Psychological Traits in Patients: A Textbook for Future Physicians, Study notes of Computer Science

Download Psychological Traits in Patients: A Textbook for Future Physicians and more Study notes Computer Science in PDF only on Docsity! I.S. Vitenko, R.I. Isakov, V.O. Rud MEDICAL PSYCHOLOGY Edited by Professor A.M. Skrypnikov 1 MINISTRY OF HEALTH OF UKRAINE UKRAINIAN MEDICAL STOMATOLOGY ACADEMY DEPARTMENT OF PSYCHIATRY, NARCOLOGY AND MEDICAL PSYCHOLOGY I.S. Vitenko, R.I. Isakov, V.O. Rud MEDICAL PSYCHOLOGY Recommend by Ministry of Public Health of Ukraine as Textbook for Students of Medical Universities IV accreditation’s level with English education’s form POLTAVA-2010 4 PART I General Medical Psychology CHAPTER I SUBJECT, TASKS, STRUCTURE AND METHODS OF MEDICAL PSYCHOLOGY Objectives: to learn the subject and tasks of medical psychology, it's history and place in the structure of psychological sciences, to get acquainted with main methods of medical psychology. Psychology is a science about the origin, development and regular manifestations of psychic activity of a human being. This term was formed from the Greek words "psyche"(soul) and "logos"(science). The main stages in development of psychology were: 1) Psychology as a science about human soul appeared in the field of philosophy more than 2 000 years ago. 2) In 17th century due to the accelerated development of natural sciences psychology appears as a science about consciousness which supposed to control the thoughts, wills and emotions. 3) In the 70ies of 19 century psychology develops as an independent science. Its task was the observation of human behavior, deeds and reactions without taking into account the motives and subjective factors. Also the experimental branch of psychology begins to develop. 4) Development of modern psychology. The principal tasks of psychology are: 1) Study of the regulations of the psychic development of a human in its development. 2) Investigations of the reflection of reality in the mind of a human being. 3) Study of mechanisms, regulating the actions and activity of a human being. 4) Study of the mechanisms creating the psychic traits of a person. 5 5) Determination of a certain dependence of psychic phenomena depending on the way of life and activity of the individual. Nowadays psychology is a complex system of interdependent psychological sciences. The principal branches of psychology are: - General psychology – the study of common regularities in the psychic activity of a grown-up. - Child psychology – the study of regularities of the psychic development of a child. - Teenage psychology – the study of regularities of the psychic activity of teenagers. - Late-age psychology – the study of regularities of psychic activity of elderly people. - Social psychology – the study of psychic phenomena in groups and collectives. - Pedagogical psychology – the study of the psychological basis of teaching and upbringing. - Work psychology – the study of the psychological basis of a man's working activity. - Pathopsychology – the study of various forms of disorders of psychic activity and their development. - Other (e.g. medical, military, artistic, space etc.). Separation of medical psychology and an attempt to determine its importance as a subject of teaching goes back to 1852 with the publication of "Medzinsche Psychologie", a work by R.H. Lotze, a German scientist. Medical psychology is a branch of psychology which studies the psychology of the patient, the role of psychic factors in the origin and development of the disease, the psychology of relationships between doctor, staff and patient, as well as the use of a psychological approach in medical practice. Medical psychology has two lines of development – general medical psychology and applied medical psychology. General medical psychology studies psychological peculiarities of the patient; the criteria of normal, temporarily altered and morbid psychics; the correlations between an individual and a disease; psychology of a doctor in his relations with the hospital staff; psychology of relationships between the doctor, his patient and relatives; teaching on a doctor's duty and ethics; teaching on iatrogeny caused by the carelessness of a doctor's words; peculiarities of ageing and its influence on the disease. Applied medical psychology studies psychology of patients suffering from nervous-psychic disorders; psychology of psychiatric patients and patients with dependencies; psychology of patients 6 with nervous diseases; psychology of patients prior to and after an operation; psychology of patients with cardio-vascular, gastric infectious, veneric, pulmonary, gynecological diseases; psychohygiene and psychoprophylactics in cases of pregnancy and child-birth; psychology of endocrinological and oncological patients; psychology of patients with physical abnormalities and sensory defects (e.g. blindness, deafness); psychology of the disabled. The basic points of contact of these sciences are the psycholo- gical peculiarities in doctor's conduct, correction of mentality while treating the patient and psycholotherapeutic influence. Medical psychology is connected with all medical specialities (therapy, surgery, obstetrics, gynaecology, paediatrics, hygiene and others). It has some specific methods and thus it plays an important role in doctor's training in any speciality. Mental phenomena are determined by the factors of environment (mentality is a form of reflection of the objective reality). However, any outer influence produces one or another psychological effect under inner conditions such as the mood of the individual, his aims, needs and life experience. Due to activity the mentality fulfils the function of orientation of the person in a variety of surrounding events and phenomena (it is manifested in selectivity of the subject regarding outer influence) and the function of regulating behavior (stimulation to the activity which meets needs and interests of the individual). In a definite situation the person's behavior depends on his interpretation and treatment of the situation. On the other hand, the character of treatment of the given situation, extent of knowledge about the situation will depend on interaction of the person with this situation. For the scientific cognition of different mental phenomena and their functional mechanisms medical psychology uses such methods: 1. Method of observation. 2. Method of clinical interview. 3. Experiment. 4. Psycho-diagnostic examination. One of the most typical ways of examination is observation of an object (a person, a group of people) pending the phenomena interested by an examiner will show themselves to be recorded and described. By means of this method the mental processes, states and properties of sick and healthy are studied. Mentality is studied under natural living conditions, and this study differs from an experiment because a doctor or a psychologist is a passive observer that has to wait for those phenomena he is interested in. The advantage of this method is that during the observation the natural 9 prognosis of its efficiency, development, contact, effect of this or that individual activity. A test is a try-out, a task or a task system which helps to estimate the mental state or maturity of the examined. Psycho- diagnosis uses a number of experimental psychological methods or tests which help to estimate the functioning of both separate areas of mental activity and integrative formation such as temperament types, personality peculiarities and personal traits. There are verbal (language) and non-verbal (picture) tests. Two groups of tests - standard and project - are usually distinguished. The test directed toward estimation is called a standard test (maturity, creativity, aptitude tests). However, there are tests that are directed not toward the estimation indices, but toward the qualitative personality peculiarities. Project methods belong to this group of tests. They are based on the fact that the personality is realized through various manifestations of an individual including some hidden unconscious needs, conflicts, feelings. Thus the main thing is subjective contents and attitude that a test can cause in an examined person and it allows making conclusions about the personality peculiarities. Following tests could make a good example of big variety of these methods. For the perception examination such methods are used: "Sensory excitability", "Aschaffenburg's test", "Reichardt's test", "Liepmann's test". For the memory examination: "Ten words test", "Memorizing numbers", "Story reproduction". For the attention examination: "Schulte's tables", "Proof test", "Anfimov's tables", "Counting by Kraepelin". For the thinking examination: "Classification", "Exception of notions", "Syllogisms", "Analogies", "Generalization tests", "Association experiment", "Pictogram". For the intellect examination: "Raven's matrices", "Wechsler's test". For the emotions examination: "Spielberg's test", "Luscher's methods of color choices". And finally for complex examination of the personality "Rorschach's test", "MMPI" and "Topical apperceptive test (TAT)" are used. Questionnaires are the methods containing a number of questions to be answered by an examined person in order to find out whether he agrees with them or not. There are questionnaires of an "open" type (answers are given arbitrarily) and of a "closed" type (answers are chosen from the variants given in the questionnaire). 10 Besides, there are questionnaires-surveys and personality questionnaires. Questionnaires-surveys give an opportunity to get such information about the examined person that doesn't show directly his personality characteristics. They are biography, interests, aims questionnaires, for example. Personality questionnaires used for the evaluation of personality characteristics are divided into several groups: a) Typological questionnaires worked out on the basis of personality type determination allow referring the examined to this or that type which differs in its peculiar manifestations; b) Personality traits questionnaires which determine the expression of traits, i.e. stable personality signs; c) Motives questionnaires; d) Importance questionnaires; e) Aims questionnaires; f) Interests questionnaires. The different methods of psychological examination can be used in combination, thus creating a full picture of a person's mental condition. The last stage of experimental psychological examination necessarily contains a written conclusion based on the received data. 11 CHAPTER II COGNITIVE PROCESSES OF THE PERSONALITY For easy learning and investigation entire mental activity is conventionally divided into three spheres: cognitive, emotional and motor. Without this it is impossible to understand separate links of mental processes and symptoms of mental disturbances. But it is necessary to remember that mental processes and states and their unity with the personality constitute a whole. All mental processes are not isolated; they take place as a unity with the personality and are its expression. Cognition and evaluation of the reality are carried out through gnostic processes: perception, memory and thinking. SENSATION AND PERCEPTION Objectives: to learn the definition and structure of sensation and perception, the notion of analyzers. Sensation and perception which represent the sensory sphere are the initial stage of cognitive activity. Together with representation, perception and sensation are the basis of direct active and concrete-image thinking and belong to the level of perceptive cognition. The process of perceptive cognition is inherent for both humans and animals, yet they are not identical. Sensation and perception as a mental act are formed as a result of individual development under the influence of training, education and experience. The process of their acquisition takes place from perception of simple signs and details of the surrounding objects to perception of more complicated phenomena as well as the inner state of the organism. Sensation is the simplest mental act; it reflects some properties of the objects and phenomena of the environment as well as inner state of the organism which influence the analyzers of the person. Sensations permit us to tell the taste, color, weight, temperature of surrounding objects, as well as properties of their surface – 14 Perception is a mental process which consists in holistic representation of the objects and phenomena of the world at their immediate influence on the sense organs which is combined with the past human experience. The physiological basis of perception is interaction of different analyzer systems or separate parts of the same analyzer and formation of conditional reflexes to complex stimuli resulting in a more or less complicated image of an object or phenomenon. Main properties of perception are entity, selectivity, constancy, comprehension, apperception and objectiveness. Perception is always whole, that is an object or a phenomenon is represented as a whole of their properties and signs. Selectivity is revealed when one object has advantages over other objects. The main object which is more important to observer at that time appears as a vivid figure, as well as all other objects and phenomena go to background. Constancy is more or less long stability of separate properties and qualities of the objects irrespective of the noted changes which have taken place. Comprehension is an understanding of the essence of the object, a capability to classify it, a generalization in the world, an association with the familiar objects. Apperception is dependence of perception on the general content of the mental activity of person and his individual characteristics, on the past experience, interests, motives, profession. Objectivity is revealed in the act of objectification that is in the relation of the obtained information (images) to the world (object, phenomena). Among complicated forms of perception, perception of time, space and motion are distinguished. Perception of time is representation of the duration, consequence and velocity of events or phenomena of the real world. The basis of perception of time is conditional reflexes. Prolonged periods of time are perceived, on the one hand, in the association with the processes which take place in the organism, on the other hand, in association with the rhythms of the natural phenomena. It was noted that the periods of time are evaluated subjectively, which maybe due to the interests and the character of the activity of the person as well as to the disease. The basis for perception of space is the knowledge of non-spatial properties of the objects through visual, vestibular, motor and cutaneous sensations. Together they allow the understanding of the relation of the body to the vertical, spatial location and distance to other objects. Perception of movement is representation of spatial 15 movement of the objects, which are defined by the distance from the objects, the speed of their movement or the movement of the observer. Sensation and perception are characterized by sensitive liveliness (objectiveness, reality, liveliness, brightness), extra- projection (the image is transferred to the place of the objective stimulant) and absence of arbitrary changes in the perceived image (objectivity of perception). There is an interesting peculiarity of perception. It finishes all figures and objects which are not complete automatically. For example when there are 4 dots on the paper we unconsciously see a square or a trapezoid (1). Or if there's an unfinished picture we'll complete it according to the unique characteristics of our own perception (2). 