Datasets:

burgerbee

/

psychiatry_wiki

like 0

Trauma-informed care

Trauma-informed care (TIC) or Trauma-and violence-informed care (TVIC), is a framework for relating to and helping people who have experienced negative consequences after exposure to dangerous experiences. There is no one single TIC framework, or model, and some go by slightly different names, including Trauma- and violence-Informed Care (TVIC). They incorporate a number of perspectives, principles and skills. TIC frameworks can be applied in many contexts including medicine, mental health, law, education, architecture, addiction, gender, culture, and interpersonal relationships. They can be applied by individuals and organizations. TIC principles emphasize the need to understand the scope of what constitutes danger and how resulting trauma impacts human health, thoughts, feelings, behaviors, communications, and relationships. People who have been exposed to life-altering danger need safety, choice, and support in healing relationships. Client-centered and capacity-building approaches are emphasized. Most frameworks incorporate a biopsychosocial perspective, attending to the integrated effects on biology (body and brain), psychology (mind), and sociology (relationship). A basic view of trauma-informed care (TIC) involves developing a holistic appreciation of the potential effects of trauma with the goal of expanding the care-provider's empathy while creating a feeling of safety. Under this view, it is often stated that a trauma-informed approach asks not "What is wrong with you?" but rather "What happened to you?" A more expansive view includes developing an understanding of danger-response. In this view, danger is understood to be broad, include relationship dangers, and can be subjectively experienced. Danger exposure is understood to impact someone's past and present adaptive responses and information processing patterns. History Harris and Fallot first articulated the concept of trauma-informed care (TIC) in 2001. They described trauma-informed as a vital paradigm shift, from focusing on the apparently immediate presenting problem to first considering past experience of trauma and violence. They focused on three primary issues: instituting universal trauma screening and assessment, not causing re-traumatization through the delivery methods of professional services, and promoting an understanding of the biopsychosocial nature and effects of trauma. Researchers and government agencies immediately began expanding on the concept. In the 2000's, the Substance Abuse and Mental Health Services Administration (SAMHSA) began to measure the effectiveness of TIC programs. The U.S. Congress created the National Child Traumatic Stress Network which SAMHSA administers. SAMHSA commissioned a longitudinal study, the Women, Co-Occurring Disorders and Violence Study (WCDVS) to produce empirical knowledge on the development and effectiveness of a comprehensive approach to help women with mental health, substance abuse, and trauma histories. Several significant events happened in 2005. SAMHSA formed the National Center for Trauma-Informed Care. Elliott, Fallot and colleagues identified a consensus of 10 TIC concepts for working with individuals. They more finely parsed Harris and Fallot's earlier ideas, and included relational collaboration, strengths and resilience, cultural competence, and consumer input. They offered application examples, such as providing parenting support to create healing for parents and their children. Huntington and colleagues reviewed the WCDVS data, and working with a steering committee, they reached a consensus on a framework of four core principles for organizations to implement. Organizations and services must be integrated to meet the needs of the relevant population. Settings and services for this population must be trauma-informed. Consumer/survivor/recovering persons must be integrated into the design and provision of services. A comprehensive array of services must be made available. In 2011 SAMHSA issued a policy statement that all mental health service systems should identify and apply TIC principles. The TIC concept expanded into specific disciplines such as education, child welfare agencies, homeless shelters, and domestic violence services. SAMHSA issued a more comprehensive statement about the TIC concept in 2014, described below. The term (TVIC) was first used by Browne and colleagues in 2014, in the context of developing strategies for primary health care organizations. In 2016, the Canadian Department of Justice published "Trauma- (and violence-) informed approaches to supporting victims of violence: Policy and practice considerations". Wathen and Varcoe expanded and further detailed the TVIC concept in 2023. In many ways TIC/TVIC concepts and models overlap or incorporate other models, and there is some debate about whether there is a difference. The confusion may be due to whether TIC is seen as a model instead of a framework or approach which brings in knowledge and techniques from other models. A client/person-centered approach is fundamental to Rogerian and humanistic models, and foundational in ethical codes for lawyers and medical professionals. Attachment-informed healing professionals conceptualize their essential role as being a transitional attachment figure (TAF), where they focus on providing protection from danger, safety, and appropriate comfort in the professional relationship. TIC proponents argue the concept promotes a deeper awareness of the many forms of danger and trauma, and the scope and lifetime effects exposure to danger can cause. The prolific use of TIC may be evidence it is a practical and useful framework, concept, model, or set of strategies for helping-professionals. What is trauma and violence? Trauma can result from a wide range of experiences which expose humans to one or more physical, emotional, and/or relational dangers. Physical: Physical injury, brain injury, assault, crime, natural disaster, war, pain, and situational harm like vehicle or industrial accidents. Relational—adult: Interpersonal trauma, domestic violence, intimate partner violence, controlling behavior and coercive control, betrayal, gaslighting, DARVO, traumatic bonding, and intense emotional experiences such as shame and humiliation. Relational—child: For children, it can also involve childhood trauma, adverse childhood experiences, separation distress, and negative attachment experience (controlling, dismissive, inconsistent, harsh, or harmful caregiving environments). Social/structural: Social and political, structural violence, racism, historical, collective, national, poverty, religious, educational, the various forms of slavery, and cultural environments. PTSD: Non-complex or complex post-traumatic stress disorder, and continuous traumatic stress. Psychological and pharmacological: Psychological harm, mental disorders, drug addiction, isolation, and solitary confinement. Secondary: Vicarious or secondary exposure to other's trauma. Van der Kolk describes trauma as an experience and response to exposure to one or more overwhelming dangers, which causes harm to neurobiological functioning, and leaves a person with impaired ability to identify and manage dangers. This leaves them "constantly fighting unseen dangers". Crittenden describes how relational dangers in childhood caregiving environments can cause chronic trauma: "Some parents are dangerous to their children. Stated more accurately, all parents harm their children more or less, just as all are more or less protective and comforting." Parenting, or caregiver, styles which are dismissive, inconsistent, harsh, abusive or expose children to other physical or relational dangers can cause a trauma which impairs neurodevelopment. Children adapt to achieve maximum caregiver protection, but the adaptation may be maladaptive if used in other relationships. The Dynamic-Maturational Model of Attachment and Adaptation (DMM) describes how children's repeated exposure to these dangers can result in lifespan impairments to information processing. Because danger to humans is so widespread, trauma is extremely common, although the effects of negative and ongoing experience is less common. The effects are dimensional and can vary in scope and degree. TIC frameworks There are many TIC-related concepts, principles, approaches, frameworks, or models, some general and some more context specific. Trauma- and violence-informed care (TVIC), is also described as trauma- (and violence-) informed care (T(V)IC). Other terms include trauma-informed, trauma-informed approach, trauma-informed perspective, trauma-focused, trauma-based, trauma-sensitive, trauma-informed care/practice (TIC/P), and trauma-informed practice (TIP). The U.S. government's Substance Abuse and Mental Health Services Administration (SAMHSA) is an agency which has given significant attention to trauma-informed care. SAMHSA sought to develop a broad definition of the concept. It starts with "the three E's of trauma": Event(s), Experience of events, and Effect. SAMHSA offers four assumptions about a TIC approach with the four R's: Realizing the widespread impact of trauma, Recognizing the signs and symptoms, Responding with a trauma-informed approach, and Resisting re-traumatization. SAMHSA gives six key principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice and choice, and; cultural, historical and gender issues. They also list 10 implementation domains: governance and leadership; policy; physical environment; engagement and involvement; cross sector collaboration; screening, assessment and treatment services; training and workforce development; progress monitoring and quality assurance; financing; and evaluation. Researchers Casassa and colleagues interviewed sex trafficking survivors to search for how trauma bonds can be broken and healing can occur. The survivors identified three essential elements. Education, or a framework, to understand trauma experience and trauma bonding. Building a safe and trusted relationship, where brutal honesty can happen. Cultivating self-love. Researchers Wathen and colleagues describe four integrated principles evolved by key authors in this field. Understand structural and interpersonal experiences of trauma and violence and their impacts on peoples' lives and behaviors. Create emotionally, culturally, and physically safe spaces for service users and providers. Foster opportunities for choice, collaboration, and connections. Provide strengths-based and capacity building ways to support service users. By comparison, Landini, a child and adolescent psychiatrist, describes five primary principles from DMM theory for helping people better manage danger response. Define problems in terms of response to danger. The professional acts as a transitional attachment figure. Explore the family's past and present responses to danger. Work progressively and recursively with the family. Practice reflective integration with the client as a form of teaching reflective integration. Bowen and Murshid identified a framework of seven core TIC principles for social policy development. Safety Trustworthiness Transparency Collaboration Empowerment Choice intersectionality Researchers Mitchell and colleagues searched for a consensus of TIC principles among early intervention specialists. A trauma-informed early intervention psychosis service will work to protect the service user from ongoing abuse. Staff within a trauma-informed early intervention psychosis service are trained to understand the link between trauma and psychosis and will be knowledgeable about trauma and its effects. A trauma-informed early intervention psychosis service will: Seek agreement and consent from the service user before beginning any intervention; Build a trusting relationship with the service user; Provide appropriate training on trauma-informed care for all staff; Support staff in delivering safe assessment and treatments for the effects of trauma; Adopt a person-centred approach; Maintain a safe environment for service users; Have a calm, compassionate and supportive ethos; Be trustworthy; Acknowledge the relevance of psychological therapies; Be sensitive when discussing trauma; Be empathetic and non-judgmental; Provide supervision to staff; Provide regular supervision to practitioners who are working directly with trauma. General applications and techniques of TIC SAMHSA's National Center for Trauma-Informed Care provides resources for developing a trauma-informed approach, including: (1) interventions; (2) national referral resources; and (3) information on how to shift from a paradigm that asks, "What's wrong with you?" to one that asks, "What has happened to you?" Understand Gaining knowledge about and understanding the effects of trauma may be the most complicated component of TIC, because it generally requires going beyond surface level explanations and using multiple explanatory theories and models or complex biopsychosocial models. Trauma related behaviors, thoughts, feelings, and current experiences can seem confusing, perplexing, dysfunctional, or dangerous. These are usually adaptions to survive extreme contexts, methods to cope in the current moment, or efforts to communicate pain. Whatever the cause and adaptation, the professional's response can cause more harm, or some measure of emotional co-regulation, lessening of distress, and opportunity for healing. Safety The opposite of danger is safety, and most or all TIC models emphasize the provision of safety. In attachment theory the focus would be on protection from danger. Van der Kolk describes how the "Brain and body are [neurobiologically] programmed to run for home, where safety can be restored and stress hormones can come to rest." Safety can be enhanced by anticipating danger. Leary and colleagues describe how interpersonal rejection may be one of the most common precursors to aggression. While boundary-holding is a key aspect of TIC, avoiding a sudden and dramatic devaluation in an interpersonal relationship can reduce the subjective experience of rejection and reduce the risk violent aggression. Relationship The nature and quality of the relationship between two people talking about trauma can have a significant impact on the outcome of the discussion. Communication Traumatic experiences, including childhood attachment trauma, can impact memory function and communication style in children and adults. Katz describes some experiences working with her legal clients and how she adjusts her relational and communication approach to meet their needs. Some clients need information delivered in short pieces with extra time to process, and some need to not have unannounced phone calls and be informed by email prior to verbal discussions. TIC helped her shift from thinking about how to develop a "litigation strategy" for clients, to thinking about developing a "representation strategy", which is a major shift in thinking for many lawyers. Nurses can use enhanced communication skills, such as mindful presence, enhanced listening skills including the use of mirroring and rephrasing statements, allowing short periods of silence as a strategy to facilitate safety, and minimizing the use of "no" statements to facilitate patients sense of safety. Resilience and strength building Building psychological resilience and leveraging a person's existing strengths is a common element in most or all TIC models. Integration of principles Safety and relationship are intertwined. Roger's person-centered theory is founded on this basic principle. Attachment theory describes how a child's survival and well-being are dependent on a protective relationship with at least one primary caregiver. Badenoch's first principle of trauma-informed counseling is to use the practice of nonjudgmental and agendaless presence to create a foundation of safety and co-regulation. "Once the [client] sees (or feels) that the [professional] understands, then together they can begin the dangerous journey from where the [client] is, across the chasm, to safety." Talking about trauma Researchers and clinicians describe how to talk about trauma, particularly when people are reluctant to bring it up. Read and colleagues offer comprehensive details for mental health professionals navigating difficult discussions. There are numerous barriers for professionals which can inhibit raising discussions about trauma with clients/patients. They include lack of time, being too risk-averse, lack of training and understanding of trauma, fear of discussing emotions and difficult situations, fear of upsetting clients, male or older clients, lack of opportunity to reflect on professional experiences, over-reliance on non trauma-informed care models (such as traditional psychology, and biomedical and biogenetic models of mental distress). Sweeney and colleagues suggest trauma discussions may include the following techniques and principles. Ask every client about trauma experience, especially in initial assessment of general psychosocial history. To establish relational safety and trust, or rapport, approach people sensitively while attuning to their emotions, nonverbal expressions, what they are saying, and what they might be excluding from their narrative. Badenoch suggests a stance of "agendaless presence" helps professionals reduce judgmentalism. Consider confidentiality needs. Some people may be hesitant to disclose some or all of their experience, and may wish to maintain control over to whom or in what context it is disclosed. Attorney-client privilege, so long as not waived and there is no mandatory reporting requirement, offers the strongest protection for chosen non-disclosure. It may be difficult for clients to process trauma topics in the middle of crisis situations, although creating a measure of safety and trust within the relationship may help facilitate the discussion. Clients may not be able or willing to admit traumatic experiences, but may display effects of traumatic experiences. Prefacing trauma questions with brief normalizing statements, such as "That is a common reaction" might facilitate deeper discussions about trauma. Asking for details about the experience may be traumatizing for the client. In situations where detail disclosure is necessary, such as law enforcement or litigation, certain approaches may be needed. Specific questions rather than generalized questions may help if detail is needed, such as "Were you hit/pushed/spat on/held down?" as opposed to "Were you assaulted?" or "Was there domestic violence?" Prior disclosures can be asked about, and if so, what the person's experience of that was. Circumstances around intense emotions, such as shame and humiliation, may difficult to explore. Discussions may be paced according to the person's needs and abilities. Giving choices may provide agency, including whether to talk about it or not, and what to do about it. Working collaboratively, in partnership with the person to explore appropriate solutions may be acceptable to the client. Professionals might reflect on their own understanding of current research about safety and danger. The offer of relatively comprehensive support for trauma and safety plan options may ease and promote discussions. Particularly if the discussion about trauma is extensive, a lack of follow up support options may lead to re-traumatization. Concluding questions about how the client is feeling may be useful. Follow-up appointments and questions about what the client plans to do next may be useful. A literature review of women and clinicians views on trauma discussions during pregnancy found that both groups thought discussions were valuable and worthwhile, as long as there was both adequate time to have the conversation and support available for those who need it. Women wanted to know in advance that the issue would be raised and to speak with a clinician they knew and trusted. Specific applications and techniques of TIC TIC principles are applied in child welfare services, child abuse, social work, psychology, medicine, oral health services, nursing, correctional services. They have been applied in interpersonal abuse situations including domestic violence, elder abuse. Wathen and Varcoe offer specific suggestions for specific disciplines, such as primary health care clinics, emergency rooms, and for contexts involving interpersonal, structural, or any form of violence. One simple suggestion, in order to enhance the perception of care, safety and agency in the first phone call, is to provide calm phrasing and tone, minimize hold times, and offer brief explanations for delays. Trauma- and violence-informed practices can be or are addressed in mindfulness programs, yoga, education, obstetrics and gynaecology, cancer treatment, psychological trauma in older adults, military sexual trauma, cybersex trafficking, sex trafficking and trafficking of children, child advocacy, decarceration efforts, and peer support. HDR, Inc. incorporates trauma-informed design principles in prison architecture. Many therapy models utilize TIC principles, including psychodynamic theory, attachment-informed therapy, trauma focused cognitive behavioral therapy, trauma-informed feminist therapy, Trauma systems therapy which utilizes EMDR, trauma focused CBT, The Art of Yoga Project, the Wellness Recovery Action Plan, music therapy, internet-based treatments for trauma survivors, and in aging therapy. Culturally-focused applications, often considering indigenous-specific traumas have been applied in minoritized communities, and Maori culture. Domestic violence Trauma- and violence-informed (TVIC) principles are widely used in domestic violence and intimate partner violence (IPV) situations. For working with survivors, TVIC has been combined with yoga, motivational interviewing, primary physician care in sexual assault cases, improving access to employment, cases involving HIV and IPV, and cases involving PTSD and IPV. In 2015 Wilson and colleagues reviewed literature describing trauma-informed practices (TIP) used in the DV context. They found principles organized around six clusters. Promoting safety, giving choice and control, and building healthy relationships are particularly important TVIC concepts in this field. Promote emotional safety: Consider design options of physical environment. Promote a staff-wide approach to nonjudgmental interactions with clients. Develop organizational policies and communicate them clearly. Restore choice and control: Give choice and control broadly (it was taken from them previously). Allow clients to tell their stories in their own way and speed. Actively solicit client input on which services they want to utilize. Facilitate healing connections: Professionals should develop enhanced listening and relationship skills, and use these to build a supporting and trusted relationship with the client. This is sometimes called a person-centered approach. Listening skills can involve active listening, expressing no judgment, listening with the intent hear rather than with the intent to respond, and agendaless presence. Clients can be helped to develop healthy relationships at every level, including parent-child, and between survivors and their communities. Support coping: Provide clients neurobiopsycho-education about the nature and effects of DV. Help clients gain an awareness of triggers, perhaps with a triggers checklist. Validate and help strengthen client coping, or self-protective strategies. Develop a company-wide holistic and multidimensional approach improving client well-being, which includes healthy eating and living, and managing stress hormone activation. Respond to identify and context: Be mindful and responsive to gender, race, sexual orientation, ability, culture, immigration status, language, and social and historical contexts. These considerations can be reflected in informational materials. Gain awareness of assumptions based on identity and context. Organizations should be designed to be able to represent the diversity of its clients. Build strengths: Professionals can develop skills to identify, affirmatively value, and focus on client strengths. Ask "What helped in the past?" Help develop client leadership skills. Providing education or a framework for understanding is also an important element of healing. Hospice care In hospice situations, Feldman describes a multi-stage TIC process. In stage one practitioners alleviate distress by taking actions on behalf of clients. This is unlike many social work approaches which first work to empower clients to solve their own problems. Many hospice patients have little time or energy to take actions on their own. In stage two, the patient is offered tools, psychoeducation and support to cope with distress and trauma impacts. Stage three involves full-threshold PTSD treatment. The last stage is less common based on limited prognosis. Ethical guidelines Ethical guidelines and principles imply and support TIC-specific frameworks. Rudolph describes how to conceptualize and apply TIC in health care settings using egalitarian, relational, narrative and prinicplist ethical frameworks. (The clinical case vignette in Rudolph's article is informative.) Egalitarian-based ethics provide a foundation to think about how socioeconomic factors influence power and privilege to create and perpetuate loss of agency, oppression and trauma. Those factors include gender, race, education, income, and culture. One ethical approach is to provide people, especially those silenced and marginalized, the opportunity to have meaningful voice and choice. Care ethics and its relational approach promotes awareness for the need and value of compassion and empathy, integrating both patient and provider perspectives, and promoting patient safety, agency, and therapeutic alliance. The relational approach also orients clinical treatment to consider subjective and objective decision making factors rather than merely abstract or academic norms. Narrative ethics encourage providers to consider patient history and experience in a broader context such as a biopsychosocial approach to healing. A deliberate and explicit narrative approach promotes both fuller patient disclosure and provider empathy and efforts to reach a collaborative care alliance. This can lead to enhanced patient-centered moral judgments and care outcomes. Principlist ethics offers four equal moral principles to balance in individual cases. These are the right of patients to make decisions (autonomy), promotion of patient welfare (beneficence), avoidance of patient harm (nonmaleficence), and justice through the fair allocation of scarce resources. These principles align with and support TIC frameworks and goals. Vadervort and colleagues describe how child welfare workers can experience trauma participating in legal proceedings and how understanding professional ethics can reduce their trauma experiences. Organizational applications and techniques of TIC TIC principles have been applied in organizations, including behavioral health services, and policy analysis. The Connecticut Department of Children and Families (DCF) implemented wide-ranging TIC policies, which were analyzed over a five year period by Connell and colleagues in a research study. TIC components included 1) workforce development, 2) trauma screening, 3) supports for secondary traumatic stress, 4) dissemination of trauma-focused evidence-based treatments (EBTs), and 5) development of trauma-informed policy and practice guides. The study found significant and enduring improvements in DCF's capacity to provide trauma-informed care. DCF employees became more aware of TIC services and policies, although there was less improvement in awareness of efforts to implement new practices. The Child Welfare Trauma Toolkit Training program was one program implemented. Organizations and people promoting TIC Organizations which have or support TIC programs include the Substance Abuse and Mental Health Services Administration (SAMHSA), National Center for Trauma-informed care, the National Child Traumatic Stress Network, the Surgeon General of California, National Center for Victims of Crime, The Exodus Road, Stetson School, and the American Institutes for Research. Psychologist Diana Fosha promotes the use of therapeutic models and approaches which integrate relevant neurobiological processes, including implicit memory, and cognitive, emotional and sensorimotor processing. Ricky Greenwald applies eye movement desensitization and reprocessing (EMDR) and founded the Trauma Institute & Child Trauma Institute. Lady Edwina Grosvenor promotes a trauma informed approach in women's prisons in the United Kingdom. Joy Hofmeister promotes trauma-informed instruction for educators in Oklahoma. Anna Baranowsky developed the Traumatology Institute and addresses secondary trauma and effective PTSD techniques. Other notable people who have developed or promoted TIC programs include Tania Glyde, Carol Wick, Pat Frankish, Michael Huggins, Brad Lamm, Barbara Voss, Cathy Malchiodi, Activists, journalists and artists supporting TIC awareness include Liz Mullinar, Omar Bah, Ruthie Bolton, Caoimhe Butterly, and Gang Badoy. Effectiveness Some efforts have been made to measure the effectiveness of TIC implementations. Wathen and colleagues conducted a scoping review in 2020 and concluded that of the 13 measures they examined which assess TIC effectiveness, none fully assessed the effectiveness of interventions to implement TVIC (and TIC). The measures they examined mostly assessed for TVIC principles of understanding and safety, and fewer looked at collaboration, choice, strength-based and capacity-building. They found several challenges to assessing the effectiveness of TVIC implementations, or existence of vicarious trauma. There was an apparent lack of clarity on how TVIC theory related to the measure's development and validation approaches so it was not always clear precisely what was being investigated. Another is the broad range of topics within the TVIC framework. They found no assessment measured for implicit bias in professionals. They found conflation of "trauma focused", such as may be used in primary health care, policing and education, with "trauma informed" where trauma specific services are routinely provided. See also Community accountability References Clinical psychology Domestic violence Counseling Practice of law Legal communication Medical ethics Violence

Self-neglect

Self-neglect is a behavioral condition in which an individual neglects to attend to their basic needs, such as personal hygiene, appropriate clothing, feeding, or tending appropriately to any medical conditions they have. More generally, any lack of self-care in terms of personal health, hygiene and living conditions can be referred to as self-neglect. Extreme self-neglect can be known as Diogenes syndrome. Classification There are two types of self-neglect: intentional (active), and non-intentional (passive). Intentional self-neglect occurs when a person makes a conscious choice to engage in self-neglect. Non-intentional self-neglect occurs as a result of health-related conditions that contribute to the risk of developing self-neglect. Different societies and cultures can have different beliefs regarding acceptable living standards, making self-neglect a serious and complex problem requiring clinical, social, and ethical decisions in its management and treatment. Presentation Complication Without sufficient personal hygiene, sores can develop and minor wounds may become infected. Existing health problems may be exacerbated, due to insufficient attention being paid to them by the individual. Neglect of personal hygiene may mean that the person suffers social difficulties and isolation. Self-neglect can also lead to the individual having a general reduction in attempts to maintain a healthy lifestyle, with increased smoking, drug misuse or lack of exercise. Any mental causes of the self-neglect may also lead to the individual refusing offers of help from medical or adult social services. Causes Self-neglect can be as a result of brain injury, dementia or mental illness. It can be a result of any mental or physical illness which has an effect on the person's physical abilities, energy levels, attention, organizational skills or motivation. A decrease in motivation can also be a side effect of psychiatric medications, putting those who require them at a higher risk of self-neglect than might be caused by mental illness alone. Risk factors Risk factors are: Advancing age; Mental health problems; Cognitive impairment; Dementia; Frontal lobe dysfunction; Depression; Chronic illness; Nutritional deficiency; Alcohol and substance misuse; Functional and social dependency; Social isolation; and, Delirium. Age-related changes that result in functional decline, cognitive impairment, frailty, or psychiatric illness increase vulnerability for self-neglect. For this reason, it is thought that, while self-neglect can occur across the lifespan, it is more common in older people. Self-neglect is thought to be linked to underlying mental illnesses. Living in squalor is sometimes accompanied by dementia, alcoholism, schizophrenia, or personality disorders. Conversely, research has shown that 30–50% people suffering from self-neglect have shown no psychiatric disorders that would explain their behavior. Alternate models to the medical model, such as sociological and psychological, offer broader perspectives that take into account the complexities and factors associated with self-neglect. These alternate models emphasize cultural and social values and personal circumstances, and posit that self-neglect develops over time and can be rooted in family relationships and cultural values. Diagnosis Definition There is no clear operational definition of self-neglect - some research suggests it is not possible for a universal definition due to its complexity. Gibbons (2006) defined it as: "The inability (intentional or non-intentional) to maintain a socially and culturally accepted standard of self-care with the potential for serious consequences to the health and well-being of the self-neglecters and perhaps even to their community." The behaviors and characteristics of living in self-neglect include unkempt personal appearance, hoarding items and pets, neglecting household maintenance, living in an unclean environment, poor personal hygiene, and eccentric behaviors. Research also points to behaviors such as unwillingness to take medication, and feelings of isolation. Some of these behaviors could be explained by functional and financial constraints, as well as personal or lifestyle choices. Use in assessment of needs Neglect of hygiene is considered as part of the Global Assessment of Functioning, where it indicates the lowest level of individual functioning. It is also part of the activities of daily living criteria used to assess an individual's care needs. In the UK, difficulty in attending to their physical cleanliness or need for adequate food are part of the criteria indicating whether a person is eligible for Disability Living Allowance. Treatments Treatment may involve treating the cause of the individual's self-neglect, with treatments such as those for depression, dementia or any physical problems that are hampering their ability to care for themselves. The individual may be monitored, so that any excessive deterioration in their health or levels of self-care can be observed and acted upon. Treatment can involve care workers providing home care, attending to cleansing, dressing or feeding the individual as necessary, without reducing their independence and autonomy any more than is essential. In combination with other illnesses, self-neglect may be one of the indicators that a person would be a candidate for treatment in sheltered housing or residential care. This would also improve their condition by providing opportunities for social interaction. If the person is deemed not to have the mental capacity to make decisions about their own care, they may be sectioned or compelled to accept help. If they are in possession of their mental faculties, they have a right to refuse treatment. See also Clinical depression, a common cause Neglect References External links Neglect and Self-Neglect Washington State Department of Social & Health Services Self-neglect in the elderly: knowing when and how to intervene - Self-Neglect: The Professional's Challenge Self-Neglect Self-Neglect by Older Adults Self-neglect Severity Scale - Draft Age-related illness may lead to self-neglect Problem behavior

Borderline intellectual functioning

Borderline intellectual functioning, previously called borderline mental retardation (in the ICD-8), is a categorization of intelligence wherein a person has below average cognitive ability (generally an IQ of 70–85), but the deficit is not as severe as intellectual disability (below 70). It is sometimes called below average IQ (BAIQ). This is technically a cognitive impairment; however, this group may not be sufficiently mentally disabled to be eligible for specialized services. Codes The DSM-IV-TR code of borderline intellectual functioning is V62.89. DSM-5 diagnosis codes are V62.89 and R41.83. Learning skills During school years, individuals with borderline intellectual functioning are often "slow learners". Although a large percentage of this group fails to complete high school and can often achieve only a low socioeconomic status, most adults in this group blend in with the rest of the population. Differential diagnosis According to the DSM-5, differentiating borderline intellectual functioning and mild intellectual disability requires careful assessment of adaptive and intellectual functions and their variations, especially in the presence of co-morbid psychiatric disorders that may affect patient compliance with standardized test (for example, attention deficit hyperactivity disorder (ADHD) with severe impulsivity or schizophrenia). See also IQ classification Special education References Further reading Intellectual disability Pejorative terms for people with disabilities

Culture-bound syndrome

In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no known objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions (DSM-IV: Appendix I). Its counterpart in the framework of ICD-10 (Chapter V) is the culture-specific disorders defined in Annex 2 of the Diagnostic criteria for research. More broadly, an endemic that can be attributed to certain behavior patterns within a specific culture by suggestion may be referred to as a potential behavioral epidemic. As in the cases of drug use, or alcohol and smoking abuses, transmission can be determined by communal reinforcement and person-to-person interactions. On etiological grounds, it can be difficult to distinguish the causal contribution of culture upon disease from other environmental factors such as toxicity. Identification A culture-specific syndrome is characterized by: categorization as a disease in the culture (i.e., not a voluntary behaviour or false claim) widespread familiarity in the culture complete lack of familiarity or misunderstanding of the condition to people in other cultures no objectively demonstrable biochemical or tissue abnormalities (signs) recognition and treatment by the folk medicine of the culture Some culture-specific syndromes involve somatic symptoms (pain or disturbed function of a body part), while others are purely behavioral. Some culture-bound syndromes appear with similar features in several cultures, but with locally specific traits, such as penis panics. A culture-specific syndrome is not the same as a geographically localized disease with specific, identifiable, causal tissue abnormalities, such as kuru or sleeping sickness, or genetic conditions limited to certain populations. It is possible that a condition originally assumed to be a culture-bound behavioral syndrome is found to have a biological cause; from a medical perspective it would then be redefined into another nosological category. Medical perspectives The American Psychiatric Association states the following: The term culture-bound syndrome is controversial since it reflects the different opinions of anthropologists and psychiatrists. Anthropologists have a tendency to emphasize the relativistic and culture-specific dimensions of the syndromes, while physicians tend to emphasize the universal and neuropsychological dimensions. Guarnaccia & Rogler (1999) have argued in favor of investigating culture-bound syndromes on their own terms, and believe that the syndromes have enough cultural integrity to be treated as independent objects of research. Guarnaccia and Rogler demonstrate the issues that occur when diagnosing cultural bound disorders using the DSM-IV. One of the key problems that arise is the "subsumption of culture bound syndromes into psychiatric categories", which ultimately creates a medical hegemony and places the western perspective above that of other cultural and epistemological explanations of disease. The urgency for further investigation or reconsideration of the DSM-IV's authoritative power is emphasized, as the DSM becomes an international document for research and medical systems abroad. Guarnaccia and Rogler provide two research questions that must be considered, "firstly, how much do we know about the culture-bound syndromes for us to be able to fit them into standard classification; and secondly, whether such a standard and exhaustive classification in fact exists". It is suggested that the problematic nature of the DSM becomes evident when viewed as definitively conclusive. Questions are raised to whether culture-bound syndromes can be treated as discrete entities, or whether their symptoms are generalized and perceived as an amalgamation of previously diagnosed illnesses. If this is the case, then the DSM may be what Bruno Latour would define as "particular universalism". In that the Western medical system views itself to have a privileged insight into the true intelligence of nature, in contrast to the model provided by other cultural perspectives. Some studies suggest that culture-bound syndromes represent an acceptable way within a specific culture (and cultural context) among certain vulnerable individuals (i.e. an ataque de nervios at a funeral in Puerto Rico) to express distress in the wake of a traumatic experience. A similar manifestation of distress when displaced into a North American medical culture may lead to a very different, even adverse outcome for a given individual and the individual's family. The history and etymology of some syndromes such as brain-fog syndrome, have also been reattributed to 19th century Victorian Britain rather than West Africa. In 2013, the DSM 5 dropped the term culture-bound syndrome, preferring the new name "cultural concepts of distress". Cultural collision between medical perspectives Within the traditional Hmong culture, epilepsy (qaug dab peg) directly translates to "the spirit catches you and you fall down" which is said to be an evil spirit called a dab that captures one's soul and makes one ill. In this culture, individuals with seizures are seen to be blessed with a gift: an access point into the spiritual realm which no one else has been given. In westernised society, epilepsy is recognized as a serious long-term brain condition that can have a major impairment on an individual's life. The way the illness is dealt with in Hmong culture is vastly different due to the high status epilepsy has in the culture, compared to individuals who have the condition in westernised societies. Individuals with epilepsy within the Hmong culture are a source of pride for their family. Another culture-bound illness is neurasthenia, which is a vaguely described medical ailment in Chinese culture that presents as lassitude, weariness, headaches, and irritability and is mostly linked to emotional disturbance. A report done in 1942 showed that 87% of patients diagnosed by Chinese psychiatrists as having neurasthenia could be reclassified as having major depression according to the DSM-3 criteria. Another study conducted in Hong Kong showed that most patients selectively presented their symptoms according to what they perceived as appropriate and tended to only focus on somatic suffering, rather than the emotional problems they were facing. Globalisation Globalisation is a process whereby information, cultures, jobs, goods, and services are spread across national borders. This has had a powerful impact on the 21st century in many ways including through enriching cultural awareness across the globe. Greater level of cultural integration is occurring due to rapid industrialisation and globalisation, with cultures absorbing more influences from each other. As cultural awareness begins to increase between countries, there is a consideration into whether cultural bound syndromes will slowly lose their geographically bound nature and become commonly known syndromes that will then become internationally recognised. Anthropologist and psychiatrist Roland Littlewood makes the observation that these diseases are likely to vanish in an increasingly homogenous global culture in the face of globalisation and industrialisation. Depression, for example, was once only accepted in western societies; it is now recognised as a mental disorder in all parts of the world. In contrast to Eastern civilizations such as Taiwan, depression is still much more common in Western cultures like the United States. This could indicate that globalisation may have an impact on allowing disorders to be spread across borders, but these disorders may remain predominant in certain cultures. DSM-IV-TR list The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes: DSM-5 list The fifth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as cultural concepts of distress, a closely related concept: ICD-10 list The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) classifies the below syndromes as culture-specific disorders: Other examples Though "the ethnocentric bias of Euro-American psychiatrists has led to the idea that culture-bound syndromes are confined to non-Western cultures", within the contiguous United States, the consumption of kaolin, a type of clay, has been proposed as a culture-bound syndrome observed in African Americans in the rural South, particularly in areas in which the mining of kaolin is common. In South Africa, among the Xhosa people, the syndrome of amafufunyana is commonly used to describe those believed to be possessed by demons or other malevolent spirits. Traditional healers in the culture usually perform exorcisms in order to drive off these spirits. Upon investigating the phenomenon, researchers found that many of the people claimed to be affected by the syndrome exhibited the traits and characteristics of schizophrenia. Some researchers have suggested that both premenstrual syndrome (PMS) and the more severe premenstrual dysphoric disorder (PMDD), which have currently unknown physical mechanisms, are Western culture-bound syndromes. However, this is controversial. Tarantism is an expression of mass psychogenic illness documented in Southern Italy since the 11th century. Morgellons is a rare self-diagnosed skin condition that has been described as "a socially transmitted disease over the Internet". Vegetative-vascular dystonia can be considered an example of somatic condition formally recognised by local medical communities in former Soviet Union countries, but not in Western classification systems. Its umbrella term nature as neurological condition also results in diagnosing neurotic patients as neurological ones, in effect substituting possible psychiatric stigma with culture-bound syndrome disguised as a neurological condition. Refugee children in Sweden have been known to fall into coma-like states on learning their families will be deported. The condition, known in Swedish as , or resignation syndrome, is believed to only exist among the refugee population in Sweden, where it has been prevalent since the early part of the 21st century. In a 130-page report on the condition commissioned by the government and published in 2006, a team of psychologists, political scientists, and sociologists hypothesized that it was a culture-bound syndrome. A startle disorder similar to latah, called (sometimes spelled imu:), is found among Ainu people, both Sakhalin Ainu and Hokkaido Ainu. A condition similar to piblokto, called (sometimes meryachenie), is found among Yakuts, Yukaghirs, and Evenks living in Siberia. The trance-like violent behavior of the Viking age berserkers – behavior that disappeared with the arrival of Christianity – has been described as a culture-bound syndrome. See also Cross-cultural psychiatry Cross-cultural psychology Cultural competence in healthcare Dancing mania Mass psychogenic illness Hikikomori Hi-wa itck Medical anthropology Neurasthenia Zen sickness References Further reading Paperback (Note: Different preview pages result in the full chapter being viewable from the title link). External links Psychiatric Times – Introduction to Culture-Bound Syndromes Skeptical Inquirer – Culture-bound syndromes as fakery Medical anthropology

