence Scale -It is the most widely used intelligence test in clinical practice -It was first designed in 1939 and has gone several revisions.

-It is designed mainly for adults, but children versions are available.

-It comprises 11 subtests, 6 verbal and 5 performance which yields a verbal IQ, a performance IQ and a combined or full scale IQ. Verbal skills: -Information: covers general information and knowledge that are culturally related.

-Comprehension: questions about proverbs.

-Arithmetic: the ability to do simple calculations -Similarities: to explain similarities between two things.

-Digit span: to learn digits from 2-9 and recall both forward and backward.

-Vocabulary: to define 35 vocabularies which are related to the level of education.

Performance skills: -Picture completion: complete the missing part of a picture.

-Block design: to match coloured blocks and visual designs -Picture arrangement: to arrange a picture in a sequence that tells a story.

-Object assembly: to assemble objects in proper order and organization.

-Digit symbol: to match a series of digits to their corresponding symbols.

Stanford-Binet test -It is an old test made by Alfred Binet -It is suitable for children.

Progressive matrices test -To select a design that completes a given pattern -It is suitable for children and adults.

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ADMISSION TO HOSPITAL Admission to hospital is considered by most of the Egyptian a very undesirable situation. Because usually no one explain to the patient the cause of admission and what is going to happen during hospitalization. When the patient is going to be discharged, the patient does know neither the cause of discharge nor the management plan in the future. That is why a good number of the Egyptian calls admission to the hospital "detention".

Patients Needs: People feel comfortable when all their physiological and psychological needs satisfied. The physiological needs of food and water are usually satisfied in health.

In sickness, difficulty in breathing or thirst is always accompanied by anxiety.

Psychologically; people need to feel secure in their environment. They must understand the part they themselves play in it. They need to love and be loved, to be respected and to respect themselves. They need to feel that they are able to master the situation in which they find themselves. None of these needs can be fully satisfied on admission to hospital.

Patient's needs are: 1- Security: Security means the ability to predict what is going to happen and how to make things happen. On arrival, however, he knows nothing at all of the events which are to follow.

People around him move, appear busy, do things to him, but he feels completely bewildered and left out of it. His greatest anxiety occurs in relation to his own 93

behavior. He does not know what is expected of him, what will happen if he does not behave as he is supposed to do.

Anxiety due to lack of security can be alleviated by keeping the patient fully informed of what is going on. It is a mistake to tell the patient too much at a time and to give too many explanations on admission. If he knows what is going to happen, but not when, he becomes increasingly anxious while he waits and wonders.

The hospital staff often believes that the patient's anxiety is primarily related to his worry about home situation. They may not be so on admission. His most urgent task is getting to know his new environment. Therefore, reassurance must be concerned with patient's immediate need to orient himself adequately in his new surroundings.

2- Trust: When the patient is newly admitted, his general state of perplexity and despair makes him in need of people and therefore, in the best position to develop confidence in staff. Confidence in people is the most important aspect of feeling safe.

3- Self-Esteem: The more helpless the illness renders the patient the more his self-esteem needs to be supported. Incontinence is a symptom which is particularly distressing and so is the need for bedpans, the need to be fed or washed or lifted.

The more the nurse has to do for the patient, the more she must remember to assure him of her respect so that he can respect himself.

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It is always humiliating to have one's weakness exposed. In illness all weakness becomes known to doctors and nurses, not only those which are symptomatic of the illness which has caused admission to hospital, but also all those weaknesses one has learnt to hide effectively from others e.g. deformities.

When the patient begins to express concern about the welfare of his family he may wish to return to his position of responsibility as soon as possible. The patient may be begun to realize that the family can do without him. He may be glad and yet upset by his loss of status. He may worry about them to convince himself that he is really needed and may not be at all reassured by being told that all is well.

4- Independence: During the patient's recovery his independence and his needs for mastery become more pronounced. He begins to ask questions about his treatment and ask for explanations. He may begin to ignore rules, to refuse to eat prescribed diet or to smoke though it is not permitted.

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Chronic Sickness and Disability Reaction to chronic sickness and disability: one or more of the following: 1- Accepting disablement: Illness is regarded as a temporary interference in the normal process of life and does not, at first, lead to a change in outlook. Prolonged and chronic illness and permanent disablement, however, necessitate a complete reconstruction of the patient's idea of himself and a complete reorganization of relationships. The ordinary expectation of the family and society as a whole must be changed. This process is slow and painful and requires considerable assistance from those who are looking after the patient.

When the patient first realize that he cannot get completely well he may become depressed. He may feel that in such circumstances life is not worth living.

He may lose interest in himself, his treatment and the conditions surrounding him.

When the patient in this psychological state; it is very difficult to nurse him, as he himself does nothing to help. He may refuse to take sufficient nourishment, neglect his personal hygiene and lose all interest in any activity. All doctors and nurses know that the will to live is essential for recovery and they must help the patient to see that in spite of his handicap he is needed by those who love him and that he can still be useful to the community.