1 2 This effect was studied by gestalt psychologists and is call Zeigarnik effect. With the age, knowledge and experience, sensation and perception become more complicated, pithier, close to the true essence of the objects and phenomena of the reality. Besides, the culture regulates the activity of the brain, adding different peculiarities of disposition which characterize the members of the definite group. Perception of the world, life, death varies in different cultures. Sensation, perception and emotions are closely connected with each other. On the one hand, some sensations (e.g. of smell, color) can cause definite emotions; on the other hand, the mood of the person defines the brightness and strength of the perception. Fantasy is the creation of new imaginary connections based on empiric material of previous impressions. Fantasy can be: 16 a) recreative; b) creative. Recreative fantasy creates a chain of notions on the basis of a certain plan (a geographical map). Creative fantasy creates new, original ties of notions and thoughts. Perception in small children is characterized by brighter emotions especially to colored moving objects. The children of an early age (aged 1 – 2 years) can orient to the place of the objects; the visual evaluation of small distances develops very quickly. In an early childhood, auditory perception also develops very quickly, which is important for general development of the language. In children under school age we observe further perfection of visual, motor and auditory sensations. It is very important that active development of the ability to distinguish distant objects took place during concrete pithy actions. Auditory sensitivity in children is characterized by significant individual differences. Reduction in hearing in children can be unnoticed as the child who hears badly can guess the pronounced by the movements of the lips and the expression of the face. It is very important to know if the child hears well because at insufficient hearing acuity, mental and linguistic development may delay. In children under school age, the accuracy of movements and the rate of development of motion skills increase. But, if they can easily perform large movements, which do not require great physical strain (walking, running, dancing), smaller accurate movements are difficult for them (writing, drawing, sewing). Cutaneous sensations develop together with motor ones. Children under school age develop accuracy in perception of the shape, size and texture of the object at touching. Perception develops intensively together with sensations. The children under school age are more accurate (when compared with the children of early age) in representation of the objects and phenomena which they perceive. Games, observations, excursions, drawing are important for development of perception in children. The game forces the child to perceive the peculiarities of different objects more accurately and consciously. Designing, drawing, modeling make them examine and investigate the objects. In general clinical practice we can observe the following disturbances of sensation and perception: 1) Quantitative: a) hypoesthesia – decreased subjective brightness and intensity of sensation and perception. Physiologically normal is hypoesthesia 19 CHAPTER III THINKING AND SPEECH Objectives: to get acquainted with the structure of thinking, its variants and types, normal and deviant conditions, methods of examination. Thinking is a mediated generalized reflection of reality in the human mind with all its important ties and connections. Thinking is always based on a sensitive reflection of the world. The properties of things and phenomena, connections between them are reflected in a generalized form as the type of notions, laws and essence. That is the images of sensitive cognition are the material only with the help of which reflection can arise on the level of thought. It always develops as a result of the knowledge acquired by a human being. In practice, thinking as a separate mental process does not exist, it exists invisibly in all other cognitive processes: perception, attention, memory, etc. Thinking is a generalized cognition of reality where the words, language, function of analyzers are most important. With development of psychology, language, playing and studying activities one can follow gradually development and improvement of thinking with' all its features, inherent in the given historic era and appropriate individual conditions of development in a definite microenvironment (structure of society). The material embodiment of thinking and the tool for thought exchange is a speech with its grammar and vocabulary. Basic mental operations Analysis is a disassembling of a whole into parts in thoughts or mental apportionment of its aspects, actions and relations from a whole. Synthesis is a mental assembling of the parts, properties, actions into the whole. Synthesis is not a mechanical unity of the parts and thus it does not result in their summing. As a rule, analysis and synthesis are carried out together, rendering assistance to more thorough cognition of the reality. 20 Comparison is a determination of similarity or difference between subjects and phenomena or their separate signs. While considering them in different aspects and combinations we get to know the subjects, object and phenomena better and more thoroughly. Abstraction permits to pick out certain elements from the wholes and concentrate on them, thus making reality more schematized. Generalization is a selection of general and essential that is typical for the definite number of subjects and notions. Concrete definition is a transition from the abstracts to the individual real subjects and phenomena. Classification is a division and their grouping of objects on the basis of certain elements. Systematization is division with a following grouping (unification) but not of separate objects as in classification but in groups or classes. There are three categories of thinking. Concepts are the reflection in the mind of general and important properties of a group of initial objects or phenomena of reality. Concepts are the highest form of the reflection of reality as they reflect the general, most important, regular properties of objects and phenomena. Definite concepts reflect the ties and relationship between objects and phenomena. Abstract concepts do not reflect real objects or phenomena. They reflect only certain properties of objects combining into notions on the basis of abstractions of the given objects. Judgment is a reflection of links between the subjects and phenomena of reality or between their properties and signs. Judgment is a result of somebody's expression about something. They affirm or reject any relations between subjects, events and phenomena of the reality. Conclusion is a link between thoughts (notions, judgments) resulting in getting different judgment from one or several judgments, or withdrawing it from the content of initial judgments. Induction and deduction are the means of making conclusions which reflect direction of thought. Induction is movement of thought from a single statement to general knowledge. Inductive conclusion results in general judgment. Deduction is movement of knowledge from more general to less general. Classification of types of thinking: 1) By the character of the aids used: – Visual aid is a material for thinking activity presented in a visual, specific form (plaster cast, laboratory equipment and others). 21 – Semantic aid is a material for thinking activity presented in a sense, symbolic form (operating with numbers, verbal description of the situation). 2) By the character of duration of the cognitive processes: – Intuitive thinking is performed as «gripping» the situation, provided decision without information about the ways and conditions of its performance. – Analytical thinking is performed by means of logical conclusions leading to the correct understanding the main principle of appropriateness. 3) By the character of the tasks solved: – Practical thinking takes place if the person has to solve the definite situation with its characteristic features and conditions. – Theoretical thinking takes place if the tasks are being solved by the person in general and they submit to the search of the main appropriateness, rules, determination of the type of situation. 4) By functions: – Creative thinking is reproduction of new ideas, search of the original solving the task. – Stereotype thinking is reproductive decision of typical tasks according to the earlier acquired scheme. Depending on the content of the task being solved there are three kinds of thinking: a) Visually-active thinking is thinking where solving the task includes outer motive tests. It is characteristic for this type of thinking that the task is solved with the help of real, physical transformation of the situations, approbation of the properties of the objects. At preschool age (under 3 years) thinking is visually- active in general. It is often applied in adults in every day life and is necessary if it is impossible to provide the results of any actions beforehand (the work of tester, constructor). b) Concrete-graphic thinking is connected with operating images. This form of thinking is completely and extensively represented in children of pre-school (4-7 year old) and young school ages, but in adults it occurs in the people whose professions are connected with clear and lively conception about different subjects or phenomena (writers, artists, musicians, actors). c) Abstract-logical thinking operates on the base of linguistic means and represents later stage of historic and ontogenetic development of thinking. This thinking is characterized by the use of notions, logical constructions which sometimes do not have a graphic description (honesty, pride and others). Due to verbal- logical thinking a person can establish more general 24 - Ambitendency of thinking (simultaneous being of two alternative thoughts). - Pathological philosophizing. - Pathological detailed elaboration (inability of picking out the most principal and important, sticking on separate details). - Pathological symbolism (conclusions which are built on occasional associations). - Neologisms (creation of new words which are understandable only for the creator). 3) Disturbances by content of formed associations: - Obsessive thoughts occur without the person's desire and against his wish. The patient assesses them in a critical way, fights against them but can not make effort to avoid them. - Overvalued ideas are the judgments occurring as a result of real situation but have disproportionate, prevalent meaning in thinking due to the strongly pronounced emotional coloring. These thoughts would not be incorrect if the patient did not pay great attention to them. Pathology occurs because of strong exaggeration of the importance of the thought. One of the variants of these thoughts is hypochondriac state (hypernosognosia) when the patient overestimates real unhealthy sensations and considers being ill with a very serious and dangerous disease. These patients constantly visit doctors, ask for treatment, change drugs all the time. - Raving ideas are produced by a psychotic mind. They could seem like truth or be absolutely fantastic and weird. It's common to pick out paranoial, paranoid and paraphrenic raving. Methods of thinking examination When talking to the patient one should pay attention to the speed of associations and their features. It is necessary to give the patient possibility to talk freely about everything he wants including every abstract topics. A number of experimental psychological methods can be used for examination of thinking. Generalization of notions. Four initial notions are proposed and the task to define them by one word is given. In such way ability to synthesize is determined. Exclusion of notions. Four or five words are proposed and it is necessary to find the word inappropriate in meaning to the others. It gives the possibility to judge about the ability to analyze. Methods of comparison. The patient is given the task to find out similarities and differences between two notions. 25 Explanation of figurative sense of proverbs gives the possibility to evaluate the level of thinking and intellectual development. Associative experiment. 20-25 words prepared beforehand are proposed to the patient, and he is to answer in one word after 2-3 seconds what are those words about. This method gives the possibility to judge about the speed of thinking, content of dominative notions, and qualitative peculiarities of the person. Explanations of topical pictures. The patient is given a postcard with a reproduction of a picture, and he is to retell its content. The method checks up quick wits of the patients, their ability to emphasize the essence and emotional reaction. Establishment of sequence of events. Using a series of 3-6 pictures of some event the patient have to reproduce a connected narrative. This method is intended for revealing quick wits of the patients, ability to understand the links of events and make some sequent conclusions. Classification. For examination it's necessary to use a set of cards with pictures of different objects or their verbal signs. A set of cards provides different possibilities to solve the task. The patient is proposed to isolate one picture which is inappropriate in meaning to three ones. This method is used for examining the level of processes of generalization and abstraction, sequence of judgments. Pictograms. The patient is given a blank sheet of paper, pencil and is proposed to draw a sketch for memorizing the words. This method gives the possibility to study individual thinking productivity in patients. Little determination and regulation of thinking processes by condition of experience gives the possibility to find out disturbances of thinking in patient. 26 CHAPTER IV ATTENTION, MEMORY AND INTELLECT Objectives: to learn the role of attention and its liaisons to other mental functions, to get acquainted with the notion and types of memory and intellect, to get the overview of their disorders, methods of examination. Human sensory organs are permanently influenced by a great number of irritants. Nevertheless, not all the influences reach consciousness simultaneously. Something having prior significance for a person, satisfying his needs and interests is selected. All the rest is either perceived indistinctly or completely ignored. Selective nature of psychic activity is defined as attention. Attention is observed as concentration of consciousness on a chosen object or phenomenon, as a result this object or phenomenon is reflected clearer. In contrast to cognitive processes (sensation and perception) attention does not have its own content. It characterizes the dynamics of psychic processes. E.g. if a student does his lesson, he adopts some material, thinks over something he has read, picks out the main idea and tries to remember it. Through this an activity of cognitive processes becomes apparent, i.e. perception, thinking, memory. For a long while the student concentrates on one subject and ignores the others. Strong irritants can distract him from his educational activity, but he voluntarily turns back to the subject in question. This purposeful cognitive process is an example of attention. Attention is reflex in its nature. Its direction to the object is a specific response of an organism to some changes in the environment, which are of importance for a person. I.P.Pavlov considered specially directing sensors analyzer to perception of object, which causes creating a nidus of optimal irritation in the corresponding area part of cortex to be the basis of attention. As a result temporary nervous connections are easily formed. At this time neurons in other areas of cortex are inhibited. Irritations which get into inhibited areas do not create temporary connections, 29 infection, intoxications, injuries, tumors, vascular sclerosis of a brain. When frontal lobes of cortex are affected, ability of switching attention decreases. Switching can be inhibited to such extent that a patient repeats some action many times not even noticing it. In clinic opposite phenomena are also observed when ability to switching attention increases. This deviation characterizes maniac patients. Frequently somatic, infections and other pathologies may result in increased exhaustion of attention, i.e. decrease of stability and volume of attention. Memory is a form of mental reflection of the reality and with its help earlier acquired data; knowledge and events are fixed, kept and recreated. The human memory contains two types of information: specific memory, which has been accumulated in the process of evolution for many thousands of years, which is determined by unconditioned reflexes and instincts, and hereditable and acquired memory in the process of human life realized in conditioned reflexes. The basis of the human memory and its physiological mechanisms contain the system of conditioned reflexes, forming temporary connections or «traces», processes occurring in the nervous system which were studied in detail by I.P. Pavlov and his scientific school. Of all the present theories of memory chemical theory has the biggest influence. According to it, impulses coming from the periphery toward the brain cortex cause changes in the chemical composition of the nervous cells; the RNA plays a major role in the processes of encoding and decoding of data as well as placing it for storage. The processes of memory are following: 1)Memorizing (fixation) – acquisition of information; 2) Retention – the process of keeping information; 3) Reproduction – the process of getting information from the storage to use; 4) Forgetting – forcing out the information which lost its urgency to the latent layers of memory or perhaps the complete destruction of all the information. Types of memory. According to participation of analyzers and functional systems, there is visual, aural, olfactory, sense, tactile, emotional, motor, mixed memory (memorizing images, sounds, smell, touches, emotional stress, movements, complex action, etc.). 