International Classification of Functioning, Disability and Health

The International Classification of Functioning, Disability and Health (ICF) is a classification of the health components of functioning and disability. The ICF received approval from all 191 World Health Organization (WHO) member states on May 22, 2001, during the 54th World Health Assembly. Its approval followed nine years of international revision efforts coordinated by WHO. WHO's initial classification for the effects of diseases, the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), was created in 1980. The ICF classification complements WHO's International Classification of Diseases-10th Revision (ICD), which contains information on diagnosis and health condition, but not on functional status. The ICD and ICF constitute the core classifications in the WHO Family of International Classifications (WHO-FIC). Overview The ICF is structured around the following broad components: Body functions and structure Activities (related to tasks and actions by an individual) and participation (involvement in a life situation) Additional information on severity and environmental factors Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors. The picture produced by this combination of factors and dimensions is of "the person in his or her world". The classification treats these dimensions as interactive and dynamic rather than linear or static. It allows for an assessment of the degree of disability, although it is not a measurement instrument. It is applicable to all people, whatever their health condition. The language of the ICF is neutral as to etiology, placing the emphasis on function rather than condition or disease. It also is carefully designed to be relevant across cultures as well as age groups and genders, making it highly appropriate for heterogeneous populations. Benefits There are benefits of using the ICF for both the patient and the health professional. A major advantage for the patient is the integration of the physical, mental, and social aspects of his or her health condition. All aspects of a person's life (development, participation and environment) are incorporated into the ICF instead of solely focusing on his or her diagnosis. A diagnosis reveals little about one's functional abilities. Diagnoses are important for defining the cause and prognosis, but identifying the limitations of function is often the information used to plan and implement interventions. Once a rehabilitation team is aware of the daily activities a client is required to participate in, the problem solving sequence set up by the ICF can be utilized. An occupational therapist, for example, would observe a patient performing his or her daily activities and note the patient's functional abilities. This information would then be used to determine the extent to which the individual's abilities can be improved through therapy and to what extent the environment can be changed to facilitate the individual's performance. Intervention at one level (current abilities) has the potential to prevent or modify events at a succeeding level (participation). For example, teaching a deaf child manual signs will foster effective interaction and increase one's participation with his or her family. Rehabilitation therapists will be empowered with the ICF not only in their daily work with their patients, but also when working with other medical disciplines; hospitals and other health care administrations; health authorities and policy makers. All items are operationally defined with clear descriptions that can be applied to real life evaluations with clarity and ease. The language used in the ICF helps facilitate better communication between these groups of people. Clinical relevance Knowing how a disease affects one's functioning enables better planning of services, treatment, and rehabilitation for persons with long-term disabilities or chronic conditions. The current ICF creates a more integrative understanding of health forming a comprehensive profile of an individual instead of focusing on one's disease, illness, or disability. The implications of using the ICF include an emphasis on the strengths of individuals, assisting individuals in participating more extensively in society by the use of interventions aimed at enhancing their abilities, and taking into consideration the environmental and personal factors that might hamper their participation. Qualifiers: The ICF qualifiers "may be best translated clinically as the levels of functioning seen in a standardized or clinic setting and in everyday environments". Qualifiers support standardization and the understanding of functioning in a multidisciplinary assessment. They enable all team members to quantify the extent of problems, even in areas of functioning where one is not a specialist. Without qualifiers codes have no inherent meaning. An impairment, limitation or restriction, is qualified from 0 (No problem; 0–4%), 1 (Mild problem: 5–24%), 2 (Moderate problem: 25–49%), 3 (Severe problem: 50–95%) to 4 (Complete problem: 96–100%). Environmental factors are quantified with a negative and positive scale denoting the extent to which the environment acts as a barrier or facilitator. For insurance purposes, the qualifiers can describe the effectiveness of treatment. One can interpret the decreasing of a qualifier score to be an increase in the functional ability of a patient. Core sets An ICF Core Set can serve as a reference framework and a practical tool to classify and describe patient functioning in a more time efficient way. ICF Core Sets can be used along the continuum of care and over the course of a health condition. The ICF classification includes more than 1,400 categories limiting its use in clinical practice. It is time-consuming for a clinician to utilize the main volume of the ICF with his or her patients. Only a fraction of the categories is needed. As a general rule, 20% of the codes will explain 80% of the variance observed in practice. ICF Core Sets contain as few as possible, but as many ICF categories as necessary, to describe a patient's level of functioning. It is hypothesized that using an ICF Core Set will increase the inter-rater reliability when coding clinical cases as only the relevant categories for a particular patient will be utilized. Since all of the relevant categories are listed in an ICF Core Set, its use in multidisciplinary assessments protects health professionals from missing important aspects of functioning. Pediatric use As clinicians and researchers used the ICF, they became more aware of its limitations. The ICF lacks the ability to classify the functional characteristics of a developing child. Different ICF codes are needed across the first years of a child's life to capture the growth and development of a disability even when the child's diagnosis does not change. The coding system can provide essential information about the severity of a health condition in terms of its impact on functioning. This can serve a significant role for providers caring for children with spectrum disorders such as autism or cerebral palsy. Children with these conditions may have the same diagnoses, but their abilities and levels of functioning widely vary across and within individuals over time. The first draft of the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) was completed in year 2003 and published in 2007. The ICF-CY was developed to be structurally consistent with the ICF for adults. A major difference between the ICF-CY and ICF is that the generic qualifiers from the adult ICF now include developmental aspects for children and youth in the ICF-CY. Descriptions of codes in the ICF-CY were revised and expanded and new content was added to previously unused codes. Codes were added to document characteristics as adaptability, responsivity, predictability, persistence, and approachability. "Sensing" and "exploration of objects" codes were expanded as well as the "importance of learning". Since a child's main occupation is playing, it is also important to include more codes in this area. Different levels of play have separate codes in the ICF-CY (solitary, onlooker, parallel). This contrasts with the adult ICF as only one code existed in regards to leisure or recreation. Changes in ICF-CY codes over time reflect developmental effects attributable to the child's interaction with the environment. Environmental factors influence functioning and development and can be documented as barriers or facilitators using the ICF-CY. The key environments of children and adolescents include their homes, day care centers, schools and recreation settings of playground, parks, and ball fields. Children will transition between different environments many times as they grow. For example, a child will transition into elementary or high school or from one service setting or agency to another. Attention to these transitions of children with disabilities has been identified as an important role for health care providers. A transition requires preparation and planning to find an appropriate and accommodating setting for a child's needs. With a coding system such as the ICF-CY, the transition will be smoother and interventions can start where the previous health provider left off. See also Social model of disability References Further reading External links The ICF and ICF-CY browsing tool of the Italian Collaborating Centre of the World Health Organization for the Family of International Classifications. World Health Organization Medical classification Medical assessment and evaluation instruments Disability

Verbal abuse

Verbal abuse (also known as verbal aggression, verbal attack, verbal violence, verbal assault, psychic aggression, or psychic violence) is a type of psychological/mental abuse that involves the use of oral, gestured, and written language directed to a victim. Verbal abuse can include the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual. It can also include the use of derogatory terms, the delivery of statements intended to frighten, humiliate, denigrate, or belittle a person. These kinds of attacks may result in mental and/or emotional distress for the victim. Verbal aggression and abuse affects all populations, cultures, and individuals. These actions are psychologically damaging and are considered forms of emotional and physical harm to the victim. This type of behavior leaves individuals feeling poorly about themselves and can lead to the developing numerous negative health issues and disorders such as suicidal thoughts, depression, poor physical health, anxiety, obsessive-compulsive behaviors, personality disorders, and aggression. Types Victims of verbal abuse may display abusive behaviors towards other individuals. Verbal abuse and verbal aggression can take form in many ways. When individuals understand how verbal abuse may be presented, they can better analyze and act accordingly in certain situations. Verbal aggression can be defined as a characteristic or trait that drives a person to attack the self-values and concepts of others in addition to, or instead of, their own values and concepts. Bullying – "The use of physical, psychological and verbal aggression to intimidate others to submit to the will of another and/or cause emotional upset". Bullying is typically one-sided and unprovoked by the victim and can be present in any environment. Gaslighting – The abuser makes the victim question not just their own self, but also their own sanity. One way abusers tend to use gaslighting is by questioning the victim in a manner that gets the victim to question their own perceptions of things. The effects of gaslighting include, individuals seeing themselves as outsiders, having low self-esteem, and feeling like they have no support in decision making. Accusations/Denial of wrongdoing: When an individual falsely accuses another individual of performing a certain action; When an individual denies his/her actions performed against another individual that could have or did cause the victim harm to self-preserve and protect the abuser. (Gaslighting also fits into this type of abuse). Minimization – Refers to when the abuser is attempting to down-scale the severity of the situation and making it seem insignificant to the victim or audience Threatening – When an aggressor uses words or actions against a victim that indicates if the victim does not comply with certain situations and/or actions, harm will be inflicted upon them. Name calling – The use of offensive language/names to gain something from the situation (ex: win an argument) or to probe a negative reaction out of another individual or situation; this is also used to induce rejection or condemnation without consideration of the facts in the situation. Impacts Age Children and adolescents Research shows that if a young child has been constantly verbally abused over the years they begin to develop constant feelings of mistrust, shame, doubt, guilt, and inferiority. Studies show that two out of three American children are victims of experiencing verbal aggression from their parents. This can affect their mental, social, and interpersonal development during the most critical psychological developmental years which are generally between 2 and 19 years of age. It has been found that verbally abusive behaviors in young children are generally learned through an adult role model such as a parent or caregiver. There are various ways a caregiver can use verbal communication to abuse a child: rejection of a child's worth, isolating a child from social experiences, terrorizing a child with verbal assaults, ignoring a child's needs, corrupting a child's views of the world and teaching them that delinquent activity is normal, verbally assaulting a child, and over-pressuring a child to mature faster than the normal rate of maturity for the child's age. Children who have experienced maternal verbal abuse have been more likely to develop personality disorders in their adolescent and young adult years, they have also been known to develop obsessive-compulsive characteristics and narcissistic behaviors. College students It has been found that verbal abuse damages the self-esteem of students, places irrational blame onto themselves, and affects mental health and social interaction abilities in the students; this type of abuse in students can be projected through their peers and professors. The effects of experiencing verbal abuse as a young child – developing negative feelings and in some occurrences, mental disorders – bled onto young adulthood and when they are moving onto higher education and becoming a young adult, they are more prone to experience more of these negative feelings, disorders, and even have an increased chance of drug use in adulthood. In the college population, research has shown that one of the most impactful forms of verbal abuse was peer-related verbal abuse which started with a student blaming another peer for something they did not do and escalated to yelling, cursing, and using derogatory terms; this type of abuse has been associated with increasing the risks of the student falling into a depressive mood, developing anxiety, anger-hostility, and other emotional barriers. Gender Research has shown that in some grade-school scenarios – specifically middle school – verbal aggression is prevalent between boys and girls in different ways. Boys experienced insults and threats to a greater extent, while girls experienced sexual name-calling to a greater extent. Boys were often verbally abusive towards other boys and girls, this showed researchers that these characteristics were used to build masculinity amongst themselves. Often, boys are portrayed as needing to be "tough" or masculine, to be able to paint this image, they often resort to verbal abuse, which in turn, made them unfavorable to girls. Verbally abusive girls' reasoning for their actions of abuse was that they, in turn, were victims of bullying and/or verbal abuse by their peers and/or instructors because some of the girls would display the wrong kind of sexuality, femininity, and social age – according to their peers' and instructors' judgments. In some instances, the victims can become the perpetrators. It has been shown that Hispanic women who have experienced verbal conflicts and/or abuse with their father also go on to have verbal conflicts and/or abuse with their daughter. When Hispanic mothers exert a high level of verbal conflicts and/or abuse towards her husband, their daughter most likely will have a conflict with them – her parents - as well, when this happens it is also predicted that the daughter will go on to have the same conflicts with her partner. In America, a vulnerable group for verbal aggression are college-aged women. 80% of these women are aware that verbal abuse is a serious ongoing issue and 25% of them have reported to have experienced verbal abuse in an intimate relationship. In other instances, 65% of 358 low-income pregnant women claimed to have experienced verbal or physical abuse during their pregnancies, with younger women experiencing significantly higher rates of this abuse. Abuse in the workplace The workplace can be a breeding ground for verbal aggression. Slurs, racist comments, and derogatory terms have been used against ethnic minorities. Although it seems like this issue has resolved in the workplace because we are becoming more inclusive as a society, aggressors still have found ways to abuse ethnic minorities verbally and nonverbally in the office. It is more discrete, but aggressors are still deeply wounding ethnic minorities in the workplace with slurs and derogatory comments toward them. All of these things also apply to non-minorities, as they can experience just as much verbal abuse. In a study where 1000 nurses received a questionnaire and 46% responded, 91% of them claimed that they had experienced verbal abuse within the past month and more than 50% of them said that they did not feel capable of responding to the abuse. Adults who have been victims of verbal abuse and workplace mistreatment have been more susceptible to suffer from mental health illnesses and social disorders. Relationships In romantic relationships, specifically physically and verbally abusive ones, it has been found that when the couple has a conflict, 53% of the victims to this abuse say that physical aggression was the factor that started the conflict while 33% of the aggressors, in this case, claim that verbal aggression was the factor that ignited the issue. It is not a surprise that both the victim and the aggressor have different points of views as to what caused the abuse to escalate. In marital relationships, it is common to see that if one individual – whether it be the husband or wife – has trouble communicating their needs and expectations to their partner, instead of having "healthy" argumentation, they resort to using verbal aggression against their partner which in turn causes more distress and conflict in the relationship. Just like in the workplace, adults who have experienced intimate partner violence have also had their mental health and brain morphology be affected. References External links Psychological Effects of Being Yelled At Abuse Harassment and bullying Psychological abuse

Dementia praecox

Dementia praecox (meaning a "premature dementia" or "precocious madness") is a disused psychiatric diagnosis that originally designated a chronic, deteriorating psychotic disorder characterized by rapid cognitive disintegration, usually beginning in the late teens or early adulthood. Over the years, the term dementia praecox was gradually replaced by the term schizophrenia, which initially had a meaning that included what is today considered the autism spectrum. The term dementia praecox was first used by German psychiatrist Heinrich Schüle in 1880. It was also used in 1891 by Arnold Pick (1851–1924), a professor of psychiatry at Charles University in Prague. In a brief clinical report, he described a person with a psychotic disorder resembling "hebephrenia" (an adolescent-onset psychotic condition). German psychiatrist Emil Kraepelin (1856–1926) popularised the term dementia praecox in his first detailed textbook descriptions of a condition that eventually became a different disease concept later relabeled as schizophrenia. Kraepelin reduced the complex psychiatric taxonomies of the nineteenth century by dividing them into two classes: manic-depressive psychosis and dementia praecox. This division, commonly referred to as the Kraepelinian dichotomy, had a fundamental impact on twentieth-century psychiatry, though it has also been questioned. The primary disturbance in dementia praecox was seen to be a disruption in cognitive or mental functioning in attention, memory, and goal-directed behaviour. Kraepelin contrasted this with manic-depressive psychosis, now termed bipolar disorder, and also with other forms of mood disorder, including major depressive disorder. He eventually concluded that it was not possible to distinguish his categories on the basis of cross-sectional symptoms. Kraepelin viewed dementia praecox as a progressively deteriorating disease from which no one recovered. However, by 1913, and more explicitly by 1920, Kraepelin admitted that while there may be a residual cognitive defect in most cases, the prognosis was not as uniformly dire as he had stated in the 1890s. Still, he regarded it as a specific disease concept that implied incurable, inexplicable madness. History First use of the term Dementia is an ancient term which has been in use since at least the time of Lucretius in 50 BC where it meant "being out of one's mind". Until the seventeenth century, dementia referred to states of cognitive and behavioural deterioration leading to psychosocial incompetence. This condition could be innate or acquired, and the concept had no reference to a necessarily irreversible condition. It is the concept in this popular notion of psychosocial incapacity that forms the basis for the idea of legal incapacity. By the eighteenth century, at the period when the term entered into European medical discourse, clinical concepts were added to the vernacular understanding such that dementia was now associated with intellectual deficits arising from any cause and at any age. By the end of the nineteenth century, the modern 'cognitive paradigm' of dementia was taking root. This holds that dementia is understood in terms of criteria relating to aetiology, age and course which excludes former members of the family of the demented such as adults with acquired head trauma or children with cognitive deficits. Moreover, it was now understood as an irreversible condition and a particular emphasis was placed on memory loss in regard to the deterioration of intellectual functions. The term was used in passing to describe the characteristics of a subset of young mental patients by the French physician Bénédict Augustin Morel in 1852 in the first volume of his . and the term is used more frequently in his textbook which was published in 1860. Morel, whose name will be forever associated with religiously inspired concept of degeneration theory in psychiatry, used the term in a descriptive sense and not to define a specific and novel diagnostic category. It was applied as a means of setting apart a group of young men and women with "stupor". As such their condition was characterised by a certain torpor, enervation, and disorder of the will and was related to the diagnostic category of melancholia. He did not conceptualise their state as irreversible and thus his use of the term dementia was equivalent to that formed in the eighteenth century as outlined above. While some have sought to interpret, if in a qualified fashion, the use by Morel of the term as amounting to the discovery of schizophrenia, others have argued convincingly that Morel's descriptive use of the term should not be considered in any sense as a precursor to Kraepelin's dementia praecox disease concept. This is due to the fact that their concepts of dementia differed significantly from each other, with Kraepelin employing the more modern sense of the word and that Morel was not describing a diagnostic category. Indeed, until the advent of Pick and Kraepelin, Morel's term had vanished without a trace and there is little evidence to suggest that either Pick or indeed Kraepelin were even aware of Morel's use of the term until long after they had published their own disease concepts bearing the same name. As Eugène Minkowski stated, "An abyss separates Morel's from that of Kraepelin." Morel described several psychotic disorders that ended in dementia, and as a result he may be regarded as the first alienist or psychiatrist to develop a diagnostic system based on presumed outcome rather than on the current presentation of signs and symptoms. Morel, however, did not conduct any long-term or quantitative research on the course and outcome of dementia praecox (Kraepelin would be the first in history to do that) so this prognosis was based on speculation. It is impossible to discern whether the condition briefly described by Morel was equivalent to the disorder later called dementia praecox by Pick and Kraepelin. Time component Psychiatric nosology in the nineteenth-century was chaotic and characterised by a conflicting mosaic of contradictory systems. Psychiatric disease categories were based upon short-term and cross-sectional observations of patients from which were derived the putative characteristic signs and symptoms of a given disease concept. The dominant psychiatric paradigms which gave a semblance of order to this fragmentary picture were Morelian degeneration theory and the concept of "unitary psychosis". This latter notion, derived from the Belgian psychiatrist Joseph Guislain (1797–1860), held that the variety of symptoms attributed to mental illness were manifestations of a single underlying disease process. While these approaches had a diachronic aspect they lacked a conception of mental illness that encompassed a coherent notion of change over time in terms of the natural course of the illness and based upon an empirical observation of changing symptomatology. In 1863, the Danzig-based psychiatrist Karl Ludwig Kahlbaum (1828–1899) published his text on psychiatric nosology (The Classification of Psychiatric Diseases). Although with the passage of time this work would prove profoundly influential, when it was published it was almost completely ignored by German academia despite the sophisticated and intelligent disease classification system which it proposed. In this book Kahlbaum categorized certain typical forms of psychosis as a single coherent type based upon their shared progressive nature which betrayed, he argued, an ongoing degenerative disease process. For Kahlbaum the disease process of was distinguished by the passage of the patient through clearly defined disease phases: a melancholic stage; a manic stage; a confusional stage; and finally a demented stage. In 1866, Kahlbaum became the director of a private psychiatric clinic in Görlitz (Prussia, today Saxony, a small town near Dresden). He was accompanied by his younger assistant, Ewald Hecker (1843–1909), and during a ten-year collaboration they conducted a series of research studies on young psychotic patients that would become a major influence on the development of modern psychiatry. Together Kahlbaum and Hecker were the first to describe and name such syndromes as dysthymia, cyclothymia, paranoia, catatonia, and hebephrenia. Perhaps their most lasting contribution to psychiatry was the introduction of the "clinical method" from medicine to the study of mental diseases, a method which is now known as psychopathology. When the element of time was added to the concept of diagnosis, a diagnosis became more than just a description of a collection of symptoms: diagnosis now also defined by prognosis (course and outcome). An additional feature of the clinical method was that the characteristic symptoms that define syndromes should be described without any prior assumption of brain pathology (although such links would be made later as scientific knowledge progressed). Karl Kahlbaum made an appeal for the adoption of the clinical method in psychiatry in his 1874 book on catatonia. Without Kahlbaum and Hecker there would be no dementia praecox. Upon his appointment to a full professorship in psychiatry at the University of Dorpat (now Tartu, Estonia) in 1886, Kraepelin gave an inaugural address to the faculty outlining his research programme for the years ahead. Attacking the "brain mythology" of Meynert and the positions of Griesinger and Gudden, Kraepelin advocated that the ideas of Kahlbaum, who was then a marginal and little known figure in psychiatry, should be followed. Therefore, he argued, a research programme into the nature of psychiatric illness should look at a large number of patients over time to discover the course which mental disease could take. It has also been suggested that Kraepelin's decision to accept the Dorpat post was informed by the fact that there he could hope to gain experience with chronic patients and this, it was presumed, would facilitate the longitudinal study of mental illness. Quantitative component Understanding that objective diagnostic methods must be based on scientific practice, Kraepelin had been conducting psychological and drug experiments on patients and normal subjects for some time when, in 1891, he left Dorpat and took up a position as professor and director of the psychiatric clinic at Heidelberg University. There he established a research program based on Kahlbaum's proposal for a more exact qualitative clinical approach, and his own innovation: a quantitative approach involving meticulous collection of data over time on each new patient admitted to the clinic (rather than only the interesting cases, as had been the habit until then). Kraepelin believed that by thoroughly describing all of the clinic's new patients on index cards, which he had been using since 1887, researcher bias could be eliminated from the investigation process. He described the method in his posthumously published memoir: The fourth edition of his textbook, , published in 1893, two years after his arrival at Heidelberg, contained some impressions of the patterns Kraepelin had begun to find in his index cards. Prognosis (course and outcome) began to feature alongside signs and symptoms in the description of syndromes, and he added a class of psychotic disorders designated "psychic degenerative processes", three of which were borrowed from Kahlbaum and Hecker: dementia paranoides (a degenerative type of Kahlbaum's paranoia, with sudden onset), catatonia (per Kahlbaum, 1874) and dementia praecox, (Hecker's hebephrenia of 1871). Kraepelin continued to equate dementia praecox with hebephrenia for the next six years. In the March 1896 fifth edition of , Kraepelin expressed confidence that his clinical method, involving analysis of both qualitative and quantitative data derived from long term observation of patients, would produce reliable diagnoses including prognosis: In this edition dementia praecox is still essentially hebephrenia, and it, dementia paranoides and catatonia are described as distinct psychotic disorders among the "metabolic disorders leading to dementia". Kraepelin's influence on the next century In the 1899 (6th) edition of , Kraepelin established a paradigm for psychiatry that would dominate the following century, sorting most of the recognized forms of insanity into two major categories: dementia praecox and manic-depressive illness. Dementia praecox was characterized by disordered intellectual functioning, whereas manic-depressive illness was principally a disorder of affect or mood; and the former featured constant deterioration, virtually no recoveries and a poor outcome, while the latter featured periods of exacerbation followed by periods of remission, and many complete recoveries. The class, dementia praecox, comprised the paranoid, catatonic and hebephrenic psychotic disorders, and these forms were found in the Diagnostic and Statistical Manual of Mental Disorders until the fifth edition was released, in May 2013. These terms, however, are still found in general psychiatric nomenclature. Change in prognosis In the seventh, 1904, edition of , Kraepelin accepted the possibility that a small number of patients may recover from dementia praecox. Eugen Bleuler reported in 1908 that in many cases there was no inevitable progressive decline, there was temporary remission in some cases, and there were even cases of near recovery with the retention of some residual defect. In the eighth edition of Kraepelin's textbook, published in four volumes between 1909 and 1915, he described eleven forms of dementia, and dementia praecox was classed as one of the "endogenous dementias". Modifying his previous more gloomy prognosis in line with Bleuler's observations, Kraepelin reported that about 26% of his patients experienced partial remission of symptoms. Kraepelin died while working on the ninth edition of with Johannes Lange (1891–1938), who finished it and brought it to publication in 1927. Cause Though his work and that of his research associates had revealed a role for heredity, Kraepelin realized nothing could be said with certainty about the aetiology of dementia praecox, and he left out speculation regarding brain disease or neuropathology in his diagnostic descriptions. Nevertheless, from the 1896 edition onwards Kraepelin made clear his belief that poisoning of the brain, "auto-intoxication," probably by sex hormones, may underlie dementia praecox – a theory also entertained by Eugen Bleuler. Both theorists insisted dementia praecox is a biological disorder, not the product of psychological trauma. Thus, rather than a disease of hereditary degeneration or of structural brain pathology, Kraepelin believed dementia praecox was due to a systemic or "whole body" disease process, probably metabolic, which gradually affected many of the tissues and organs of the body before affecting the brain in a final, decisive cascade. Kraepelin, recognizing dementia praecox in Chinese, Japanese, Tamil and Malay patients, suggested in the eighth edition of that, "we must therefore seek the real cause of dementia praecox in conditions which are spread all over the world, which thus do not lie in race or in climate, in food or in any other general circumstance of life..." Treatment Kraepelin had experimented with hypnosis but found it wanting, and disapproved of Freud's and Jung's introduction, based on no evidence, of psychogenic assumptions to the interpretation and treatment of mental illness. He argued that, without knowing the underlying cause of dementia praecox or manic-depressive illness, there could be no disease-specific treatment, and recommended the use of long baths and the occasional use of drugs such as opiates and barbiturates for the amelioration of distress, as well as occupational activities, where suitable, for all institutionalized patients. Based on his theory that dementia praecox is the product of autointoxication emanating from the sex glands, Kraepelin experimented, without success, with injections of thyroid, gonad and other glandular extracts. Use of term spreads Kraepelin noted the dissemination of his new disease concept when in 1899 he enumerated the term's appearance in almost twenty articles in the German-language medical press. In the early years of the twentieth century the twin pillars of the Kraepelinian dichotomy, dementia praecox and manic depressive psychosis, were assiduously adopted in clinical and research contexts among the Germanic psychiatric community. German-language psychiatric concepts were always introduced much faster in America (than, say, Britain) where émigré German, Swiss and Austrian physicians essentially created American psychiatry. Swiss-émigré Adolf Meyer (1866–1950), arguably the most influential psychiatrist in America for the first half of the 20th century, published the first critique of dementia praecox in an 1896 book review of the 5th edition of Kraepelin's textbook. But it was not until 1900 and 1901 that the first three American publications regarding dementia praecox appeared, one of which was a translation of a few sections of Kraepelin's 6th edition of 1899 on dementia praecox. Adolf Meyer was the first to apply the new diagnostic term in America. He used it at the Worcester Lunatic Hospital in Massachusetts in the fall of 1896. He was also the first to apply Eugen Bleuler's term "schizophrenia" (in the form of "schizophrenic reaction") in 1913 at the Henry Phipps Psychiatric Clinic of the Johns Hopkins Hospital. The dissemination of Kraepelin's disease concept to the Anglophone world was facilitated in 1902 when Ross Diefendorf, a lecturer in psychiatry at Yale, published an adapted version of the sixth edition of the . This was republished in 1904 and with a new version, based on the seventh edition of Kraepelin's appearing in 1907 and reissued in 1912. Both dementia praecox (in its three classic forms) and "manic-depressive psychosis" gained wider popularity in the larger institutions in the eastern United States after being included in the official nomenclature of diseases and conditions for record-keeping at Bellevue Hospital in New York City in 1903. The term lived on due to its promotion in the publications of the National Committee on Mental Hygiene (founded in 1909) and the Eugenics Records Office (1910). But perhaps the most important reason for the longevity of Kraepelin's term was its inclusion in 1918 as an official diagnostic category in the uniform system adopted for comparative statistical record-keeping in all American mental institutions, The Statistical Manual for the Use of Institutions for the Insane. Its many revisions served as the official diagnostic classification scheme in America until 1952 when the first edition of the Diagnostic and Statistical Manual: Mental Disorders, or DSM-I, appeared. Dementia praecox disappeared from official psychiatry with the publication of DSM-I, replaced by the Bleuler/Meyer hybridization, "schizophrenic reaction". Schizophrenia was mentioned as an alternate term for dementia praecox in the 1918 Statistical Manual. In both clinical work as well as research, between 1918 and 1952 five different terms were used interchangeably: dementia praecox, schizophrenia, dementia praecox (schizophrenia), schizophrenia (dementia praecox) and schizophrenic reaction. This made the psychiatric literature of the time confusing since, in a strict sense, Kraepelin's disease was not Bleuler's disease. They were defined differently, had different population parameters, and different concepts of prognosis. The reception of dementia praecox as an accepted diagnosis in British psychiatry came more slowly, perhaps only taking hold around the time of World War I. There was substantial opposition to the use of the term "dementia" as misleading, partly due to findings of remission and recovery. Some argued that existing diagnoses such as "delusional insanity" or "adolescent insanity" were better or more clearly defined. In France a psychiatric tradition regarding the psychotic disorders predated Kraepelin, and the French never fully adopted Kraepelin's classification system. Instead the French maintained an independent classification system throughout the 20th century. From 1980, when DSM-III totally reshaped psychiatric diagnosis, French psychiatry began to finally alter its views of diagnosis to converge with the North American system. Kraepelin thus finally conquered France via America. From dementia praecox to schizophrenia Due to the influence of alienists such as Adolf Meyer, August Hoch, George Kirby, Charles Macphie Campbell, Smith Ely Jelliffe and William Alanson White, psychogenic theories of dementia praecox dominated the American scene by 1911. In 1925 Bleuler's schizophrenia rose in prominence as an alternative to Kraepelin's dementia praecox. When Freudian perspectives became influential in American psychiatry in the 1920s schizophrenia became an attractive alternative concept. Bleuler corresponded with Freud and was connected to Freud's psychoanalytic movement, and the inclusion of Freudian interpretations of the symptoms of schizophrenia in his publications on the subject, as well as those of C.G. Jung, eased the adoption of his broader version of dementia praecox (schizophrenia) in America over Kraepelin's narrower and prognostically more negative one. The term "schizophrenia" was first applied by American alienists and neurologists in private practice by 1909 and officially in institutional settings in 1913, but it took many years to catch on. It is first mentioned in The New York Times in 1925. Until 1952 the terms dementia praecox and schizophrenia were used interchangeably in American psychiatry, with occasional use of the hybrid terms "dementia praecox (schizophrenia)" or "schizophrenia (dementia praecox)". Diagnostic manuals Editions of the Diagnostic and Statistical Manual of Mental Disorders since the first in 1952 had reflected views of schizophrenia as "reactions" or "psychogenic" (DSM-I), or as manifesting Freudian notions of "defense mechanisms" (as in DSM-II of 1969 in which the symptoms of schizophrenia were interpreted as "psychologically self-protected"). The diagnostic criteria were vague, minimal and wide, including either concepts that no longer exist or that are now labeled as personality disorders (for example, schizotypal personality disorder). There was also no mention of the dire prognosis Kraepelin had made. Schizophrenia seemed to be more prevalent and more psychogenic and more treatable than either Kraepelin or Bleuler would have allowed. Conclusions As a direct result of the effort to construct Research Diagnostic Criteria in the 1970s that were independent of any clinical diagnostic manual, Kraepelin's idea that categories of mental disorder should reflect discrete and specific disease entities with a biological basis began to return to prominence. Vague dimensional approaches based on symptoms—so highly favored by the Meyerians and psychoanalysts—were overthrown. For research purposes, the definition of schizophrenia returned to the narrow range allowed by Kraepelin's dementia praecox concept. Furthermore, after 1980 the disorder was a progressively deteriorating one once again, with the notion that recovery, if it happened at all, was rare. This revision of schizophrenia became the basis of the diagnostic criteria in DSM-III (1980). Some of the psychiatrists who worked to bring about this revision referred to themselves as the "neo-Kraepelinians". Footnotes Bibliography Further reading Bibliography of scholarly histories on schizophrenia and dementia praecox, part 1 (2000 – mid 2007). Burgmair, Wolfgang & Eric J. Engstrom & Matthias Weber, et al., eds. Emil Kraepelin. 8 vols. Munich: Belleville, 2000–2013. Vol. VIII. Kraepelin in München, Teil III: 1921–1926 (2013), . Vol. VII: Kraepelin in München, Teil II: 1914–1926 (2008). Vol. VI: Kraepelin in München, Teil I: 1903–1914 (2006), Vol. V: Kraepelin in Heidelberg, 1891–1903 (2005), Vol. IV: Kraepelin in Dorpat, 1886–1891 (2003), Vol. III: Briefe I, 1868–1886 (2002), Vol. II: Kriminologische und forensische Schriften: Werke und Briefe (2001), Vol. I: Persönliches, Selbstzeugnisse (2000), Engels, Huub (2006). Emil Kraepelins Traumsprache 1908–1926. annotated edition of Kraepelin's dream speech in the mentioned period. . Kraepelin, Emil. Psychiatrie: Ein kurzes Lehrbuch fur Studirende und Aerzte. Vierte, vollständig umgearbeitete Auflage. Leipzig: Abel Verlag, 1893. Kraepelin, Emil. Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte. Fünfte, vollständig umgearbeitete Auflage. Leipzig: Verlag von Johann Ambrosius Barth, 1896. Kraepelin, Emil. Psychiatrie: Ein Lehrbuch fur Studirende und Aerzte. Sechste, vollständig umgearbeitete Auflage. Leipzig: Verlag von Johann Ambrosius Barth, 1899. Pick, Arnold. Ueber primare chronische Demenz (so. Dementia praecox) im jugendlichen Alter. Prager medicinische Wochenschrift, 1891, 16: 312–315. See also Daniel Paul Schreber, a famous case of dementia praecox. External links Obsolete terms for mental disorders Obsolete medical terms Schizophrenia