2- Stigma: Often the patient who realizes that he is permanently disabled becomes furiously angry with himself and with everyone whom he feels he can blame for his disability. He may express his feeling in his criticism of the treatment and care 96

he is receiving in the hospital. He may accuse his family or people in general of being hard-hearted, disliking him because he is a burden to them. This is displacement of aggression.

At some stage of the illness most disabled people refuse to meet people, refuse to be seen or to go out.

3- Difficulty in communication: It is inevitable that a disabled person must lose some of his former friends. If he can no longer work he loses interest in discussion about his former job. After an initial attempt to keep in touch he becomes increasingly isolated from all those interests he can no longer share.

The greatest isolation occurs in those who lose sight, hearing or speech. We rely on our social contacts and communication by speech and we keep informed about our environment mainly by sight and hearing. It must be remembered that deaf people are suspicious. Partially deaf people may be seen more handicapped because they may be less conscious of defective hearing and more inclined to blame others for failing to make themselves clear.

The total isolation of those who cannot see may lead to a period of confusion, disorientation and a terrifying feeling of being lost which may result in uncontrolled, sometimes aggressive, behavior. It is sometimes difficult to know how soon the patient should be confirmed with the fact that prognosis is not too good. Often, in a well-meaning attempt to spare him suffering it is not mentioned for a long time. By then the patient has already begun to realize that all is not well and, sensing other people's reluctance to face facts, he keeps his worry to himself and begins to see himself as an object of pity and despair. It may be much wiser to encourage talk of the future as early as possible, and to help the patient to get to know himself as a different, but in no way inferior, person to the one he used to be.

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4- Rehabilitation: This can best be done by emphasizing what the patient can do rather than what is no longer possible for him. If he has lost the power of his leg, he can work with his hand; he can paint or learn a new craft. Many patients are able first to accept the fact that they may be useful to other sufferers of their own kind.

Associations for sufferers from poliomyelitis, paraplegia or epilepsy may, for example, offer the opportunity of doing useful work and of developing the ability to meet people again. Help is more easily accepted from these who are fellow sufferers because there is no need to feel that help is given only out of pity.

Gradually, the disabled person must be led to feel equal to, though different from, other people, able to hold his own in a newly-formed circle of friends and fellow workers. When the family begins to treat him as a responsible person he may respond by accepting responsibility and becoming interested in living once more as full a life as possible.

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Psychological Reactions to Illness Most of patients respond to minor common illness e.g. common cold, bronchitis,…etc with smooth way or with considerable distress; however the condition is extremely different on facing serious illness and impending death e. g. cancer, hepatic or renal failure, ….

The following stages can be encountered on facing serious illness: Stage 1- Shock and Denial On being told that they are seriously ill or dying, people initially react with shock.

They may appear dazed at first and they may refuse to believe the diagnosis; they may deny that anything is wrong and they may never pass beyond this stage and go from doctor to doctor until they find one who supports their positions.

Stage 2- Anger People become frustrated, irritable, and angry that they are ill. They may become angry with their family members, friends or even blame themselves. They may displace their anger onto the hospital staff members and the doctors.

Stage 3- Bargaining Patients may attempt to negotiate with physicians, friends, or even God for a return of a cure. They may begin to give gifts to poor people or relatives, more prayers…etc. Another aspect of bargaining is believing that if they are good and cheerful with the doctors, the doctors will treat them in a better way.

Stage 4- Depression Patients in this stage show clinical signs of depression e.g. withdrawal, retardation, sleep disturbance, hopelessness…etc. depression may be due to the impact of the 99

illness on their life e.g. loss of jobs, financial difficulties, isolation from family and friends, or due to the threat to lose the life itself.

People suffering from some diseases as epilepsy, tuberculosis, venereal diseasesâ&#x20AC;Ś..are suffering, in addition, from a more complicated feeling that they are wicked, they must be shame of their illness, they are refused by the society, and their illness is a punishment for them,....what is called stigma of the illness Stage 5- Acceptance In this stage, patients realize that death or diseases are inevitable, and they accept the universality of the experience and their feelings begin to shift to the normal neutral mood. Those with strong religious beliefs and conviction of life after death are the best to reach this stage in a more or less smooth rapid way.

Psychological needs on admission to hospital 1) Security and trust Security means the ability to predict what is going to happen. On arrival, the patient knows nothing at all about the events which are to follow, what he is supposed to do, and the way he must behave. People around him move, appear busy, do things to him, but he feels completely confused about all of this.

The patient may appear anxious in front of the hospital staff members, this actually not because of his illness, but actually due to the current confusing situation as a new patient in the hospital.

In such situation, the patients are in extreme need for trust with the hospital staff members, as confidence with them are the only way to feel safe.