30 According to participation of the signal system: image memory (the first signal system is the memory for the image, sounds, smell, activities, etc.); verbal-logical memory (the second signal system) is the memory for the words, judgment, etc. According to the mechanism of memorizing: mechanical (mechanical memorizing of information – phone numbers, definite numbers, material without support of semantic association) and verbal-logical (memorizing information with support of semantic meaning and internal logical connection). According to the degree of involvement of active attention and volition: involuntary (involuntary memorizing and reproducing) and voluntary (purposeful memorizing and reproducing). According to the place and role in the structure of activity: operative (short storage of information which is necessary for achieving the definite aim and loses its urgency after achievement of the task), short memory (memorizing for a short time) and prolonged memory (memorizing knowledge, abilities and practical skills for a long time). According to the degree of use of memorizing means: mediated and immediate memory. At each age the memory has its own peculiarities: - In children under 1 year – image memory (memorizing bright stimuli and images of relatives, their recognition); - In children aged 2-3 years – improvement of image memory, appearance of verbal-logical memory; - At the age of 4-5 years – rapid development of verbal-logical memory, voluntary memorizing and reproducing, richness of content of memory images, using not only perceptions but notions; - From 14-15 to 25-30 years – the highest level of development of memory; - After 30 years – gradual reducing ability for mechanical memorizing and the highest level of logical memory; - After 40-45 years – evident prevalence of logical memory; - After 60 years – decreasing mechanical and verbal-logical memory for the current events; everything that happened at the younger age is recalled better. This peculiarity is called a law of reverse motion of memory (T. Ribot, 1881). Individual peculiarities of memory play a great role in memorizing processes. For example, general level of its components and properties, prevalence of aural, visual and other memories, its training, daily and age dynamics of processes of memory (especially fixation and reproduction), change of image and verbal-logical memory depending on the state of health, interest, emotional 31 condition, personal meaning of information, figurativeness of the material and others varies greatly in each person. Properties of memorizing: - Simple events in life accompanied by strong feelings like exultation, fear of rage are memorized quicker and kept for a long time; - Complex but less interesting events which are emotionally neutral are memorized more slowly and are kept for a longer period than emotionally significant ones; - Better facilitation to the process of memorizing and repro- ducing results in increasing concentration of attention to the definite information; - When memorizing a quite big piece of data, its beginning and end are recollected in mind quicker ("edge effect"); - It is important for associative connection of impressions and their reproduction whether they are a logically connected in a whole or they are separate elements; - Strange, weird and unusual impressions are memorized better that common ones. Some tips for memory improvement: 1) Defining which kind of data (audio, visual or kinesthetic) you memorize the best and then using mainly of that data type supported by other types. 2) Understanding of the text, formulas, pictures and other material. 3) Clarity of aim and connection of the material learned with earlier acquired content and the practical performance. 4) Active logical processing of the material includes making a plan of the text, expressing its main idea, joining data in groups and categories, selecting their titles, establishing different logical connections within this material and connections of this material with the other; 5) Positive motivation for the data memorizing. 6) Rational use of illustrative material (pictures, drawings, diagrams and others); 7) Connection of the memorizing process with bright emotional states. 8) Rational organization of revising in time, for example, 5-6 times at the first day, 4 times at the second day, 2-3 times at the third day, change of methods of revision (individually, in chorus, etc.), partial change of revision methods. 9) Implementation of self-control for evaluating the material that has been poorly acquired. 34 The condition of memory is studied by questioning the patient. It helps to find out whether the patient calls things by their right names (year, month, date), if he knows the place where he is and who is close to him, if he says his age, date of birth in a proper way. Amnesic disorientation connected with disorders of memory should differ from disorientation observed against a background of impaired consciousness and it is usually accompanied by torpor and other disturbances. While studying memory about the past events besides questions concerning different periods of the patient's life, the dates which are sometimes difficult to check up, it is necessary to examine memorizing well-known historic dates more or less remote in time, events in recent times (circumstances of hospitalization, etc.), events preceded the disease or trauma. Severe disturbances in memorizing of current events, fictional recollections (pseudo-reminiscences and confabulations) are found out in questions concerning the recent events ("Where were you yesterday?" or "What have you done today?", "Whom did you meet?"). Taking into account instability of the content of fictional recollections one should repeat the same questions later in the conversation. With such examining the primary content of the answer usually changes. Visual memory includes memorizing linear geometrical figures (F.E.Rybakov), simple and more complex drawings. The patient is proposed to look through attentively for 10 seconds and memorize geometrical figures and then find them among the figures represented in the other chart. The patient usually memorizes 5-6 figures. Memorizing the objects in the charts is investigated by the same way. Oral memory is the memorizing of numbers, words and sentences by hearing. The patient is proposed to listen to the numbers attentively, memorize words and sentences and repeat them. It is necessary to read words slowly and clearly. The studies are recommended to start from simple digits, then come to two-digit numbers, three-digit numbers and so on (it concerns memorizing words with different number of syllables). The patient is to read the proposed material for memorizing just once. The necessity of repeated reading points to hypomnesia. Memorizing 10 words (according to A.R. Luria) – the patient is read 10 words and proposed to repeat them. The exercise is repeated 5 times and in 50-60 minutes the patient is asked to reproduce the words he has memorized, The chart of the results is made normally, about 9-10 words are reproduced by the third repetition. It allows to judge about the condition of the memory, 35 stability of attention and emotional attitude of the patient to the test. Reproduction of stories – after reading and listening to a short story the patient retells its content orally or in writing. The method allows checking up the condition of memory, stability of attention and logical thinking. Examination of intellect The studies of intellect according to Wechsler – this method consists of two groups of subtests (verbal – 6 and non verbal – 5). The peculiarities of the answers in every test are taken into account, and then the coefficients of verbal, non verbal and general intellects are calculated. Raven's charts – this test consists of 60 charts (5 sets). Every set of charts contains a task of increasing level. The correct solution of every task is evaluated as 1. After it the total number of points in all the charts and separate series is calculated. The result is considered as index of intellect level, mental productivity of the patient. 36 CHAPTER V EMOTIONS AND FEELINGS Objectives: to learn the emotion's structure in normal state, types of feelings and to get the overview of their disorders, methods of examination. Emotions are the subjective states of man and animals, which arise up under the action of external and internal irritants and expressed as a direct experiencing (satisfaction or not, fright, gladness, anger ect). They are acting important part in the teaching process (gaining vital experience). Executing the role of negative or positive reinforcement, emotions are instrumental in making of biologically active forms of behavior and removal of reactions, losing the biological value. Thus, emotions are the method of increase of adjusting possibilities of organism, and also one of main mechanisms of the internal regulations psychical activity and behavior, necessities of organism directed on satisfaction. Human's emotions has a social determination. They are existed under the influencing of morality and law rules of certain social- economy formation. So highest forms of emotions arise up on the basis of social (morality) and spiritual (esthetic, intellectual) necessities. Classification Basic and complex categories, where some are modified in some way to form complex emotions (e.g. Paul Ekman). In one model, the complex emotions could arise from cultural conditioning or association combined with the basic emotions. Alternatively, analogous to the way primary colors combine, primary emotions could blend to form the full spectrum of human emotional experience. For example interpersonal anger and disgust could blend to form contempt. Robert Plutchik proposed a three-dimensional "circumplex model" which describes the relations among emotions. This model 39 circa 180 million years ago, smell replaced vision as the dominant sense, and a different way of responding arose from the olfactory sense, which is proposed to have developed into mammalian emotion and emotional memory. In the Jurassic Period, the mammalian brain invested heavily in olfaction to succeed at night as reptiles slept — one explanation for why olfactory lobes in mammalian brains are proportionally larger than in the reptiles. These odor pathways gradually formed the neural blueprint for what was later to become our limbic brain. Emotions are thought to be related to activity in brain areas that direct our attention, motivate our behavior, and determine the significance of what is going on around us. Pioneering work by Broca (1878), Papez (1937), and MacLean (1952) suggested that emotion is related to a group of structures in the center of the brain called the limbic system, which includes the hypothalamus, cingulate cortex, hippocampi, and other structures. More recent research has shown that some of these limbic structures are not as directly related to emotion as others are, while some non-limbic structures have been found to be of greater emotional relevance. Prefrontal Cortex There is ample evidence that the left prefrontal cortex is activated by stimuli that cause positive approach. If attractive stimuli can selectively activate a region of the brain, then logically the converse should hold, that selective activation of that region of the brain should cause a stimulus to be judged more positively. This was demonstrated for moderately attractive visual stimuli and replicated and extended to include negative stimuli. Two neurobiological models of emotion in the prefrontal cortex made opposing predictions. The Valence Model predicted that anger, a negative emotion, would activate the right prefrontal cortex. The Direction Model predicted that anger, an approach emotion, would activate the left prefrontal cortex. The second model was supported. This still left open the question of whether the opposite of approach in the prefrontal cortex is better described as moving away (Direction Model), as unmoving but with strength and resistance (Movement Model), or as unmoving with passive yielding (Action Tendency Model). Support for the Action Tendency Model (passivity related to right prefrontal activity) comes from research on shyness and research on behavioral inhibition. Research that tested the competing hypotheses generated by all four models also supported the Action Tendency Model. Homeostatic Emotion 40 Another neurological approach, described by Bud Craig in 2003, distinguishes between two classes of emotion. "Classical emotions" include lust, anger and fear, and they are feelings evoked by environmental stimuli, which motivate us (to, in these examples, respectively, copulate/fight/flee). "Homeostatic emotions" are feelings evoked by internal body states, which modulate our behavior. Thirst, hunger, feeling hot or cold (core temperature), feeling sleep deprived, salt hunger and air hunger are all examples of homeostatic emotion; each is a signal from a body system saying "Things aren't right down here. Drink/eat/move into the shade/put on something warm/sleep/lick salty rocks/breathe." We begin to feel a homeostatic emotion when one of these systems drifts out of balance, and the feeling prompts us to do what is necessary to restore that system to balance. Pain is a homeostatic emotion telling us "Things aren't right here. Withdraw and protect."