Sanity

Sanity (from ) refers to the soundness, rationality, and health of the human mind, as opposed to insanity. A person is sane if they are rational. In modern society, the term has become exclusively synonymous with compos mentis (, having mastery of, and , mind), in contrast with non compos mentis, or insanity, meaning troubled conscience. A sane mind is nowadays considered healthy both from its analytical - once called rational - and emotional aspects. According to the writer G. K. Chesterton, sanity involves wholeness, whereas insanity implies narrowness and brokenness. Psychiatry and psychology Alfred Korzybski proposed a theory of sanity in his general semantics. He believed sanity was tied to the logical reasoning about and comprehension of what is going on in the world. He imposed this notion in a map-territory analogy: "A map is not the territory it represents, but, if correct, it has a 'similar structure' to the territory, which accounts for its usefulness." Given that science continually seeks to adjust its theories structurally to fit the facts, i.e., improves its maps to fit the territory, and thus advances more rapidly than any other field, he believed that the key to understanding sanity would be found in the study of the methods of science (and the study of structure as revealed by science). The adoption of a scientific outlook and attitude of continual adjustment by the individual toward their assumptions was the way, so he claimed. In other words, there were "factors of sanity to be found in the physico-mathematical methods of science." He also stressed that sanity requires the awareness that "whatever you say a thing is, it is not" because anything expressed through language is not the reality it refers to: language is like a map, and the map is not the territory. The territory, or reality, remains unnamable, unspeakable, and mysterious. Hence, the widespread assumption that we can grasp reality through language involves a degree of insanity. Psychiatrist Philip S. Graven suggested the term "un-sane" to describe a condition that is not exactly insane, but not quite sane either. In The Sane Society, published in 1955, psychologist Erich Fromm proposed that not just individuals, but entire societies "may be lacking in sanity." Fromm argued that one of the most deceptive features of social life involves "consensual validation": It is naively assumed that the fact that the majority of people share certain ideas or feelings proves the validity of these ideas and feelings. Nothing is further from the truth... Just as there is a folie à deux there is a folie à millions. The fact that millions of people share the same vices does not make these vices virtues, the fact that they share so many errors does not make the errors to be truths, and the fact that millions of people share the same form of mental pathology does not make these people sane. Law In criminal and mental health law, sanity is a legal term denoting that an individual is of sound mind and therefore can bear legal responsibility for their actions. The official legal term is compos mentis. It is generally defined in terms of the absence of insanity (non compos mentis). It is not a medical term, although the opinions of medical experts are often important in making a legal decision as to whether someone is sane or insane. It is also not the same concept as mental illness. One can be acting under profound mental illness and yet be sane, and one can also be ruled insane without an underlying mental illness. Legal definitions of sanity have been little explored by science and medicine, as the concentration has been on illness. It remains entirely impossible to prove sanity. Furthermore, as Korzybski has pointed out repeatedly, insanity to various degrees is widespread in the general population, which includes many people that are considered mentally fit in medical and legal terms. In this connection, Erich Fromm referred to the "pathology of normalcy," while David Cooper proposed that normality was opposed to both madness and sanity. For a last will and testament to be valid, the testator must have testamentary capacity. This is often expressed using the phrase "being of sound mind and memory". See also George Eman Vaillant Insanity defense Rationalism Sanism Self-actualisation References Mental health law General semantics

SOCRATES (pain assessment)

SOCRATES is a mnemonic acronym used by emergency medical services, physicians, nurses, and other health professionals to evaluate the nature of pain that a patient is experiencing. Uses SOCRATES is used to gain an insight into the patient's condition, and to allow the health care provider to develop a plan for dealing with it. It can be useful for differentiating between nociceptive pain and neuropathic pain. Adverse effects SOCRATES only focuses on the physical effects of pain, and ignores the social and emotional effects of pain. Procedure History SOCRATES is often poorly used by health care providers. Although pain assessments usually cover many or most of the aspects, they rarely included all 8 aspects. See also History of presenting complaint Medical history OPQRST References Medical mnemonics Pain management Mnemonic acronyms

Coping

Coping refers to conscious or unconscious strategies used to reduce and manage unpleasant emotions. Coping strategies can be cognitions or behaviors and can be individual or social. To cope is to deal with struggles and difficulties in life. It is a way for people to maintain their mental and emotional well-being. Everybody has ways of handling difficult events that occur in life, and that is what it means to cope. Coping can be healthy and productive, or destructive and unhealthy. It is recommended that an individual cope in ways that will be beneficial and healthy. "Managing your stress well can help you feel better physically and psychologically and it can impact your ability to perform your best." Theories of coping Hundreds of coping strategies have been proposed in an attempt to understand how people cope. Classification of these strategies into a broader architecture has not been agreed upon. Researchers try to group coping responses rationally, empirically by factor analysis, or through a blend of both techniques. In the early days, Folkman and Lazarus split the coping strategies into four groups, namely problem-focused, emotion-focused, support-seeking, and meaning-making coping. Weiten and Lloyd have identified four types of coping strategies: appraisal-focused (adaptive cognitive), problem-focused (adaptive behavioral), emotion-focused, and occupation-focused coping. Billings and Moos added avoidance coping as one of the emotion-focused coping. Some scholars have questioned the psychometric validity of forced categorization as those strategies are not independent to each other. Besides, in reality, people can adopt multiple coping strategies simultaneously. Typically, people use a mixture of several functions of coping strategies, which may change over time. All these strategies can prove useful, but some claim that those using problem-focused coping strategies will adjust better to life. Problem-focused coping mechanisms may allow an individual greater perceived control over their problem, whereas emotion-focused coping may sometimes lead to a reduction in perceived control (maladaptive coping). Lazarus "notes the connection between his idea of 'defensive reappraisals' or cognitive coping and Sigmund Freud's concept of 'ego-defenses, coping strategies thus overlapping with a person's defense mechanisms. Appraisal-focused coping strategies Appraisal-focused (adaptive cognitive) strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. Individuals who use appraisal coping strategies purposely alter their perspective on their situation in order to have a more positive outlook on their situation. An example of appraisal coping strategies could be individuals purchasing tickets to a football game, knowing their medical condition would likely cause them to not be able to attend. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humor in a situation: "Some have suggested that humor may play a greater role as a stress moderator among women than men". Adaptive behavioral coping strategies The psychological coping mechanisms are commonly termed coping strategies or coping skills. The term coping generally refers to adaptive (constructive) coping strategies, that is, strategies which reduce stress. In contrast, other coping strategies may be coined as maladaptive, if they increase stress. Maladaptive coping is therefore also described, based on its outcome, as non-coping. Furthermore, the term coping generally refers to reactive coping, i.e. the coping response which follows the stressor. This differs from proactive coping, in which a coping response aims to neutralize a future stressor. Subconscious or unconscious strategies (e.g. defense mechanisms) are generally excluded from the area of coping. The effectiveness of the coping effort depends on the type of stress, the individual, and the circumstances. Coping responses are partly controlled by personality (habitual traits), but also partly by the social environment, particularly the nature of the stressful environment. People using problem-focused strategies try to deal with the cause of their problem. They do this by finding out information on the problem and learning new skills to manage the problem. Problem-focused coping is aimed at changing or eliminating the source of the stress. The three problem-focused coping strategies identified by Folkman and Lazarus are: taking control, information seeking, and evaluating the pros and cons. However, problem-focused coping may not be necessarily adaptive, but backfire, especially in the uncontrollable case that one cannot make the problem go away. Emotion-focused coping strategies Emotion-focused strategies involve: releasing pent-up emotions distracting oneself managing hostile feelings meditating mindfulness practices using systematic relaxation procedures. situational exposure Emotion-focused coping "is oriented toward managing the emotions that accompany the perception of stress". The five emotion-focused coping strategies identified by Folkman and Lazarus are: disclaiming escape-avoidance accepting responsibility or blame exercising self-control and positive reappraisal. Emotion-focused coping is a mechanism to alleviate distress by minimizing, reducing, or preventing, the emotional components of a stressor. This mechanism can be applied through a variety of ways, such as: seeking social support reappraising the stressor in a positive light accepting responsibility using avoidance exercising self-control distancing The focus of this coping mechanism is to change the meaning of the stressor or transfer attention away from it. For example, reappraising tries to find a more positive meaning of the cause of the stress in order to reduce the emotional component of the stressor. Avoidance of the emotional distress will distract from the negative feelings associated with the stressor. Emotion-focused coping is well suited for stressors that seem uncontrollable (ex. a terminal illness diagnosis, or the loss of a loved one). Some mechanisms of emotion focused coping, such as distancing or avoidance, can have alleviating outcomes for a short period of time, however they can be detrimental when used over an extended period. Positive emotion-focused mechanisms, such as seeking social support, and positive re-appraisal, are associated with beneficial outcomes. Emotional approach coping is one form of emotion-focused coping in which emotional expression and processing is used to adaptively manage a response to a stressor. Other examples include relaxation training through deep breathing, meditation, yoga, music and art therapy, and aromatherapy. Health theory of coping The health theory of coping overcame the limitations of previous theories of coping, describing coping strategies within categories that are conceptually clear, mutually exclusive, comprehensive, functionally homogenous, functionally distinct, generative and flexible, explains the continuum of coping strategies. The usefulness of all coping strategies to reduce acute distress is acknowledged, however, strategies are categorized as healthy or unhealthy depending on their likelihood of additional adverse consequences. Healthy categories are self-soothing, relaxation/distraction, social support and professional support. Unhealthy coping categories are negative self-talk, harmful activities (e.g., emotional eating, verbal or physical aggression, drugs such as alcohol, self-harm), social withdrawal, and suicidality. Unhealthy coping strategies are used when healthy coping strategies are overwhelmed, not in the absence of healthy coping strategies. Research has shown that everyone has personal healthy coping strategies (self-soothing, relaxation/distraction), however, access to social and professional support varies. Increasing distress and inadequate support results in the additional use of unhealthy coping strategies. Overwhelming distress exceeds the capacity of healthy coping strategies and results in the use of unhealthy coping strategies. Overwhelming distress is caused by problems in one or more biopsychosocial domains of health and wellbeing. The continuum of coping strategies (healthy to unhealthy, independent to social, and low harm to high harm) have been explored in general populations, university students, and paramedics. New evidence propose a more comprehensive view of a continuum iterative transformative process of developing coping competence among palliative care professionals Reactive and proactive coping Most coping is reactive in that the coping response follows stressors. Anticipating and reacting to a future stressor is known as proactive coping or future-oriented coping. Anticipation is when one reduces the stress of some difficult challenge by anticipating what it will be like and preparing for how one is going to cope with it. Social coping Social coping recognises that individuals are bedded within a social environment, which can be stressful, but also is the source of coping resources, such as seeking social support from others. (see help-seeking) Humor Humor used as a positive coping method may have useful benefits to emotional and mental health well-being. However, maladaptive humor styles such as self-defeating humor can also have negative effects on psychological adjustment and might exacerbate negative effects of other stressors. By having a humorous outlook on life, stressful experiences can be and are often minimized. This coping method corresponds with positive emotional states and is known to be an indicator of mental health. Physiological processes are also influenced within the exercise of humor. For example, laughing may reduce muscle tension, increase the flow of oxygen to the blood, exercise the cardiovascular region, and produce endorphins in the body. Using humor in coping while processing feelings can vary depending on life circumstance and individual humor styles. In regards to grief and loss in life occurrences, it has been found that genuine laughs/smiles when speaking about the loss predicted later adjustment and evoked more positive responses from other people. A person might also find comedic relief with others around irrational possible outcomes for the deceased funeral service. It is also possible that humor would be used by people to feel a sense of control over a more powerless situation and used as way to temporarily escape a feeling of helplessness. Exercised humor can be a sign of positive adjustment as well as drawing support and interaction from others around the loss. Negative techniques (maladaptive coping or non-coping) Whereas adaptive coping strategies improve functioning, a maladaptive coping technique (also termed non-coping) will just reduce symptoms while maintaining or strengthening the stressor. Maladaptive techniques are only effective as a short-term rather than long-term coping process. Examples of maladaptive behavior strategies include anxious avoidance, dissociation, escape (including self-medication), use of maladaptive humor styles such as self-defeating humor, procrastination, rationalization, safety behaviors, and sensitization. These coping strategies interfere with the person's ability to unlearn, or break apart, the paired association between the situation and the associated anxiety symptoms. These are maladaptive strategies as they serve to maintain the disorder. Anxious avoidance is when a person avoids anxiety provoking situations by all means. This is the most common method. Dissociation is the ability of the mind to separate and compartmentalize thoughts, memories, and emotions. This is often associated with post traumatic stress syndrome. Escape is closely related to avoidance. This technique is often demonstrated by people who experience panic attacks or have phobias. These people want to flee the situation at the first sign of anxiety. The use of self-defeating humor means that a person disparages themselves in order to entertain others. This type of humor has been shown to lead to negative psychological adjustment and exacerbate the effect of existing stressors. Procrastination is when a person willingly delays a task in order to receive a temporary relief from stress. While this may work for short-term relief, when used as a coping mechanism, procrastination causes more issues in the long run. Rationalization is the practice of attempting to use reasoning to minimize the severity of an incident, or avoid approaching it in ways that could cause psychological trauma or stress. It most commonly manifests in the form of making excuses for the behavior of the person engaging in the rationalization, or others involved in the situation the person is attempting to rationalize. Sensitization is when a person seeks to learn about, rehearse, and/or anticipate fearful events in a protective effort to prevent these events from occurring in the first place. Safety behaviors are demonstrated when individuals with anxiety disorders come to rely on something, or someone, as a means of coping with their excessive anxiety. Overthinking Emotion suppression Emotion-driven behavior Further examples Further examples of coping strategies include emotional or instrumental support, self-distraction, denial, substance use, self-blame, behavioral disengagement and the use of drugs or alcohol. Many people think that meditation "not only calms our emotions, but...makes us feel more 'together, as too can "the kind of prayer in which you're trying to achieve an inner quietness and peace". Low-effort syndrome or low-effort coping refers to the coping responses of a person refusing to work hard. For example, a student at school may learn to put in only minimal effort as they believe if they put in effort it could unveil their flaws. Historical psychoanalytic theories Otto Fenichel Otto Fenichel summarized early psychoanalytic studies of coping mechanisms in children as "a gradual substitution of actions for mere discharge reactions...[&] the development of the function of judgement" – noting however that "behind all active types of mastery of external and internal tasks, a readiness remains to fall back on passive-receptive types of mastery." In adult cases of "acute and more or less 'traumatic' upsetting events in the life of normal persons", Fenichel stressed that in coping, "in carrying out a 'work of learning' or 'work of adjustment', [s]he must acknowledge the new and less comfortable reality and fight tendencies towards regression, towards the misinterpretation of reality", though such rational strategies "may be mixed with relative allowances for rest and for small regressions and compensatory wish fulfillment, which are recuperative in effect". Karen Horney In the 1940s, the German Freudian psychoanalyst Karen Horney "developed her mature theory in which individuals cope with the anxiety produced by feeling unsafe, unloved, and undervalued by disowning their spontaneous feelings and developing elaborate strategies of defence." Horney defined four so-called coping strategies to define interpersonal relations, one describing psychologically healthy individuals, the others describing neurotic states. The healthy strategy she termed "Moving with" is that with which psychologically healthy people develop relationships. It involves compromise. In order to move with, there must be communication, agreement, disagreement, compromise, and decisions. The three other strategies she described – "Moving toward", "Moving against" and "Moving away" – represented neurotic, unhealthy strategies people utilize in order to protect themselves. Horney investigated these patterns of neurotic needs (compulsive attachments). The neurotics might feel these attachments more strongly because of difficulties within their lives. If the neurotic does not experience these needs, they will experience anxiety. The ten needs are: Affection and approval, the need to please others and be liked. A partner who will take over one's life, based on the idea that love will solve all of one's problems. Restriction of one's life to narrow borders, to be undemanding, satisfied with little, inconspicuous; to simplify one's life. Power, for control over others, for a facade of omnipotence, caused by a desperate desire for strength and dominance. Exploitation of others; to get the better of them. Social recognition or prestige, caused by an abnormal concern for appearances and popularity. Personal admiration. Personal achievement. Self-sufficiency and independence. Perfection and unassailability, a desire to be perfect and a fear of being flawed. In Compliance, also known as "Moving toward" or the "Self-effacing solution", the individual moves towards those perceived as a threat to avoid retribution and getting hurt, "making any sacrifice, no matter how detrimental." The argument is, "If I give in, I won't get hurt." This means that: if I give everyone I see as a potential threat whatever they want, I will not be injured (physically or emotionally). This strategy includes neurotic needs one, two, and three. In Withdrawal, also known as "Moving away" or the "Resigning solution", individuals distance themselves from anyone perceived as a threat to avoid getting hurt – "the 'mouse-hole' attitude ... the security of unobtrusiveness." The argument is, "If I do not let anyone close to me, I won't get hurt." A neurotic, according to Horney desires to be distant because of being abused. If they can be the extreme introvert, no one will ever develop a relationship with them. If there is no one around, nobody can hurt them. These "moving away" people fight personality, so they often come across as cold or shallow. This is their strategy. They emotionally remove themselves from society. Included in this strategy are neurotic needs three, nine, and ten. In Aggression, also known as the "Moving against" or the "Expansive solution", the individual threatens those perceived as a threat to avoid getting hurt. Children might react to parental in-differences by displaying anger or hostility. This strategy includes neurotic needs four, five, six, seven, and eight. Related to the work of Karen Horney, public administration scholars developed a classification of coping by frontline workers when working with clients (see also the work of Michael Lipsky on street-level bureaucracy). This coping classification is focused on the behavior workers can display towards clients when confronted with stress. They show that during public service delivery there are three main families of coping: Moving towards clients: Coping by helping clients in stressful situations. An example is a teacher working overtime to help students. Moving away from clients: Coping by avoiding meaningful interactions with clients in stressful situations. An example is a public servant stating "the office is very busy today, please return tomorrow." Moving against clients: Coping by confronting clients. For instance, teachers can cope with stress when working with students by imposing very rigid rules, such as no cellphone use in class and sending everyone to the office when they use a cellphone. Furthermore, aggression towards clients is also included here. In their systematic review of 35 years of the literature, the scholars found that the most often used family is moving towards clients (43% of all coping fragments). Moving away from clients was found in 38% of all coping fragments and Moving against clients in 19%. Heinz Hartmann In 1937, the psychoanalyst (as well as a physician, psychologist, and psychiatrist) Heinz Hartmann marked it as the evolution of ego psychology by publishing his paper, "Me" (which was later translated into English in 1958, titled, "The Ego and the Problem of Adaptation"). Hartmann focused on the adaptive progression of the ego "through the mastery of new demands and tasks". In fact, according to his adaptive point of view, once infants were born they have the ability to be able to cope with the demands of their surroundings. In his wake, ego psychology further stressed "the development of the personality and of 'ego-strengths'...adaptation to social realities". Object relations Emotional intelligence has stressed the importance of "the capacity to soothe oneself, to shake off rampant anxiety, gloom, or irritability....People who are poor in this ability are constantly battling feelings of distress, while those who excel in it can bounce back far more quickly from life's setbacks and upsets". From this perspective, "the art of soothing ourselves is a fundamental life skill; some psychoanalytic thinkers, such as John Bowlby and D. W. Winnicott see this as the most essential of all psychic tools." Object relations theory has examined the childhood development both of "independent coping...capacity for self-soothing", and of "aided coping. Emotion-focused coping in infancy is often accomplished through the assistance of an adult." Gender differences Gender differences in coping strategies are the ways in which men and women differ in managing psychological stress. There is evidence that males often develop stress due to their careers, whereas females often encounter stress due to issues in interpersonal relationships. Early studies indicated that "there were gender differences in the sources of stressors, but gender differences in coping were relatively small after controlling for the source of stressors"; and more recent work has similarly revealed "small differences between women's and men's coping strategies when studying individuals in similar situations." In general, such differences as exist indicate that women tend to employ emotion-focused coping and the "tend-and-befriend" response to stress, whereas men tend to use problem-focused coping and the "fight-or-flight" response, perhaps because societal standards encourage men to be more individualistic, while women are often expected to be interpersonal. An alternative explanation for the aforementioned differences involves genetic factors. The degree to which genetic factors and social conditioning influence behavior, is the subject of ongoing debate. Physiological basis Hormones also play a part in stress management. Cortisol, a stress hormone, was found to be elevated in males during stressful situations. In females, however, cortisol levels were decreased in stressful situations, and instead, an increase in limbic activity was discovered. Many researchers believe that these results underlie the reasons why men administer a fight-or-flight reaction to stress; whereas, females have a tend-and-befriend reaction. The "fight-or-flight" response activates the sympathetic nervous system in the form of increased focus levels, adrenaline, and epinephrine. Conversely, the "tend-and-befriend" reaction refers to the tendency of women to protect their offspring and relatives. Although these two reactions support a genetic basis to differences in behavior, one should not assume that in general females cannot implement "fight-or-flight" behavior or that males cannot implement "tend-and-befriend" behavior. Additionally, this study implied differing health impacts for each gender as a result of the contrasting stress-processes. See also References Sources Further reading Susan Folkman and Richard S. Lazarus, "Coping and Emotion", in Nancy Stein et al. eds., Psychological and Biological Approaches to Emotion (1990) Arantzamendi M, Sapeta P, Belar A, Centeno C. How palliative care professionals develop coping competence through their career: A grounded theory. Palliat Med. 2024 Feb 21:2692163241229961. doi: 10.1177/02692163241229961. External links Coping Skills for Trauma Coping Strategies for Children and Teenagers Living with Domestic Violence Interpersonal conflict Personal life Psychological stress Human behavior Life skills

Therapy

A therapy or medical treatment is the attempted remediation of a health problem, usually following a medical diagnosis. Both words, treatment and therapy, are often abbreviated tx, Tx, or Tx. As a rule, each therapy has indications and contraindications. There are many different types of therapy. Not all therapies are effective. Many therapies can produce unwanted adverse effects. Treatment and therapy are often synonymous, especially in the usage of health professionals. However, in the context of mental health, the term therapy may refer specifically to psychotherapy. Semantic field The words care, therapy, treatment, and intervention overlap in a semantic field, and thus they can be synonymous depending on context. Moving rightward through that order, the connotative level of holism decreases and the level of specificity (to concrete instances) increases. Thus, in health-care contexts (where its senses are always noncount), the word care tends to imply a broad idea of everything done to protect or improve someone's health (for example, as in the terms preventive care and primary care, which connote ongoing action), although it sometimes implies a narrower idea (for example, in the simplest cases of wound care or postanesthesia care, a few particular steps are sufficient, and the patient's interaction with the provider of such care is soon finished). In contrast, the word intervention tends to be specific and concrete, and thus the word is often countable; for example, one instance of cardiac catheterization is one intervention performed, and coronary care (noncount) can require a series of interventions (count). At the extreme, the piling on of such countable interventions amounts to interventionism, a flawed model of care lacking holistic circumspection—merely treating discrete problems (in billable increments) rather than maintaining health. Therapy and treatment, in the middle of the semantic field, can connote either the holism of care or the discreteness of intervention, with context conveying the intent in each use. Accordingly, they can be used in both noncount and count senses (for example, therapy for chronic kidney disease can involve several dialysis treatments per week). The words aceology and iamatology are obscure and obsolete synonyms referring to the study of therapies. The English word therapy comes via Latin therapīa from and literally means "curing" or "healing". The term is a somewhat archaic doublet of the word therapy. Types of therapies By chronology, priority, or intensity Levels of care Levels of care classify health care into categories of chronology, priority, or intensity, as follows: Urgent care handles health issues that need to be handled today but are not necessarily emergencies; the urgent care venue can send a patient to the emergency care level if it turns out to be needed. In the United States (and possibly various other countries), urgent care centers also serve another function as their other main purpose: U.S. primary care practices have evolved in recent decades into a configuration whereby urgent care centers provide portions of primary care that cannot wait a month, because getting an appointment with the primary care practitioner is often subject to a waitlist of 2 to 8 weeks. Emergency care handles medical emergencies and is a first point of contact or intake for less serious problems, which can be referred to other levels of care as appropriate. Intensive care, also called critical care, is care for extremely ill or injured patients. It thus requires high resource intensity, knowledge, and skill, as well as quick decision making. Ambulatory care is care provided on an outpatient basis. Typically patients can walk into and out of the clinic under their own power (hence "ambulatory"), usually on the same day. Home care is care at home, including care from providers (such as physicians, nurses, and home health aides) making house calls, care from caregivers such as family members, and patient self-care. Primary care is meant to be the main kind of care in general, and ideally a medical home that unifies care across referred providers. Secondary care is care provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists and dermatologists. A patient reaches secondary care as a next step from primary care, typically by provider referral although sometimes by patient self-initiative. Tertiary care is specialized consultative care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment, such as a tertiary referral hospital. Follow-up care is additional care during or after convalescence. Aftercare is generally synonymous with follow-up care. End-of-life care is care near the end of one's life. It often includes the following: Palliative care is supportive care, most especially (but not necessarily) near the end of life. Hospice care is palliative care very near the end of life when cure is very unlikely. Its main goal is comfort, both physical and mental. Lines of therapy Treatment decisions often follow formal or informal algorithmic guidelines. Treatment options can often be ranked or prioritized into lines of therapy: first-line therapy, second-line therapy, third-line therapy, and so on. First-line therapy (sometimes referred to as induction therapy, primary therapy, or front-line therapy) is the first therapy that will be tried. Its priority over other options is usually either: (1) formally recommended on the basis of clinical trial evidence for its best-available combination of efficacy, safety, and tolerability or (2) chosen based on the clinical experience of the physician. If a first-line therapy either fails to resolve the issue or produces intolerable side effects, additional (second-line) therapies may be substituted or added to the treatment regimen, followed by third-line therapies, and so on. An example of a context in which the formalization of treatment algorithms and the ranking of lines of therapy is very extensive is chemotherapy regimens. Because of the great difficulty in successfully treating some forms of cancer, one line after another may be tried. In oncology the count of therapy lines may reach 10 or even 20. Often multiple therapies may be tried simultaneously (combination therapy or polytherapy). Thus combination chemotherapy is also called polychemotherapy, whereas chemotherapy with one agent at a time is called single-agent therapy or monotherapy. Adjuvant therapy is therapy given in addition to the primary, main, or initial treatment, but simultaneously (as opposed to second-line therapy). Neoadjuvant therapy is therapy that is begun before the main therapy. Thus one can consider surgical excision of a tumor as the first-line therapy for a certain type and stage of cancer even though radiotherapy is used before it; the radiotherapy is neoadjuvant (chronologically first but not primary in the sense of the main event). Premedication is conceptually not far from this, but the words are not interchangeable; cytotoxic drugs to put a tumor "on the ropes" before surgery delivers the "knockout punch" are called neoadjuvant chemotherapy, not premedication, whereas things like anesthetics or prophylactic antibiotics before dental surgery are called premedication. Step therapy or stepladder therapy is a specific type of prioritization by lines of therapy. It is controversial in American health care because unlike conventional decision-making about what constitutes first-line, second-line, and third-line therapy, which in the U.S. reflects safety and efficacy first and cost only according to the patient's wishes, step therapy attempts to mix cost containment by someone other than the patient (third-party payers) into the algorithm. Therapy freedom and the negotiation between individual and group rights are involved. By intent By therapy composition Treatments can be classified according to the method of treatment: By matter by drugs: pharmacotherapy, chemotherapy (also, medical therapy often means specifically pharmacotherapy) by medical devices: implantation cardiac resynchronization therapy by specific molecules: molecular therapy (although most drugs are specific molecules, molecular medicine refers in particular to medicine relying on molecular biology) by specific biomolecular targets: targeted therapy molecular chaperone therapy by chelation: chelation therapy by specific chemical elements: by metals: by heavy metals: by gold: chrysotherapy (aurotherapy) by platinum-containing drugs: platin therapy by biometals by lithium: lithium therapy by potassium: potassium supplementation by magnesium: magnesium supplementation by chromium: chromium supplementation; phonemic neurological hypochromium therapy by copper: copper supplementation by nonmetals: by diatomic oxygen: oxygen therapy, hyperbaric oxygen therapy (hyperbaric medicine) transdermal continuous oxygen therapy by triatomic oxygen (ozone): ozone therapy by fluoride: fluoride therapy by other gases: medical gas therapy by water: hydrotherapy aquatic therapy rehydration therapy oral rehydration therapy water cure (therapy) by biological materials (biogenic substances, biomolecules, biotic materials, natural products), including their synthetic equivalents: biotherapy by whole organisms by viruses: virotherapy by bacteriophages: phage therapy by animal interaction: see animal interaction section by constituents or products of organisms by plant parts or extracts (but many drugs are derived from plants, even when the term phytotherapy is not used) scientific type: phytotherapy traditional (prescientific) type: herbalism by animal parts: quackery involving shark fins, tiger parts, and so on, often driving threat or endangerment of species by genes: gene therapy gene therapy for epilepsy gene therapy for osteoarthritis gene therapy for color blindness gene therapy of the human retina gene therapy in Parkinson's disease by epigenetics: epigenetic therapy by proteins: protein therapy (but many drugs are proteins despite not being called protein therapy) by enzymes: enzyme replacement therapy by hormones: hormone therapy hormonal therapy (oncology) hormone replacement therapy estrogen replacement therapy androgen replacement therapy hormone replacement therapy (menopause) transgender hormone therapy feminizing hormone therapy masculinizing hormone therapy antihormone therapy androgen deprivation therapy by whole cells: cell therapy (cytotherapy) by stem cells: stem cell therapy by immune cells: see immune system products below by immune system products: immunotherapy, host modulatory therapy by immune cells: T-cell vaccination cell transfer therapy autologous immune enhancement therapy TK cell therapy by humoral immune factors: antibody therapy by whole serum: serotherapy, including antiserum therapy by immunoglobulins: immunoglobulin therapy by monoclonal antibodies: monoclonal antibody therapy by urine: urine therapy (some scientific forms; many prescientific or pseudoscientific forms) by food and dietary choices: medical nutrition therapy grape therapy (quackery) by salts (but many drugs are the salts of organic acids, even when drug therapy is not called by names reflecting that) by salts in the air by natural dry salt air: "taking the cure" in desert locales (especially common in prescientific medicine; for example, one 19th-century way to treat tuberculosis) by artificial dry salt air: low-humidity forms of speleotherapy negative air ionization therapy by moist salt air: by natural moist salt air: seaside cure (especially common in prescientific medicine) by artificial moist salt air: water vapor forms of speleotherapy by salts in the water by mineral water: spa cure ("taking the waters") (especially common in prescientific medicine) by seawater: seaside cure (especially common in prescientific medicine) by aroma: aromatherapy by other materials with mechanism of action unknown by occlusion with duct tape: duct tape occlusion therapy By energy by electric energy as electric current: electrotherapy, electroconvulsive therapy Transcranial magnetic stimulation Vagus nerve stimulation by magnetic energy: magnet therapy pulsed electromagnetic field therapy magnetic resonance therapy by electromagnetic radiation (EMR): by light: light therapy (phototherapy) ultraviolet light therapy PUVA therapy photodynamic therapy photothermal therapy cytoluminescent therapy blood irradiation therapy by darkness: dark therapy by lasers: laser therapy low level laser therapy by gamma rays: radiosurgery Gamma Knife radiosurgery stereotactic radiation therapy cobalt therapy by radiation generally: radiation therapy (radiotherapy) intraoperative radiation therapy by EMR particles: particle therapy proton therapy electron therapy intraoperative electron radiation therapy Auger therapy neutron therapy fast neutron therapy neutron capture therapy of cancer by radioisotopes emitting EMR: by nuclear medicine by brachytherapy quackery type: electromagnetic therapy (alternative medicine) by mechanical: manual therapy as massotherapy and therapy by exercise as in physical therapy inversion therapy by sound: by ultrasound: ultrasonic lithotripsy extracorporeal shockwave therapy sonodynamic therapy by music: music therapy by temperature by heat: heat therapy (thermotherapy) by moderately elevated ambient temperatures: hyperthermia therapy by dry warm surroundings: Waon therapy by dry or humid warm surroundings: sauna, including infrared sauna, for sweat therapy by cold: by extreme cold to specific tissue volumes: cryotherapy by ice and compression: cold compression therapy by ambient cold: hypothermia therapy for neonatal encephalopathy (in newborns) targeted temperature management (therapeutic hypothermia, protective hypothermia) by hot and cold alternation: contrast bath therapy By procedure and human interaction Surgery by counseling, such as psychotherapy (see also: list of psychotherapies) systemic therapy by group psychotherapy by cognitive behavioral therapy by cognitive therapy by behaviour therapy by dialectical behavior therapy by cognitive emotional behavioral therapy by cognitive rehabilitation therapy by family therapy by education by psychoeducation by information therapy by speech therapy, physical therapy, occupational therapy, vision therapy, massage therapy, chiropractic or acupuncture by lifestyle modifications, such as avoiding unhealthy food or maintaining a predictable sleep schedule by coaching By animal interaction by pets, assistance animals, or working animals: animal-assisted therapy by horses: equine therapy, hippotherapy by dogs: pet therapy with therapy dogs, including grief therapy dogs by cats: pet therapy with therapy cats by fish: ichthyotherapy (wading with fish), aquarium therapy (watching fish) by maggots: maggot therapy by worms: by internal worms: helminthic therapy by leeches: leech therapy by immersion: animal bath By meditation by mindfulness: mindfulness-based cognitive therapy By reading by bibliotherapy By creativity by expression: expressive therapy by writing: writing therapy journal therapy by play: play therapy by art: art therapy sensory art therapy comic book therapy by gardening: horticultural therapy by dance: dance therapy by drama: drama therapy by recreation: recreational therapy by music: music therapy By sleeping and waking by deep sleep: deep sleep therapy by sleep deprivation: wake therapy See also Biophilia hypothesis Classification of Pharmaco-Therapeutic Referrals Compassion-focused therapy Emotionally focused therapy Greyhound therapy Inverse benefit law List of therapies Mature minor doctrine Medication Medicine Nutraceutical Prevention Psychedelic therapy Therapeutic inertia Therapeutic nihilism, the idea that treatment is useless Treatment as prevention References External links "Chapter Nine of the Book of Medicine Dedicated to Mansur, with the Commentary of Sillanus de Nigris" is a Latin book by Rhazes, from 1483, that is known for its ninth chapter, which is about therapeutics Therapy Drug discovery Health policy Medicinal chemistry Pharmaceutical sciences