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Anxiety due to lack of security can be alleviated by keeping the patient fully informed of what is going on. This should be done in a simplified manner and step by step, as too much information may increase anxiety and confusion of the patient.

2) Self esteem and independence Patients may feel that they are burden and useless people on their relatives and staff members. Some of them begin to apologize for the troubles and disturbance they make. The more helpless the illness renders the patient e. g. incontinence, the more the self esteem is affected and more psychological support is needed to maintain self esteem.

In illness all weaknesses become known to doctors and nurses; not only those which are symptomatic of the current illness, but also all those one has learnt to hide effectively from others, e.g. deformities.

The patients, also, may realize that their families can do well without them, so, their importance and self appreciation are greatly lowered.

Psychological and behavioral support and assurance of the patients are very important till achieving psychological and physical independence of the patients.

One of the early signs of regaining self esteem and trust is to resist doctors' instructions and to start negotiations about the procedures of treatment.

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Human sexuality Definitions: Sexual identity: It is the person’s biological sexual characteristics e.g.

A- Chromosomes (XX in females versus XY in males) B- External genitalia (Vulva, labia majora and minora, clitoris in females versus penis, tests and scrotum in males) C- Internal genitalia (ovaries, tubes, uterus in females versus prostate, internal urethra in males) D- Hormonal composition (estrogen, progesterone in females and testosterone in males) E- Secondary sexual characters (breast, hair distribution, voice, muscle bulk in females and hair distribution, voice and muscles in males).

Gender role: it is the social behavior that allows others to categorize the person as a male or female.

Gender Identity: It is the person’s subjective sense of maleness or femaleness - By the age of 2-3 years, the baby started to identify his own gender. The dressing and play of children are of the items that give ideas about the gender.

- Gender identity is based on parental and culture attitudes, the infant’s external genitalia, and genetic influence - Usually both Sex identity and gender identity are the same but may develop in conflicting or opposite ways and this Gender identity disorder.

Sexual identity: It is the object of a person’s sexual impulses and attraction, it may be: - Heterosexual: attraction only to persons of the opposite sex - Homosexual: sexual attraction to same sex 102

- Bisexual : sexual attraction to both sexes SEXUAL RESPONSE CYCLE It is a four-stage model of physiological responses during sexual stimulation. Fourphase response cycles are defined: excitement, plateau, orgasm and resolution Excitement phase (also known as the arousal phase or initial excitement phase): This phase includes penile erection, increased testicular volume, elevation of the testes and scrotal contraction in males. In younger males this may happen within seconds after sexual stimulation of any kind, while in older men it may take longer to get an erection and it can come and go, depending on the amount of direct stimulation of the penis by self or partner.

In females this phase includes clitoris and labial engorgement, expansion of the inner two-thirds of the vagina, thickening of the vaginal walls, elevation and engorgement of the uterus and breast enlargement.

Both males and females may experience nipple erections and show some increase in myotonia, heart rate and blood pressure.

Plateau phase Although described as a “level” region, this is an advanced state of arousal that precedes orgasm. In males thereis a slight increase in the circumference of the coronal ridge of the penis and a colour change in the glans to a purplish hue. The testes elevate even further in preparation for ejaculation. In many males there would also be a few droplets of Cowper’s gland secretion present at the meatus.

In females further vasocongestion of the lower third of the vagina would form the orgasmic platform. The inner part of the vagina expands fully and the uterus becomes fully elevated. The clitoris can withdraw beneath the clitoral hood and the labia minora change colour.

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Both males and females can show a sexual flush, while myotonia increases, breathing becomes more rapid and heart rate further increases. Blood pressure also continues to rise.

In younger men the plateau phase tends to be shorter than that of a female, leading to the saying that males are destination or endpoint orientated and females are journey orientated. A metaphor further describing this difference is that of a male being like a switch that can be switched on and off very easily, while a female is like two hundred candles.

It takes a very long time to get them burning, but once they are burning it is very difficult to blow them out again!

Orgasmic phase Spastic contraction of the internal sphincter of the bladder prevents retrograde ejaculation and contributes to the feeling of ejaculatory inevitability in males when emission (contraction of the vas deferens, seminal vesicles and prostate) of semen into the bulbous urethra has taken place. The next step is propulsion of semen, through relaxation of the external bladder sphincter and contraction of the bulbo cavernous muscles. Sensations of pleasure tend to be related to the strength of the contractions that take place at 0.8-second intervals, as well as to the volume of seminal fluid.

Female orgasm involves rhythmic contractions, also at 0.8-second intervals, of the vaginal walls, anal sphincter and uterus.

Resolution: In both males and females everything returns back to its original state.

After resolution men go to refractory period which prolonged with age. It may be few minutes up to days. Females did not have refractory period and can achieve another orgasm by the end of the sexual cycle.

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