[13][14] Cognitive theories There are some theories on emotions arguing that cognitive activity in the form of judgments, evaluations, or thoughts is necessary in order for an emotion to occur. This, argued by Richard Lazarus, is necessary to capture the fact that emotions are about something or have intentionality. Such cognitive activity may be conscious or unconscious and may or may not take the form of conceptual processing. An influential theory here is that of Lazarus. A prominent philosophical exponent is Robert C. Solomon (e.g. The Passions, Emotions and the Meaning of Life, 1993). The theory proposed by Nico Frijda where appraisal leads to action tendencies is another example. It has also been suggested that emotions (affect heuristics, feelings and gut-feeling reactions) are often used as shortcuts to process information and influence behaviour. Perceptual theory A recent hybrid of the somatic and cognitive theories of emotion is the perceptual theory. This theory is neo-Jamesian in arguing that bodily responses are central to emotions, yet it emphasises the meaningfulness of emotions or the idea that emotions are about something, as is recognised by cognitive theories. The novel claim of this theory is that conceptually based cognition is unnecessary for such meaning. Rather the bodily changes themselves perceive the meaningful content of the emotion because of being causally triggered by certain situations. In this respect, emotions are held to be analogous to faculties such as vision or touch, which provide information about the relation between the subject and the world in various ways. A sophisticated defense of this view is found in philosopher Jesse Prinz's book Gut Reactions and psychologist James Laird's book Feelings. 41 Affective Events Theory This a communication-based theory developed by Howard M. Weiss and Russell Cropanzano (1996), that looks at the causes, structures, and consequences of emotional experience (especially in work contexts.) This theory suggests that emotions are influenced and caused by events which in turn influence attitudes and behaviors. This theoretical frame also emphasizes time in that human beings experience what they call emotion episodes - a ―series of emotional states extended over time and organized around an underlying theme‖. This theory has been utilized by numerous researchers to better understand emotion from a communicative lens, and was reviewed further by Howard M. Weiss and Daniel J. Beal in their article, Reflections on Affective Events Theory published in Research on Emotion in Organizations in 2005. Cannon-Bard theory In the Cannon-Bard theory, Walter Bradford Cannon argued against the dominance of the James-Lange theory regarding the physiological aspects of emotions in the second edition of Bodily Changes in Pain, Hunger, Fear and Rage. Where James argued that emotional behaviour often precedes or defines the emotion, Cannon and Bard argued that the emotion arises first and then stimulates typical behaviour. Two-factor theory Another cognitive theory is the Singer-Schachter theory. This is based on experiments purportedly showing that subjects can have different emotional reactions despite being placed into the same physiological state with an injection of adrenaline. Subjects were observed to express either anger or amusement depending on whether another person in the situation displayed that emotion. Hence the combination of the appraisal of the situation (cognitive) and the participants' reception of adrenaline or a placebo together determined the response. This experiment has been criticized in Jesse Prinz (2004) Gut Reactions. Disorders of emotions Apathy (also called impassivity or perfunctoriness) is a state of indifference, or the suppression of emotions such as concern, excitement, motivation and passion. An apathetic individual has an absence of interest or concern to emotional, social, or physical life. They may also exhibit an insensibility or sluggishness. Depression or moping is a state of low mood and aversion to activity. While often described as a dysfunction, there are also strong arguments for seeing depression as an adaptive defense mechanism. 44 during all period of examination and conversation. Additional dates may be received by means of conversation with relatives, colleagues or other patients. Experimental methods: a). Investigation of a self-estimating by Dembo-Rubinshtein. On the symbolic line of some human’s peculiarities (health, mind, character, happiness ect.) psychologist propose to the patient to find his/her position by drop marking and explain it. Fixate self- estimating level, explanations and peculiarities of emotion’s reactions. b). There are many indirect methods of investigation of emotional functioning, such as associative experiment, Rozenzveig Test, Rorschach Test, anxiety evaluation ect. 45 CHAPTER VI PSYCHOLOGY OF CONSCIOUSNESS Objectives: to study the structure, peculiarities and neurophysiological basis of consciousness. To learn main philosophical conceptions of consciousness. To get the overview of consciousness disorders, methods of examination. Consciousness is subjective experience or awareness or wakefulness or the executive control system of the mind. It is an umbrella term that may refer to a variety of mental phenomena. Although humans realize what everyday experiences are, consciousness refuses to be defined, philosophers note. "Anything that we are aware of at a given moment forms part of our consciousness, making conscious experience at once the most familiar and most mysterious aspect of our lives" (Schneider and Velmans, 2007). Consciousness in medicine (e.g., anesthesiology) is assessed by observing a patient's alertness and responsiveness, and can been seen as a continuum of states ranging from alert, oriented to time and place, and communicative through disorientation, then delirium, then loss of any meaningful communication, and ending with loss of movement in response to painful stimulation. Consciousness in psychology and philosophy has four characteristics: subjectivity, change, continuity and selectivity. Intentionality or aboutness (that consciousness is about something) has also been suggested by philosopher Brentano. However, within the philosophy of mind there is no consensus on whether intentionality is a requirement for consciousness. Consciousness is the subject of much research in philosophy of mind, psychology, neuroscience, cognitive science, cognitive neuroscience and artificial intelligence. Issues of practical concern include how the presence of consciousness can be assessed in severely ill or comatose people; whether non-human consciousness 46 exists and if so how it can be measured; at what point in fetal development consciousness begins; and whether computers can achieve a conscious state. There are many philosophical stances on consciousness, including: behaviorism, dualism, idealism, functionalism, reflexive monism, phenomenalism, phenomenology and intentionality, physicalism, emergentism, mysticism, personal identity etc. Phenomenal and access consciousness Phenomenal consciousness (P-consciousness) is simply experience; it is moving, colored forms, sounds, sensations, emotions and feelings with our bodies and responses at the center. These experiences, considered independently of any impact on behavior, are called qualia. The hard problem of consciousness, formulated by David Chalmers in 1996, deals with the issue of "how to explain a state of phenomenal consciousness in terms of its neurological basis". Access consciousness (A-consciousness) is the phenomenon whereby information in our minds is accessible for verbal report, reasoning, and the control of behavior. So, when we perceive, information about what we perceive is often access conscious; when we introspect, information about our thoughts is access conscious; when we remember, information about the past (e.g., something that we learned) is often access conscious, and so on. Chalmers thinks that access consciousness is less mysterious than phenomenal consciousness, so that it is held to pose one of the easy problems of consciousness. Daniel C. Dennett denies that there is a "hard problem", asserting that the totality of consciousness can be understood in terms of impact on behavior, as studied through heterophenomenology. There have been numerous approaches to the processes that act on conscious experience from instant to instant. Dennett suggests that what people think of as phenomenal consciousness, such as qualia, are judgments and consequent behavior. He extends this analysis by arguing that phenomenal consciousness can be explained in terms of access consciousness, denying the existence of qualia, hence denying the existence of a "hard problem." Chalmers, on the other hand, argues that Dennett's explanatory processes merely address aspects of the easy problem. Eccles and others have pointed out the difficulty of explaining the evolution of qualia, or of 'minds' which experience them, given that all the processes governing evolution are physical and so have no direct access to them. There is no guarantee that all people have minds, nor anyway to verify whether one does or does not possess one. 49 theories of consciousness, reflexive monism, and Electromagnetic theories of consciousness to explain the correspondence between brain activity and experience. Parapsychologists sometimes appeal to the unproven concepts of psychokinesis or telepathy to support the belief that consciousness is not confined to the brain. Philosophical criticisms From the eighteenth to twentieth centuries many philosophers concentrated on relations, processes and thought as the most important aspects of consciousness. These aspects would later become known as "access consciousness" and this focus on relations allowed philosophers such as Marx, Nietzsche and Foucault to claim that individual consciousness was dependent on such factors as social relations, political relations and ideology. Locke's "forensic" notion of personal identity founded on an individual conscious subject would be criticized in the 19th century by Marx, Nietzsche, and Freud following different angles. Martin Heidegger's concept of the Dasein ("Being-there") would also be an attempt to think beyond the conscious subject. Marx considered that social relations ontologically preceded individual consciousness, and criticized the conception of a conscious subject as an ideological conception on which liberal political thought was founded. Marx in particular criticized the 1789 Declaration of the Rights of Man and of the Citizen, considering that the so-called individual natural rights were ideological fictions camouflaging social inequality in the attribution of those rights. Later, Louis Althusser would criticize the "bourgeois ideology of the subject" through the concept of interpellation ("Hey, you!"). Nietzsche, for his part, once wrote that "they give you free will only to later blame yourself", thus reversing the classical liberal conception of free will in a critical account of the genealogy of consciousness as the effect of guilt and ressentiment, which he described in On the Genealogy of Morals. Hence, Nietzsche was the first one to make the claim that the modern notion of consciousness was indebted to the modern system of penalty, which judged a man according to his "responsibility", that is by the consciousness through which acts can be attributed to an individual subject: "I did this! this is me!". Consciousness is thus related by Nietzsche to the classic philosopheme of recognition which, according to him, defines knowledge. According to Pierre Klossowski (1969), Nietzsche considered consciousness to be a hypostatization of the body, composed of multiple forces (the "Will to Power"). According to him, the subject 50 was only a "grammatical fiction": we believed in the existence of an individual subject, and therefore of a specific author of each act, insofar as we speak. Therefore, the conscious subject is dependent on the existence of language, a claim which would be generalized by critical discourse analysis (see for example Judith Butler). Michel Foucault's analysis of the creation of the individual subject through disciplines, in Discipline and Punish (1975), would extend Nietzsche's genealogy of consciousness and personal identity - i.e. individualism - to the change in the juridico-penal system: the emergence of penology and the disciplinization of the individual subject through the creation of a penal system which judged not the acts as it alleged to, but the personal identity of the wrong-doer. In other words, Foucault maintained that, by judging not the acts (the crime), but the person behind those acts (the criminal), the modern penal system was not only following the philosophical definition of consciousness, once again demonstrating the imbrications between ideas and social institutions ("material ideology" as Althusser would call it); it was by itself creating the individual person, categorizing and dividing the masses into a category of poor but honest and law-abiding citizens and another category of "professional criminals" or recidivists. Gilbert Ryle has argued that traditional understandings of consciousness depend on a Cartesian outlook that divides into mind and body, mind and world. He proposed that we speak not of minds, bodies, and the world, but of individuals, or persons, acting in the world. Thus, by saying 'consciousness,' we end up misleading ourselves by thinking that there is any sort of thing as consciousness separated from behavioral and linguistic understandings. The failure to produce a workable definition of consciousness also raises formidable philosophical questions. It has been argued that when Antonio Damasio defines consciousness as "an organism's awareness of its own self and its surroundings", the definition has not escaped circularity, because awareness in that context can be considered a synonym for consciousness. Consciousness and language Because humans express their conscious states using language, it is tempting to equate language abilities and consciousness. There are, however, speechless humans (infants, feral children, aphasics, severe forms of autism), to whom consciousness is attributed despite language lost or not yet acquired. Moreover, the study of brain states of non-linguistic primates, in particular the macaques, has been used extensively by 51 scientists and philosophers in their quest for the neural correlates of the contents of consciousness. Julian Jaynes argued to the contrary, in The Origin of Consciousness in the Breakdown of the Bicameral Mind, that for consciousness to arise in a person, language needs to have reached a fairly high level of complexity. According to Jaynes, human consciousness emerged as recently as 1300 BCE or thereabouts. He defines consciousness in such a way as to show how he conceives of it as a type of thinking which builds upon non human ways of perceiving. Some philosophers, including W.V. Quine, and some neuroscientists, including Christof Koch, contest this hypothesis, arguing that it suggests that prior to this "discovery" of consciousness, experience simply did not exist. Ned Block argued that Jaynes had confused consciousness with the concept of consciousness, the latter being what was discovered between the Iliad and the Odyssey. Daniel Dennett points out that these approaches misconceive Jaynes's definition of consciousness as more than mere perception or awareness of an object. He notes that consciousness is like money in that having the thing requires having the concept of it, so it is a revolutionary proposal and not a ridiculous error to suppose that consciousness only emerges when its concept does. More recently, Merlin Donald, seeing a similar connection between language and consciousness, and a similar link to cultural, and not purely genetic, evolution, has put a similar proposal to Jaynes' forward - though relying on less specific speculation about the more recent pre-history of consciousness. The idea that language and consciousness are not innate to humans, a characteristic of human nature, but rather the result of cultural evolution, beginning with something similar to the culture of chimpanzees, goes back before Darwin to Rousseau's Second Discourse. Cognitive psychology and cognitive neuroscience For a long time in scientific psychology, consciousness as a research topic or explanatory concept had been banned. Research on topics associated with consciousness were conducted under the banner of attention. Modern investigations into consciousness are based on psychological statistical studies and case studies of consciousness states and the deficits caused by lesions, stroke, injury, or surgery that disrupt the normal functioning of human senses and cognition. These discoveries suggest that the mind is a complex structure derived from various localized functions that are bound together with a unitary awareness. 