Spectrum disorder

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits". In some cases, a spectrum approach joins conditions that were previously considered separately. A notable example of this trend is the autism spectrum, where conditions on this spectrum may now all be referred to as autism spectrum disorders. A spectrum approach may also expand the type or the severity of issues which are included, which may lessen the gap with other diagnoses or with what is considered "normal". Proponents of this approach argue that it is in line with evidence of gradations in the type or severity of symptoms in the general population. Origin The term spectrum was originally used in physics to indicate an apparent qualitative distinction arising from a quantitative continuum (i.e. a series of distinct colors experienced when a beam of white light is dispersed by a prism according to wavelength). Isaac Newton first used the word spectrum (Latin for "appearance" or "apparition") in print in 1671, in describing his experiments in optics. The term was first used by analogy in psychiatry with a slightly different connotation, to identify a group of conditions that is qualitatively distinct in appearance but believed to be related from an underlying pathogenic point of view. It has been noted that for clinicians trained after the publication of DSM-III (1980), the spectrum concept in psychiatry may be relatively new, but that it has a long and distinguished history that dates back to Emil Kraepelin and beyond. A dimensional concept was proposed by Ernst Kretschmer in 1921 for schizophrenia (schizothymic – schizoid – schizophrenic) and for affective disorders (cyclothymic temperament – cycloid 'psychopathy' – manic-depressive disorder), as well as by Eugen Bleuler in 1922. The term "spectrum" was first used in psychiatry in 1968 in regard to a postulated schizophrenia spectrum, at that time meaning a linking together of what were then called "schizoid personalities", in people diagnosed with schizophrenia and their genetic relatives (see Seymour S. Kety). For different investigators, the hypothetical common disease-causing link has been of a different nature. Related concepts A spectrum approach generally overlays or extends a categorical approach, which today is most associated with the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases (ICD). In these diagnostic guides, disorders are considered present if there is a certain combination and number of symptoms. Gradations of present versus absent are not allowed, although there may be subtypes of severity within a category. The categories are also polythetic, because a constellation of symptoms is laid out and different patterns of them can qualify for the same diagnosis. These categories are aids important for our practical purposes such as providing specific labels to facilitate payments for mental health professionals. They have been described as clearly worded, with observable criteria, and therefore an advance over some previous models for research purposes. A spectrum approach sometimes starts with the nuclear, classic DSM diagnostic criteria for a disorder (or may join several disorders), and then include an additional broad range of issues such as temperaments or traits, lifestyle, behavioral patterns, and personality characteristics. In addition, the term 'spectrum' may be used interchangeably with continuum, although the latter goes further in suggesting a direct straight line with no significant discontinuities. Under some continuum models, there are no set types or categories at all, only different dimensions along which everyone varies (hence a dimensional approach). An example can be found in personality or temperament models. For example, a model that was derived from linguistic expressions of individual differences is subdivided into the Big Five personality traits, where everyone can be assigned a score along each of the five dimensions. This is by contrast to models of 'personality types' or temperament, where some have a certain type and some do not. Similarly, in the classification of mental disorders, a dimensional approach, which is being considered for the DSM-V, would involve everyone having a score on personality trait measures. A categorical approach would only look for the presence or absence of certain clusters of symptoms, perhaps with some cut-off points for severity for some symptoms only, and as a result diagnose some people with personality disorders. A spectrum approach, by comparison, suggests that although there is a common underlying link, which could be continuous, particular sets of individuals present with particular patterns of symptoms (i.e. syndrome or subtype), reminiscent of the visible spectrum of distinct colors after refraction of light by a prism. It has been argued that within the data used to develop the DSM system there is a large literature leading to the conclusion that a spectrum classification provides a better perspective on phenomenology (appearance and experience) of psychopathology (mental difficulties) than a categorical classification system. However, the term has a varied history, meaning one thing when referring to a schizophrenia spectrum and another when referring to bipolar or obsessive–compulsive disorder spectrum, for example. Types of spectrum The widely used DSM and ICD manuals are generally limited to categorical diagnoses. However, some categories include a range of subtypes which vary from the main diagnosis in clinical presentation or typical severity. Some categories could be considered subsyndromal (not meeting criteria for the full diagnosis) subtypes. In addition, many of the categories include a 'not otherwise specified' subtype, where enough symptoms are present but not in the main recognized pattern; in some categories this is the most common diagnosis. Spectrum concepts used in research or clinical practice include the following. Anxiety, stress, and dissociation Several types of spectrum are in use in these areas, some of which are being considered in the DSM-5. A generalized anxiety spectrum – this spectrum has been defined by duration of symptoms: a type lasting over six months (a DSM-IV criterion), over one month (DSM-III), or lasting two weeks or less (though may recur), and also isolated anxiety symptoms not meeting criteria for any type. A social anxiety spectrum – this has been defined to span shyness to social anxiety disorder, including typical and atypical presentations, isolated signs and symptoms, and elements of avoidant personality disorder. A panic-agoraphobia spectrum – due to the heterogeneity (diversity) found in individual clinical presentations of panic disorder and agoraphobia, attempts have been made to identify symptom clusters in addition to those included in the DSM diagnoses, including through the development of a dimensional questionnaire measure. A post-traumatic stress spectrum or trauma and loss spectrum – work in this area has sought to go beyond the DSM category and consider in more detail a spectrum of severity of symptoms (rather than just presence or absence for diagnostic purposes), as well as a spectrum in terms of the nature of the stressor (e.g. the traumatic incident) and a spectrum of how people respond to trauma. This identifies a significant amount of symptoms and impairment below threshold for DSM diagnosis but nevertheless important, and potentially also present in other disorders a person might be diagnosed with. A depersonalization-derealization spectrum – although the DSM identifies only a chronic and severe form of depersonalization derealization disorder, and the ICD a 'depersonalization-derealization syndrome', a spectrum of severity has long been identified, including short-lasting episodes commonly experienced in the general population and often associated with other disorders. Obsessions and compulsions An obsessive–compulsive spectrum – this can include a wide range of disorders from Tourette syndrome to the hypochondrias, as well as forms of eating disorder, itself a spectrum of related conditions. General developmental disorders An autistic spectrum – in its simplest form this joins autism and Asperger syndrome, and can additionally include other pervasive developmental disorders (PDD). These include PDD 'not otherwise specified' (including 'atypical autism'), as well as Rett syndrome and childhood disintegrative disorder (CDD). The first three of these disorders are commonly called the autism spectrum disorders; the last two disorders are much rarer, and are sometimes placed in the autism spectrum and sometimes not. The merging of these disorders is based on findings that the symptom profiles are similar, such that individuals are better differentiated by clinical specifiers (i.e. dimensions of severity, such as extent of social communication difficulties or how fixed or restricted behaviors or interests are) and associated features (e.g. known genetic disorders, epilepsy, intellectual disabilities). The term specific developmental disorders is reserved for categorizing particular specific learning disabilities and developmental disorders affecting coordination. Schizophrenia spectrum The schizophrenia spectrum or psychotic spectrum – there are numerous psychotic spectrum disorders already in the DSM, many involving reality distortion. These include: Five subtypes of schizophrenia (although eliminated in DSM-5) Two forms of shorter duration (schizophreniform disorder and brief psychotic disorder) three delusional disorders (persistent delusional disorder, shared psychotic disorder, other delusional disorders) Schizoaffective disorder: symptoms of schizophrenia and a mood disorder (depression or bipolar disorder) Catatonia Schizotypal personality disorder Other and unspecified non-organic psychotic disorders (Atypical psychosis), (inc: chronic hallucinatory psychosis) Predisposition to schizophrenia is classified with the neologism schizotaxia. There are also traits identified in first degree relatives of those diagnosed with schizophrenia associated with the spectrum. Other spectrum approaches include more specific individual phenomena which may also occur in non-clinical forms in the general population, such as some paranoid beliefs or hearing voices. Psychosis accompanied by mood disorder may be included as a schizophrenia spectrum disorder, or may be classed separately as below. Schizophrenia spectrum disorders do not necessarily involve psychotic symptoms. Schizoid personality disorder, schizotypal personality disorder, and paranoid personality disorder can be considered 'schizophrenia-like personality disorders' because of their similarities to the schizophrenia spectrum. Some researchers have also proposed that avoidant personality disorder and related social anxiety traits should be considered part of a schizophrenia spectrum. From a psychodynamic or psychoanalytic perspective, the distinction between schizoid, schizotypal and avoidant personality disorders is sometimes considered inconsequential, as these disorders are understood to share similar experiential characteristics and be differentiated chiefly by surface-level observations about behavioral differences. Psychotic disorders such as schizophrenia and schizoaffective disorders are then thought to be the psychotic expression of a shared underlying personality structure. Schizoaffective disorders A schizoaffective spectrum – this spectrum refers to features of both psychosis (hallucinations, delusions, thought disorder etc.) and mood disorder (see below). The DSM has, on the one hand, a category of schizoaffective disorder (which may be more affective (mood) or more schizophrenic), and on the other hand psychotic bipolar disorder and psychotic depression categories. A spectrum approach joins these together and may additionally include specific clinical variables and outcomes, which initial research suggested may not be particularly well captured by the different diagnostic categories except at the extremes. Mood A mood disorder (affective) spectrum or bipolar spectrum or depressive spectrum. These approaches have expanded out in different directions. On the one hand, work on major depressive disorder has identified a spectrum of subcategories and sub-threshold symptoms that are prevalent, recurrent and associated with treatment needs. People are found to move between the subtypes and the main diagnostic type over time, suggesting a spectrum. This spectrum can include already recognised categories of minor depressive disorder, 'melancholic depression' and various kinds of atypical depression. In another direction, numerous links and overlaps have been found between major depressive disorder and bipolar syndromes, including mixed states (simultaneous depression and mania or hypomania). Hypomanic ('below manic') and more rarely manic signs and symptoms have been found in a significant number of cases of major depressive disorder, suggesting not a categorical distinction but a dimension of frequency that is higher in bipolar II and higher again in bipolar I. In addition, numerous subtypes of bipolar have been proposed beyond the types already in the DSM (which includes a milder form called cyclothymia). These extra subgroups have been defined in terms of more detailed gradations of mood severity, or the rapidity of cycling, or the extent or nature of psychotic symptoms. Furthermore, due to shared characteristics between some types of bipolar disorder and borderline personality disorder, some researchers have suggested they may both lie on a spectrum of affective disorders, although others see more links to post-trauma syndromes. Substance use A spectrum of drug use, drug abuse and substance dependence – one spectrum of this type, adopted by the Health Officers Council of British Columbia in 2005, does not employ loaded terms and distinctions such as "use" versus "abuse", but explicitly recognizes a spectrum ranging from potentially beneficial to chronic dependence. The model includes the role not just of the individual but of society, culture and availability of substances. In concert with the identified spectrum of drug use, a spectrum of policy approaches was identified which depended partly on whether the drug in question was available in a legal, for-profit commercial economy, or at the other of the spectrum only in a criminal/prohibition, black-market economy. In addition, a standardized questionnaire has been developed in psychiatry based on a spectrum concept of substance use. Paraphilias and obsessions The interpretative key of "spectrum," developed from the concept of "related disorders," has been considered also in paraphilias. Paraphilic behavior is triggered by thoughts or urges that are psychopathologically close to obsessive impulsive area. Hollander (1996) includes in the obsessive-compulsive spectrum neurological obsessive disorders, body-perception-related disorders and impulsivity-compulsivity disorders. In this continuum from impulsivity to compulsivity it is particularly hard to find a clear borderline between the two entities. On this point of view, paraphilias represent such as sexual behaviors due to a high impulsivity-compulsivity drive. It is difficult to distinguish impulsivity from compulsivity: Sometimes paraphilic behaviors are prone to achieve pleasure (desire or fantasy); in some other cases, these attitudes are merely expressions of anxiety, and the atypical behavior is an attempt to reduce anxiety. In the last case, the pleasure gained is short in time and is followed by a new increase in anxiety levels, such as it can be seen in an obsessive patient after he performs his compulsion. Eibl-Eibelsfeldt (1984) underlines a female sexual arousal condition during flight and fear reactions. Some women, with masochistic traits, can reach orgasm in such conditions. Broad spectrum approach Various higher-level types of spectrum have also been proposed, that subsume conditions into fewer but broader overarching groups. One psychological model based on factor analysis, originating from developmental studies but also applied to adults, posits that many disorders fall on either an "internalizing" spectrum (characterized by negative affectivity; subdivides into a "distress" subspectrum and a "fear" subspectrum) or an "externalizing" spectrum (characterized by negative affectivity plus disinhibition). These spectra are hypothetically linked to underlying variation in some of the big five personality traits. Another theoretical model proposes that the dimensions of fear and anger, defined in a broad sense, underlie a broad spectrum of mood, behavioral and personality disorders. In this model, different combinations of excessive or deficient fear and anger correspond to different neuropsychological temperament types hypothesized to underlie the spectrum of disorders. Similar approaches refer to the overall "architecture" or "meta-structure," particularly in relation to the development of the DSM or ICD systems. Five proposed meta-structure groupings were recently proposed in this way, based on views and evidence relating to risk factors and clinical presentation. The clusters of disorder that emerged were described as neurocognitive (identified mainly by neural substrate abnormalities), neurodevelopmental (identified mainly by early and continuing cognitive deficits), psychosis (identified mainly by clinical features and biomarkers for information processing deficits), emotional (identified mainly by being preceded by a temperament of negative emotionality), and externalizing (identified mainly be being preceded by disinhibition). However, the analysis was not necessarily able to validate one arrangement over others. From a psychological point of view, it has been suggested that the underlying phenomena are too complex, inter-related and continuous – with too poorly understood a biological or environmental basis – to expect that everything can be mapped into a set of categories for all purposes. In this context the overall system of classification is to some extent arbitrary, and could be thought of as a user interface which may need to satisfy different purposes. See also Classification of mental disorders Psychopathology Abnormal psychology Neurodiversity Mentalism (discrimination) Recovery approach External links A Video Introduction to RDoC (Research Domain Criteria): A Spectrum or Dimensional Approach to Understanding and Classifying Mental Disorders from the U.S. National Institute of Mental Health (2013) Spectrum and nosology: implications for DSM-V Collection of standardized questionnaires from the Italy-USA collaborative spectrum project Psychiatric Clinics of North America Special Issue on Spectrum Concepts (2002) References Classification of mental disorders

Physical therapy

Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease prevention, and health promotion. Physical therapist is the term used for such professionals in the United States, and physiotherapist is the term used in many other countries. The career has many specialties including musculoskeletal, orthopedics, cardiopulmonary, neurology, endocrinology, sports medicine, geriatrics, pediatrics, women's health, wound care and electromyography. PTs practice in many settings, both public and private. In addition to clinical practice, other aspects of physical therapy practice include research, education, consultation, and health administration. Physical therapy is provided as a primary care treatment or alongside, or in conjunction with, other medical services. In some jurisdictions, such as the United Kingdom, physical therapists may have the authority to prescribe medication. Overview Physical therapy addresses the illnesses or injuries that limit a person's abilities to move and perform functional activities in their daily lives. PTs use an individual's history and physical examination to arrive at a diagnosis and establish a management plan and, when necessary, incorporate the results of laboratory and imaging studies like X-rays, CT-scan, or MRI findings. Physical therapists can use sonography to diagnose and manage common musculoskeletal, nerve, and pulmonary conditions. Electrodiagnostic testing (e.g., electromyograms and nerve conduction velocity testing) may also be used. PT management commonly includes prescription of or assistance with specific exercises, manual therapy, and manipulation, mechanical devices such as traction, education, electrophysical modalities which include heat, cold, electricity, sound waves, radiation, assistive devices, prostheses, orthoses, and other interventions. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness and wellness-oriented programs for healthier and more active lifestyles, providing services to individuals and populations to develop, maintain, and restore maximum movement and functional ability throughout the lifespan. This includes providing treatment in circumstances where movement and function are threatened by aging, injury, disease, or environmental factors. Functional movement is central to what it means to be healthy. Physical therapy is a professional career that has many specialties including musculoskeletal, orthopedics, cardiopulmonary, neurology, endocrinology, sports medicine, geriatrics, pediatrics, women's health, wound care and electromyography. Neurological rehabilitation is, in particular, a rapidly emerging field. PTs practice in many settings, such as privately-owned physical therapy clinics, outpatient clinics or offices, health and wellness clinics, rehabilitation hospital facilities, skilled nursing facilities, extended care facilities, private homes, education and research centers, schools, hospices, industrial and these workplaces or other occupational environments, fitness centers and sports training facilities. Physical therapists also practice in non-patient care roles such as health policy, health insurance, health care administration and as health care executives. Physical therapists are involved in the medical-legal field serving as experts, performing peer review and independent medical examinations. Education varies greatly by country. The span of education ranges from some countries having little formal education to others having doctoral degrees and post-doctoral residencies and fellowships. Regarding its relationship to other healthcare professions, physiotherapy is one of the allied health professions. World Physiotherapy has signed a "memorandum of understanding" with the four other members of the World Health Professions Alliance "to enhance their joint collaboration on protecting and investing in the health workforce to provide safe, quality and equitable care in all settings". History Physicians like Hippocrates and later Galen are believed to have been the first practitioners of physical therapy, advocating massage, manual therapy techniques and hydrotherapy to treat people in 460 BC. After the development of orthopedics in the eighteenth century, machines like the Gymnasticon were developed to treat gout and similar diseases by systematic exercise of the joints, similar to later developments in physical therapy. The earliest documented origins of actual physical therapy as a professional group date back to Per Henrik Ling, "Father of Swedish Gymnastics," who founded the Royal Central Institute of Gymnastics (RCIG) in 1813 for manipulation, and exercise. Up until 2014, the Swedish word for a physical therapist was sjukgymnast = someone involved in gymnastics for those who are ill, but the title was then changed to fysioterapeut (physiotherapist), the word used in the other Scandinavian countries. In 1887, PTs were given official registration by Sweden's National Board of Health and Welfare. Other countries soon followed. In 1894, four nurses in Great Britain formed the Chartered Society of Physiotherapy. The School of Physiotherapy at the University of Otago in New Zealand in 1913, and the United States 1914 Reed College in Portland, Oregon, which graduated "reconstruction aides." Since the profession's inception, spinal manipulative therapy has been a component of the physical therapist practice. Modern physical therapy was established towards the end of the 19th century due to events that affected on a global scale, which called for rapid advances in physical therapy. Following this, American orthopedic surgeons began treating children with disabilities and employed women trained in physical education, and remedial exercise. These treatments were further applied and promoted during the Polio outbreak of 1916. During the First World War, women were recruited to work with and restore physical function to injured soldiers, and the field of physical therapy was institutionalized. In 1918 the term "Reconstruction Aide" was used to refer to individuals practicing physical therapy. The first school of physical therapy was established at Walter Reed Army Hospital in Washington, D.C., following the outbreak of World War I. Research catalyzed the physical therapy movement. The first physical therapy research was published in the United States in March 1921 in "The PT Review." In the same year, Mary McMillan organized the American Women's Physical Therapeutic Association (now called the American Physical Therapy Association (APTA). In 1924, the Georgia Warm Springs Foundation promoted the field by touting physical therapy as a treatment for polio. Treatment through the 1940s primarily consisted of exercise, massage, and traction. Manipulative procedures to the spine and extremity joints began to be practiced, especially in the British Commonwealth countries, in the early 1950s. Around the time polio vaccines were developed, physical therapists became a normal occurrence in hospitals throughout North America and Europe. In the late 1950s, physical therapists started to move beyond hospital-based practice to outpatient orthopedic clinics, public schools, colleges/universities health-centres, geriatric settings (skilled nursing facilities), rehabilitation centers and medical centers. Specialization in physical therapy in the U.S. occurred in 1974, with the Orthopaedic Section of the APTA being formed for those physical therapists specializing in orthopedics. In the same year, the International Federation of Orthopaedic Manipulative Physical Therapists was formed, which has ever since played an important role in advancing manual therapy worldwide. An international organization for the profession is the World Confederation for Physical Therapy (WCPT). It was founded in 1951 and has operated under the brand name World Physiotherapy since 2020. Education Educational criteria for physical therapy providers vary from state to state, country to country, and among various levels of professional responsibility. Most U.S. states have physical therapy practice acts that recognize both physical therapists (PT) and physical therapist assistants (PTA) and some jurisdictions also recognize physical therapy technicians (PT Techs) or aides. Most countries have licensing bodies that require physical therapists to be member of before they can start practicing as independent professionals. Canada The Canadian Alliance of Physiotherapy Regulators (CAPR) offers eligible program graduates to apply for the national Physiotherapy Competency Examination (PCE). Passing the PCE is one of the requirements in most provinces and territories to work as a licensed physiotherapist in Canada. CAPR has members which are physiotherapy regulatory organizations recognized in their respective provinces and territories: Government of Yukon, Consumer Services College of Physical Therapists of British Columbia College of Physiotherapists of Alberta Saskatchewan College of Physical Therapists College of Physiotherapists of Manitoba College of Physiotherapists of Ontario Ordre professionnel de la physiothérapie du Québec College of Physiotherapists of New Brunswick/Collège des physiothérapeutes du Nouveau-Brunswick Nova Scotia College of Physiotherapists Prince Edward Island College of Physiotherapists Newfoundland & Labrador College of Physiotherapists Physiotherapy programs are offered at fifteen universities, often through the university's respective college of medicine. Each of Canada's physical therapy schools has transitioned from three-year Bachelor of Science in Physical Therapy (BScPT) programs that required two years of prerequisite university courses (five-year bachelor's degree) to two-year Master's of Physical Therapy (MPT) programs that require prerequisite bachelor's degrees. The last Canadian university to follow suit was the University of Manitoba, which transitioned to the MPT program in 2012, making the MPT credential the new entry to practice standard across Canada. Existing practitioners with BScPT credentials are not required to upgrade their qualifications. In the province of Quebec, prospective physiotherapists are required to have completed a college diploma in either health sciences, which lasts on average two years, or physical rehabilitation technology, which lasts at least three years, to apply to a physiotherapy program or program in university. Following admission, physical therapy students work on a bachelor of science with a major in physical therapy and rehabilitation. The B.Sc. usually requires three years to complete. Students must then enter graduate school to complete a master's degree in physical therapy, which normally requires one and a half to two years of study. Graduates who obtain their M.Sc. must successfully pass the membership examination to become members of the Ordre Professionnel de la physiothérapie du Québec (PPQ). Physiotherapists can pursue their education in such fields as rehabilitation sciences, sports medicine, kinesiology, and physiology. In the province of Quebec, physical rehabilitation therapists are health care professionals who are required to complete a four-year college diploma program in physical rehabilitation therapy and be members of the Ordre Professionnel de la physiothérapie du Québec (OPPQ) to practice legally in the country according to specialist De Van Gerard. Most physical rehabilitation therapists complete their college diploma at Collège Montmorency, Dawson College, or Cégep Marie-Victorin, all situated in and around the Montreal area. After completing their technical college diploma, graduates have the opportunity to pursue their studies at the university level to perhaps obtain a bachelor's degree in physiotherapy, kinesiology, exercise science, or occupational therapy. The Université de Montréal, the Université Laval and the Université de Sherbrooke are among the Québécois universities that admit physical rehabilitation therapists in their programs of study related to health sciences and rehabilitation to credit courses that were completed in college. To date, there are no bridging programs available to facilitate upgrading from the BScPT to the MPT credential. However, research Master's of Science (MSc) and Doctor of Philosophy (Ph.D.) programs are available at every university. Aside from academic research, practitioners can upgrade their skills and qualifications through continuing education courses and curriculums. Continuing education is a requirement of the provincial regulatory bodies. The Canadian Physiotherapy Association offers a curriculum of continuing education courses in orthopedics and manual therapy. The program consists of 5 levels (7 courses) of training with ongoing mentorship and evaluation at each level. The orthopedic curriculum and examinations take a minimum of 4 years to complete. However, upon completion of level 2, physiotherapists can apply to a unique 1-year course-based Master's program in advanced orthopedics and manipulation at the University of Western Ontario to complete their training. This program accepts only 16 physiotherapists annually since 2007. Successful completion of either of these education streams and their respective examinations allows physiotherapists the opportunity to apply to the Canadian Academy of Manipulative Physiotherapy (CAMPT) for fellowship. Fellows of the Canadian Academy of manipulative Physiotherapists (FCAMPT) are considered leaders in the field, having extensive post-graduate education in orthopedics and manual therapy. FCAMPT is an internationally recognized credential, as CAMPT is a member of the International Federation of Manipulative Physiotherapists (IFOMPT), a branch of World Physiotherapy (formerly World Confederation of Physical Therapy (WCPT)) and the World Health Organization (WHO). Scotland Physiotherapy degrees are offered at four universities: Edinburgh Napier University in Edinburgh, Robert Gordon University in Aberdeen, Glasgow Caledonian University in Glasgow, and Queen Margaret University in Edinburgh. Students can qualify as physiotherapists by completing a four-year Bachelor of Science degree or a two-year master's degree (if they already have an undergraduate degree in a related field). To use the title 'Physiotherapist', a student must register with the Health and Care Professions Council, a UK-wide regulatory body, on qualifying. Many physiotherapists are also members of the Chartered Society of Physiotherapy (CSP), which provides insurance and professional support. United States The primary physical therapy practitioner is the Physical Therapist (PT) who is trained and licensed to examine, evaluate, diagnose and treat impairment, functional limitations, and disabilities in patients or clients. Physical therapist education curricula in the United States culminate in a Doctor of Physical Therapy (DPT) degree, with some practicing PTs holding a Master of Physical Therapy degree, and some with a Bachelor's degree. The Master of Physical Therapy and Master of Science in Physical Therapy degrees are no longer offered, and the entry-level degree is the Doctor of Physical Therapy degree, which typically takes 3 years after completing a bachelor's degree. PTs who hold a Masters or bachelors in PT are encouraged to get their DPT because APTA's goal is for all PT's to be on a doctoral level. WCPT recommends physical therapist entry-level educational programs be based on university or university-level studies, of a minimum of four years, independently validated and accredited. Curricula in the United States are accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). According to CAPTE, there are 37,306 students currently enrolled in 294 accredited PT programs in the United States while 10,096 PTA students are currently enrolled in 396 PTA programs in the United States. The physical therapist professional curriculum includes content in the clinical sciences (e.g., content about the cardiovascular, pulmonary, endocrine, metabolic, gastrointestinal, genitourinary, integumentary, musculoskeletal, and neuromuscular systems and the medical and surgical conditions frequently seen by physical therapists). Current training is specifically aimed to enable physical therapists to appropriately recognize and refer non-musculoskeletal diagnoses that may present similarly to those caused by systems not appropriate for physical therapy intervention, which has resulted in direct access to physical therapists in many states. Post-doctoral residency and fellowship education prevalence is increasing steadily with 219 residency, and 42 fellowship programs accredited in 2016. Residencies are aimed to train physical therapists in a specialty such as acute care, cardiovascular & pulmonary, clinical electrophysiology, faculty, geriatrics, neurology, orthopaedics, pediatrics, sports, women's health, and wound care, whereas fellowships train specialists in a subspecialty (e.g. critical care, hand therapy, and division 1 sports), similar to the medical model. Residency programs offer eligibility to sit for the specialist certification in their respective area of practice. For example, completion of an orthopedic physical therapy residency, allows its graduates to apply and sit for the clinical specialist examination in orthopedics, achieving the OCS designation upon passing the examination. Board certification of physical therapy specialists is aimed to recognize individuals with advanced clinical knowledge and skill training in their respective area of practice, and exemplifies the trend toward greater education to optimally treat individuals with movement dysfunction. Physical therapist assistants may deliver treatment and physical interventions for patients and clients under a care plan established by and under the supervision of a physical therapist. Physical therapist assistants in the United States are currently trained under associate of applied sciences curricula specific to the profession, as outlined and accredited by CAPTE. As of December 2022, there were 396 accredited two-year (Associate degree) programs for physical therapist assistants In the United States of America. Curricula for the physical therapist assistant associate degree include: Anatomy & physiology Exercise physiology Human biology Physics Biomechanics Kinesiology Neuroscience Clinical pathology Behavioral sciences Communication Ethics Research Other coursework as required by individual programs Job duties and education requirements for Physical Therapy Technicians or Aides may vary depending on the employer, but education requirements range from a high school diploma or equivalent to completion of a 2-year degree program. O-Net reports that 64% of PT Aides/Techs have a high school diploma or equivalent, 21% have completed some college but do not hold a degree, and 10% hold an associate degree. Some jurisdictions allow physical therapists to employ technicians or aides or therapy assistants to perform designated routine tasks related to physical therapy under the direct supervision of a physical therapist. Some jurisdictions require physical therapy technicians or aides to be certified, and education and certification requirements vary among jurisdictions. Employment Physical therapy-related jobs in North America have shown rapid growth in recent years, but employment rates and average wages may vary significantly between different countries, states, provinces, or regions. A study from 2013 states that 56.4% of physical therapists were globally satisfied with their jobs. Salary, interest in work, and fulfillment in a job are important predictors of job satisfaction. In a Polish study, job burnout among the physical therapists was manifested by increased emotional exhaustion and decreased sense of personal achievement. Emotional exhaustion is significantly higher among physical therapists working with adults and employed in hospitals. Other factors that increased burnout include working in a hospital setting and having seniority from 15 to 19 years. United States According to the United States Department of Labor's Bureau of Labor Statistics, there were approximately 210,900 physical therapists employed in the United States in 2014, earning an average of $84,020 annually in 2015, or $40.40 per hour, with 34% growth in employment projected by 2024. The Bureau of Labor Statistics also reports that there were approximately 128,700 Physical Therapist Assistants and Aides employed in the United States in 2014, earning an average $42,980 annually, or $20.66 per hour, with 40% growth in employment projected by 2024. To meet their needs, many healthcare and physical therapy facilities hire "travel physical therapists", who work temporary assignments between 8 and 26 weeks for much higher wages; about $113,500 a year. Bureau of Labor Statistics data on PTAs and Techs can be difficult to decipher, due to their tendency to report data on these job fields collectively rather than separately. O-Net reports that in 2015, PTAs in the United States earned a median wage of $55,170 annually or $26.52 hourly and that Aides/Techs earned a median wage of $25,120 annually or $12.08 hourly in 2015. The American Physical Therapy Association reports vacancy rates for physical therapists as 11.2% in outpatient private practice, 10% in acute care settings, and 12.1% in skilled nursing facilities. The APTA also reports turnover rates for physical therapists as 10.7% in outpatient private practice, 11.9% in acute care settings, 27.6% in skilled nursing facilities. Definitions and licensing requirements in the United States vary among jurisdictions, as each state has enacted its own physical therapy practice act defining the profession within its jurisdiction, but the Federation of State Boards of Physical Therapy has also drafted a model definition to limit this variation. The Commission on Accreditation in Physical Therapy Education (CAPTE) is responsible for accrediting physical therapy education curricula throughout the United States of America. United Kingdom The title of Physiotherapist is a protected professional title in the United Kingdom. Anyone using this title must be registered with the Health & Care Professions Council (HCPC). Physiotherapists must complete the necessary qualifications, usually an undergraduate physiotherapy degree (at university or as an intern), a master rehabilitation degree, or a doctoral degree in physiotherapy. This is typically followed by supervised professional experience lasting two to three years. All professionals on the HCPC register must comply with continuing professional development (CPD) and can be audited for this evidence at intervals. Specialty areas The body of knowledge of physical therapy is large, and therefore physical therapists may specialize in a specific clinical area. While there are many different types of physical therapy, the American Board of Physical Therapy Specialties lists ten current specialist certifications. Most Physical Therapists practicing in a specialty will have undergone further training, such as an accredited residency program, although individuals are currently able to sit for their specialist examination after 2,000 hours of focused practice in their respective specialty population, in addition to requirements set by each respective specialty board. Cardiovascular and pulmonary Cardiovascular and pulmonary rehabilitation respiratory practitioners and physical therapists offer therapy for a wide variety of cardiopulmonary disorders or pre and post cardiac or pulmonary surgery. An example of cardiac surgery is coronary bypass surgery. The primary goals of this specialty include increasing endurance and functional independence. Manual therapy is used in this field to assist in clearing lung secretions experienced with cystic fibrosis. Pulmonary disorders, heart attacks, post coronary bypass surgery, chronic obstructive pulmonary disease, and pulmonary fibrosis, treatments can benefit from cardiovascular and pulmonary specialized physical therapists. Clinical electrophysiology This specialty area includes electrotherapy/physical agents, electrophysiological evaluation (EMG/NCV), physical agents, and wound management. Geriatric Geriatric physical therapy covers a wide area of issues concerning people as they go through normal adult aging but is usually focused on the older adult. There are many conditions that affect many people as they grow older and include but are not limited to the following: arthritis, osteoporosis, cancer, Alzheimer's disease, hip and joint replacement, balance disorders, incontinence, etc. Geriatric physical therapists specialize in providing therapy for such conditions in older adults. Physical rehabilitation can prevent deterioration in health and activities of daily living among care home residents. The current evidence suggests benefits to physical health from participating in different types of physical rehabilitation to improve daily living, strength, flexibility, balance, mood, memory, exercise tolerance, fear of falling, injuries, and death. It may be both safe and effective in improving physical and possibly mental state, while reducing disability with few adverse events. The current body of evidence suggests that physical rehabilitation may be effective for long-term care residents in reducing disability with few adverse events. However, there is insufficient to conclude whether the beneficial effects are sustainable and cost-effective. The findings are based on moderate quality evidence. Wound management Wound management physical therapy includes the treatment of conditions involving the skin and all its related organs. Common conditions managed include wounds and burns. Physical therapists may utilize surgical instruments, wound irrigations, dressings, and topical agents to remove the damaged or contaminated tissue and promote tissue healing. Other commonly used interventions include exercise, edema control, splinting, and compression garments. The work done by physical therapists in the integumentary specialty does work similar to what would be done by medical doctors or nurses in the emergency room or triage. Neurology Neurological physical therapy is a field focused on working with individuals who have a neurological disorder or disease. These can include stroke, chronic back pain, Alzheimer's disease, Charcot-Marie-Tooth disease (CMT), ALS, brain injury, cerebral palsy, multiple sclerosis, Parkinson's disease, facial palsy and spinal cord injury. Common impairments associated with neurologic conditions include impairments of vision, balance, ambulation, activities of daily living, movement, muscle strength and loss of functional independence. The techniques involve in neurological physical therapy are wide-ranging and often require specialized training. Neurological physiotherapy is also called neurophysiotherapy or neurological rehabilitation. It is recommended for neurophysiotherapists to collaborate with psychologists when providing physical treatment of movement disorders. This is especially important because combining physical therapy and psychotherapy can improve neurological status of the patients. Orthopaedics Orthopedic physical therapists diagnose, manage, and treat disorders and injuries of the musculoskeletal system including rehabilitation after orthopedic surgery, acute trauma such as sprains, strains, injuries of insidious onset such as tendinopathy, bursitis, and deformities like scoliosis. This specialty of physical therapy is most often found in the outpatient clinical setting. Orthopedic therapists are trained in the treatment of post-operative orthopedic procedures, fractures, acute sports injuries, arthritis, sprains, strains, back and neck pain, spinal conditions, and amputations. Joint and spine mobilization/manipulation, dry needling (similar to acupuncture), therapeutic exercise, neuromuscular techniques, muscle reeducation, hot/cold packs, and electrical muscle stimulation (e.g., cryotherapy, iontophoresis, electrotherapy) are modalities employed to expedite recovery in the orthopedic setting. Additionally, an emerging adjunct to diagnosis and treatment is the use of sonography for diagnosis and to guide treatments such as muscle retraining. Those with injury or disease affecting the muscles, bones, ligaments, or tendons will benefit from assessment by a physical therapist specialized in orthopedics. Pediatrics Pediatric physical therapy assists in the early detection of health problems and uses a variety of modalities to provide physical therapy for disorders in the pediatric population. These therapists are specialized in the diagnosis, treatment, and management of infants, children, and adolescents with a variety of congenital, developmental, neuromuscular, skeletal, or acquired disorders/diseases. Treatments focus mainly on improving gross and fine motor skills, balance and coordination, strength and endurance as well as cognitive and sensory processing/integration. Sports Physical therapists are closely involved in the care and wellbeing of athletes including recreational, semi-professional (paid), and professional (full-time employment) participants. This area of practice encompasses athletic injury management under 5 main categories: acute care – assessment and diagnosis of an initial injury; treatment – application of specialist advice and techniques to encourage healing; rehabilitation – progressive management for full return to sport; prevention – identification and address of deficiencies known to directly result in, or act as precursors to injury, such as movement assessment education – sharing of specialist knowledge to individual athletes, teams, or clubs to assist in prevention or management of injury Physical therapists who work for professional sports teams often have a specialized sports certification issued through their national registering organization. Most Physical therapists who practice in a sporting environment are also active in collaborative sports medicine programs too (See also: athletic trainers). Women's health Women's health or pelvic floor physical therapy mostly addresses women's issues related to the female reproductive system, child birth, and post-partum. These conditions include lymphedema, osteoporosis, pelvic pain, prenatal and post-partum periods, and urinary incontinence. It also addresses incontinence, pelvic pain, pelvic organ prolapse and other disorders associated with pelvic floor dysfunction. Manual physical therapy has been demonstrated in multiple studies to increase rates of conception in women with infertility. Oncology Physical therapy in the field of oncology and palliative care is a continuously evolving and developing specialty, both in malignant and non-malignant diseases. Physical therapy for both groups of patients is now recognized as an essential part of the clinical pathway, as early diagnoses and new treatments are enabling patients to live longer. it is generally accepted that patients should have access to an appropriate level of rehabilitation, so that they can function at a minimum level of dependency and optimize their quality of life, regardless of their life expectancy. Physical therapist–patient collaborative relationship People with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies benefit from a positive alliance between patient and therapist. Outcomes include the ability to perform activities of daily living, manage pain, complete specific physical function tasks, depression, global assessment of physical health, treatment adherence, and treatment satisfaction. Studies have explored four themes that may influence patient-therapist interactions: interpersonal and communication skills, practical skills, individualized patient-centered care, and organizational and environmental factors. Physical therapists need to be able to effectively communicate with their patients on a variety of levels. Patients have varying levels of health literacy so physical therapists need to take that into account when discussing the patient's ailments as well as planned treatment. Research has shown that using communication tools tailored to the patient's health literacy leads to improved engagement with their practitioner and their clinical care. In addition, patients reported that shared decision-making will yield a positive relationship. Practical skills such as the ability to educate patients about their conditions, and professional expertise are perceived as valuable factors inpatient care. Patients value the ability of a clinician to provide clear and simple explanations about their problems. Furthermore, patients value when physical therapists possess excellent technical skills that improve the patient effectively. Environmental factors such as the location, equipment used, and parking are less important to the patient than the physical therapy clinical encounter itself. Based on the current understanding, the most important factors that contribute to the patient-therapist interactions include that the physical therapist: spends an adequate amount of time with the patient, possesses strong listening and communication skills, treats the patient with respect, provides clear explanations of the treatment, and allows the patient to be involved in the treatment decisions. Effectiveness Physical therapy has been found to be effective for improving outcomes, both in terms of pain and function, in multiple musculoskeletal conditions. Spinal manipulation by physical therapists is a safe option to improve outcomes for lower back pain. Several studies have suggested that physical therapy, particularly manual therapy techniques focused on the neck and the median nerve, combined with stretching exercises, may be equivalent or even preferable to surgery for carpal tunnel syndrome. While spine manipulation and therapeutic massage are effective interventions for neck pain, electroacupuncture, strain-counterstrain, relaxation massage, heat therapy, and ultrasound therapy are not as effective, and thus not recommended. Studies also show physical therapy is effective for patients with other conditions. Physiotherapy treatment may improve quality of life, promote cardiopulmonary fitness and inspiratory pressure, as well as reduce symptoms and medication use by people with asthma. Physical therapy is sometimes provided to patients in the ICU, as early mobilization can help reduce ICU and hospital length of stay and improve long-term functional ability. Early progressive mobilization for adult, intubated ICU patients on mechanical ventilation is safe and effective. Psychologically informed physical therapy (PIPT), in which a physical therapist treats patients while other members of a multidisciplinary care team help in preoperative planning for patient management of pain and quality of life, helps improve patient outcomes, especially before and after spine, hip, or knee surgery. Telehealth Telehealth (or telerehabilitation) is a developing form of physical therapy in response to the increasing demand for physical therapy treatment. Telehealth is online communication between the clinician and patient, either live or in pre-recorded sessions with mixed reviews when compared to usual, in-person care. The benefits of telehealth include improved accessibility in remote areas, cost efficiency, and improved convenience for people who are bedridden and home-restricted, or physically disabled. Some considerations for telehealth include: limited evidence to prove effectiveness and compliance more than in-person therapy, licensing and payment policy issues, and compromised privacy. Studies are controversial as to the effectiveness of telehealth in patients with more serious conditions, such as stroke, multiple sclerosis, and lower back pain. The interstate compact, enacted in March 2018, allows patients to participate in Telehealth appointments with medical practices located in different states. During the COVID-19 pandemic, the need for telehealth came to the fore as patients were less able to safely attend in-person, particularly if they were elderly or had chronic diseases. Telehealth was considered to be a proactive step to prevent decline in individuals that could not attend classes. Physical decline in at risk groups is difficult to address or undo later. The platform licensing or development are found to be the most substantial cost in telehealth. Telehealth does not remove the need for the physical therapist as they still need to oversee the program. See also American Board of Physical Therapy Specialties American Physical Therapy Association Basic body-awareness methodology Chiropractic Doctor (title) Doctor of Physical Therapy Exercise physiology Exercise prescription List of exercise prescription software Neurophysiotherapy Occupational therapy Physical medicine and rehabilitation Postural Restoration Sports medicine Therapy World Physiotherapy References External links Europe: Regulated professions database – Physiotherapist, European Commission Allied health professions Hospital departments Manual therapy Physical exercise Rehabilitation medicine Rehabilitation team Sports medicine Sports occupations and roles