54 In recent years the theory of two visual streams, vision for perception versus vision for action has been refined by Melvyn Goodale, David Milner and others. According to this theory, visual perception arises as the result of processing of visual information by the ventral stream areas (located mostly in the temporal lobe), whereas the dorsal stream areas (located mostly in the parietal lobe) process visual information unconsciously. For example, catching a ball quickly would engage the dorsal stream areas, whereas viewing a painting would engage the ventral stream. Overall, these studies show that conscious versus unconscious behaviors can be linked to specific brain areas and patterns of neuronal activation. An alternative and more global approach to analyzing neurophysiological correlates of consciousness is referred to by the Fingelkurts as Operational Architectonics. This still-untested theory postulates that thoughts are matched with and generated by underlying neurophysiological activity patterns that can be revealed directly by EEG. Evolutionary psychology Consciousness can be viewed from the standpoints of evolutionary psychology or evolutionary biology approach as an adaptation because it is a trait that increases fitness.[33] Consciousness also adheres to John Alcock's theory of animal behavioral adaptations because it possesses both proximate and ultimate causes. The proximate causes for consciousness, i.e. how consciousness evolved in animals, is a subject considered by Sir John C. Eccles in his paper "Evolution of consciousness." He argues that special anatomical and physical properties of the mammalian cerebral cortex gave rise to consciousness. Budiansky, by contrast, limits consciousness to humans, proposing that human consciousness may have evolved as an adaptation to anticipate and counter social strategems of other humans, predators, and prey. Alternatively, it has been argued that the recursive circuitry underwriting consciousness is much more primitive, having evolved initially in premammalian species because it improves the capacity for interaction with both social and natural environments by providing an energy-saving "neutral" gear in an otherwise energy- expensive motor output machine. Another theory, proposed by Shaun Nichols and Todd Grantham, proposes that it is unnecessary to trace the exact evolutionary or causal role of phenomenal consciousness because the complexity of phenomenal consciousness alone implies that it is an adaptation. Once in place, this recursive circuitry may well have provided a basis for the subsequent development of many of the functions which 55 consciousness facilitates in higher organisms, as outlined by Bernard J. Baars. Konrad Lorenz sees the roots of consciousness in the process of self-exploration of an organism that sees itself acting and learns a lifetime. Behind the Mirror: A Search for a Natural History of Human Knowledge Functions of Consciousness Function Purpose Definition and context-setting Relating global input to its contexts, thereby defining input and removing ambiguities Adaptation and learning Representing and adapting to novel and significant events Editing, flagging, and debugging Monitoring conscious content, editing it, and trying to change it if it is consciously "flagged" as an error Recruiting and control function Recruiting subgoals and motor systems to organize and carry out mental and physical actions Prioritizing and access control Control over what will become conscious Decision-making or executive function Recruiting unconscious knowledge sources to make proper decisions, and making goals conscious to allow widespread recruitment of conscious and unconscious "votes" for or against them Analogy-forming function Searching for a partial match between contents of unconscious systems and a globally displayed (conscious) message Metacognitive or self-forming function Reflection upon and control of our own conscious and unconscious functioning Auto-programming and self- maintenance function Maintenance of maximum stability in the face of changing inner and outer conditions . Disturbances of consciousness There are two main groups of consciousness disturbances in the clinical practice: quantitative (nonpsychotic, simplex forms) and 56 qualitative (psychotic or complicated forms, which includes symptoms of sensory, moving, thinking and another disorders). a) Nonpsychotic: - Somnolence (or "drowsiness") is a state of near-sleep, a strong desire for sleep, or sleeping for unusually long periods (c.f. hypersomnia). It has two distinct meanings, referring both to the usual state preceding falling asleep, and the chronic condition referring to being in that state independent of a circadian rhythm. The disorder characterized by the latter condition is most commonly associated with the use of prescription medications such as mirtazapine or zolpidem. It is considered a lesser impairment of consciousness than stupor or coma. - Sopor is abnormally deep sleep or a stupor which is difficult to get rid of. Sopor may be caused by a drug. Such drugs are called soporific. The name is derived from Latin sopor (cognate with the Latin noun Somnus and the Greek noun Hypnos). - Coma (from the Greek κῶμα koma, meaning deep sleep) is a profound state of unconsciousness. A comatose person cannot be awakened, fails to respond normally to pain or light, does not have sleep-wake cycles, and does not take voluntary actions. Coma may result from a variety of conditions, including intoxication, metabolic abnormalities, central nervous system diseases, acute neurologic injuries such as stroke, and hypoxia. A coma may also result from head trauma caused by mechanisms such as falls or car accidents. It may also be deliberately induced by pharmaceutical agents in order to preserve higher brain function following another form of brain trauma, or to save the patient from extreme pain during healing of injuries or diseases. The underlying cause of coma is bilateral damage to the Reticular formation of the midbrain, which is important in regulating sleep. If the cause of coma is not clear, various investigations (blood tests, medical imaging) may be performed to establish the cause and identify reversible causes. Coma usually necessitates admission to a hospital and often the intensive care unit. b) Psychotic: - Depersonalization is a malfunction or anomaly of the mechanism by which an individual has self awareness. It is a feeling of watching oneself act, while having no control over a situation. It can be considered desirable, such as in the use of recreational drugs, but it usually refers to the severe form found in anxiety and, in the most intense cases, panic attacks. A sufferer feels he or she has changed and the world has become less real, vague, dreamlike, or lacking in significance. It can sometimes be a 59 CHAPTER VII PSYCHOLOGY OF PERSONALITY Objectives: to study the structure and psychological peculiarities of personality (temperament, character), influences of biological and social factors to the personality development. To get the overview of personality disorders, methods of examination. Personality psychology is a branch of psychology that studies personality and individual differences. Its areas of focus include:  Constructing a coherent picture of a person and his or her major psychological processes.  Investigating individual differences, that is, how people can differ from one another.  Investigating human nature, that is, how all people's behaviour is similar. One emphasis in this area is to construct a coherent picture of a person and his or her major psychological processes. Another emphasis views personality as the study of individual differences, in other words, how people differ from each other. A third area of emphasis examines human nature and how all people are similar to one another. These three viewpoints merge together in the study of personality. Personality can be defined as a dynamic and organized set of characteristics possessed by a person that uniquely influences his or her cognitions, motivations, and behaviors in various situations [3]. The word "personality" originates from the Latin persona, which means mask. Significantly, in the theatre of the ancient Latin- speaking world, the mask was not used as a plot device to disguise the identity of a character, but rather was a convention employed to represent or typify that character. The pioneering American psychologist, Gordon Allport (1937) described two major ways to study personality, the nomothetic and the idiographic. Nomothetic psychology seeks general laws that can be applied to many different people, such as the principle of self- actualization, or the trait of extraversion. Idiographic psychology is 60 an attempt to understand the unique aspects of a particular individual. The study of personality has a rich and varied history in psychology, with an abundance of theoretical traditions. The major theories include dispositional (trait) perspective, psychodynamic, humanistic, biological, behaviorist and social learning perspective. There is no consensus on the definition of "personality" in psychology. Most researchers and psychologists do not explicitly identify themselves with a certain perspective and often take an eclectic approach. Some research is empirically driven such as the "Big 5" personality model whereas other research emphasizes theory development such as psychodynamics. There is also a substantial emphasis on the applied field of personality testing. Personality theories Critics of personality theory claim personality is "plastic" across time, places, moods, and situations. Changes in personality may indeed result from diet (or lack thereof), medical effects, significant events, or learning. However, most personality theories emphasize stability over fluctuation. Trait theories According to the Diagnostic and Statistical Manual of the American Psychiatric Association, personality traits are "enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts." Theorists generally assume a) traits are relatively stable over time, b) traits differ among individuals (e.g. some people are outgoing while others are reserved), and c) traits influence behavior. The most common models of traits incorporate three to five broad dimensions or factors. The least controversial dimension, observed as far back as the ancient Greeks, is simply extraversion vs. introversion (outgoing and physical-stimulation-oriented vs. quiet and physical-stimulation-averse).  Gordon Allport delineated different kinds of traits, which he also called dispositions. Central traits are basic to an individual's personality, while secondary traits are more peripheral. Common traits are those recognized within a culture and thus may vary from culture to culture. Cardinal traits are those by which an individual may be strongly recognized.  Raymond Cattell's research propagated a two-tiered personality structure with sixteen "primary factors" (16 Personality Factors) and five "secondary factors."  Hans Eysenck believed just three traits—extraversion, neuroticism and psychoticism—were sufficient to describe human 61 personality. Differences between Cattell and Eysenck emerged due to preferences for different forms of factor analysis, with Cattell using oblique, Eysenck orthogonal, rotation to analyse the factors that emerged when personality questionnaires were subjected to statistical analysis. Today, the Big Five factors have the weight of a considerable amount of empirical research behind them, building on the work of Cattell and others.  Lewis Goldberg proposed a five-dimension personality model, nicknamed the "Big Five": 1. Openness to Experience: the tendency to be imaginative, independent, and interested in variety vs. practical, conforming, and interested in routine. 2. Conscientiousness: the tendency to be organized, careful, and disciplined vs. disorganized, careless, and impulsive. 3. Extraversion: the tendency to be sociable, fun-loving, and affectionate vs. retiring, somber, and reserved. 4. Agreeableness: the tendency to be softhearted, trusting, and helpful vs. ruthless, suspicious, and uncooperative. 5. Neuroticism: the tendency to be calm, secure, and self- satisfied vs. anxious, insecure, and self-pitying. The Big Five contain important dimensions of personality. However, some personality researchers argue that this list of major traits is not exhaustive. Some support has been found for two additional factors: excellent/ordinary and evil/decent. However, no definitive conclusions have been established.  John L. Holland's RIASEC vocational model, commonly referred to as the Holland Codes, stipulates that six personality traits lead people to choose their career paths. In this circumplex model, the six types are represented as a hexagon, with adjacent types more closely related than those more distant. The model is widely used in vocational counseling. Trait models have been criticized as being purely descriptive and offering little explanation of the underlying causes of personality. Eysenck's theory, however, does propose biological mechanisms as driving traits, and modern behavior genetics researchers have shown a clear genetic substrate to them. Another potential weakness of trait theories is that they lead people to accept oversimplified classifications, or worse offer advice, based on a superficial analysis of their personality. Finally, trait models often underestimate the effect of specific situations on people's behavior. It is important to remember that traits are statistical generalizations that do not always correspond to an individual's behavior. 64 id in accordance with the outside world, adhering to the reality principle. Finally, the superego (conscience) inculcates moral judgment and societal rules upon the ego, thus forcing the demands of the id to be met not only realistically but morally. The superego is the last function of the personality to develop, and is the embodiment of parental/social ideals established during childhood. According to Freud, personality is based on the dynamic interactions of these three components. The channeling and release of sexual (libidal) and aggressive energies, which ensues from the "Eros" (sex; instinctual self- preservation) and "Thanatos" (death; instinctual self-annihilation) drives respectively, are major components of his theory. It is important to note Freud's broad understanding of sexuality included all kinds of pleasurable feelings experienced by the human body. Freud proposed five psychosexual stages of personality development. He believed adult personality is dependent upon early childhood experiences and largely determined by age five. Fixations that develop during the Infantile stage contribute to adult personality and behavior. One of Sigmund Freud's earlier associates, Alfred Adler, did agree with Freud early childhood experiences are important to development, and believed birth order may influence personality development. Adler believed the oldest was the one that set high goals to achieve to get the attention they lost back when the younger siblings were born. He believed the middle children were competitive and ambitious possibly so they are able to surpass the first-born’s achievements, but were not as much concerned about the glory. Also he believed the last born would be more dependent and sociable but be the baby. He also believed that the only child loves being the center of attention and matures quickly, but in the end fails to become independent. Heinz Kohut thought similarly to Freud’s idea of transference. He used narcissism as a model of how we develop our sense of self. Narcissism is the exaggerated sense of one self in which is believed to exist in order to protect one's low self esteem and sense of worthlessness. Kohut had a significant impact on the field by extending Freud's theory of narcissism and introducing what he called the 'self-object transferences' of mirroring and idealization. In other words, children need to idealize and emotionally "sink into" and identify with the idealized competence of admired figures such as parents or older siblings. They also need to have their self-worth mirrored by these people. These experiences allow them to thereby 65 learn the self-soothing and other skills that are necessary for the development of a healthy sense of self. Another important figure in the world of personality theory was Karen Horney. She is credited with the development of the "real self" and the "ideal self". She believes all people have these two views of their own self. The "real self" is how you really are with regards to personality, values, and morals; but the "ideal self" is a construct you apply to yourself to conform to social and personal norms and goals. Ideal self would be "I can be successful, I am CEO material"; and real self would be "I just work in the mail room, with not much chance of high promotion". Behaviorist theories Behaviorists explain personality in terms of the effects external stimuli have on behavior. It was a radical shift away from Freudian philosophy. This school of thought was developed by B. F. Skinner who put forth a model which emphasized the mutual interaction of the person or "the organism" with its environment. Skinner believed children do bad things because the behavior obtains attention that serves as a reinforcer. For example: a child cries because the child's crying in the past has led to attention. These are the response, and consequences. The response is the child crying, and the attention that child gets is the reinforcing consequence. According to this theory, people's behavior is formed by processes such as operant conditioning. Skinner put forward a "three term contingency model" which helped promote analysis of behavior based on the "Stimulus - Response - Consequence Model" in which the critical question is: "Under which circumstances or antecedent 'stimuli' does the organism engage in a particular behavior or 'response', which in turn produces a particular 'consequence'?" Richard Herrnstein extended this theory by accounting for attitudes and traits. An attitude develops as the response strength (the tendency to respond) in the presences of a group of stimuli become stable. Rather than describing conditionable traits in non- behavioral language, response strength in a given situation accounts for the environmental portion. Herrstein also saw traits as having a large genetic or biological component as do most modern behaviorists. Ivan Pavlov is another notable influence. He is well known for his classical conditions experiments involving a dog. These physiological studies on this dog led him to discover the foundation of behaviorism as well as classical conditioning. Social cognitive theories In cognitivism, behavior is explained as guided by cognitions (e.g. expectations) about the world, especially those about other 66 people. Cognitive theories are theories of personality that emphasize cognitive processes such as thinking and judging. Albert Bandura, a social learning theorist suggested the forces of memory and emotions worked in conjunction with environmental influences. Bandura was known mostly for his "Bobo Doll experiment". During these experiments, Bandura video taped a college student kicking and verbally abusing a bobo doll. He then showed this video to a class of kindergarten children who were getting ready to go out to play. When they entered the play room, they saw bobo dolls, and some hammers. The people observing these children at play saw a group of children beating the doll. He called this study and his findings observational learning, or modeling. Early examples of approaches to cognitive style are listed by Baron (1982). These include Witkin's (1965) work on field dependency, Gardner's (1953) discovering people had consistent preference for the number of categories they used to categorise heterogeneous objects, and Block and Petersen's (1955) work on confidence in line discrimination judgments. Baron relates early development of cognitive approaches of personality to ego psychology. More central to this field have been:  Self-efficacy work, dealing with confidence people have in abilities to do tasks;  Locus of control theory dealing with different beliefs people have about whether their worlds are controlled by themselves or external factors;  Attributional style theory dealing with different ways in which people explain events in their lives. This approach builds upon locus of control, but extends it by stating we also need to consider whether people attribute to stable causes or variable causes, and to global causes or specific causes. Various scales have been developed to assess both attributional style and locus of control. Locus of control scales include those used by Rotter and later by Duttweiler, the Nowicki and Strickland (1973) Locus of Control Scale for Children and various locus of control scales specifically in the health domain, most famously that of Kenneth Wallston and his colleagues, The Multidimensional Health Locus of Control Scale. Attributional style has been assessed by the Attributional Style Questionnaire, the Expanded Attributional Style Questionnaire, the Attributions Questionnaire, the Real Events Attributional Style Questionnaire and the Attributional Style Assessment Test. Walter Mischel (1999) has also defended a cognitive approach to personality. His work refers to "Cognitive Affective Units", and 69 specific types of activity, is the hypostatic model of personality, created by Codrin Stefan Tapu. Temperament In psychology, temperament refers to those aspects of an individual's personality, such as introversion or extroversion, that are often regarded as innate rather than learnt. A great many classificatory schemes for temperament have been developed; none, though, has achieved general consensus. Historically, the concept of temperament was part of the theory of the four humours, with their corresponding four temperaments. The concept played an important part in pre-modern psychology, and was explored by philosophers such as Immanuel Kant and Hermann Lotze. David W. Keirsey also drew upon the early models of temperament when developing the Keirsey Temperament Sorter. More recently, scientists seeking evidence of a biological basis of personality have further examined the relationship between temperament and character (defined in this context as the learnt aspects of personality). However, biological correlations have proven hard to confirm. Temperament is determined through specific behavioural profiles, usually focusing on those that are both easily measurable and testable early in childhood. Commonly tested factors include irritability, activity, frequency of smiling, and an approach or avoidant posture to unfamiliar events. There is generally a low correlation between descriptions by teachers and behavioural observations by scientists of features used in determining temperament. Temperament is hypothesized to be associated with biological factors, but these have proven difficult to test directly. Character structure A character structure is a system of relatively permanent motivational and other traits that are manifested in the specific ways that an individual relates and reacts to others, to various kinds of stimuli, and the environment that will most likely bring about a normal or productive character structure. On the other hand, a child whose nurture and/or education are not ideal, living in a treacherous environment and interacting with adults who do not take the long-term interests of the child to heart will be more likely to form a pattern of behavior that suits the child to avoid the challenges put forth by a malign social environment. The means that the child invents to make the best of a hostile environment. Although this may serve the child well while in that bad environment, it may also cause the child to react in inappropriate ways, ways damaging to his or her own interests, when interacting 70 with people in a more ideal social context. Major trauma that occurs later in life, even in adulthood, can sometimes have a profound effect. See post-traumatic stress disorder. However, character may also develop in a positive way according to how the individual meets the psychosocial challenges of the life cycle (Erikson). Freud's first paper on character described the anal character consisting of stubbornness, stinginess and extreme neatness. He saw this as a reaction formation to the child's having to give up pleasure in anal eroticism.The positive version of this character is the conscientious, inner directed obsessive. Freud also described the erotic character as both loving and dependent. And the narcissistic character as the natural leader, aggressive and independent because of not internalizing a strong super-ego. For Erich Fromm character develops as the way in which an individual structures modes of assimilation and relatedness.The character types are almost identical to Freud's but Fromm gives them different names, receptive, hoarding, exploitative. Fromm adds the marketing type as the person who continually adapts the self to succeed in the new service economy. For Fromm, character types can be productive or unproductive. Fromm notes that character structures develop in each individual to enable him or her to interact successfully within a given society, to adapt to its mode of production and social norms, (see social character) may be very counter-productive when used in a different society. Fromm got his ideas about character structure from two associates/students of Freud, Sándor Ferenczi and Wilhelm Reich. It is Reich who really developed the concept from Ferenczi, and added to it an exploration of character structure as it applies to body structure and development as well mental life. For Wilhelm Reich, character structures are based upon blocks- -chronic, unconsciously held muscular contractions--against awareness of feelings. The blocks result from trauma: the child learns to limit his awareness of strong feelings as his needs are thwarted by parents and they meet his cries for fulfillment with neglect or punishment. Reich argued for five basic character structures, each with its own body type developed as a result of the particular blocks created due to deprivation or frustration of the child's stage-specific needs. The schizoid structure, which could result in full blown schizophrenia: this is the result of a wound of not feeling wanted by hostile parents, even in the womb. There is a fragmentation of both body and mind with this structure. 71 The oral structure: from deprivation of warmth and milk from the mother, around age 1. The oral structure adopts an attitude of "you do it for me, because you didn't nurture me when I was young." Shoulders are usually hunched, head bent forward, wrists and ankles weak, as if to say, "I can't get it for myself." The masochist structure: this wound occurs when the parent refuses to allow the child to say "no," the first step in setting boundaries. The child seeks relief from the rage that builds up underneath bounded muscle and fat, by provoking others to punish him. The psychopath or upwardly displaced structure: this wound, around the age of 3, is around the parent manipulating, emotionally molesting the child, seducing him into feeling he is "special," for her (the parent's) own narcisstic needs. The child concludes he must never again permit himself to be vulnerable, and so decides he will instead manipulate and overpower others with his will. The body is well developed above, weak below, as the psychopath pulls away from the ground and attempts to overpower from above. This structure has variations, depending on the admixture with prior wounds: the overbearing is the pure type, the submissive is mixed with oral, the withdrawing, with schizoid. The rigid: this wound occurs around the time of the first puberty, the age of 4. The child's sexuality is not affirmed by the parent, but instead shamed or denied. This structure seeks to prove to the parents and others that he is worthy of love. He is often beautifully harmonious, but there is a physical split around the diaphragm between heart and pelvis: love and sex. This person has trouble with being aware of his emotions, which are strong, yet buried. This rigid structure has many substructures, depending on the exact nature of the wound, the admixture with other pre-rigid (oedipal) structures, and the gender: in women, the masculine aggressive, hysterical, and the alternating; in men, the phallic narcissist, the compulsive, and the passive feminine. While each of these structures has blocks, and these blocks to some degree resemble "armour," it is only the rigid structure that truly has what Reich called "character armour": a system of blocks all over the body. Depending on which version of rigid one is, the rigid character possesses either 'plate' (i.e. clanky) or 'mesh'(much more flexible) character armour. Disorders of Personality Psychopathy is a psychological construct that describes chronic disregard for ethical principles and antisocial behavior. The term is often used interchangeably with sociopathy. This is a 74 PART II Special Medical Psychology CHAPTER VIII PSYCHOLOGY OF MEDICAL PROCESS Objectives: to study psychological aspects of the medical process, to learn how to communicate with concrete patients in different forms of pathology taking into consideration psychological peculiarities of these patients. The process of treatment of every disease is accompanied by a number of psychological phenomena closely connected with the personality of the patient and the doctor, as well as the applied therapeutic methods which produce both the positive and (sometimes) negative effects. Consideration of the psychological factors in the medical process makes it possible to obtain a more profound assessment for the efficacy of the therapy and prognosis. Assessment of the therapeutic dynamics in the somatic, psychological and social planes should be regarded as the most adequate one. Organizing the medical process, it is important to take into account the attitude of each particular patient to his disease, this attitude being significantly dependent on the inner picture of the disease, i.e. a complex of feelings and sensations of the patient, his emotional and intellectual responses to the disease and its treatment. The inner picture of the disease does not consist only of the subjective complaints of the patient, but also includes his emotional and intellectual attitude dependent upon the personality peculiarities, the general cultural level, the social medium and upbringing. The attitude of the patients to their disease may be as follows. 1. Normal, i.e. corresponding to the patient's state or the information given to him about the disease. 2. Scornful, when the patient underestimates the severity of his disease, is not treated and does not take any care of himself, as well as demonstrates ungrounded optimism with respect to the prognosis of the disease. 75 3. Denying, when the patient «does not pay attention to the disease», does not take medical advice, fights back any thoughts on his disease and reasonings about it; it also includes dissimulation. 4. Nosophobic, when the patient is disproportionately afraid of the disease, undergoes repeated examinations, changes his doctors; to a greater or less degree he understands that his fears are exaggerated but cannot fight them. 5. Hypochondriac, when the patient guesses or is sure that he suffers from a severe disease, or when he overestimates the severity of some less serious disease. 