Antisocial personality disorder

Antisocial personality disorder (ASPD or APD), sometimes referred to as dissocial personality disorder, is a personality disorder characterized by a limited capacity for empathy and a long-term pattern of disregard for or violation of the rights of others, starting before one was 15 years old. Other notable symptoms include impulsivity, reckless behavior (including substance abuse), a lack of remorse after hurting others, deceitfulness, irresponsibility, and aggressive behavior. Symptoms of ASPD must be present before the age of 15 to receive a diagnosis. In nearly 80% of ASPD cases, the subject will develop their first symptoms by age 11. The disorder is more common in males. The prevalence of ASPD is increased in people aged 24 to 44 and decreased in people aged 45 to 64. In the United States, the prevalence of antisocial personality disorder in the general population is estimated to be between 1% and 4%. Personality disorders are a class of mental disorders characterized by enduring and inflexible maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by any culture. These patterns develop in early adulthood and are associated with significant distress or impairment. Criteria for diagnosing personality disorders are listed in the fifth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). Dissocial personality disorder (DPD) is another term for the same general disorder used in the International Statistical Classification of Diseases and Related Health Problems (ICD). Both have been referred to as psychopathy or sociopathy; however, some researchers have drawn distinctions between the concepts of antisocial personality disorder and psychopathy, with many arguing that psychopathy overlaps with, but is distinguishable from, ASPD. Furthermore, ASPD can sometimes be confused with being asocial. While their disregard for other people characterizes the first sign, the latter is characterized by a lack of interest in social activities. Symptoms and behaviors Due to tendencies toward recklessness and impulsivity, patients with ASPD are at a higher risk of drug and alcohol abuse. ASPD is the personality disorder most likely to be associated with addiction. Individuals with ASPD are at a higher risk of illegal drug usage, blood-borne diseases, HIV, shorter periods of abstinence, misuse of oral administrations, and compulsive gambling as a consequence of their tendency towards addiction. In addition, sufferers are more likely to abuse substances or develop an addiction at a young age. Due to ASPD being associated with higher levels of impulsivity, suicidality, and irresponsible behavior, the condition is correlated with heightened levels of aggressive behavior, domestic violence, illegal drug use, pervasive anger, and violent crimes. This behavior typically has negative effects on their education, relationships, and/or employment. Alongside this, sexual behaviors of risk such as having multiple sexual partners in a short period of time, seeing prostitutes, inconsistent use of condoms, trading sex for drugs, and frequent unprotected sex are also common. Patients with ASPD have been documented to describe emotions with ambivalence and experience heightened states of emotional coldness and detachment. Individuals with ASPD, or who display antisocial behavior, may often experience chronic boredom. They may experience emotions such as happiness and fear less clearly than others. It is also possible that they may experience emotions such as anger and frustration more frequently and clearly than other emotions. People with ASPD may have a limited capacity for empathy and can be more interested in benefiting themselves than avoiding harm to others. They may have no regard for morals, social norms, or the rights of others. People with ASPD can have difficulty beginning or sustaining relationships. It is common for the interpersonal relationships of someone with ASPD to revolve around the exploitation and abuse of others. People with ASPD may display arrogance, think lowly and negatively of others, have limited remorse for their harmful actions, and have a callous attitude toward those they have harmed. People with ASPD can have difficulty mentalizing, or interpreting the mental state of others. Alternately, they may display a perfectly intact theory of mind, or the ability to understand one's mental state, but have an impaired ability to understand how another individual may be affected by an aggressive action. These factors might contribute to aggressive and criminal behavior as well as empathy deficits. Despite this, they may be adept at social cognition, or the ability to process and store information about other people, which can contribute to an increased ability to manipulate others. ASPD is highly prevalent among prisoners. People with ASPD tend to be convicted more, receive longer sentences, and are more likely to be charged with almost any crime, with assault and other violent crimes being the most common charges. Those who have committed violent crimes tend to have higher levels of testosterone than the average person, also contributing to the higher likelihood for men to be diagnosed with ASPD. The effect of testosterone is counteracted by cortisol, which facilitates the cognitive control of impulsive tendencies. Arson and the destruction of others' property are also behaviors commonly associated with ASPD. Alongside other conduct problems, many people with ASPD had conduct disorder in their youth, characterized by a pervasive pattern of violent, criminal, defiant, and anti-social behavior. Although behaviors vary by degree, individuals with this personality disorder have been known to exploit others in harmful ways for their own gain or pleasure, and frequently manipulate and deceive other people. While some do so with a façade of superficial charm, others do so through intimidation and violence. Individuals with antisocial personality disorder may deliberately show irresponsibility, have difficulty acknowledging their faults and/or attempt to redirect attention away from harmful behaviors. Comorbidity ASPD commonly co-occurs with the following conditions: When combined with alcoholism, people may show frontal brain function deficits on neuropsychological tests greater than those associated with each condition. Alcohol use disorder is likely caused by lack of impulse and behavioral control exhibited by antisocial personality disorder patients. Causes Personality disorders are generally believed to be caused by a combination and interaction of genetics and environmental influences. People with an antisocial or alcoholic parent are considered to be at higher risk of developing ASPD. Fire-setting and cruelty to animals during childhood are also linked to the development of an antisocial personality disorder, along with being more common in males and among incarcerated populations. Although the causes listed correlate to the risk of developing ASPD, one factor alone is unlikely to be the only cause associated with ASPD and relating to a listed cause does not necessarily mean that a person should identify or be identified as having ASPD. According to professor Emily Simonoff of the Institute of Psychiatry, Psychology and Neuroscience, there are many variables that are consistently connected to ASPD, such as: childhood hyperactivity and conduct disorder, criminality in adulthood, lower IQ scores, and reading problems. Additionally, children who grow up with a predisposition of ASPD and interact with other delinquent children are likely to later be diagnosed with ASPD. Genetic Research into genetic associations in antisocial personality disorder suggests that ASPD has some or even a strong genetic basis. The prevalence of ASPD is higher in people related to someone with the disorder. Twin studies, which are designed to discern between genetic and environmental effects, have reported significant genetic influences on antisocial behavior and conduct disorder. In the specific genes that may be involved, one gene that has shown particular promise in its correlation with ASPD is the gene that encodes for Monoamine oxidase A (MAO-A), an enzyme that breaks down monoamine neurotransmitters such as serotonin and norepinephrine. Various studies examining the gene's relationship to behavior have suggested that variants of the gene resulting in less MAO-A being produced (such as the 2R and 3R alleles of the promoter region) have associations with aggressive behavior in men. This association is also influenced by negative experiences early in life, with children possessing a low-activity variant (MAOA-L) who have experienced negative circumstances being more likely to develop antisocial behavior than those with the high-activity variant (MAOA-H). Even when environmental interactions (e.g. emotional abuse) are taken out of the equation, a small association between MAOA-L and aggressive and antisocial behavior remains. The gene that encodes for the serotonin transporter (SLC6A4), a gene that is heavily researched for its associations with other mental disorders, is another gene of interest in antisocial behavior and personality traits. Genetic association's studies have suggested that the short "S" allele is associated with impulsive antisocial behavior and ASPD in the inmate population. However, research into psychopathy find that the long "L" allele is associated with the Factor 1 traits of psychopathy, which describes its core affective (e.g. lack of empathy, fearlessness) and interpersonal (e.g. grandiosity, manipulativeness) personality disturbances. This is suggestive of two different forms of the disorder, one associated more with impulsive behavior and emotional dysregulation, and the other with predatory aggression and affective disturbance. Various other gene candidates for ASPD have been identified by a genome-wide association study published in 2016. Several of these gene candidates are shared with attention-deficit hyperactivity disorder, with which ASPD is often comorbid. The study found that those who carry four mutations on chromosome 6 are 50% more likely to develop antisocial personality disorder than those who do not. Physiological Hormones and neurotransmitters Traumatic events can lead to a disruption of the standard development of the central nervous system, which can generate a release of hormones that can change normal patterns of development. One of the neurotransmitters that has been discussed in individuals with ASPD is serotonin, also known as 5HT. A meta-analysis of 20 studies found significantly lower 5-HIAA levels (indicating lower serotonin levels), especially in those who are younger than 30 years of age. While it has been shown that lower levels of serotonin may be associated with ASPD, there has also been evidence that decreased serotonin function is highly correlated with impulsiveness and aggression across a number of different experimental paradigms. Impulsivity is not only linked with irregularities in 5HT metabolism but may be the most essential psychopathological aspect linked with such dysfunction. Correspondingly, the DSM classifies "impulsivity or failure to plan ahead" and "irritability and aggressiveness" as two of seven sub-criteria in category A of the diagnostic criteria of ASPD. Some studies have found a relationship between monoamine oxidase A and antisocial behavior, including conduct disorder and symptoms of adult ASPD, in maltreated children. Neurological Antisocial behavior may be related to a number of neurological defects, such as head trauma. Antisocial behavior is associated with decreased grey matter in the right lentiform nucleus, left insular, and frontopolar cortex. Increased volumes of grey matter have been observed in the right fusiform gyrus, inferior parietal cortex, right cingulate gyrus, and post-central cortex. Intellectual and cognitive ability is often found to be impaired or reduced in the ASPD population. Contrary to stereotypes in popular culture of the "psychopathic genius", antisocial personality disorder is associated with reduced overall intelligence and specific reductions in individual aspects of cognitive ability. These deficits also occur in general-population samples of people with antisocial traits and in children with the precursors to antisocial personality disorder. People that exhibit antisocial behavior tend to demonstrate decreased activity in the prefrontal cortex, and is more apparent in functional neuroimaging as opposed to structural neuroimaging. Some investigators have questioned whether the reduced volume in prefrontal regions is associated with antisocial personality disorder, or whether they result from co-morbid disorders, such as substance use disorder or childhood maltreatment. It is still considered an open question if the anatomical abnormality causes the psychological and behavioral abnormality, or vice versa. Cavum septi pellucidi (CSP) is a marker for limbic neural maldevelopment, and its presence has been loosely associated with certain mental disorders, such as schizophrenia and post-traumatic stress disorder. One study found that those with CSP had significantly higher levels of antisocial personality, psychopathy, arrests and convictions compared with controls. Environmental Family environment Many studies suggest that the social and home environment contribute to the development of ASPD. Parents of children with ASPD may display antisocial behavior themselves, which are then adopted by their children. A lack of parental stimulation and affection during early development can lead to high levels of cortisol with the absence of balancing hormones such as oxytocin. This disrupts and overloads the child's stress response systems, which is thought to lead to underdevelopment of the part of the child's brain that deals with emotion, empathy, and ability to connect to other humans on an emotional level. According to Dr. Bruce Perry in his book The Boy Who Was Raised as a Dog, "the infant's developing brain needs to be patterned, repetitive stimuli to develop properly. Spastic, unpredictable relief from fear, loneliness, discomfort, and hunger keeps a baby's stress system on high alert. An environment of intermittent care punctuated by total abandonment may be the worst of all worlds for a child." Parenting styles Parenting styles can directly affect how children experience and develop in their youth, and can have an impact on a child's diagnosis of ASPD. The four parenting styles demonstrate the main approaches to raising children and their outcomes that lead into adulthood. Authoritarian - Authoritarian parenting styles involve stricter rules than any other parenting style, with greater consequences if rules are disobeyed. Authoritarian parents set high expectations for their children that may cause the children to later develop rebellious behavior, low self-esteem, aggression, and resentfulness. Permissive - Permissive parenting styles involve a more relaxed attitude towards rules that are less enforced than any other parenting style. Permissive parents tend to allow more freedom for children to make their own decisions which can lead to impulsivity, lack of self-control, and a lack of acknowledgment of boundaries later in life. Neglectful - Neglectful parenting styles tend to have little to no rules for children to follow, and may even withhold basic needs required for child development. Parents who display neglectful behavior are less involved than any other parenting style and can cause children to develop mental health issues, withdrawal from emotions, and delinquent behavior. Authoritative - Authoritative parenting styles involve guidelines and expectations as well as support and understanding. Authoritative parents tend to have more balance within their parenting style compared to the other parenting styles, and parent in a way that lets children understand not only what the rules are, but why they are important. Individuals who were raised by authoritative parents tend to be more self-confident, responsible, successful, and have a greater chance of developing positive coping skills. Having a healthy, safe, stable/consistent, understanding, and attentive parenting style in an environment with positive role models and influences at home as well as out in the community help to ensure more positive behavior for children and an overall decrease in ASPD symptoms. Childhood trauma ASPD is highly comorbid with emotional and physical abuse in childhood. Physical neglect also has a significant correlation to ASPD. The way a child bonds with its parents early in life is important. Poor parental bonding due to abuse or neglect puts children at greater risk for developing antisocial personality disorder. There is also a significant correlation with parental overprotection and people who develop ASPD. Studies have shown that non-abused (especially in childhood) individuals are less likely to develop ASPD. Those with ASPD may have experienced any of the following forms of childhood trauma or abuse: physical or sexual abuse, neglect, coercion, abandonment or separation from caregivers, violence in a community, acts of terror, bullying, or life-threatening incidents. Some symptoms can mimic other forms of mental illness, such as: post-traumatic stress disorder (symptoms of upsetting/terrifying memories of traumatic events) reactive attachment disorder (little to no response regarding emotional triggers) disinhibited social engagement disorder (roaming off with people you don't know without caregivers being informed) dissociative identity disorder (disconnection from self or environment) The comorbidity rate of the previously listed disorders with ASPD tend to be much higher. Cultural influences The sociocultural perspective of clinical psychology views disorders as influenced by cultural aspects; since cultural norms differ significantly, mental disorders (such as ASPD) are viewed differently. Robert D. Hare suggested that the rise in ASPD that has been reported in the United States may be linked to changes in cultural norms, serving to validate the behavioral tendencies of many individuals with ASPD. While the rise reported may be in part a byproduct of the widening use (and abuse) of diagnostic techniques, given Eric Berne's division between individuals with active and latent ASPD – the latter keeping themselves in check by attachment to an external source of control like the law, traditional standards, or religion – it has been suggested that the erosion of collective standards may serve to release the individual with latent ASPD from their previously prosocial behavior. There is also a continuous debate as to the extent to which the legal system should be involved in the identification and admittance of patients with preliminary symptoms of ASPD. Controversial clinical psychiatrist Pierre-Édouard Carbonneau suggested that the problem with legal forced admittance is the rate of failure when diagnosing ASPD. He contends that the possibility of diagnosing and coercing a patient into prescribing medication to someone without ASPD, but is diagnosed with ASPD, could be potentially disastrous. But the possibility of not diagnosing ASPD and seeing a patient go untreated because of a lack of sufficient evidence of cultural or environmental influences is something a psychiatrist must ignore; and in his words, "play it safe". Conduct disorder While antisocial personality disorder is a mental disorder diagnosed in adulthood, it has its precedent in childhood. The DSM-5's criteria for ASPD require that the individual have conduct problems evident by the age of 15. Persistent antisocial behavior, as well as a lack of regard for others in childhood and adolescence, is known as conduct disorder and is the precursor of ASPD. About 25–40% of youths with conduct disorder will be diagnosed with ASPD in adulthood. Conduct disorder (CD) is a disorder diagnosed in childhood that parallels the characteristics found in ASPD. It is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated by the child. Children with the disorder often display impulsive and aggressive behavior, may be callous and deceitful, may repeatedly engage in petty crime (such as stealing or vandalism), or get into fights with other children and adults. This behavior is typically persistent and may be difficult to deter with either threat or punishment. Attention deficit hyperactivity disorder (ADHD) is common in this population, and children with the disorder may also engage in substance use. CD is distinct from oppositional defiant disorder (ODD) in that children with ODD do not commit aggressive or antisocial acts against other people, animals, or property, though many children diagnosed with ODD are subsequently re-diagnosed with CD. Two developmental courses for CD have been identified based on the age at which the symptoms become present. The first course is known as the "childhood-onset type" and occurs when conduct disorder symptoms are present before the age of 10. This course is often linked to a more persistent life course and more pervasive behaviors, and children in this group express greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence. The second course is known as the "adolescent-onset type" and occurs when conduct disorder develops after the age of 10 years. Compared to the childhood-onset type, less impairment in various cognitive and emotional functions are present, and the adolescent-onset variety may remit by adulthood. In addition to this differentiation, the DSM-5 provides a specifier for a callous and unemotional interpersonal style, which reflects characteristics seen in psychopathy and are believed to be a childhood precursor to this disorder. Compared to the adolescent-onset subtype, the childhood-onset subtype tends to have a worse treatment outcome, especially if callous and unemotional traits are present. Diagnosis DSM-5 Section II The main text of fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines antisocial personality disorder as being characterized by at least three of the following traits: Failure to conform to social norms and laws, indicated by repeatedly engaging in illegal activities. Deceitfulness, indicated by continuously lying, using aliases, or conning others for personal gain and pleasure. Exhibiting impulsivity or failing to plan ahead. Irritability and aggressiveness, indicated by repeatedly getting into fights or physically assaulting others. Reckless behaviors that disregard the safety of others. Irresponsibility, indicated by repeatedly failing to consistently work or honor financial obligations. Lack of remorse after hurting or mistreating another person. In order to be diagnosed with antisocial personality disorder under the DSM-5, one must be at least 18 years old, show evidence of onset of conduct disorder before age 15, and antisocial behavior cannot be explained by schizophrenia or bipolar disorder. Section III (Alternative Model of Personality Disorders) In response to criticisms of the extant (Section II/DSM-IV) criteria for personality disorders, including their discordance with current models in the scientific literature, high comorbidity rate, overuse of some categories, underuse of others, and overwhelming use of the personality disorder-not otherwise specified (PD-NOS) diagnosis, the DSM-5 Workgroup on personality disorders devised a dimensional model, wherein categoric personality diagnoses reflect extreme variations of normal personality traits. In response to criticisms of the extant Section II/DSM-IV criteria for ASPD, namely its failure to capture the interpersonal and affective features of psychopathy, new criteria were proposed. In addition to the new criteria, the individual must be at least 18 years old, the traits must cause dysfunction or distress, and should not be better explained by another mental disorder, the pathophysiological effects of a substance, or a person's cultural or social background. Also included as a "with psychopathic traits" specifier modelled after the Fearless Dominance scale of the Psychopathic Personality Inventory, defined by low Anxiousness and Withdrawal and high Attention-Seeking. Researchers have also proposed the inclusion of Grandiosity and Restricted Affectivity to better capture psychopathy. Psychopathy Psychopathy is commonly defined as a personality disorder characterized partly by antisocial behavior, a diminished capacity for empathy and remorse, and poor behavioral controls. Psychopathic traits are assessed using various measurement tools, including Canadian researcher Robert D. Hare's Psychopathy Checklist, Revised (PCL-R). "Psychopathy" is not the official title of any diagnosis in the DSM or ICD; nor is it an official title used by any other major psychiatric organizations. The DSM and ICD, however, state that their antisocial diagnoses are at times referred to (or include what is referred to) as psychopathy or sociopathy. American psychiatrist Hervey Cleckley's work on psychopathy formed the basis of the diagnostic criteria for ASPD, and the DSM states ASPD is often referred to as psychopathy. However, critics argue ASPD is not synonymous with psychopathy as the diagnostic criteria are not the same, since criteria relating to personality traits are emphasized relatively less in the former. These differences exist in part because it was believed such traits were difficult to measure reliably and it was "easier to agree on the behaviors that typify a disorder than on the reasons why they occur". Although the diagnosis of ASPD covers two to three times as many prisoners as the diagnosis of psychopathy, Robert Hare believes the PCL-R is better able to predict future criminality, violence, and recidivism than a diagnosis of ASPD. He suggests there are differences between PCL-R-diagnosed psychopaths and non-psychopaths on "processing and use of linguistic and emotional information", while such differences are potentially smaller between those diagnosed with ASPD and without. Additionally, Hare argued confusion regarding how to diagnose ASPD, confusion regarding the difference between ASPD and psychopathy, as well as the differing future prognoses regarding recidivism and treatability, may have serious consequences in settings such as court cases where psychopathy is often seen as aggravating the crime. Nonetheless, psychopathy has been proposed as a specifier under an alternative model for ASPD. In the DSM-5, under "Alternative DSM-5 Model for Personality Disorders", ASPD with psychopathic features is described as characterized by "a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence)". Low levels of withdrawal and high levels of attention-seeking combined with low anxiety are associated with "social potency" and "stress immunity" in psychopathy. Under the specifier, affective and interpersonal characteristics are comparatively emphasized over behavioral components. Research suggests that, even without the "with psychopathic traits" specifier, these Section III criteria accurately capture the affective-interpersonal features of psychopathy, though the specifier increases coverage of the Interpersonal and Lifestyle facets of the PCL-R. Millon's subtypes Theodore Millon suggested 5 subtypes of ASPD. However, these constructs are not recognized in the DSM or ICD. Elsewhere, Millon differentiates ten subtypes (partially overlapping with the above) – covetous, risk-taking, malevolent, tyrannical, malignant, disingenuous, explosive, and abrasive – but specifically stresses that "the number 10 is by no means special ... Taxonomies may be put forward at levels that are more coarse or more fine-grained." Treatment ASPD is considered to be among the most difficult personality disorders to treat. Rendering an effective treatment for ASPD is further complicated due to the inability to look at comparative studies between psychopathy and ASPD due to differing diagnostic criteria, differences in defining and measuring outcomes and a focus on treating incarcerated patients rather than those in the community. Because of their very low or absent capacity for remorse, individuals with ASPD often lack sufficient motivation and fail to see the costs associated with antisocial acts. They may only simulate remorse rather than truly commit to change: they can be charming and dishonest, and may manipulate staff and fellow patients during treatment. Studies have shown that outpatient therapy is not likely to be successful, but the extent to which persons with ASPD are entirely unresponsive to treatment may have been exaggerated. Most treatment done is for those in the criminal justice system to whom the treatment regimes are given as part of their imprisonment. Those with ASPD may stay in treatment only as required by an external source, such as parole conditions. Residential programs that provide a carefully controlled environment of structure and supervision along with peer confrontation have been recommended. There has been some research on the treatment of ASPD that indicated positive results for therapeutic interventions. Psychotherapy, also known as "talk" therapy, has been found to help treat patients with ASPD. Schema therapy is also being investigated as a treatment for ASPD. A review by Charles M. Borduin features the strong influence of multisystemic therapy (MST) that could potentially improve this issue. However, this treatment requires complete cooperation and participation of all family members. Some studies have found that the presence of ASPD does not significantly interfere with treatment for other disorders, such as substance use, although others have reported contradictory findings. Therapists working with individuals with ASPD may have considerable negative feelings toward patients with extensive histories of aggressive, exploitative, and abusive behaviors. Rather than attempt to develop a sense of conscience in these individuals, which is extremely difficult considering the nature of the disorder, therapeutic techniques are focused on rational and utilitarian arguments against repeating past mistakes. These approaches would focus on the tangible, material value of prosocial behavior and abstaining from antisocial behavior. However, the impulsive and aggressive nature of those with this disorder may limit the effectiveness of this form of therapy. The use of medications in treating antisocial personality disorder is still poorly explored, and no medications have been approved by the FDA to specifically treat ASPD. A 2020 Cochrane review of studies that explored the use of pharmaceuticals in ASPD patients, of which eight studies met the selection criteria for review, concluded that the current body of evidence was inconclusive for recommendations concerning the use of pharmaceuticals in treating the various issues of ASPD. Nonetheless, psychiatric medications such as antipsychotics, antidepressants, and mood stabilizers can be used to control symptoms such as aggression and impulsivity, as well as treat disorders that may co-occur with ASPD for which medications are indicated. Prognosis Boys are almost twice as likely to meet all of the diagnostic criteria for ASPD than girls (40% versus 25%) and they will often start showing symptoms of the disorder much earlier in life. Children that do not show symptoms of the disease through age 15 will almost never develop ASPD later in life. If adults exhibit milder symptoms of ASPD, it is likely that they never met the criteria for the disorder in their childhood and were consequently never diagnosed. Overall, symptoms of ASPD tend to peak in late teens and early twenties, but can often reduce or improve through age 40. ASPD is ultimately a lifelong disorder that has chronic consequences, though some of these can be moderated over time. There may be a high variability of the long-term outlook of antisocial personality disorder. The treatment of this disorder can be successful, but it entails unique difficulties. It is unlikely to see rapid change especially when the condition is severe. In fact, past studies revealed that remission rates were small, with 27-31% of patients with ASPD seeing an improvement "with the most violent and dangerous features remitting". As a result of the characteristics of ASPD (e.g., displaying charm in effort of personal gain, manipulation), patients seeking treatment (mandated or otherwise) may appear to be "cured" in order to get out of treatment. According to definitions found in the DSM-5, people with ASPD can be deceitful and intimidating in their relationships. When they are caught doing something wrong, they often appear to be unaffected and unemotional about the consequences. Over time, continual behavior that lacks empathy and concern may lead to someone with ASPD taking advantage of the kindness of others, including their therapist. Without proper treatment, individuals with ASPD could lead a life that brings about harm to themselves or others. This can be detrimental to their families and careers. Those with ASPD lack interpersonal skills (e.g., lack of remorse, lack of empathy, lack of emotional-processing skills). As a result of the inability to create and maintain healthy relationships due to the lack of interpersonal skills, individuals with ASPD may find themselves in predicaments such as divorce, unemployment, homelessness and even premature death by suicide. They also see higher rates of committed crime, reaching peaks in their late teens and often committing higher-severity crimes in their younger ages of diagnoses. Comorbidity of other mental illnesses such as depression or substance use disorder is prevalent among patients with ASPD. People with ASPD are also more likely to commit homicides and other crimes. Those who are imprisoned longer often see higher rates of improvement with symptoms of ASPD than others who have been imprisoned for a shorter amount of time. According to one study, aggressive tendencies show in about 72% of all male patients diagnosed with ASPD. About 29% of the men studied with ASPD also showed a prevalence of pre-meditated aggression. Based on the evidence in the study, the researchers concluded that aggression in patients with ASPD is mostly impulsive, though there are some long-term evidences of pre-meditated aggressions. It often occurs that those with higher psychopathic traits will exhibit the pre-meditated aggressions to those around them. Over the course of a patient's life with ASPD, he or she can exhibit this aggressive behavior and harm those close to him or her. Additionally, many people (especially adults) who have been diagnosed with ASPD become burdens to their close relatives, peers, and caretakers. Harvard Medical School recommends that time and resources be spent treating victims who have been affected by someone with ASPD, because the patient with ASPD may not respond to the administered therapies. In fact, a patient with ASPD may only accept treatment when ordered by a court, which will make their course of treatment difficult and severe. Because of the challenges in treatment, the patient's family and close friends must take an active role in decisions about therapies that are offered to the patient. Ultimately, there must be a group effort to aid the long-term effects of the disorder. Epidemiology The estimated lifetime prevalence of ASPD amongst the general population falls within 1% to 4%, skewed towards 6% men and 2% women. The prevalence of ASPD is even higher in selected populations, like prisons, where there is a preponderance of violent offenders. It has been found that the prevalence of ASPD among prisoners is just under 50%. According to one study (n=23000), the prevalence of ASPD in prisoners is 47% in men and 21% in women. Thus, with only 27-31% of patients with ASPD seeing an improvement in symptoms over time, statistically around one third (33%) of male prisoners will not see any improvement in their symptoms, and are thus essentially prognostically hopeless. The corresponding percentage of female prisoners with statistically no chance of improvement in symptoms is around 15% or roughly one in six. Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) use treatment programs than in the general population, suggesting a link between ASPD and AOD use and dependence. As part of the Epidemiological Catchment Area (ECA) study, men with ASPD were found to be three to five times more likely to excessively use alcohol and illicit substances than those men without ASPD. There was found to be increased severity of this substance use in women with ASPD. In a study conducted with both men and women with ASPD, women were more likely to misuse substances compared to their male counterparts. Homelessness is also common amongst people with ASPD. A study on 31 youths of San Francisco and 56 youths in Chicago found that 84% and 48% of the homeless met the diagnostic criteria for ASPD respectively. Another study on the homeless found that 25% of participants had ASPD. Individuals with ASPD are at an elevated risk for suicide. Some studies suggest this increase in suicidality is in part due to the association between suicide and symptoms or trends within ASPD, such as criminality and substance use. Children of people with ASPD are also at risk. Some research suggests that negative or traumatic experiences in childhood, perhaps as a result of the choices a parent with ASPD might make, can be a predictor of delinquency later on in the child's life. Additionally, with variability between situations, children of a parent with ASPD may face consequences of delinquency if they are raised in an environment in which crime and violence is common. Suicide is a leading cause of death among youth who display antisocial behavior, especially when mixed with delinquency. Incarceration, which could come as a consequence of actions from a person with ASPD, is a predictor for suicide ideation in youth. History The first version of the DSM in 1952 listed sociopathic personality disturbance. This category was for individuals who were considered "...ill primarily in terms of society and of conformity with the prevailing milieu, and not only in terms of personal discomfort and relations with other individuals." There were four subtypes, referred to as "reactions": antisocial, dyssocial, sexual, and addiction. The antisocial reaction was said to include people who were "always in trouble" and not learning from it, maintaining "no loyalties", frequently callous and lacking responsibility, with an ability to "rationalize" their behavior. The category was described as more specific and limited than the existing concepts of "constitutional psychopathic state" or "psychopathic personality" which had a very broad meaning; the narrower definition was in line with criteria advanced by Hervey M. Cleckley from 1941, while the term sociopathic had been advanced by George Partridge in 1928 when studying the early environmental influence on psychopaths. Partridge discovered the correlation between antisocial psychopathic disorder and parental rejection experienced in early childhood. The DSM-II in 1968 rearranged the categories and "antisocial personality" was now listed as one of ten personality disorders but still described similarly, to be applied to individuals who are: "basically unsocialized", in repeated conflicts with society, incapable of significant loyalty, selfish, irresponsible, unable to feel guilt or learn from prior experiences, and who tend to blame others and rationalize. The manual preface contains "special instructions" including "Antisocial personality should always be specified as mild, moderate, or severe." The DSM-II warned that a history of legal or social offenses was not by itself enough to justify the diagnosis, and that a "group delinquent reaction" of childhood or adolescence or "social maladjustment without manifest psychiatric disorder" should be ruled out first. The dyssocial personality type was relegated in the DSM-II to "dyssocial behavior" for individuals who are predatory and follow more or less criminal pursuits, such as racketeers, dishonest gamblers, prostitutes, and dope peddlers (DSM-I classified this condition as sociopathic personality disorder, dyssocial type). It would later resurface as the name of a diagnosis in the ICD manual produced by the WHO, later spelled dissocial personality disorder and considered approximately equivalent to the ASPD diagnosis. The DSM-III in 1980 included the full term antisocial personality disorder and, as with other disorders, there was now a full checklist of symptoms focused on observable behaviors to enhance consistency in diagnosis between different psychiatrists ('inter-rater reliability'). The ASPD symptom list was based on the Research Diagnostic Criteria developed from the so-called Feighner Criteria from 1972, and in turn largely credited to influential research by sociologist Lee Robins published in 1966 as "Deviant Children Grown Up". However, Robins has previously clarified that while the new criteria of prior childhood conduct problems came from her work, she and co-researcher psychiatrist Patricia O'Neal got the diagnostic criteria they used from Lee's husband the psychiatrist Eli Robins, one of the authors of the Feighner criteria who had been using them as part of diagnostic interviews. The DSM-IV maintained the trend for behavioral antisocial symptoms while noting, "This pattern has also been referred to as psychopathy, sociopathy, or dyssocial personality disorder" and re-including in the 'Associated Features' text summary some of the underlying personality traits from the older diagnoses. The DSM-5 has the same diagnosis of antisocial personality disorder. The Pocket Guide to the DSM-5 Diagnostic Exam suggests that a person with ASPD may present "with psychopathic features" if he or she exhibits "a lack of anxiety or fear and a bold, efficacious interpersonal style". See also References Further reading External links DSM-V-TR criteria + additional information DSM-IV-TR Criteria for Antisocial personality disorder Psychopathy and Antisocial Personality Disorder: A Case of Diagnostic Confusion Anti-social behaviour Behavioural sciences Cluster B personality disorders Criminology Forensic psychology Psychopathy

Quackery

Quackery, often synonymous with health fraud, is the promotion of fraudulent or ignorant medical practices. A quack is a "fraudulent or ignorant pretender to medical skill" or "a person who pretends, professionally or publicly, to have skill, knowledge, qualification or credentials they do not possess; a charlatan or snake oil salesman". The term quack is a clipped form of the archaic term , derived from a "hawker of salve" or rather somebody who boasted about their salves, more commonly known as ointments. In the Middle Ages the term quack meant "shouting". The quacksalvers sold their wares at markets by shouting to gain attention. Common elements of general quackery include questionable diagnoses using questionable diagnostic tests, as well as untested or refuted treatments, especially for serious diseases such as cancer. Quackery is often described as "health fraud" with the salient characteristic of aggressive promotion. Definition Psychiatrist and author Stephen Barrett of Quackwatch defines quackery as "the promotion of unsubstantiated methods that lack a scientifically plausible rationale" and more broadly as: In addition to the ethical problems of promising benefits that are not likely to occur, quackery might cause people to forego treatments that are more likely to help them, in favor of ineffective treatments given by the "quack". American pediatrician Paul Offit has proposed four ways in which alternative medicine "becomes quackery": "by recommending against conventional therapies that are helpful." "by promoting potentially harmful therapies without adequate warning." "by draining patients' bank accounts ..." "by promoting magical thinking ..." Since it is difficult to distinguish between those who knowingly promote unproven medical therapies and those who are mistaken as to their effectiveness, United States courts have ruled in defamation cases that accusing someone of quackery or calling a practitioner a quack is not equivalent to accusing that person of committing medical fraud. However, the FDA makes little distinction between the two. To be considered a fraud, it is not strictly necessary for one to know they are misrepresenting the benefits or risks of the services offered. Quacksalver Unproven, usually ineffective, and sometimes dangerous medicines and treatments have been peddled throughout human history. Theatrical performances were sometimes given to enhance the credibility of purported medicines. Grandiose claims were made for what could be humble materials indeed: for example, in the mid-19th century revalenta arabica was advertised as having extraordinary restorative virtues as an empirical diet for invalids; despite its impressive name and many glowing testimonials it was in truth only ordinary lentil flour, sold to the gullible at many times the true cost. Even where no fraud was intended, quack remedies often contained no effective ingredients whatsoever. Some remedies contained substances such as opium, alcohol and honey, which would have given symptomatic relief but had no curative properties. Some would have addictive qualities to entice the buyer to return. The few effective remedies sold by quacks included emetics, laxatives and diuretics. Some ingredients did have medicinal effects: mercury, silver and arsenic compounds may have helped some infections and infestations; willow bark contains salicylic acid, chemically closely related to aspirin; and the quinine contained in Jesuit's bark was an effective treatment for malaria and other fevers. However, knowledge of appropriate uses and dosages was limited. Criticism of quackery in academia The evidence-based medicine community has criticized the infiltration of alternative medicine into mainstream academic medicine, education, and publications, accusing institutions of "diverting research time, money, and other resources from more fruitful lines of investigation in order to pursue a theory that has no basis in biology." For example, David Gorski criticized Brian M. Berman, founder of the University of Maryland Center for Integrative Medicine, for writing that "There [is] evidence that both real acupuncture and sham acupuncture [are] more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain." He also castigated editors and peer reviewers at the New England Journal of Medicine for allowing it to be published, since it effectively recommended deliberately misleading patients in order to achieve a known placebo effect. History in Europe and the United States With little understanding of the causes and mechanisms of illnesses, widely marketed "cures" (as opposed to locally produced and locally used remedies), often referred to as patent medicines, first came to prominence during the 17th and 18th centuries in Britain and the British colonies, including those in North America. Daffy's Elixir and Turlington's Balsam were among the first products that used branding (e.g. using highly distinctive containers) and mass marketing to create and maintain markets. A similar process occurred in other countries of Europe around the same time, for example with the marketing of Eau de Cologne as a cure-all medicine by Johann Maria Farina and his imitators. Patent medicines often contained alcohol or opium, which, while presumably not curing the diseases for which they were sold as a remedy, did make the imbibers feel better and confusedly appreciative of the product. The number of internationally marketed quack medicines increased in the later 18th century; the majority of them originated in Britain and were exported throughout the British Empire. By 1830, British parliamentary records list over 1,300 different "proprietary medicines", the majority of which were "quack" cures by modern standards. A Dutch organisation that opposes quackery, (VtdK), was founded in 1881, making it the oldest organisation of this kind in the world. It has published its magazine (Dutch Magazine against Quackery) ever since. In these early years the played a part in the professionalisation of medicine. Its efforts in the public debate helped to make the Netherlands one of the first countries with governmental drug regulation. In 1909, in an attempt to stop the sale of quack medicines, the British Medical Association published Secret Remedies, What They Cost And What They Contain. This publication was originally a series of articles published in the British Medical Journal between 1904 and 1909. The publication was composed of 20 chapters, organising the work by sections according to the ailments the medicines claimed to treat. Each remedy was tested thoroughly, the preface stated: "Of the accuracy of the analytical data there can be no question; the investigation has been carried out with great care by a skilled analytical chemist." The book did lead to the end of some of the quack cures, but some survived the book by several decades. For example, Beecham's Pills, which according to the British Medical Association contained in 1909 only aloes, ginger and soap, but claimed to cure 31 medical conditions, were sold until 1998. The failure of the medical establishment to stop quackery was rooted in the difficulty of defining what precisely distinguished real medicine, and in the appeals that quackery held out to consumers. British patent medicines lost their dominance in the United States when they were denied access to the Thirteen Colonies markets during the American Revolution, and lost further ground for the same reason during the War of 1812. From the early 19th century "home-grown" American brands started to fill the gap, reaching their peak in the years after the American Civil War. British medicines never regained their previous dominance in North America, and the subsequent era of mass marketing of American patent medicines is usually considered to have been a "golden age" of quackery in the United States. This was mirrored by similar growth in marketing of quack medicines elsewhere in the world. In the United States, false medicines in this era were often denoted by the slang term snake oil, a reference to sales pitches for the false medicines that claimed exotic ingredients provided the supposed benefits. Those who sold them were called "snake oil salesmen", and usually sold their medicines with a fervent pitch similar to a fire and brimstone religious sermon. They often accompanied other theatrical and entertainment productions that traveled as a road show from town to town, leaving quickly before the falseness of their medicine was discovered. Not all quacks were restricted to such small-time businesses however, and a number, especially in the United States, became enormously wealthy through national and international sales of their products. In 1875, the Pacific Medical and Surgical Journal complained: One among many examples is William Radam, a German immigrant to the US, who, in the 1880s, started to sell his "Microbe Killer" throughout the United States and, soon afterwards, in Britain and throughout the British colonies. His concoction was widely advertised as being able to "cure all diseases", and this phrase was even embossed on the glass bottles the medicine was sold in. In fact, Radam's medicine was a therapeutically useless (and in large quantities actively poisonous) dilute solution of sulfuric acid, coloured with a little red wine. Radam's publicity material, particularly his books, provide an insight into the role that pseudoscience played in the development and marketing of "quack" medicines towards the end of the 19th century. Advertising claims similar to those of Radam can be found throughout the 18th, 19th, 20th and 21st centuries. "Dr." Sibley, an English patent medicine seller of the late 18th and early 19th centuries, even went so far as to claim that his Reanimating Solar Tincture would, as the name implies, "restore life in the event of sudden death". Another English quack, "Dr. Solomon" claimed that his Cordial Balm of Gilead cured almost anything, but was particularly effective against all venereal complaints, from gonorrhea to onanism. Although it was basically just brandy flavoured with herbs, the price of a bottle was a half guinea (£sd system) in 1800, equivalent to over £ ($) in 2014. Not all patent medicines were without merit. Turlingtons Balsam of Life, first marketed in the mid-18th century, did have genuinely beneficial properties. This medicine continued to be sold under the original name into the early 20th century, and can still be found in the British and American pharmacopoeias as "Compound tincture of benzoin". In these cases, the treatments likely lacked empirical support when they were introduced to the market, and their benefits were simply a convenient coincidence discovered after the fact. The end of the road for the quack medicines now considered grossly fraudulent in the nations of North America and Europe came in the early 20th century. 21 February 1906 saw the passage into law of the Pure Food and Drug Act in the United States. This was the result of decades of campaigning by both government departments and the medical establishment, supported by a number of publishers and journalists (one of the most effective was Samuel Hopkins Adams, who wrote "The Great American Fraud" series in Collier's in 1905). This American Act was followed three years later by similar legislation in Britain and in other European nations. Between them, these laws began to remove the more outrageously dangerous contents from patent and proprietary medicines, and to force quack medicine proprietors to stop making some of their more blatantly dishonest claims. The Act, however, left advertising and claims of effectiveness unregulated as the Supreme Court interpreted it to mean only that ingredients on labels had to be accurate. Language in the 1912 Sherley Amendment, meant to close this loophole, was limited to regulating claims that were false and fraudulent, creating the need to show intent. Throughout the early 20th century, the American Medical Association collected material on medical quackery, and one of their members and medical editors in particular, Arthur J. Cramp, devoted his career to criticizing such products. The AMA's Department of Investigation closed in 1975, but their only archive open to non-members remains, the American Medical Association Health Fraud and Alternative Medicine Collection. "Medical quackery and promotion of nostrums and worthless drugs were among the most prominent abuses that led to formal self-regulation in business and, in turn, to the creation of the Better Business Bureau." Contemporary culture "Quackery is the promotion of false and unproven health schemes for a profit. It is rooted in the traditions of the marketplace", with "commercialism overwhelming professionalism in the marketing of alternative medicine". Quackery is most often used to denote the peddling of the "cure-alls" described above. Quackery is an ongoing problem that can be found in any culture and in every medical tradition. Unlike other advertising mediums, rapid advancements in communication through the Internet have opened doors for an unregulated market of quack cures and marketing campaigns rivaling the early 20th century. Most people with an e-mail account have experienced the marketing tactics of spamming – in which modern forms of quackery are touted as miraculous remedies for "weight loss" and "sexual enhancement", as well as outlets for medicines of unknown quality. India In 2008, the Hindustan Times reported that some officials and doctors estimated that there were more than 40,000 quacks practicing in Delhi, following outrage over a "multi-state racket where unqualified doctors conducted hundreds of illegal kidney transplants for huge profits." The president of the Indian Medical Association (IMA) in 2008 criticized the central government for failing to address the problem of quackery and for not framing any laws against it. In 2017, IMA again asked for an antiquackery law with stringent action against those practicing without a license. As of 2024, the government of India is yet to pass an anti-quackery law. Ministry of Ayush In 2014, the Government of India formed a Ministry of AYUSH that includes the seven traditional systems of healthcare. The Ministry of Ayush (expanded from Ayurveda, Yoga, Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy), is purposed with developing education, research and propagation of indigenous alternative medicine systems in India. The ministry has faced significant criticism for funding systems that lack biological plausibility and are either untested or conclusively proven as ineffective. Quality of research has been poor, and drugs have been launched without any rigorous pharmacological studies and meaningful clinical trials on Ayurveda or other alternative healthcare systems. There is no credible efficacy or scientific basis of any of these forms of treatment. A strong consensus prevails among the scientific community that homeopathy is a pseudo-scientific, unethical and implausible line of treatment. Ayurveda is deemed to be pseudoscientific. Much of the research on postural yoga has taken the form of preliminary studies or clinical trials of low methodological quality; there is no conclusive therapeutic effect except in back pain. Naturopathy is considered to be a form of pseudo-scientific quackery, ineffective and possibly harmful, with a plethora of ethical concerns about the very practice. Unani lacks biological plausibility and is considered to be pseudo-scientific quackery, as well. United States While quackery is often aimed at the aged or chronically ill, it can be aimed at all age groups, including teens, and the FDA has mentioned some areas where potential quackery may be a problem: breast developers, weight loss, steroids and growth hormones, tanning and tanning pills, hair removal and growth, and look-alike drugs. In 1992, the president of The National Council Against Health Fraud, William T. Jarvis, wrote in Clinical Chemistry that: For those in the practice of any medicine, to allege quackery is to level a serious objection to a particular form of practice. Most developed countries have a governmental agency, such as the Food and Drug Administration (FDA) in the US, whose purpose is to monitor and regulate the safety of medications as well as the claims made by the manufacturers of new and existing products, including drugs and nutritional supplements or vitamins. The Federal Trade Commission (FTC) participates in some of these efforts. To better address less regulated products, in 2000, US President Clinton signed Executive Order 13147 that created the White House Commission on Complementary and Alternative Medicine. In 2002, the commission's final report made several suggestions regarding education, research, implementation, and reimbursement as ways to evaluate the risks and benefits of each. As a direct result, more public dollars have been allocated for research into some of these methods. Individuals and non-governmental agencies are active in attempts to expose quackery. According to John C. Norcross et al. less is consensus about ineffective "compared to effective procedures" but identifying both "pseudoscientific, unvalidated, or 'quack' psychotherapies" and "assessment measures of questionable validity on psycho-metric grounds" was pursued by various authors. The evidence-based practice (EBP) movement in mental health emphasizes the consensus in psychology that psychological practice should rely on empirical research. There are also "anti-quackery" websites, such as Quackwatch, that help consumers evaluate claims. Quackwatch's information is relevant to both consumers and medical professionals. Presence and acceptance There have been several suggested reasons why quackery is accepted by patients in spite of its lack of effectiveness: Ignorance Those who perpetuate quackery may do so to take advantage of ignorance about conventional medical treatments versus alternative treatments, or may themselves be ignorant regarding their own claims. Mainstream medicine has produced many remarkable advances, so people may tend to also believe groundless claims. Placebo effect Medicines or treatments known to have no pharmacological effect on a disease can still affect a person's perception of their illness, and this belief in its turn does indeed sometimes have a therapeutic effect, causing the patient's condition to improve. This is not to say that no real cure of biological illness is effected – "though we might describe a placebo effect as being 'all in the mind', we now know that there is a genuine neurobiological basis to this phenomenon." People report reduced pain, increased well-being, improvement, or even total alleviation of symptoms. For some, the presence of a caring practitioner and the dispensation of medicine is curative in itself. Regression fallacy Lack of understanding that health conditions change with no treatment and attributing changes in ailments to a given therapy. Confirmation bias The tendency to search for, interpret, or prioritize information in a way that confirms one's beliefs or hypotheses. It is a type of cognitive bias and a systematic error of inductive reasoning. Distrust of conventional medicine Many people, for various reasons, have a distrust of conventional medicine, or of the regulating organizations such as the FDA, or the major drug corporations. For example, "CAM may represent a response to disenfranchisement [discrimination] in conventional medical settings and resulting distrust". Conspiracy theories Anti-quackery activists ("quackbusters") are often falsely accused of being part of a huge "conspiracy" to suppress "unconventional" and/or "natural" therapies, as well as those who promote them. It is alleged that this conspiracy is backed and funded by the pharmaceutical industry and the established medical care system – represented by the AMA, FDA, ADA, CDC, WHO, etc. – for the purpose of preserving their power and increasing their profits. This idea is often held by people with antiscience views. Fear of side effects A great variety of pharmaceutical medications can have very distressing side effects, and many people fear surgery and its consequences, so they may opt to shy away from these mainstream treatments. Cost There are some people who simply cannot afford conventional treatment, and seek out a cheaper alternative. Nonconventional practitioners can often dispense treatment at a much lower cost. This is compounded by reduced access to healthcare. Desperation People with a serious or terminal disease, or who have been told by their practitioner that their condition is "untreatable", may react by seeking out treatment, disregarding the lack of scientific proof for its effectiveness, or even the existence of evidence that the method is ineffective or even dangerous. Despair may be exacerbated by the lack of palliative non-curative end-of-life care. Between 2012 and 2018 appeals on UK crowdfunding sites for cancer treatment with an alternative health element have raised £8 million. This is described as "a new and lucrative revenue stream for cranks, charlatans, and conmen who prey on the vulnerable." Pride Once people have endorsed or defended a cure, or invested time and money in it, they may be reluctant or embarrassed to admit its ineffectiveness and therefore recommend a treatment that does not work. This is a manifestation of the sunk cost fallacy. Fraud Some practitioners, fully aware of the ineffectiveness of their medicine, may intentionally produce fraudulent scientific studies, for example, thereby confusing any potential consumers as to the effectiveness of the medical treatment. Deceased persons accused of quackery Thomas Allinson (1858–1918), founder of naturopathy. His views often brought him into conflict with the Royal College of Physicians of Edinburgh and the General Medical Council, particularly his opposition to doctors' frequent use of drugs, his opposition to vaccination and his self-promotion in the press. His views and publication of them led to him being labeled a quack and being struck off by the General Medical Council for infamous conduct in a professional respect. Lovisa Åhrberg (1801–1881), the first Swedish female doctor. Åhrberg was met with strong resistance from male doctors and was accused of quackery. During the formal examination she was acquitted of all charges and allowed to practice medicine in Stockholm even though it was forbidden for women in the 1820s. She later received a medal for her work. Johanna Brandt (1876–1964), a South African naturopath who advocated the "Grape Cure" as a cure for cancer. John R. Brinkley (1885–1942), a nonphysician and xenotransplant specialist in Kansas, US, who claimed to have discovered a method of effectively transplanting the testicles of goats into aging men. After state authorities took steps to shut down his practice, he retaliated by entering politics in 1930 and unsuccessfully running for the office of Governor of Kansas. Hulda Regehr Clark (1928–2009), was a controversial naturopath, author, and practitioner of alternative medicine who claimed to be able to cure all diseases and advocated methods that have no scientific validity. Max Gerson (1881–1959), was a German-born American physician who developed a dietary-based alternative cancer treatment that he claimed could cure cancer and most chronic, degenerative diseases. His treatment was called The Gerson Therapy. Most notably, Gerson Therapy was used, unsuccessfully, to treat Jessica Ainscough and Garry Winogrand. According to Quackwatch, Gerson Institute claims of cure are based not on actual documentation of survival, but on "a combination of the doctor's estimate that the departing patient has a 'reasonable chance of surviving', plus feelings that the Institute staff have about the status of people who call in". The American Cancer Society reports that "[t]here is no reliable scientific evidence that Gerson therapy is effective ..." Samuel Hahnemann (1755–1843), founder of homeopathy. Hahnemann believed that all diseases were caused by "miasms", which he defined as irregularities in the patient's vital force. He also said that illnesses could be treated by substances that in a healthy person produced similar symptoms to the illness, in extremely low concentrations, with the therapeutic effect increasing with dilution and repeated shaking. Lawrence B. Hamlin (in 1916), was fined under the 1906 US Pure Food and Drug Act for advertising that his Wizard Oil could kill cancer. L. Ron Hubbard (1911–1986), was the founder of the Church of Scientology. He was an American science fiction writer, former US Navy officer, and creator of Dianetics. He has been commonly called a quack and a con man by both critics of Scientology and by many psychiatric organizations in part for his often extreme anti-psychiatric beliefs and false claims about technologies such as the E-meter. Linda Hazzard, (1867–1938), was a self-declared doctor and fasting specialist, which she advertised as a panacea for every medical ailment. Up to 40 patients may have died of starvation in her "sanitarium" in Olalla, Washington, US. Imprisoned for one death in 1912, Hazzard was paroled in 1915 and continued to practice medicine without a license in New Zealand (1915–1920) and Washington, US (1920–1935). Died in 1938 while attempting a fasting to cure herself. William Donald Kelley, (1925–2005), was an orthodontist and a follower of Max Gerson who developed his own alternative cancer treatment called Nonspecific Metabolic Therapy. This treatment is based on the unsubstantiated belief that "wrong foods [cause] malignancy to grow, while proper foods [allow] natural body defenses to work". It involves, specifically, treatment with pancreatic enzymes, 50 daily vitamins and minerals (including laetrile), frequent body shampoos, coffee enemas, and a specific diet. According to Quackwatch, "not only is his therapy ineffective, but people with cancer who take it die more quickly and have a worse quality of life than those having standard treatment, and can develop serious or fatal side-effects. Kelley's most famous patient was actor Steve McQueen. John Harvey Kellogg (1852–1943), was a medical doctor in Battle Creek, Michigan, US, who ran a sanitarium using holistic methods, with a particular focus on nutrition, enemas and exercise. Kellogg was an advocate of vegetarianism and invented the corn flake breakfast cereal with his brother, Will Keith Kellogg. John St. John Long (1798–1834) was an Irish artist who claimed to be able to cure tuberculosis by causing a sore or wound on the back of the patient, out of which the disease would exit. He was tried twice for manslaughter of his patients who died under this treatment. Franz Anton Mesmer (1734–1815), was a German physician and astrologist, who invented what he called magnétisme animal. Theodor Morell (1886–1948), a German physician best known as Adolf Hitler's personal doctor. Morell administered approximately 74 substances, in 28 different mixtures to Hitler, including heroin, cocaine, Doktor Koster's Antigaspills, potassium bromide, papaverine, testosterone, vitamins and animal enzymes. Despite Hitler's dependence on Morell, and his recommendations of him to other Nazi leaders, Hermann Göring, Heinrich Himmler, Albert Speer and others quietly dismissed Morell as a quack. Daniel David Palmer (1845–1913), was a grocery store owner that claimed to have healed a janitor of deafness after adjusting the alignment of his back. He founded the field of chiropractic based on the principle that all disease and ailments could be fixed by adjusting the alignment of someone's back. His hypothesis was disregarded by medical professionals at the time and despite a considerable following has yet to be scientifically proven. Palmer established a magnetic healing facility in Davenport, Iowa, styling himself 'doctor'. Not everyone was convinced, as a local paper in 1894 wrote about him: "A crank on magnetism has a crazy notion that he can cure the sick and crippled with his magnetic hands. His victims are the weak-minded, ignorant and superstitious, those foolish people who have been sick for years and have become tired of the regular physician and want health by the short-cut method … he has certainly profited by the ignorance of his victims … His increase in business shows what can be done in Davenport, even by a quack." Louis Pasteur (1822–1895), was a French chemist best known for his remarkable breakthroughs in microbiology. His experiments confirmed the germ theory of disease, also reducing mortality from puerperal fever (childbed), and he created the first vaccine for rabies. He is best known to the general public for showing how to stop milk and wine from going sourthis process came to be called pasteurization. His hypotheses initially met with much hostility, and he was accused of quackery on multiple occasions. However, he is now regarded as one of the three main founders of microbiology, together with Ferdinand Cohn and Robert Koch. Linus Pauling (1901–1994), a Nobel Prize winner in chemistry, Pauling spent much of his later career arguing for the treatment of somatic and psychological diseases with orthomolecular medicine. Among his claims were that the common cold could be cured with massive doses of vitamin C. Together with Ewan Cameron he wrote the 1979 book Cancer and Vitamin C, which was again more popular with the public than the medical profession, which continued to regard claims about the effectiveness of vitamin C in treating or preventing cancer as quackery. A biographer has discussed how controversial his views on megadoses of Vitamin C have been and that he was "still being called a 'fraud' and a 'quack' by opponents of his 'orthomolecular medicine. Doctor John Henry Pinkard (1866–1934) was a Roanoke, Virginia businessman and "Yarb Doctor" or "Herb Doctor" who concocted quack medicines that he sold and distributed in violation of the Food and Drugs Act and the earlier Pure Food and Drug Act. He was also known as a "clairvoyant, herb doctor and spiritualist." Some of Pinkard's Sanguinaria Compound, made from bloodroot or bloodwort, was seized by federal officials in 1931. "Analysis by this department of a sample of the article showed that it consisted essentially of extracts of plant drugs including sanguinaria, sugar, alcohol, and water. It was alleged in the information that the article was misbranded in that certain statements, designs, and devices regarding the therapeutic and curative effects of the article, appearing on the bottle label, falsely and fraudulently represented that it would be effective as a treatment, remedy, and cure for pneumonia, coughs, weak lungs, asthma, kidney, liver, bladder, or any stomach troubles, and effective as a great blood and nerve tonic." He pleaded guilty and was fined. Wilhelm Reich (1897–1957), Austrian-American Psychoanalyst. Claimed that he had discovered a primordial cosmic energy called Orgone. He developed several devices, including the Cloudbuster and the Orgone Accumulator, that he believed could use orgone to manipulate the weather, battle space aliens and cure diseases, including cancer. After an investigation, the US Food and Drug Administration concluded that they were dealing with a "fraud of the first magnitude". On 10 February 1954, the US Attorney for Maine filed a complaint seeking a permanent injunction under Sections 301 and 302 of the Federal Food, Drug, and Cosmetic Act, to prevent interstate shipment of orgone accumulators and to ban some of Reich's writing promoting and advertising the devices. Reich refused to appear in court, arguing that no court was in a position to evaluate his work. Reich was arrested for contempt of court, and convicted to two years in jail, a US$10,000 fine, and his Orgone Accumulators and work on Orgone were ordered to be destroyed. On 23 August 1956, six tons of his books, journals, and papers were burned in the 25th Street public incinerator in New York. On 12 March 1957 he was sent to Danbury Federal Prison, where Richard C. Hubbard, a psychiatrist who admired Reich, examined him, recording paranoia manifested by delusions of grandiosity, persecution, and ideas of reference. Nine months later, on 18 November 1957, Reich died of a heart attack while he was in the federal penitentiary in Lewisburg, Pennsylvania. William Herbert Sheldon (1898–1977), who created the theory of somatotypes corresponding to intelligence. Information Age quackery As technology has evolved, particularly with the advent and wide adoption of the internet, it has increasingly become a source of quackery. For example, writing in The New York Times Magazine, Virginia Heffernan criticized WebMD for biasing readers toward drugs that are sold by the site's pharmaceutical sponsors, even when they are unnecessary. She wrote that WebMD "has become permeated with pseudomedicine and subtle misinformation." See also Association for Science in Autism Treatment Confidence trick Crystal healing Detoxification foot baths Health care fraud List of topics characterized as pseudoscience Medical error Medicines and Healthcare products Regulatory Agency Osteopathy Psychic Quackdown Notes References Works cited Carroll, 2003. "The Skeptics Dictionary". New York: Wiley. Della Sala, 1999. Mind Myths: Exploring Popular Assumptions about the Mind and Brain. New York: Wiley. Eisner, 2000. The Death of Psychotherapy; From Freud to Alien Abductions. Westport, CT: Praegner. Lilienfeld, SO., Lynn, SJ., Lohr, JM. 2003. Science and Pseudoscience in Clinical Psychology. New York: Guildford External links Quackwatch Medline Plus – entry on Health Fraud 'Miracle' Health Claims: Add a Dose of Skepticism Article at the Federal Trade Commission Pejorative terms Alternative medicine Unnecessary health care Health care quality Social problems in medicine Ignorance Deception

Home care

Homecare (home care, in-home care), also known as domiciliary care, personal care or social care, is health care or supportive care provided in the individual home where the patient or client is living, generally focusing on paramedical aid by professional caregivers, assistance in daily living for ill, disabled or elderly people, or a combination thereof. Depending on legislation, a wide range of other services can also be included in homecare. Homecare can be organised by national or local government, by volunteer organizations or on a market basis. Purpose Homecare is an alternative to institutional care such as can be provided at group accommodations and nursing home. Research shows that clients receiving home health care may incur lower costs, receive equal to better care, and have increased satisfaction in contrast to other settings. Services included The services included varys vastly between jurisdictions, volunteer organizations and markets. Some examples of homecare services are: assistance with activities of daily living (ADLs), such as bathing, toileting, food preparation, feeding, incontinence laundry, bed changing, paramedical aid and qualified nursing care, such as injections, management of pressure sores, catheter and stoma care, carrying out physician orders, tracking vital signs, drawing blood, and documentation of health status, palliative and end-of-life care, communication between patient, family and physician, mobility support, including short walks, conveyance to and from health institutions, or adapted public transportation services, counselling, including behaviour management, psychological support and reminding devices, and providing or managing mechanical and manual aids. Caregivers Caregivers can range from qualified nurses and advanced medical staff to nurses and nursing aids. Some caregivers travel to multiple homes per day and provide short visits to multiple patients, while others may stay with one patient for a certain amount of time per day. See also Aging in place Assisted living Home care in the United Kingdom Home care in the United States Healthcare in India Paratransit References Caregiving