6. Nosophilic, connected with some calming and pleasant sensations during the disease; it proceeds from the fact that the patient should not perform his duties, the children can play and dream, the adults can read or be engaged in some of their hobbies; the family is attentive to the patient and takes more care of him. 7. Utilitarian, which is the highest manifestation of the nosophilic response. It can have a triple motivation: a) receiving of sympathy, attention and a better examination; b) finding a way out of some unpleasant situation, as, for instance, imprisonment, military service, hated work, obligation to pay alimony; c) receiving of material benefits: pension, vacation, free time which can be also used with some economic benefit. The utilitarian response can be more or less deliberate; it may be based on some slight or severe disease, but sometimes is observed even in a healthy person. The utilitarian response can be manifested with different forms of the patients' behaviour: aggravation, simulation and dissimulation. Aggravation is exaggeration of signs of the disease and subjective complaints. This exaggeration can be completely deliberate, but sometimes is rather caused by emotional motives of a deeper origin, e.g. fear, distrust, feeling of solitude, hopelessness, suspect that the doctor does not believe him. Transitions from the deliberate aggravation to a less deliberate one are sometimes rather unostentatious, and in some cases even hardly perceptible. Simulation is a pretence with the help of which a person tries to create an impression that there is a disease and its signs. It occurs less frequently than aggravation. As a rule, it is used only by very primitive persons in whom its revealing can be relatively easy, or, on the contrary, by well-experienced, pushful and irresponsible persons. A great risk for the malingerer is incurred by the fact that he strives for a certain benefit, this aim being revealed sooner or later. If he does not reach his aim, e.g. receives a pension promising 76 him a well-to-do life with a possibility to earn extra money, this circumstance cannot be concealed from surrounding people and revision of the case will put an end to the simulation. The doctor should not be in a hurry to make a conclusion about simulation until he absolutely makes sure that his suspicions are correct. In this case, a less experienced doctor must always consult his more experienced colleague. Substantiation and argumentation of simulation are particularly important in case of drawing a written conclusion about it. Substitution of the wording "a deliberate production of signs" or "an attempt of a deliberate affected representation of a disease" for the word "simulation" in a medical conclusion is more expedient. Dissimulation means concealing of the disease and its signs. It often occurs in psychiatry in cases of psychoses. As far as other patients are concerned, it is mainly observed in the diseases resulting in some objective or subjective disadvantages for the patient, e.g.: in tuberculosis it is a prolonged staying at a sanatorium, syphilis is accompanied by notification about the disease and revealing of the focus of the infection, surgery is fraught with a possible operation. The greater is the extent of saving the patient from the fear of the forthcoming examination, treatment and consequences of the disease, the more successful is prevention of dissimulation. The success of the medical influence does not depend only upon the psychological peculiarities of the patient, but first of all is determined by the moral make-up of the doctor whose professional activity radically differs from that of any other specialist. The life makes great demands of the doctor as a specialist. First of all, they include a high professionalism, an aspiration for a constant enrichment of his own knowledge. The doctor must be a person of high moral standards whose authority is established by profound knowledge in his field, a personal charm, modesty, optimism, honesty, truthfulness, justice, selflessness and humanism. A sincere and deep personal interest of the doctor in elimination of the patient's ailments gives rise to inventiveness in the forms of help. Confidence in the doctor often depends upon the first impression which develops in the patient during the first meeting with his doctor, the doctor's urgent facial expression, gesticulation, tone of his voice, expressions, as well as his appearance: if the patient sees that his doctor is untidy and sleepy for some reasons which are not caused by his work, he looses any belief considering that a person who is not able to take care of himself cannot care for others and be reliable in his work. The patients are rather inclined to excuse different deviations in the external manifestations and 79 to the doctor by an uncomfortable transport and, moreover, wait his turn for a long time at the reception room may often become inadequately apparent when meeting a nurse or a doctor who have not the slightest idea of the causes of this reaction and groundlessly explain it as a hostile attitude towards them. It is also necessary to mention a possible action of «the transfer of the aesthetic stereotype». Beautiful people rather arouse sympathy and confidence, while plain ones stir up antipathy and uncertainty. In this way, the notion of beauty is associated with good features, and ugliness with evil. Despite the fact that this supposition is groundless, it subconsciously produces a rather strong effect: an outwardly attractive patient arouses more sympathy in the doctor even if in reality he requires less help than a patient whose appearance stirs up antipathy. And, on the contrary, the doctor acting esthetically positively arouses more confidence. In making contact with the patient, the first impression created by the doctor on him is important. It is also influenced by the general atmosphere of the medical institution and behaviour of all its workers: auxiliary personnel, administrative staff, the nurse on reception and registration of the patient. During the first contact with the doctor the patient must gain the impression that the doctor wants to help him. The doctor is obliged to control himself to such an extent that all common norms of the social contact were observed. It means that he must personally introduce himself to the patient, if the latter is not acquainted with him, and hold out his hand. Such behaviour calms the patient, develops a feeling of safety in him and increases his consciousness of the personal dignity. To give the patient an opportunity for a free and uninterrupted account of his sufferings, problems, complaints, troubles and fears is one of the prerequisites for developing a positive attitude. The doctor should not demonstrate that he is very busy, though it may be in reality. The doctor must «resound to the patient's statements» with his own personality. If the patient is not given an opportunity to express his opinion to a necessary extent, he often complains that the doctor «has not listened to him at all» and he has not been examined in compliance with all the rules, though in reality all the necessary things were made. From the patient's side, such cases reveal dissatisfaction that he is neglected as a personality. A talkative patient, an extroverted type achieves psychic ventilation easier; moreover, he even excites curiosity of the doctor in his account if it is entertaining. But actually the above psychic ventilation is more necessary for a concealed introverted type who conceals his problems, complaints and sometimes even signs of a disease as a result of timidness, shame or exaggerated modesty. 80 Confidence is the main component in the patient's attitude to his doctor. Nevertheless, gaining of the confidence does not proceed only from the psychological aspect of the relations between the doctor and the patient, but it also has a broader social aspect. The doctor can gain the confidence of his patient and establish positive contact with him through satisfying his groundless demands. Development of such relations usually proceeds from the mutual satisfaction of the interests, where one side is presented by the doctor and the other one with the patients who may render him some service, but thereby affecting the effective and actually necessary examination of all the patients that in the first place must be performed from the viewpoint of their diseases, but not depending upon their social standing or abilities. A psychological problem arises also in those cases when the doctor notices that his relations with the patient develop in an unfavourable direction. Then the doctor should behave with restraint and patience, resist any provocations, do not provoke himself and try to gradually gain his patient's confidence with calmness and understanding. Medical practice knows cases when the doctor experiences diagnostic difficulties that sometimes result in medical mistakes. There are objective and subjective causes of these mistakes. A medical mistake means a delusion of the doctor with absence of any negligence, carelessness or a thoughtless attitude to his duties. Medical mistakes are often caused by peculiarities in the doctor's personality and character, as well as by how he feels rather than by his insufficient professional training and qualification. This subjective factor accounts for 60 — 70 % of the total number of mistakes. Sometimes mistakes are caused by the doctor's sluggishness, indecision, diffidence, insufficient constructiveness of his thinking, inability to correctly and rapidly orientate himself in a difficult situation, an insufficiently developed ability to correctly and logically compare and synthesize all the elements of the information obtained about the patient. Unwarranted caution taken by the doctor may be extremely dangerous in situations when the patient's state requires prompt and decisive actions, On the other hand, unwarranted self-confidence which is not supported by real evidence sometimes results in making «popular» florid diagnoses. Such peculiarities in the doctor's character as optimism or pessimism may play a part in a wrong prognostic assessment of the severity of a disease. The doctor must always really assess the true situation and should not take the desired thing for the real one. 81 Diagnostic mistakes may also result from the fact how the doctor feels, his asthenic states, the feeling of tiredness and sleepiness. The paramount significance of personality peculiarities in the medical profession must be assessed during the professional selection for higher medical schools. If the applicant's individual personality peculiarities, interests and inclinations do not satisfy the demands of medical deontology he should not choose the profession of a doctor. The work of the nurse who spends much more time in direct contact with the patient than the doctor is of great importance at in-patient medical institutions. The patient seeks for understanding and support from her. She must both professionally master the skills of caring for her patients and know the rules of the psychological approach to them, as a lack of knowledge of these rules often results in the fact that the patients express their «displeasure» and protest against the «formal» and «barrack» behaviour of some nurses despite the fact that from the physical viewpoint the care for them was good. On the other hand, the development of relationships between the nurse and the patient is sometimes fraught with appearance of both a danger of not keeping a certain necessary distance and an aspiration to a flirt or helpless sympathy. The nurse must be able to manifest her understanding of the patient's difficulties and problems, but should not seek to solve these problems. Depending upon their character and attitude to the work, the following individual types of nurses are separated. 1. The practical type, characterized by accuracy and strictness, sometimes forgetting the humane side of the patient. In a paradoxical form it may be sometimes manifested by the fact that she awakens a sleeping patient in order to give him some soporific. 2. The artistic type, characterized by affected behaviour; without any sense of proportion, such a nurse tries to impress the patient and be pompous. 3. The nervous type; such a nurse is often tired, irritated and the patients do not feel calmness near her. She subconsciously tries to evade some duties; for example, out of apprehension to be infected. 4. The male type of the nurse, with a strong constitution: she is resolute, energetic, self-confident and consistent. The patients characterize her behaviour as «military». In a favourable case, she becomes a good organizer and successfully trains young nurses. In an unfavourable case, such nurses may be primitive, aggressive and despotic. 84 tiredness and haste. The cause of a harmful effect of some unsuccessfully chosen drug consists, first of all, in the person who administered it rather than in the drug itself. Psychic iatrogeny is a type of psychogeny. The latter means the psychogenic mechanism in the development of a disease, i.e. development of the disease caused by psychic effects and impressions. Psychic iatrogeny includes a harmful psychic effect produced by the doctor on his patient through words and all means of contacts among people which have their effect on the whole organism of the patient rather than on his mentality only. Possible sources of iatrogenies are mentioned below. An incorrect provision of medical education and popularization of data of the medical science may become a collective source of psychic iatrogeny. In the process of sanitary-instructive work, it is prohibited to describe the signs of a disease without their purposeful selection and give a full objective description of the treatment. It is necessary to focus attention only on those facts and circumstances that can help persons without any medical education get a real idea of the disease and the necessary information how to prevent it. If the listeners have no medical education, the medical worker should not discuss the differential diagnosis even if they ask questions concerning their personal signs and complaints, but the whole picture of the disease and its treatment is unknown. Such explanations may be given during individual sanitary-instructive work with sick and healthy persons. In the process of preventive medical examinations at factories, examinations of the men called up for military service, donors, sportsmen, expectant mothers (these measures are directed at promoting good health for the population) doctors may often reveal some accidental and insignificant abnormalities, e.g. unimportant deviations on an electrocardiogram, minute gynaecological or neurological signs, etc. If the examinee gets to know about these deviations, their meaning should be immediately explained to him, otherwise he may think that they are very serious and it is for this that he was not informed about them. However it is better to do preventive examinations in such a way that the examine ( does not get any information about these insignificant deviations. Mentality is affected by a «medical labyrinth». The patient seeks for medical advice but is sent from one doctor to another, and everywhere he is said that he «should be treated by another doctor», with different degrees of politeness he is not rendered any aid. The feelings of dissatisfaction, tension and anger begin to grow in the patient, he is afraid that for this reason his disease will become neglected and difficult for treatment. 85 The following types of iatrogeny are distinguished: 1. Etiological iatrogeny, e.g. iatrogeny due to overestimation of heredity; the doctor's phrase «It is hereditary)) causes hopelessness in the patient, the latter fears that the same bad fate will overtake the other members of his family. 2. Organolocalistic iatrogeny develops in the case where the doctor explains undiagnosed neurosis, i.e. a functional psychogenic disease, as an organic local process in the brain, e.g. thrombosis of the cerebral vessels. 