Functional gastrointestinal disorder

Functional gastrointestinal disorders (FGID), also known as disorders of gut–brain interaction, include a number of separate idiopathic disorders which affect different parts of the gastrointestinal tract and involve visceral hypersensitivity and motility disturbances. Definition Using the Delphi method, the Rome Foundation and its board of directors, chairs and co-chairs of the ROME IV committees developed the current definition for disorders of gut-brain interaction. A group of disorders classified by GI symptoms related to any combination of: Motility disturbance Visceral hypersensitivity Altered mucosal and immune function Altered gut microbiota Altered central nervous system (CNS) processing Classification Terms such as functional colonic disease (or functional bowel disorder) refer in medicine to a group of bowel disorders which are characterized by chronic abdominal complaints without a structural or biochemical cause that could explain symptoms. Other functional disorders relate to other aspects of the process of digestion. The consensus review process of meetings and publications organised by the Rome Foundation, known as the Rome process, has helped to define the functional gastrointestinal disorders. Successively, the Rome I, Rome II, Rome III and Rome IV proposed consensual classification system and terminology, as recommended by the Rome Coordinating Committee. These now include classifications appropriate for adults, children and neonates/toddlers. The current ROME IV classification, published in 2016, is as follows: A. Esophageal disorders A1. Functional chest pain A2. Functional heartburn A3. Reflux hypersensitivity A4. Globus A5. Functional dysphagia B. Gastroduodenal disorders B1. Functional dyspepsia B1a. Postprandial distress syndrome (PDS) B1b. Epigastric pain syndrome (EPS) B2. Belching disorders B2a. Excessive supragastric belching B2b. Excessive gastric belching B3. Nausea and vomiting disorders B3a. Chronic nausea vomiting syndrome (CNVS) B3b. Cyclic vomiting syndrome (CVS) B3c. Cannabinoid hyperemesis syndrome (CHS) B4. Rumination syndrome C. Bowel disorders C1. Irritable bowel syndrome (IBS) IBS with predominant constipation (IBS-C) IBS with predominant diarrhea (IBS-D) IBS with mixed bowel habits (IBS-M) IBS unclassified (IBS-U) C2. Functional constipation C3. Functional diarrhea C4. Functional abdominal bloating/distension C5. Unspecified functional bowel disorder C6. Opioid-induced constipation D. Centrally mediated disorders of gastrointestinal pain D1. Centrally mediated abdominal pain syndrome (CAPS) D2. Narcotic bowel syndrome (NBS)/ Opioid-induced GI hyperalgesia E. Gallbladder and sphincter of Oddi disorders E1. Biliary pain E1a. Functional gallbladder disorder E1b. Functional biliary sphincter of Oddi disorder E2. Functional pancreatic sphincter of Oddi disorder F. Anorectal disorders F1. Fecal incontinence F2. Functional anorectal pain F2a. Levator ani syndrome F2b. Unspecified functional anorectal pain F2c. Proctalgia fugax F3. Functional defecation disorders F3a. Inadequate defecatory propulsion F3b. Dyssynergic defecation G. Childhood functional GI disorders: Neonate/Toddler G1. Infant regurgitation G2. Rumination syndrome G3. Cyclic vomiting syndrome (CVS) G4. Infant colic G5. Functional diarrhea G6. Infant dyschezia G7. Functional constipation H. Childhood functional GI disorders: Child/Adolescent H1. Functional nausea and vomiting disorders H1a. Cyclic vomiting syndrome (CVS) H1b. Functional nausea and functional vomiting H1b1. Functional nausea H1b2. Functional vomiting H1c. Rumination syndrome H1d. Aerophagia H2. Functional abdominal pain disorders H2a. Functional dyspepsia H2a1. Postprandial distress syndrome H2a2. Epigastric pain syndrome H2b. Irritable bowel syndrome (IBS) H2c. Abdominal migraine H2d. Functional abdominal pain ‒ NOS H3. Functional defecation disorders H3a. Functional constipation H3b. Nonretentive fecal incontinence Causes FGIDs share in common any of several physiological features including increased motor reactivity, enhanced visceral hypersensitivity, altered mucosal immune and inflammatory function (associated with bacterial dysbiosis), and altered central nervous system and enteric nervous system (CNS-ENS) regulation. The pathophysiology of FGID has been best conceptualized using biopsychosocial model help to explain the relationships between an individual factors in their early life that in turn can influence their psychosocial factor and physiological functioning. This model also shows the complex interactions between these factors through the brain-gut axis. These factors affect how FGID manifest in terms of symptoms but also affect the clinical outcome. These factors are interconnected and the influences on these factors are bidirectional and mutually interactive. Early life factors Early life factors include genetic factors, psychophysiological and sociocultural factors, and environmental exposures. Genetics – Several polymorphisms and candidate genes may predispose individuals to develop FGID. These include alpha-2 adrenergic and 5-HT receptors; serotonin and norepinephrine transporters (SERT, NET); inflammatory markers interleukin-(IL)10, tumor necrosis factor-(TNF) alpha, and TNF super family member 15 (TNF-SF15); intracellular cell signaling (G proteins); and ion channels (SCN5A). However, the expression of a FGID requires the influence of additional environmental exposures such as infection, illness modeling and other factors. Psychophysiological factors may affect the expression of these genes, thus leading to symptoms production associated with FGID. Sociocultural factors and family interactions have been shown to shape later reporting of symptoms, the development of FGIDs, and health care seeking. The expression of pain varies across cultures as well including denial of symptoms to dramatic expression. Environmental exposures  – Prior studies have shown the effect of environmental exposures in relation to the development of FGIDs. Environmental exposures such as childhood salmonella infection can be a risk factor for IBS in adulthood. Psychosocial factors There is a strong link between FGIDs and psychosocial factors. Psychosocial factors influence the functioning of the GI tract through the brain-gut axis, including the GI tract's motility, sensitivity, and barrier function. Psychosocial factors also affect experience and behavior, treatment selection, and clinical outcome. Psychological stress or one's emotional response to stress exacerbates gastrointestinal symptoms and may contribute to FGID development and maintenance. Specifically in children and adolescents, anxiety and depression may present as FGID-associated somatic complaints, such as nausea, vomiting, and abdominal pain. Similarly, anxiety in individuals with FGIDs is linked to greater pain severity, frequency, duration, chronicity, and disabling effects. This is because psychological stress can impact the gut's mucosal barrier functions, allowing bacteria and bacterial products to migrate and cause pain, diarrhea, and other GI symptoms. Conversely, since the brain-gut axis is bidirectional, GI inflammation and injury can amplify pain signals to the brain and contribute to worsened mental status, including anxiety and depression symptoms. Individuals with FGIDs may also experience poor socialization. Due to the nature of the disease, individuals with an FGID may have difficulty with regular school or work attendance and participation in extracurricular activities, leading to isolation and a lack of peer support. This lack of peer support may lead to depression and loneliness, conditions which exacerbate FGIDs symptoms. In addition, children with FGIDs are more likely to experience bullying. As such, stressful situations which influence socialization (seen as either a lack thereof or negative experiences) may lead to an impaired functioning in patients with FGIDs. Family interactions may also play a role in the development of FGIDs through their effects on the physical and psychosocial functioning of an individual. Family factors which may influence the development of an FGID include child attachment style, maladaptive parenting behaviors (paternal rejection and hostility), and even the parents' health status, as children of chronically ill parents experience increased somatization, insecure attachment, and worsened biopsychosocial functioning. Each of these factors leads to the accumulation of stressors, which can ultimately lead to the development of an FGID. In addition, family units which have a member with an FGIDs diagnosis are more likely to face family functioning difficulties, including challenges to familial roles, communication, affective involvement, organization, and cohesion. These challenges arise due to the nature of the disease, and ultimately worsen symptoms for the FGID patient. Physiology The physiology of FGID is characterized by abnormal motility, visceral hypersensitivity as well as dysregulation of the immune system and barrier function of the GI tract as well as inflammatory changes. Abnormal motility Studies have shown altered muscle contractility and tone, bowel compliance, and transit may contribute to many of the gastrointestinal symptoms of FGID which may include diarrhea, constipation, and vomiting. Visceral hypersensitivity In FGID there is poor association of pain with GI motility in many functional GI disorders. These patient often have a lower pain threshold with balloon distension of the bowel (visceral hyperalgesia), or they have increased sensitivity even to normal intestinal function; Visceral hypersensitivity may be amplified in patients with FGIDs. Immune dysregulation, inflammation, and barrier dysfunction Studies on postinfectious IBS have shown that factors such as mucosal membrane permeability, the intestinal flora, and altered mucosal immune function. Ultimately leading to visceral hypersensitivity. Factors contributing to this occurrence include genetics, psychological stress, and altered receptor sensitivity at the gut mucosa and myenteric plexus, which are enabled by mucosal immune dysfunction. Microbiome There has been increased attention to the role of bacteria and the microbiome in overall health and disease. There is evidence for a group of microorganisms which play a role in the brain-gut axis. Studies have revealed that the bacterial composition of the gastrointestinal tract in IBS patient differs from healthy individuals (e.g., increased Firmicutes and reduced Bacteroidetes and Bifidobacteria) However, further research is needed to determine the role of the microbiome in FGIDs. Food and diet The types of food consumed and diet consumed plays a role in the manifestation of FGID and also their relationship to intestinal microbiota. Studies have shown that specific changes in diet (e.g., low FODMAP—fermentable oligo-, di-, and monosaccharides and polyols, or gluten restriction in some patients) may help and reduce the symptom burden in FGID. However, no one diet has been shown to be recommended for all people. Brain-gut axis The brain-gut axis is a bidirectional mechanism in which psychosocial factors influence the GI tract and vice versa. Specifically, the emotional and cognitive centers of the brain influence GI activity and immune cell function, and the microbes within the gut regulate mood, cognition, and mental health. These two systems interact through several mechanisms. There are direct, physical connections between the central nervous system and nerve plexuses to the visceral muscles. In addition, neurotransmitters send signals related to thoughts, feelings, and pain regulation from the brain to the GI tract. The brain-gut axis influences the entire body through a variety of pathways; it regulates sensory, motor, endocrine, autonomic, immune, and inflammatory reactions. Within the physical and psychological interactions of FGIDs specifically, psychiatric disorders such as anxiety, depression, and even autism are well-linked to GI dysfunction. Conversely, functional GI diseases are linked to several comorbid psychiatric diseases. Negative emotions such as fear, anxiety, anger, stress, and pain may delay gastric emptying, decrease intestinal and colonic transit time, and induce defecation and diarrhea. Treatments Psychotherapeutic treatments Because FGIDs are known to be multifactorial with external stressors and environmental factors playing a role in their development, current research demonstrates that psychological treatments may be effective in relieving some symptoms of the disease. Interventions such as cognitive behavioral therapy (CBT), hypnotherapy, and biofeedback-assisted relaxation training (BART) each show promise in symptom reduction. Each of these therapies aims to alter an individual's thought patterns and behaviors while improving self-efficacy, which all work together to improve health outcomes. Cognitive behavioral therapy is a treatment based on the theory that thinking affects one's feelings and behaviors. As such, alterations in one's thought process can have a positive or negative effect on actions and perceptions. Through the lens of FGIDs, a negative thought pattern may be associated with a negative physical experience of abdominal pain, discomfort, and general sickness. In theory, retraining the patient's thought patterns can alleviate these symptoms and improve quality of life. In patients with FGIDs, CBT is an effective treatment option; one study found 87.5% of participants to be completely pain-free following treatment. Internet-based CBT (iCBT) is similarly effective, and may be a good treatment option for individuals who either cannot afford or otherwise lack access to traditional CBT. Hypnotherapy, another method for reducing symptoms of FGIDs, teaches users how to alter their perception of uncomfortable sensations in the body. Gut-directed hypnotherapy specifically gives greater improvements in symptoms than standard treatment of the disease. Research demonstrates directed hypnotherapy to be an effective mechanism of reducing visceral hypersensitivity (a low pain threshold of the internal organs) and sympathetic activity, due to the reduced activity of the anterior cingulated cortex and state of relaxation achieved during hypnosis. For patients with irritable bowel syndrome (IBS) and functional abdominal pain (FAP), hypnotherapy reduces pain intensity and frequency. BART therapies monitor the physiological changes occurring with thoughts, feelings, and emotions. These therapies aim to teach patients how to visualize the effects of the interventions they are undergoing. BART is used to improve mood and somatic responses to anxiety disorders, which may relieve some of the psychological and physiological symptoms of FGIDs. The visual, real-time feedback given through BART empowers the patient to see the difference that the therapy is making, thus giving the patient control over the physiological components of the disease. This allows the patient to maximize their mind-body connection and eventually optimize symptom management and quality of life. BART allows the patient to break the positive feedback loop of anxiety and pain, thus reducing disease exacerbations. Pharmaceutical treatments Antidepressants have been thoroughly studied as a potential treatment for FGIDs. Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and selective norepinephrine reuptake inhibitors (SNRIs) show the most promise in treating some of the symptoms of FGIDs. TCAs, specifically amitriptyline, show promising results when examining common FGIDs symptoms such as pain and poor quality of life. SNRIs also demonstrate pain-relieving qualities. SSRIs are less effective in pain management, but may reduce symptoms of anxiety and depression, which would, in turn, reduce some FGIDs symptoms. Epidemiology Functional gastrointestinal disorders are very common. Globally, irritable bowel syndrome and functional dyspepsia alone may affect 16–26% of the population. Research There is considerable research into the causes, diagnosis and treatments for FGIDs. Diet, microbiome, genetics, neuromuscular function and immunological response all interact. A role for mast cell activation has been proposed as one of the factors. See also Allergy Food intolerance Functional indigestion Histamine intolerance References External links Gastrointestinal tract disorders

Malingering

Malingering is the fabrication, feigning, or exaggeration of physical or psychological symptoms designed to achieve a desired outcome, such as personal gain, relief from duty or work, avoiding arrest, receiving medication, or mitigating prison sentencing. It presents a complex ethical dilemma within domains of society, including healthcare, legal systems, and employment settings. Although malingering is not a medical diagnosis, it may be recorded as a "focus of clinical attention" or a "reason for contact with health services". It is coded by both the ICD-10 and DSM-5. The intent of malingerers vary. For example, the homeless may fake a mental illness to gain hospital admission. Impacts of failure to detect malingering are extensive, impacting insurance industries, healthcare systems, public safety, and veterans' disability benefits. Malingered behaviour typically ends as soon as the external goal is obtained. Malingering is established as separate from similar forms of excessive illness behaviour, such as somatization disorder, wherein symptoms are not deliberately falsified. Another disorder is factitious disorder, which lacks a desire for secondary, external gain. Both of these are recognised as diagnosable by the DSM-5. However, not all medical professionals are in agreement with these distinctions. History Antiquity According to 1 Samuel in the Old Testament, King David feigned madness to Achish, the king of the Philistines. Some scholars believe this was not feigned but real epilepsy, and phrasing in the Septuagint supports that position. Odysseus was said to have feigned insanity to avoid participating in the Trojan War. Malingering was recorded in Roman times by the physician Galen, who reported two cases: one patient simulated colic to avoid a public meeting, and another feigned an injured knee to avoid accompanying his master on a long journey. Renaissance In 1595, a treatise on feigned diseases was published in Milan by Giambattista Silvatico. Various phases of malingering are represented in the etchings and engravings of Jacques Callot (1592–1635). In his Elizabethan-era social-climbing manual, George Puttenham recommends a would-be courtier to have "sickness in his sleeve, thereby to shake off other importunities of greater consequence". Modern period Although the concept of malingering has existed since time immemorial, the term for malingering was introduced in the 1900s due to those who would feign illness or disability to avoid military service. In 1943, US Army General George S. Patton found a soldier in a field hospital with no wounds; the soldier claimed to be suffering from battle fatigue. Believing the patient was malingering, Patton flew into a rage and physically assaulted him. The patient had malarial parasites. Agnes was the first subject of an in-depth discussion of transgender identity in sociology, published by Harold Garfinkel in 1967. In the 1950s, Agnes feigned symptoms and lied about almost every aspect of her medical history. Garfinkel concluded that fearing she would be denied access to sexual reassignment surgery, she had avoided every aspect of her case which would have indicated gender dysphoria and hidden the fact that she had taken hormone therapy. Physicians observing her feminine appearance therefore concluded she had testicular feminization syndrome, which legitimized her request for the surgery. Types Classifying malingering behaviour into different categories allows for an easier assessment of possible deception, as created by Robert Resnick. As individuals within institutions grapple with the challenges posed by malingering, a critical examination ethical duties emerges as imperative. Balancing compassion for those genuinely in need with the responsibility to uphold integrity and fairness, ethical obligations in addressing malingering extend beyond mere detection to encompass considerations of empathy, justice, and the broader implications for trust and societal welfare. Pure malingering: feigning a disorder or illness that is nonexistent. It is arguably the most simple to detect. This is because malingerers of this type tend to provide unreliable, additional symptoms when describing their supposed disorder, since they have to create an entire story from scratch. It is, therefore, difficult to entirely accurately mimic real-world scenarios. Partial malingering: purposefully exaggerating symptoms for an existing disorder or illness. This may be particularly difficult to detect, because those who partake in this would be building on their own genuine traumatic experiences, rather than completely falsifying claims. False imputation: attributing of existing symptoms to a cause that the patient knows is unrelated to their illness. Identifying this type of malingering is less difficult than partial malingering, as patients may inaccurately transpose symptoms from their real experience to the supposed cause of their disorder. This entails inaccurate storytelling and would indicate deliberate deception. Society and culture Post-traumatic stress disorder Veterans may be denied disability benefits if their doctor believes that they are malingering, especially regarding post-traumatic stress disorder. In navigating these ethical dimensions, it becomes essential to foster a nuanced understanding that acknowledges the complexities inherent in distinguishing genuine suffering from deceptive behavior, while also safeguarding against the misuse of resources and the erosion of trust in systems designed to support those in need. PTSD is the only condition for which the DSM-5 explicitly warns clinicians to observe in case of malingering. Distinguishing malingered PTSD from genuine symptoms is challenging due to the range of the nature and severity of the disorder. An assessment showed that in over 10% of cases, veterans were falsifying or exaggerating their service history. Attention deficit hyperactivity disorder Research that focuses on malingering attention deficit hyperactivity disorder are largely centred around university or college students. This is because of the significant benefits that may be gained if the student is successful, including student financial aid and exemptions for academic work. Medicinal treatments of ADHD may also be nootropics, which would enhance cognitive performance in examinations. Legal issues Malingering is a court-martial offense in the United States military under the Uniform Code of Military Justice, which defines the term as "feign[ing] illness, physical disablement, mental lapse, or derangement." According to the Texas Department of Insurance, fraud that includes malingering costs the US insurance industry approximately $150 billion each year. Other non-industry sources report it may be as low as $5.4 billion. Detection Richard Rogers and Daniel Shuman found that the use of DSM-5 criteria results in the accurate identification of only 13.6–20.1% of actual malingerers (true positives). However, 79.9–86.4% of individuals are misclassified as malingerers (false positives) using the same criteria. Being falsely accused of malingering may cause adverse reactions, some of which lead to violence. Thus, the accurate detection of malingering is a pressing societal issue. Tests There are multiple methods to evaluate malingering, such as the Minnesota Multiphasic Personality Inventory-2, which is the most validated test. Other tests include the Structured Interview of Reported Symptoms, which is used for psychiatric symptoms, and the Test of Memory Malingering (TOMM), intended for false memory deficits. Culture and education also likely affect overall performance in these tests. Research found that Colombian adults with low literacy skills perform significantly worse on the Test of Memory Malingering, so there are concerns with the impact of education levels on malingering assessments. Existing criteria for one malingered disorder may not be applicable to a different disorder. For example, tests for malingered PTSD may not work for malingered neurocognitive disorders; therefore, there is a need for newer criteria to be created. Indicative behaviour Although there is no singular test that definitively discerns malingering, medical professionals are told to watch out for certain behaviours that may indicate deliberate deception. Signs that illustrate malingering include: providing contradictory statements about symptoms; dramatic or peculiar behaviour that is meant to be convincing; behaviour that is inconsistent with described symptoms; acting adverse to accepting treatment for their supposed disorder; overenthusiasm about negative symptoms through going into extensive detail; sudden termination or onset of symptoms See also Doctor shopping Drug seeking behaviour Falsifiability Ganser syndrome Hypochondriasis Insanity defense Münchausen syndrome Ocular malingering Structured Inventory of Malingered Symptomatology Syndrome K, illness fabricated by doctors to protect Jews from Nazis References Forensic psychology Medical law

Social environment

The social environment, social context, sociocultural context or milieu refers to the immediate physical and social setting in which people live or in which something happens or develops. It includes the culture that the individual was educated or lives in, and the people and institutions with whom they interact. The interaction may be in person or through communication media, even anonymous or one-way, and may not imply equality of social status. The social environment is a broader concept than that of social class or social circle. The physical and social environment is a determining factor in active and healthy aging in place, being a central factor in the study of environmental gerontology. Moreover, the social environment is the setting where people live and interact. It includes the buildings and roads around them, the jobs available, and how money flows; relationships between people, like who has power and how different groups get along; and culture, like art, religion, and traditions. It includes the physical world and the way people relate to each other and their communities. Components The physical environment is the ever-changing natural world, including weather, land, and natural resources. Floods or earthquakes can alter the landscape, affecting how plants and animals live. Human interaction with nature can also have an impact. For example, logging can change the weather in that area, pollution can make water dirty, and habitat fragmentation caused by human activity makes it so animals cannot move around as easily, which can cause problems for their families. Social relations are how people interact with each other. Sociologist Emile Durkheim thought that if these interactions were disrupted, it could affect how we feel. Social relations can offer social support, which means the different ways people help each other out. This could be emotional support, like comforting someone when they are sad, or practical support, like helping with chores. Being part of groups, like families or clubs, can also make people feel good about ourselves; conversely, not having good relationships or having too many problems with others can make them feel bad. So, having good connections with people can make us happier and healthier. "Sociocultural" basically means the mix of society and culture that affects how people think, feel, and act, which can also affect our health. It includes things like how wealth, education, career, cultural background, race, ethnicity, language, and beliefs shape people's identity and health. Interpersonal relationships are how people connect with others emotionally and socially. When someone has a mental disorder, it often affects how they get along with people. Sometimes, the disorder itself can cause conflicts with others. These conflicts can appear in different areas of our relationships. Family relationships are important because having a supportive family makes life easier. They're there for you no matter what, whether things are going great or not so great. When life gets tough, hearing comforting words from your mom, spouse, or siblings can help you feel better and give you the courage to face challenges. In this post, we're going to talk about why family is important, what makes a good family, and how to make your relationships with family members stronger. Social relationships are the connections between people like family, friends, neighbors, and coworkers. When scientists study how relationships affect human health and behavior, they usually focus on these close connections, not just formal ones like with doctors or lawyers. They are interested in how people interact with their social circle and how it impacts them overall. Work relationship: Work friendships are special connections between people at work. They are important because they affect the people involved and the company they work for. Friendships at work play a big role in how well someone does their job and how motivated they are. These relationships can be complicated, happening both at work and outside of it, and they can be good or bad. Not having any work friends can make someone feel really lonely and left out. Religious relationship: Religion can have a significant impact on relationships. Couples who share the same religious beliefs can find comfort and support in their faith. For example, they might pray together when they are arguing, which can help them deal with their feelings. Studies have shown that couples who pray together tend to focus more on what they have in common rather than their own individual worries. Having a strong religious foundation can also help couples get through difficult situations, like cheating. They might feel like their relationship is special because they believe it is part of God's plan for them. Overall, when couples share the same religious beliefs, it can make it easier for them to talk about their faith and support each other in their relationship. A sexual relationship, also called an intimate relationship, is when two people have a close bond either physically or emotionally. Intimacy usually means being close in a special way, and while it often involves sex, it can also happen in relationships without any sexual attraction, like between friends or family members. Importance of positive social environments and relationships for parents Where a child grows up and goes to school has a big impact on who they become friends with and how good those friendships are. Most of the time, kids make friends with people in their family or neighborhood. So, where parents choose to live, work, and send their kids to school can affect how healthy and happy their children are. Solidarity People with the same social environment often develop a sense of social solidarity; people often tend to trust and help one another, and to congregate in social groups. They will often think in similar styles and patterns, even though the conclusions which they reach may differ. Natural/artificial environment In order to enrich their lives, people have used natural resources, and in the process have brought about many changes in the natural environment. Human settlements, roads, farmlands, dams, and many other elements have all developed through the process. All these man-made components are included in human cultural environment, Erving Goffman in particular emphasising the deeply social nature of the individual environment. There are still many people living in villages and this is their social environment. A village is a township with production, living, ecology and culture. The state is trying to solve the problem of integrated rural development, which includes construction, expansion, and road building. Milieu/social structure C. Wright Mills contrasted the immediate milieu of jobs/family/neighborhood with the wider formations of the social structure, highlighting in particular a distinction between "the personal troubles of milieu" and the "public crises of social structure". Emile Durkheim took a wider view of the social environment (milieu social), arguing that it contained internalized expectations and representations of social forces/social facts: "Our whole social environment seems to be filled with forces which really exist only in our own minds" – collective representations. Phenomenology Phenomenologists contrast two alternative visions of society, as a deterministic constraint (milieu) and as a nurturing shell (ambiance). Max Scheler distinguishes between milieu as an experienced value-world, and the objective social environment on which we draw to create the former, noting that the social environment can either foster or restrain our creation of a personal milieu. Social surgery Pierre Janet saw neurosis in part as the product of the identified patient's social environment – family, social network, work etc. – and considered that in some instances what he termed "social surgery" to create a healthier environment could be a beneficial measure. Similar ideas have since been taken up in community psychiatry and family therapy. See also Alfred Schütz – The four divisions of the lifeworld Communitarianism Community of practice Family nexus Framing (social sciences) Generalized other Habitus (sociology) Microculture Milieu control Milieu therapy Pillarisation References Further reading Leo Spitzer, "Milieu and Ambience: An Essay in Historical Semantics", in Philosophy and Phenomenological Research III (1942-3) James Morrow, Where the Everyday Begins. A Study of Environment and Everyday Life. transcript, Bielefeld 2017, . Alfred Russel Wallace (1913), Social Environment and Moral Progress Sociological terminology Personal life

Emergency psychiatry

Emergency psychiatry is the clinical application of psychiatry in emergency settings. Conditions requiring psychiatric interventions may include attempted suicide, substance abuse, depression, psychosis, violence or other rapid changes in behavior. Psychiatric emergency services are rendered by professionals in the fields of medicine, nursing, psychology and social work. The demand for emergency psychiatric services has rapidly increased throughout the world since the 1960s, especially in urban areas. Care for patients in situations involving emergency psychiatry is complex. Individuals may arrive in psychiatric emergency service settings through their own voluntary request, a referral from another health professional, or through involuntary commitment. Care of patients requiring psychiatric intervention usually encompasses crisis stabilization of many serious and potentially life-threatening conditions which could include acute or chronic mental disorders or symptoms similar to those conditions. Definition Symptoms and conditions behind psychiatric emergencies may include attempted suicide, substance dependence, alcohol intoxication, acute depression, presence of delusions, violence, panic attacks, and significant, rapid changes in behavior. Emergency psychiatry exists to identify and/or treat these symptoms and psychiatric conditions. In addition, several rapidly lethal medical conditions present themselves with common psychiatric symptoms. A physician's or a nurse's ability to identify and intervene with these and other medical conditions is critical. A psychiatric emergency is a disturbance in thought, mood and/or action which causes sudden distress to the individual/others and sudden disability or death, thus requiring immediate management. Delivery of services The place where emergency psychiatric services are delivered are most commonly referred to as Psychiatric Emergency Services, Psychiatric Emergency Care Centers, or Comprehensive Psychiatric Emergency Programs. Mental health professionals from a wide area of disciplines, including medicine, nursing, psychology, and social work in these settings alongside psychiatrists and emergency physicians. The facilities, sometimes housed in a psychiatric hospital, psychiatric ward, or emergency department, provide immediate treatment to both voluntary and involuntary patients 24 hours a day, 7 days a week. Within a protected environment, psychiatric emergency services exist to provide brief stay of two or three days to gain a diagnostic clarity, find appropriate alternatives to psychiatric hospitalization for the patient, and to treat those patients whose symptoms can be improved within that brief period of time. Even precise psychiatric diagnoses are a secondary priority compared with interventions in a crisis setting. The functions of psychiatric emergency services are to assess patients' problems, implement a short-term treatment consisting of no more than ten meetings with the patient, procure a 24-hour holding area, mobilize teams to carry out interventions at patients' residences, utilize emergency management services to prevent further crises, be aware of inpatient and outpatient psychiatric resources, and provide 24/7 telephone counseling. History Since the 1960s, the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalization both in Europe and the United States. Deinstitutionalization, in some locations, has resulted in a larger number of severely mentally ill people living in the community. There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication. The actual number of psychiatric emergencies has also increased significantly, especially in psychiatric emergency service settings located in urban areas. Emergency psychiatry has involved the evaluation and treatment of unemployed, homeless and other disenfranchised populations. Emergency psychiatry services have sometimes been able to offer accessibility, convenience, and anonymity. While many of the patients who have used psychiatric emergency services shared common sociological and demographic characteristics, the symptoms and needs expressed have not conformed to any single psychiatric profile. The individualized care needed for patients utilizing psychiatric emergency services is evolving, requiring an always changing and sometimes complex treatment approach. Scope Suicide attempts and suicidal thoughts As of 2000, the World Health Organization estimated one million suicides in the world each year. There are countless more suicide attempts. Psychiatric emergency service settings exist to treat the mental disorders associated with an increased risk of suicide or suicide attempts. Mental health professionals in these settings are expected to predict acts of violence patients may commit against themselves (or others), even though the complex factors leading to a suicide can stem from many sources, including psychosocial, biological, interpersonal, anthropological, and religious. These mental health professionals will use any resources available to them to determine risk factors, make an overall assessment, and decide on any necessary treatment. Violent behavior Aggression can be the result of both internal and external factors that create a measurable activation in the autonomic nervous system. This activation can become evident through symptoms such as the clenching of fists or jaw, pacing, slamming doors, hitting palms of hands with fists, or being easily startled. It is estimated that 17% of visits to psychiatric emergency service settings are homicidal in origin and an additional 5% involve both suicide and homicide. Violence is also associated with many conditions such as acute intoxication, acute psychosis, paranoid personality disorder, antisocial personality disorder, narcissistic personality disorder and borderline personality disorder. Additional risk factors have also been identified which may lead to violent behavior. Such risk factors may include prior arrests, presence of hallucinations, delusions or other neurological impairment, being uneducated, unmarried, etc. Mental health professionals complete violence risk assessments to determine both security measures and treatments for the patient. Psychosis Patients with psychotic symptoms are common in psychiatric emergency service settings. The determination of the source of the psychosis can be difficult. Sometimes patients brought into the setting in a psychotic state have been disconnected from their previous treatment plan. While the psychiatric emergency service setting will not be able to provide long-term care for these types of patients, it can exist to provide a brief respite and reconnect the patient to their case manager and/or reintroduce necessary psychiatric medication. A visit to a crisis unit by a patient with a chronic mental disorder may also indicate the existence of an undiscovered precipitant, such as change in the lifestyle of the individual, or a shifting medical condition. These considerations can play a part in an improvement to an existing treatment plan. An individual could also be experiencing an acute onset of psychosis. Such conditions can be prepared for diagnosis by obtaining a medical or psychopathological history of a patient, performing a mental status examination, conducting psychological testing, obtaining neuroimages, and obtaining other neurophysiologic measurements. Following this, the mental health professional can perform a differential diagnosis and prepare the patient for treatment. As with other patient care considerations, the origins of acute psychosis can be difficult to determine because of the mental state of the patient. However, acute psychosis is classified as a medical emergency requiring immediate and complete attention according to Shubham kumar. The lack of identification and treatment can result in suicide, homicide, or other violence. Substance dependence, abuse and intoxication Another common cause of psychotic symptoms is substance intoxication. These acute symptoms may resolve after a period of observation or limited psychopharmacological treatment. However the underlying issues, such as substance dependence or abuse, is difficult to treat in the emergency department, as it is a long term condition. Both acute alcohol intoxication as well as other forms of substance abuse can require psychiatric interventions. Acting as a depressant of the central nervous system, the early effects of alcohol are usually desired for and characterized by increased talkativeness, giddiness, and a loosening of social inhibitions. Besides considerations of impaired concentration, verbal and motor performance, insight, judgment and short-term memory loss which could result in behavioral change causing injury or death, levels of alcohol below 60 milligrams per deciliter of blood are usually considered non-lethal. However, individuals at 200 milligrams per deciliter of blood are considered grossly intoxicated and concentration levels at 400 milligrams per deciliter of blood are lethal, causing complete anesthesia of the respiratory system. Beyond the dangerous behavioral changes that occur after the consumption of certain amounts of alcohol, idiosyncratic intoxication could occur in some individuals even after the consumption of relatively small amounts of alcohol. Episodes of this impairment usually consist of confusion, disorientation, delusions and visual hallucinations, increased aggressiveness, rage, agitation and violence. Chronic alcoholics may also have alcoholic hallucinosis, wherein the cessation of prolonged drinking may trigger auditory hallucinations. Such episodes can last for a few hours or an entire week. Antipsychotics are often used to treat these symptoms. Patients may also be treated for substance abuse following the administration of psychoactive substances containing amphetamine, caffeine, tetrahydrocannabinol, cocaine, phencyclidines, or other inhalants, opioids, sedatives, hypnotics, anxiolytics, psychedelics, dissociatives and deliriants. Clinicians assessing and treating substance abusers must establish therapeutic rapport to counter denial and other negative attitudes directed towards treatment. In addition, the clinician must determine substances used, the route of administration, dosage, and time of last use to determine the necessary short and long-term treatments. An appropriate choice of treatment setting must also be determined. These settings may include outpatient facilities, partial hospitals, residential treatment centers, or hospitals. Both the immediate and long-term treatment and setting is determined by the severity of dependency and seriousness of physiological complications arising from the abuse. Hazardous drug reactions and interactions Overdoses, drug interactions, and dangerous reactions from psychiatric medications, especially antipsychotics, are considered psychiatric emergencies. Neuroleptic malignant syndrome is a potentially lethal complication of first or second generation antipsychotics. If untreated, neuroleptic malignant syndrome can result in fever, muscle rigidity, confusion, unstable vital signs, or even death. Serotonin syndrome can result when selective serotonin reuptake inhibitors or monoamine oxidase inhibitors mix with buspirone. Severe symptoms of serotonin syndrome include hyperthermia, delirium, and tachycardia that may lead to shock. Often patients with severe general medical symptoms, such as unstable vital signs, will be transferred to a general medical emergency department or medicine service for increased monitoring. Personality disorders Disorders manifesting dysfunction in areas related to cognition, affectivity, interpersonal functioning and impulse control can be considered personality disorders. Patients with a personality disorder will usually not complain about symptoms resulting from their disorder. Patients with an emergency phase of a personality disorder may showcase combative or suspicious behavior, have brief psychotic episodes, or be delusional. Compared with outpatient settings and the general population, the prevalence of individuals with personality disorders in inpatient psychiatric settings is usually 7–25% higher. Clinicians working with such patients attempt to stabilize the individual to their baseline level of function. Anxiety Patients with an extreme case of anxiety may seek treatment when all support systems have been exhausted and they are unable to bear the anxiety. Feelings of anxiety may present in different ways from an underlying medical illness or psychiatric disorder, a secondary functional disturbance from another psychiatric disorder, from a primary psychiatric disorder such as panic disorder or generalized anxiety disorder, or as a result of stress from such conditions as adjustment disorder or post-traumatic stress disorder. Clinicians usually attempt to first provide a "safe harbor" for the patient so that assessment processes and treatments can be adequately facilitated. The initiation of treatments for mood and anxiety disorders are important as patients with anxiety disorders have a higher risk of premature death. Disasters Natural disasters and man-made hazards can cause severe psychological stress in victims surrounding the event. Emergency management often includes psychiatric emergency services designed to help victims cope with the situation. The impact of disasters can cause people to feel shocked, overwhelmed, immobilized, panic-stricken, or confused. Hours, days, months and even years after a disaster, individuals can experience tormenting memories, vivid nightmares, develop apathy, withdrawal, memory lapses, fatigue, loss of appetite, insomnia, depression, irritability, panic attacks, or dysphoria. Due to the typically disorganized and hazardous environment following a disaster, mental health professionals typically assess and treat patients as rapidly as possible. Unless a condition is threatening life of the patient, or others around the patient, other medical and basic survival considerations are managed first. Soon after a disaster clinicians may make themselves available to allow individuals to ventilate to relieve feelings of isolation, helplessness and vulnerability. Dependent upon the scale of the disaster, many victims may develop either chronic or acute post-traumatic stress disorder. Patients affected severely by this disorder often are admitted to psychiatric hospitals to stabilize the individual. Abuse Incidents of physical abuse, sexual abuse or rape can result in dangerous outcomes to the victim of the criminal act. Victims may have extreme anxiety, fear, helplessness, confusion, eating or sleeping disorders, hostility, guilt and shame. Managing the response usually encompasses coordinating psychological, medical and legal considerations. Dependent upon legal requirements in the region, mental health professionals may be required to report criminal activity to a police force. Mental health professionals will usually gather identifying data during the initial assessment and refer the patient, if necessary, to receive medical treatment. Medical treatment may include a physical examination, collection of medicolegal evidence, and determination of the risk of pregnancy, if applicable. Treatment Treatments in psychiatric emergency service settings are typically transitory in nature and only exist to provide dispositional solutions and/or to stabilize life-threatening conditions. Once stabilized, patients with chronic conditions may be transferred to a setting which can provide long term psychiatric rehabilitation. Prescribed treatments within the emergency service setting vary dependent upon the patient's condition. Different forms of psychiatric medication, psychotherapy, or electroconvulsive therapy may be used in the emergency setting. The introduction and efficacy of psychiatric medication as a treatment option in psychiatry has reduced the utilization of physical restraints in emergency settings, by reducing dangerous symptoms resulting from acute exacerbation of mental illness or substance intoxication. Medications With time as a critical aspect of emergency psychiatry, the rapidity of effect is an important consideration. Pharmacokinetics is the movement of drugs through the body with time and is at least partially reliant upon the route of administration, absorption, distribution and metabolism of the medication. A common route of administration is oral administration, however if this method is to work the drug must be able to get to the stomach and stay there. In cases of vomiting and nausea this method of administration is not an option. Suppositories can, in some situations, be administered instead. Medication can also be administered through intramuscular injection, or through intravenous injection. The amount of time required for absorption varies dependent upon many factors including drug solubility, gastrointestinal motility and pH. If a medication is administered orally the amount of food in the stomach may also affect the rate of absorption. Once absorbed medications must be distributed throughout the body, or usually with the case of psychiatric medication, past the blood–brain barrier to the brain. With all of these factors affecting the rapidity of effect, the time until the effects are evident varies. Generally, though, the timing with medications is relatively fast and can occur within several minutes. As an example, physicians usually expect to see a remission of symptoms thirty minutes after haloperidol, an antipsychotic, is administered intramuscularly. Antipsychotics, especially Haloperidol, as well as assorted benzodiazepines are the most frequently used drugs in emergency psychiatry, especially agitation. Psychotherapy Other treatment methods may be used in psychiatric emergency service settings. Brief psychotherapy can be used to treat acute conditions or immediate problems as long as the patient understands his or her issues are psychological, the patient trusts the physician, the physician can encourage hope for change, the patient has motivation to change, the physician is aware of the psychopathological history of the patient, and the patient understands that their confidentiality will be respected. The process of brief therapy under emergency psychiatric conditions includes the establishment of a primary complaint from the patient, realizing psychosocial factors, formulating an accurate representation of the problem, coming up with ways to solve the problem, and setting specific goals. The information gathering aspect of brief psychotherapy is therapeutic because it helps the patient place his or her problem in the proper perspective. If the physician determines that deeper psychotherapy sessions are required, he or she can transition the patient out of the emergency setting and into an appropriate clinic or center. ECT Electroconvulsive therapy is a controversial form of treatment which cannot be involuntarily applied in psychiatric emergency service settings. Instances wherein a patient is depressed to such a severe degree that the patient cannot be stopped from hurting himself or herself or when a patient refuses to swallow, eat or drink medication, electroconvulsive therapy could be suggested as a therapeutic alternative. While preliminary research suggests that electroconvulsive therapy may be an effective treatment for depression, it usually requires a course of six to twelve sessions of convulsions lasting at least 20 seconds for those antidepressant effects to occur. Observation and collateral information There are other essential aspects of emergency psychiatry: observation and collateral information. The observation of the patient's behavior is an important aspect of emergency psychiatry as it allows the clinicians working with the patient to estimate prognosis and improvements/declines in condition. Many jurisdictions base involuntary commitment on dangerousness or the inability to care for one's basic needs. Observation for a period of time may help determine this. For example, if a patient who is committed for violent behavior in the community, continues to behave in an erratic manner without clear purpose, this will help the staff decide that hospital admission may be needed. Collateral information or parallel information is information obtained from family, friends or treatment providers of the patient. Some jurisdictions require consent from the patient to obtain this information while others do not. For example, with a patient who is thought to be paranoid about people following him or spying on him, this information can be helpful discern if these thoughts are more or less likely to be based in reality. Past episodes of suicide attempts or violent behavior can be confirmed or disproven. Disposition Patient receive emergency services often on a time limited basis such as 24 or 72 hours. After this time, and sometimes earlier, the staff must decide the next place for the patient to receive services. This is referred to as disposition. This is one of the essential features of emergency psychiatry. Hospital admission The staff will need to determine if the patient needs to be admitted to a psychiatric inpatient facility or if they can be safely discharged to the community after a period of observation and/or brief treatment. Initial emergency psychiatric evaluations usually involve patients who are acutely agitated, paranoid, or who are suicidal. Initial evaluations to determine admission and interventions are designed to be as therapeutic as possible. Involuntary commitment Involuntary commitment, or sectioning, refers to situations where police officers, health officers, or health professionals classify an individual as dangerous to themselves, others, gravely disabled, or mentally ill according to the applicable government law for the region. After an individual is transported to a psychiatric emergency service setting, a preliminary professional assessment is completed which may or may not result in involuntary treatment. Some patients may be discharged shortly after being brought to psychiatric emergency services while others will require longer observation and the need for continued involuntary commitment will exist. While some patients may initially come voluntarily, it may be realized that they pose a risk to themselves or others and involuntary commitment may be initiated at that point. Referrals and voluntary hospitalization In some locations, such as the United States, voluntary hospitalizations are outnumbered by involuntary commitments partly due to the fact that insurance tends not to pay for hospitalization unless an imminent danger exists to the individual or community. In addition, psychiatric emergency service settings admit approximately one third of patients from assertive community treatment centers. Therefore, patients who are not admitted will be referred to services in the community. See also Betty Pfefferbaum, psychiatrist, mental health treatment for children after a disaster Medically indigent adult Mental health first aid References Further reading Otong-Antai, D. (2001). Psychiatric Emergencies. Eau Claire: PESI Healthcare. Sanchez, Federico, (2007), "Suicide Explained, A Neuropsychological Approach." Fishkind, AB. (2002)" Calming Agitation with Words, not Drugs: 10 Commandments for Safety" Glick RL, Berlin JS, Fishkind AB, Zeller SL (2008) "Emergency Psychiatry: Principles and Practice." Baltimore: Lippincott Williams & Wilkins Zeller SL. Treatment of psychiatric patients in emergency settings. Primary Psychiatry 2010;17:35–41 http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=2675 External links American Association for Emergency Psychiatry ATSDR - Psychological Responses to Hazardous Substances U.S. Department of Health and Human Services (public domain) Japanese Association of Emergency Psychiatry Psychiatric specialities Emergency medicine Suicide Emergency mental health services