3. Diagnostic iatrogeny, when an ungrounded diagnosis which later undergoes unsuccessful changes becomes a source of a psychic trauma for the patient. Some words produce, so to say, a «toxic» effect on the patient; first of all, these are «infarction, paralysis, tumour, cancer, schizo- phrenia)). Therefore it is better to avoid these expressions. Sometimes iatrogenies are caused by unclear statements made by the doctor, Even seemingly harmless statements made in the patient's presence at an X-ray room result in his unexpected traumatism, particularly if they are pronounced with some significance or surprise. ♦ Therapeutic iatrogeny develops in the process of treatment. Its example can be provided by the use of some drug about which the patient knows that it did not help him in the past. Here a negative placebo effect is produced. Therefore prior to administration of any treatment it is recommended to check the case history how effective was the treatment previously used. As a rule, it is often forgotten because of a lack of time. Therapeutic iatrogeny is facilitated by a so-called therapeutic nihilism, i.e. a pessimistic viewpoint of the doctor on the supposed results of the treatment. ♦ The process of treatment may be characterized by pharmaceutogeny, i.e. causing of some harm to the patient by a lame statement of the pharmacist. Patients often demand from the pharmacist to explain the features and effects of the drug administered by the doctor. It is dangerous to use such statements as «It is too potent for you» or «It is no good at all, but I have got something better». ♦ Prognostic iatrogeny proceeds from an unsuccessfully formulated prognosis of the disease. From this viewpoint, such cynical and openly traumatizing statements as, e.g. «You have only a few hours to live», deserve censure. However, both straightforward and peremptory optimistic statements are of a questionable value even in the case when the doctor believes that using them he will suggestively produce a positive effect on the patient. Such 86 statements as «In a week you will be sound as a bell, upon my word!» may become false and will shake the patient's confidence in his doctor in future. Besides the above situations and circumstances, sources of iatrogeny may be also found in the medical worker's (first of all, the doctor's) personality; e.g. in his unwarrantedly peremptory statements, excessive self-conceit: an omniscient doctor. Such a personality easily suggests the patient his opinions and viewpoints. Personalities of the peremptory type easily substitute absolute confidence for a good possibility in their statements. But the opinion once formed does not enable them also to watch other potential features in the process of the development of the disease; the above features may become predominant, e.g. during the transition of the disease from the syndrome of bronchitis initially diagnosed as a common disease to a malignant process. The diffident and doubting doctor, as a type of personality, is at the opposite pole. The patient often explains himself the way of the doctor's behaviour conformably to his disease, e.g. the doctor's hesitations are regarded as proof of the severity or even incurability of his state. The doctor increases this impression by the fact that he «thinks aloud», tells the patient about all possibilities of the differential diagnosis, does not complete a long line of auxiliary methods of examination and leaves the patient without any treatment for this time or gives him the initiative with respect to the kind of treatment, e.g. with such words as «If only I knew what to do with you!» The doctor should always be an artist in the correct understanding of the meaning of this word; he should be able to conceal from the patient a possible difficulty and, in the majority of cases, some temporary uncertainty about his diagnostic and therapeutic approach. The doctor's subjective uncertainty should not affect his objective behaviour. The patient's personality may be another source of iatrogeny. A timorous, frightened, diffident, emotionally vulnerable and mentally inflexible patient is recognized by his tense facial expression, an increased sweating of his palms when shaking hands, often also by some fine motor tremor. He is inclined to timorously interpret our wordy or other manifestations, frequently even those ones that are not of any significance for us. We may be additionally surprised how such a patient understands our silence or a tired gesture of a hand that are regarded by him more important than words. The nurse may observe how such a patient restlessly walks at the waiting-room before his turn comes, how he lively participates in talks of other patients about diseases or quietly and with strained attention listens to them. Other patients would try to get 89 ♦ an ability to be an attentive interlocutor and communicable in contacts with the patients and their relatives, an ability to memorize and effectively use the general and specific information (obtained in the process of intercourse with them) for prophylaxis and treatment; ♦ an aspiration to a collegiate solution of professional problems in the staff of the polyclinic (out-patient department); efficient performance of his functions as an organizer of the work and an educator of the junior medical and paramedical personnel; preparedness for business contacts with trade unions and ndministration (management) of enterprises in the populated area or settlement where the patients attended to the general practitioner live or work; ♦ neatness, tidiness, an immaculate appearance which attracts the patient to communication with his family doctor. 90 CHAPTER IX PSYCHOLOGY OF COMMUNICATION. BASIS OF CONFLICT STUDY Objectives: to study the means of communication, types of communication, functions of communication. To learn the basic concepts of conflict study. Communication (personal contacts) is a complicated process of establishing relations between people resulting in mental contacts which include information exchange, mutual influence, mutual experience and mutual understanding. Functions of personal contacts are as follows: information, regulation, affective. The following interrelated aspects can be distinguished in the process of communication: communicative (consists in information exchange), interactive (act exchange), perceptive (mutual understanding between partners). Depending on the characteristics of the partners communica- tion may be: — interpersonal; — individual-group; — collective-individual; — group. The communicative aspect of personal contacts is associated with revealing specific features of information process between people as active subjects, that is with the account of the relations between the partners, their purposes, aims, intentions, which results in information transmission and enrichment of the knowledge, thoughts, ideas with which the communicants exchange. The means of the process of communication are different systems of signs, language, in particular, as well as non-verbal means: mimics, gestures, pantomimic, posture of the partners, paralinguistic systems (intonation, non-verbal elements of speech, e.g. pauses), the system of organization of the space and time of communication, eye contacts. A very important feature of communicative process is intention of its participants to influence 91 one another and to provide the ideal presentation in the partner with influencing the behaviour of the partner (personalization). An important condition of this is not only the use of a uniform language but also similar understanding of the essence of the communicative situation. The interactive aspect of personal contact consists in construction of a common interrelation. Important are motives and purposes of the communication from the both parties. There are several types of personal contacts, concord, competition, and conflict. It is necessary to remember that concord, competition and conflict are not only interaction of two personalities. They take place between the parts of the groups and between the groups as a whole. Interaction is observed in the form of feelings which can both make the people closer or separate them. The intensity of feelings influences the efficacy of the action of the members of the group and is one of the signs of social psychological climate in the group. The perceptive aspect of personal contacts includes formation of the image of the other person which is achieved by "reading" the mental features and peculiarities of behaviour by the physical characteristics of the person. The process of communication requires at least two persons. Main mechanisms of learning the other person is identification (similarity), reflection (understanding how the subject is perceived by other persons), stereotyping (classification of different forms of behaviour). Reflection is understanding of the perception by the partner with contacts and correction of the own behaviour depending on the behaviour of the other person. Stereotyping is perception, classification and evaluation of the partner's personality basing on definite ideas. Identification is the process of learning the quality on the basis of which the personality can be classified. Identification and reflection are mainly performed sub- consciously that is why the mistakes in evaluation of the people are frequent, they form stereotypical ideas. A number of effects develop in the process of interpersonal perception and cognition: priority, novelty, halo. One of the tasks of social psychology is working out the means for correction and optimizing personal contacts, development of abilities and skills of communication. Among a number of forms of teaching the art of communication, a significant place is occupied by psychological training (mastering communication skills with the use of different programs). 94 clothes can underline the individual character of the person, to hide shortcomings and emphasize the advantages. To establish normal interrelations between people, especially at work or at home, the culture of contact is important. It consists in the presence of tolerance, benevolence, respect, tact, and politeness. The moral qualities of the person, the level of his culture are evaluated according to his actions. In different situations the culture of interpersonal contacts is based on definite rules which have been worked out for thousands years. These rules determine the forms of contacts regulated by the society and are termed etiquette. It contains both technical aspects of contacts, that is the rules about the outer side of the behaviour and the principles, violation of which causes punishment and blame. Numerous rules of the etiquette have become the elements of culture of contacts at hospitals. The outer side of service contacts regulates service etiquette. Thus, a component of medical ethics is observing the rules of decency, good form and behaviour. The person who knows the culture of communication exhibits it everywhere: in the family, at work, on holiday, in public places. The ability to convey the thoughts and feelings to other people, the ability not only to speak, but also to listen, to show understanding and good-will, sympathy and attention compose the culture of everyday communication. A true culture of interpersonal relations is determined by ethical norms. A great role is played by self-estimation of the personality, attention concentration, and the ability to take the position of the partner. One of the important characteristics of the personality is self- estimation, that is the ability to evaluate himself and the attitude to the others. Self-estimation allows analyzing the actions. It depends on education and cultural level. If a person has no desire to self- estimation, he cannot understand the rest and form interrelations, show such qualities as tact and delicacy. Communication begins with perception of one another. Attention concentration is important which allows perception with the account of mental features. Communication will be effective if the first impression will cause the feeling of attraction. If it fails, the communication will be difficult. In any case communication must be established and maintained with the consideration of individual features of the personality of the communicants. Interrelations can become richer if the people acquire the skills of communication and observe the rules and principles of cultured 95 communication. Showing respect to a personal dignity and individuality of the personality allows improving the interrelations. "Treat the people as you would like to be treated" is the main rule of morals which should be the credo of any doctor. Conflict is collision of opposite aims, interests, thoughts or views or the subjects of their interaction. The following stages of conflict can be distinguished: incubation, latent, open conflict, obvious conflict behaviour. Varieties of conflict are intrapersonal, interpersonal, inter- group, inter-organization, inter-state, and international. Scheme of conflict development: — Cause. — Reaction of the parties. — Key cause of the conflict. — Suggestions about the conflict resolution. — Agreement with the suggestion — the conflict does not develop. — Disagreement with the suggestion — the conflict develops. — Control of the conflict. — Consequences of the conflict. Depending on the duration, the conflicts are divided into short, long, prolonged. There are five ways to resolve interpersonal conflicts (according to K. Thomas): 1. Competition — the desire to achieve satisfaction of the interests to the prejudice of the other person. 2. Adaptation — in contrast to competition, sacrificing the interests for the sake of the other person. 3. Compromise — mutual interests of the both parties. 4. Avoidance — absence of desire to co-operation and absence of desire to achieve own interests and aims. 5. Co-operation — search for an alternative decision completely satisfying the both parties. Organization of the treatment process requires the ability to ' communicate, prevent the situations which may cause conflict as well as the ability to settle the conflict from all its participants: patients, their relatives, doctors, and paramedical personnel. In a medical team every person has a definite number of responsibilities. One of the conditions which can prevent conflict in a hospital is strict observation of the rules of medical ethics and subordination. Thus, when young doctors start their career and begin to acquire the skills of practical work, the relations between them and their medical authorities (chief doctor, department chief) resemble the 96 relations between the pupil and the teacher. When the stage of training is over, competition starts, and if it is not sound, conflict arises, The role of general group reaction of the medical staff to the patients is great. There are patients with whom everybody sympathizes; it is easy to work with them. There are patients with whom it is more difficult to work, the surrounding experiences negative feelings to them, it may become the cause of conflict. Psychological incompatibility can arise between the nurse and the patients, patient and doctor, relatives of the patients and the doctor, which impedes effective treatment. If they fail to change their relations, it is necessary to change the doctor, the nurse. A good psychological climate in hospitals is determined by well- disposed attitude between all the participants of the treatment process. It influences favorably the patients, provides more effective treatment. The arguments with the patients which some nurses allow showing their superiority are harmful. One of the most important means of communication is speech and words. The addressed words to the patient influence him greatly. The doctor must think over every word when speaking to the patient. The environment in which the patients are at the medical institution, individual mental characteristics of the patients, the attitude to them are decisive in the process of treatment. The account of mental characteristics in the whole is an important condition of optimizing mutual activity of people and their relation in the treatment process.