Speech–language pathology

Speech–language pathology (a.k.a. speech and language pathology or logopedics) is a healthcare and academic discipline concerning the evaluation, treatment, and prevention of communication disorders, including expressive and mixed receptive-expressive language disorders, voice disorders, speech sound disorders, speech disfluency, pragmatic language impairments, and social communication difficulties, as well as swallowing disorders across the lifespan. It is an allied health profession regulated by professional bodies including the American Speech-Language-Hearing Association (ASHA) and Speech Pathology Australia. The field of speech-language pathology is practiced by a clinician known as a speech-language pathologist (SLP) or a speech and language therapist (SLT). SLPs also play an important role in the screening, diagnosis, and treatment of autism spectrum disorder (ASD), often in collaboration with pediatricians and psychologists. History The development of speech-language pathology into a profession took different paths in the various regions of the world. Three identifiable trends influenced the evolution of speech-language pathology in the United States during the late 19th century to early 20th century: the elocution movement, scientific revolution, and the rise of professionalism. Groups of "speech correctionists" formed in the early 1900s. The American Academy of Speech Correction was founded in 1925, which became ASHA in 1978. The profession Speech-language pathologists (SLPs) provide a wide range of services, mainly on an individual basis, but also as support for families, support groups, and providing information for the general public. SLPs work to assess levels of communication needs, make diagnoses based on the assessments, and then treat the diagnoses or address the needs. Speech/language services begin with initial screening for communication and/or swallowing disorders and continue with assessment and diagnosis, consultation for the provision of advice regarding management, intervention, and treatment, and providing counseling and other followup services for these disorders. Services are provided in the following areas: Developmental language and early feeding neurodevelopment and prevention; cognitive aspects of communication (e.g., attention, memory, problem-solving, executive functions); speech (phonation, articulation, fluency, resonance, and voice including aeromechanical components of respiration); language (phonology, morphology, syntax, semantics, and pragmatic/social aspects of communication) including comprehension and expression in oral, written, graphic, and manual modalities; language processing; preliteracy and language-based literacy skills, phonological awareness; augmentative and alternative communication (AAC) for individuals with severe language and communication impairments; swallowing or other upper aerodigestive functions such as infant feeding and aeromechanical events (evaluation of esophageal function is for the purpose of referral to medical professionals); voice (hoarseness, dysphonia), poor vocal volume (hypophonia), abnormal (e.g., rough, breathy, strained) vocal quality. Research demonstrates voice therapy to be especially helpful with certain patient populations; individuals with Parkinson's Disease often develop voice issues as a result of their disease. sensory awareness related to communication, swallowing, or other upper aerodigestive functions. Speech, language, and swallowing disorders result from a variety of causes, such as a stroke, brain injury, hearing loss, developmental delay, a cleft palate, cerebral palsy, or emotional issues. A common misconception is that speech–language pathology is restricted to the treatment of articulation disorders (e.g., helping English-speaking individuals enunciate the traditionally difficult r) and/or the treatment of individuals who stutter but, in fact, speech–language pathology is concerned with a broad scope of speech, language, literacy, swallowing, and voice issues involved in communication, some of which include: Word-finding and other semantic issues, either as a result of a specific language impairment (SLI) such as a language delay or as a secondary characteristic of a more general issue such as dementia. Social communication difficulties involving how people communicate or interact with others (pragmatics). Language impairments, including difficulties creating sentences that are grammatical (syntax) and modifying word meaning (morphology). Literacy impairments (reading and writing) related to the letter-to-sound relationship (phonics), the word-to-meaning relationship (semantics), and understanding the ideas presented in a text (reading comprehension). Voice difficulties, such as a raspy voice, a voice that is too soft, or other voice difficulties that negatively impact a person's social or professional performance. Cognitive impairments (e.g. attention, memory, executive function) to the extent that they interfere with communication. Parent, caregiver, and other communication partner coaching. Primary pediatric speech and language disorders include: (i) receptive and (ii) expressive language disorders, (iii) speech sound disorders, (iv) childhood apraxia of speech (CAS), (v) stuttering, and (vi) language-based learning disabilities. Speech-language pathologists (SLPs) work with people of all ages. Swallowing disorders include difficulties in any phase of the swallowing process (i.e., oral, pharyngeal, esophageal), as well as functional dysphagia and feeding disorders. Swallowing disorders can occur at any age and can stem from multiple causes. Multi-discipline collaboration SLPs collaborate with other health care professionals, often working as part of a multidisciplinary team. They can provide information and referrals to audiologists, physicians, dentists, nurses, nurse practitioners, occupational therapists, rehabilitation psychologists, dietitians, educators, behavior consultants (applied behavior analysis), and parents as dictated by the individual client's needs. For example, the treatment for patients with cleft lip and palate often requires multidisciplinary collaboration. Speech–language pathologists can be very beneficial in helping resolve speech problems associated with cleft lip and palate. Research has indicated that children who receive early language intervention are less likely to develop compensatory error patterns later in life, although speech therapy outcomes are usually better when surgical treatment is performed earlier. Another area of collaboration relates to auditory processing disorders, where SLPs can collaborate in assessments and provide intervention where there is evidence of speech, language, and/or other cognitive-communication disorders. Working environments SLPs work in a variety of clinical and educational settings. SLPs work in public and private hospitals, private practices, skilled nursing facilities (SNFs), long-term acute care (LTAC) facilities, hospice, and home healthcare. SLPs may also work as part of the support structure in the education system, working in both public and private schools, colleges, and universities. Some SLPs also work in community health, providing services at prisons and young offenders' institutions or providing expert testimony in applicable court cases. Following ASHA's 2005 approval of the delivery of speech/language services via video conference or telepractice, SLPs in the United States have begun to use this service model. Children with speech, language, and communication needs (SLCN) are particularly at risk of not being heard because of communication challenges. Speech-language pathologists (SLPs) can explain the significance of supporting communication as a tool for the child to shape and influence choices available to them in their lives, even though it is advised that children with SLCN can and should be actively involved as equal partners in decision-making about their communication needs. Building these skills is especially crucial for SLPs working in settings related to traditional education. Research SLPs conduct research related to communication sciences and disorders, swallowing disorders, or other upper aerodigestive functions. Experimental, empirical, and scientific methodologies that build on hypothesis testing and logical, deductive reasoning have dominated research in speech-language pathology. Other types of research in the field are complemented by qualitative research, which has also led to new insights, techniques, and research methods as well as new approaches in ways that are responsive to our customers and communities. Education and training United States In the United States, speech–language pathologists must hold a master's degree from an ASHA-accredited program. Following graduation and passing a nation-wide board exam, SLPs typically begin their Clinical Fellowship Year, during which they are granted a provisional license and receive guidance from their supervisor. At the end of this process, SLPs may choose to apply for ASHA's Certificate of Clinical Competence and apply for full state licensure. SLPs may additionally choose to earn advanced degrees such as a clinical doctorate in speech–language pathology, PhD, or EdD. Methods of assessment Many approaches exist to assess language, communication, speech and swallowing. Two main aspects of assessment can be to determine the extent of breakdown (impairment-level), or how communication can be supported (functional level). When evaluating impairment-based level of breakdown, therapists are trained to use a cognitive neuropsychological approach to assessment, to precisely determine what aspect of communication is impaired. Some therapists use assessments that are based on historic anatomical models of language, that have since been shown to be unreliable. These tools are often preferred by therapists working within a medical model, where medics request a 'type' of impairment, and a 'severity' rating. The broad tools available allow clinicians to precisely select the aspect of communication that they wish to assess. Because school-based speech therapy is run under state guidelines and funds, the process of assessment and qualification is more strict. To qualify for in-school speech therapy, students must meet the state's criteria on language testing and speech standardization. Due to such requirements, some students may not be assessed in an efficient time frame or their needs may be undermined by criteria. For a private clinic, students are more likely to qualify for therapy because it is a paid service with more availability. Clients and patients Speech–language pathologists work with clients and patients who may present with a wide range of issues. Infants and children Premature infants are at higher risk of feeding and later language needs and SLTS work with this cohort to prevent developmental difficulties and support neonatal care Infants with injuries due to complications at birth, feeding and swallowing difficulties, including dysphagia Children with mild, moderate or severe: Genetic disorders that adversely affect speech, language and/or cognitive development including cleft palate, Down syndrome, DiGeorge syndrome Attention deficit hyperactivity disorder Autism spectrum disorders, including Asperger syndrome Developmental delay Feeding disorders, including oral motor deficits Cranial nerve damage Hearing loss Craniofacial anomalies that adversely affect speech, language and/or cognitive development Language delay Specific language impairment Specific difficulties in producing sounds, called articulation disorders, (including vocalic /r/ and lisps) Pediatric traumatic brain injury Developmental verbal dyspraxia Cleft palate United States In the US, some children are eligible to receive speech therapy services, including assessment and lessons through the public school system. If not, private therapy is readily available through personal lessons with a qualified speech–language pathologist or the growing field of telepractice. Teleconferencing tools such as Skype are being used more commonly as a means to access remote locations in private therapy practice, such as in the geographically diverse south island of New Zealand. More at-home or combination treatments have become readily available to address specific types of articulation disorders. The use of mobile applications in speech therapy is also growing as an avenue to bring treatment into the home. United Kingdom In the UK, children are entitled to an assessment by local NHS speech- and language-therapy teams, usually after referral by health visitors or education settings, but parents are also entitled to request an assessment directly. If treatment is appropriate, an educational plan will be drawn up. Speech therapists often play a role in multi-disciplinary teams when a child has speech delay or disorder as part of a wider health condition. The Children's Commissioner for England reported in June 2019 that there was a postcode lottery; £291.65 a year per head was spent on services in some areas, while the budget in some areas was £30.94 or less. In 2018, 193,971 children in English primary schools were on the special educational needs register needing speech-therapy services. Speech and language therapists work in acute settings and are often integrated into the MDT in multiple areas of speciality for neonatal, children and adult services. Areas include but not limited to; neonatal care, respiratory, ENT, gastrointestinal, stroke, Neurology,ICU, oncology and geriatric care Children and adults Puberphonia Neonatal care Respiratory ENT Cerebral palsy Head injury (Traumatic brain injury) Hearing loss and impairments Learning difficulties including Dyslexia Specific language impairment (SLI) Auditory processing disorder Physical disabilities Speech disorders (such as oral dyspraxia) Stammering, stuttering (disfluency) Stroke Voice disorders (dysphonia) Language delay Motor speech disorders (dysarthria or developmental verbal dyspraxia) Naming difficulties (anomia) Dysgraphia, agraphia Cognitive communication disorders Pragmatics Laryngectomies Tracheostomies Oncology (ear, nose or throat cancer) Adults Adults with aphasia Adults with mild, moderate, or severe eating, feeding and swallowing difficulties, including dysphagia Adults recovering from significant tumors in the bronchus, lung, oropharynx, breast, and brain Adults with mild, moderate, or severe language difficulties as a result of: Motor neuron diseases, Alzheimer's disease, Dementia, Huntington's disease, Hearing loss Multiple sclerosis, Parkinson's disease, Traumatic brain injury, Mental health issues Stroke Progressive neurological conditions such as cancer of the head, neck and throat (including laryngectomy) Aphasic Adults seeking transgender-specific voice training, including voice feminization and voice masculinization See also All India Institute of Speech and Hearing (AIIMS) Applied linguistics Communicative disorders assistant List of university speech–language pathology departments List of voice disorders Motor theory of speech perception Neurolinguistics Online speech therapy Oral myology Origin of speech Speech acquisition Speech Buddies Speech perception Speech processing Speech repetition References Further reading Janes, Tina Leann; Zupan, Barbra; Signal, Tania (2021–02). "Community awareness of speech pathology: A regional perspective". Australian Journal of Rural Health. External links American Speech–Language–Hearing Association (ASHA) – Communication for a Lifetime National Institutes of Health – Voice, Speech, and Language The Royal College of Speech and Language Therapists Speech-Language Pathologists – O*Net Online Applied linguistics Health care occupations Medical terminology Rehabilitation medicine Rehabilitation team Special education Vocal skills Speech

Truth serum

"Truth serum" is a colloquial name for any of a range of psychoactive drugs used in an effort to obtain information from subjects who are unable or unwilling to provide it otherwise. These include ethanol, scopolamine, 3-quinuclidinyl benzilate, midazolam, flunitrazepam, sodium thiopental, and amobarbital, among others. Although a variety of such substances have been tested, serious issues have been raised about their use scientifically, ethically and legally. There is currently no drug proven to cause consistent or predictable enhancement of truth-telling. Subjects questioned under the influence of such substances have been found to be suggestible and their memories subject to reconstruction and fabrication. When such drugs have been used in the course of investigating civil and criminal cases, they have not been accepted by Western legal systems and legal experts as genuine investigative tools. In the United States, it has been suggested that their use is a potential violation of the Fifth Amendment of the U.S. Constitution (the right to remain silent). Concerns have also been raised through the European Court of Human Rights arguing that use of a truth serum could be considered a violation of a human right to be free from degrading treatment, or could be considered a form of torture. It has been noted to be a violation of the Inter-American Convention to Prevent and Punish Torture. "Truth serum" was previously used in the management of psychotic patients in the practice of psychiatry. In a therapeutic context, the controlled administration of intravenous hypnotic medications is called "narcosynthesis" or "narcoanalysis". Such application was first documented by Dr. William Bleckwenn. Reliability and suggestibility of patients are concerns, and the practice of chemically inducing an involuntary mental state is now widely considered to be a form of torture. Active chemical substances Sedatives or hypnotics that alter higher cognitive function include ethanol, scopolamine, 3-quinuclidinyl benzilate, potent short or intermediate acting hypnotic benzodiazepines such as midazolam, flunitrazepam, and various short and ultra-short acting barbiturates, including sodium thiopental (commonly known by the brand name Pentothal) and amobarbital (formerly known as sodium amytal). Reliability While there have been many clinical studies of the efficacy of narcoanalysis in interrogation or lie detection, there is dispute whether any of them qualify as a randomized, controlled study, that would meet scientific standards for determining effectiveness. Use by country India India's Central Bureau of Investigation has used intravenous barbiturates for interrogation, often in high-profile cases. One such case was the interrogation of Ajmal Kasab, the only terrorist captured alive by police in the 2008 attacks in Mumbai, India. Kasab was a Pakistani militant and a member of the Lashkar-e-Taiba terrorist group. On 3 May 2010, Kasab was found guilty of 80 offences, including murder, waging war against India, possessing explosives, and other charges. On 6 May 2010, the same trial court sentenced him to death on four counts and to a life sentence on five counts. The Central Bureau of Investigation also conducted this test on Krishna, a key witness and suspect in the high-profile 2008 Aarushi-Hemraj Murder Case to seek more information from Krishna and also determine his credibility as a witness with key information, yet not known to the investigating authorities. Per unverified various media sources, Krishna had purported to have deemed Hemraj (the prime suspect) as not guilty of Aarushi's murder, claiming he [Hemraj] "treated Aarushi like his own daughter". On May 5, 2010 the Supreme Court Judge Balasubramaniam in the case "Smt. Selvi vs. State of Karnataka" held that narcoanalysis, polygraph and brain mapping tests were to be allowed with the consent of the accused. The judge stated: "We are of the considered opinion that no individual can be forced and subjected to such techniques involuntarily, and by doing so it amounts to unwarranted intrusion of personal liberty." In Gujarat, Madhya Pradesh High Court permitted narcoanalysis in the investigation of a killing of a tiger that occurred in May 2010. The Jhurjhura Tigress at Bandhavgarh National Park, a mother of three cubs, was found dead as a result of being hit by a vehicle. A Special Task Force requested the narcoanalysis testing of four persons, one of whom refused to consent on grounds of potential post-test complications. USSR In 2004, Novaya Gazeta, with reference to KGB General Oleg Kalugin, published an article that said that since the end of the 1980s the First and Second Directorates of the KGB had used, in exceptional cases and mostly on foreign citizens, a soluble odourless, colourless and tasteless substance code-named SP-117, an improved successor to similar drugs used by the KGB prior, that was effective in making a subject lose control of oneself 15 minutes after intake. Most importantly, a person who would be given, consecutively, two parts of the drug, i.e. both the "dote" and "antidote", would have no recollection of what had occurred in between and feel afterward as though he had suddenly fallen asleep, the preferable way to administer the "dote" being in an alcoholic drink, as that would serve as a plausible explanation of the sudden onset of drowsiness. Other reports state that SP-117 was just a form of concentrated alcohol meant to be added to alcoholic drinks such as champagne. Russian Federation According to the Russian Foreign Intelligence Service (SVR) officer, Alexander Kouzminov, who quit the service in the early 1990s, the officers of SVR′s Directorate S, which runs SVR's "illegals", primarily used the drug to verify fidelity and trustworthiness of their agents who operated overseas, such as Vitaly Yurchenko. According to Alexander Litvinenko, Russian presidential candidate Ivan Rybkin was drugged with the same substance by FSB agents during his kidnapping in 2004. United States Scopolamine was promoted by obstetrician Robert Ernest House as an advance that would prevent false convictions, beginning in 1922. He had noted that women in childbirth who were given scopolamine could answer questions accurately even while in a state of twilight sleep, and were oftentimes "exceedingly candid" in their remarks. House proposed that scopolamine could be used when interrogating suspected criminals. He even arranged to administer scopolamine to prisoners in the Dallas County jail. Both men were believed to be guilty, both denied guilt under scopolamine, and both were eventually acquitted. In 1926, the use of scopolamine was rejected in a court case, by Judge Robert Walker Franklin, who questioned both its scientific origin, and the uncertainty of its effect. The United States Office of Strategic Services (OSS) experimented with the use of mescaline, scopolamine, and marijuana as possible truth drugs during World War II. They concluded that the effects were not much different from those of alcohol: subjects became more talkative but that did not mean they were more truthful. Like hypnosis, there were also issues of suggestibility and interviewer influence. Cases involving scopolamine resulted in a mixture of testimonies both for and against those suspected, at times directly contradicting each other. LSD was also considered as a possible truth serum, but found unreliable. During the 1950s and 1960s, the United States Central Intelligence Agency (CIA) carried out a number of investigations including Project MKUltra and Project MKDELTA, which involved illegal use of truth drugs including LSD. A CIA report from 1961, released in 1993, concludes: In 1963, the U.S. Supreme Court ruled, in Townsend v. Sain, that confessions produced as a result of ingestion of truth serum were "unconstitutionally coerced" and therefore inadmissible. The viability of forensic evidence produced from truth sera has been addressed in lower courts – judges and expert witnesses have generally agreed that they are not reliable for lie detection. In 1967, during his investigation into the assassination of President John F. Kennedy, New Orleans District Attorney Jim Garrison arranged for his key witness, Perry Russo, to be administered sodium pentothal before being questioned about his knowledge regarding an alleged conspiracy. Russo would later describe "his conditioning by the DA's office as a complete brainwashing job." In 1995, during the search for evidence that could acquit Andres English-Howard, his defense attorney employed methohexital. More recently, a judge approved the use of narcoanalysis in the 2012 Aurora, Colorado shooting trial to evaluate whether James Eagan Holmes's state of mind was valid for an insanity plea. Judge William Sylvester ruled that prosecutors would be allowed to interrogate Holmes "under the influence of a medical drug designed to loosen him up and get him to talk", such as sodium amytal, if he filed an insanity plea. The hope was that a 'narcoanalytic interview' could confirm whether or not he had been legally insane on 20 July, the date of the shootings. It is not known whether such an examination was carried out. William Shepherd, chair of the criminal justice section of the American Bar Association, stated, with respect to the Holmes case, that use of a "truth drug" as proposed, "to ascertain the veracity of a defendant's plea of insanity... would provoke intense legal argument relating to Holmes's right to remain silent under the fifth amendment of the US constitution." Discussing possible effectiveness of such an examination, psychiatrist August Piper stated that "amytal's inhibition-lowering effects in no way prompt the subject to offer up true statements or memories." Psychology Today Scott Linfield noted, as per Piper, that "there's good reason to believe that truth serums merely lower the threshold for reporting virtually all information, both true and false." See also Human experimentation Microexpression Narcotics Pharmacological torture Polygraph Project MKUltra Project Chatter Project Bluebird In vino veritas References External links Informal demonstration of thiopental (video), BBC, 4 October 2013. Psychopharmacology Deception Drug culture Lie detection Human rights abuses

Structuralism

Structuralism is an intellectual current and methodological approach, primarily in the social sciences, that interprets elements of human culture by way of their relationship to a broader system. It works to uncover the structural patterns that underlie all the things that humans do, think, perceive, and feel. Alternatively, as summarized by philosopher Simon Blackburn, structuralism is:"The belief that phenomena of human life are not intelligible except through their interrelations. These relations constitute a structure, and behind local variations in the surface phenomena there are constant laws of abstract structure."The structuralist mode of reasoning has since been applied in a range of fields, including anthropology, sociology, psychology, literary criticism, economics, and architecture. Along with Claude Lévi-Strauss, the most prominent thinkers associated with structuralism include linguist Roman Jakobson and psychoanalyst Jacques Lacan. History and background The term structuralism is ambiguous, referring to different schools of thought in different contexts. As such, the movement in humanities and social sciences called structuralism relates to sociology. Emile Durkheim based his sociological concept on 'structure' and 'function', and from his work emerged the sociological approach of structural functionalism. Apart from Durkheim's use of the term structure, the semiological concept of Ferdinand de Saussure became fundamental for structuralism. Saussure conceived language and society as a system of relations. His linguistic approach was also a refutation of evolutionary linguistics. Structuralism in Europe developed in the early 20th century, mainly in France and the Russian Empire, in the structural linguistics of Ferdinand de Saussure and the subsequent Prague, Moscow, and Copenhagen schools of linguistics. As an intellectual movement, structuralism became the heir to existentialism. After World War II, an array of scholars in the humanities borrowed Saussure's concepts for use in their respective fields. French anthropologist Claude Lévi-Strauss was arguably the first such scholar, sparking a widespread interest in structuralism. Throughout the 1940s and 1950s, existentialism, such as that propounded by Jean-Paul Sartre, was the dominant European intellectual movement. Structuralism rose to prominence in France in the wake of existentialism, particularly in the 1960s. The initial popularity of structuralism in France led to its spread across the globe. By the early 1960s, structuralism as a movement was coming into its own and some believed that it offered a single unified approach to human life that would embrace all disciplines. By the late 1960s, many of structuralism's basic tenets came under attack from a new wave of predominantly French intellectuals/philosophers such as historian Michel Foucault, Jacques Derrida, Marxist philosopher Louis Althusser, and literary critic Roland Barthes. Though elements of their work necessarily relate to structuralism and are informed by it, these theorists eventually came to be referred to as post-structuralists. Many proponents of structuralism, such as Lacan, continue to influence continental philosophy and many of the fundamental assumptions of some of structuralism's post-structuralist critics are a continuation of structuralist thinking. Russian functional linguist Roman Jakobson was a pivotal figure in the adaptation of structural analysis to disciplines beyond linguistics, including philosophy, anthropology, and literary theory. Jakobson was a decisive influence on anthropologist Claude Lévi-Strauss, by whose work the term structuralism first appeared in reference to social sciences. Lévi-Strauss' work in turn gave rise to the structuralist movement in France, also called French structuralism, influencing the thinking of other writers, most of whom disavowed themselves as being a part of this movement. This included such writers as Louis Althusser and psychoanalyst Jacques Lacan, as well as the structural Marxism of Nicos Poulantzas. Roland Barthes and Jacques Derrida focused on how structuralism could be applied to literature. Accordingly, the so-called "Gang of Four" of structuralism is considered to be Lévi-Strauss, Lacan, Barthes, and Michel Foucault.[dubious – discuss] Ferdinand de Saussure The origins of structuralism are connected with the work of Ferdinand de Saussure on linguistics along with the linguistics of the Prague and Moscow schools. In brief, Saussure's structural linguistics propounded three related concepts. Saussure argued for a distinction between langue (an idealized abstraction of language) and parole (language as actually used in daily life). He argued that a "sign" is composed of a "signified" (signifié, i.e. an abstract concept or idea) and a "signifier" (signifiant, i.e. the perceived sound/visual image). Because different languages have different words to refer to the same objects or concepts, there is no intrinsic reason why a specific signifier is used to express a given concept or idea. It is thus "arbitrary." Signs gain their meaning from their relationships and contrasts with other signs. As he wrote, "in language, there are only differences 'without positive terms. Lévi-Strauss Structuralism rejected the concept of human freedom and choice, focusing instead on the way that human experience and behaviour is determined by various structures. The most important initial work on this score was Lévi-Strauss's 1949 volume The Elementary Structures of Kinship. Lévi-Strauss had known Roman Jakobson during their time together at the New School in New York during WWII and was influenced by both Jakobson's structuralism, as well as the American anthropological tradition. In Elementary Structures, he examined kinship systems from a structural point of view and demonstrated how apparently different social organizations were different permutations of a few basic kinship structures. In the late 1958, he published Structural Anthropology, a collection of essays outlining his program for structuralism. Lacan and Piaget Blending Freud and Saussure, French (post)structuralist Jacques Lacan applied structuralism to psychoanalysis. Similarly, Jean Piaget applied structuralism to the study of psychology, though in a different way. Piaget, who would better define himself as constructivist, considered structuralism as "a method and not a doctrine," because, for him, "there exists no structure without a construction, abstract or genetic." 'Third order' Proponents of structuralism argue that a specific domain of culture may be understood by means of a structure that is modelled on language and is distinct both from the organizations of reality and those of ideas, or the imagination—the "third order." In Lacan's psychoanalytic theory, for example, the structural order of "the Symbolic" is distinguished both from "the Real" and "the Imaginary;" similarly, in Althusser's Marxist theory, the structural order of the capitalist mode of production is distinct both from the actual, real agents involved in its relations and from the ideological forms in which those relations are understood. Althusser Although French theorist Louis Althusser is often associated with structural social analysis, which helped give rise to "structural Marxism," such association was contested by Althusser himself in the Italian foreword to the second edition of Reading Capital. In this foreword Althusser states the following: Despite the precautions we took to distinguish ourselves from the 'structuralist' ideology…, despite the decisive intervention of categories foreign to 'structuralism'…, the terminology we employed was too close in many respects to the 'structuralist' terminology not to give rise to an ambiguity. With a very few exceptions…our interpretation of Marx has generally been recognized and judged, in homage to the current fashion, as 'structuralist'.… We believe that despite the terminological ambiguity, the profound tendency of our texts was not attached to the 'structuralist' ideology. Assiter In a later development, feminist theorist Alison Assiter enumerated four ideas common to the various forms of structuralism: a structure determines the position of each element of a whole; every system has a structure; structural laws deal with co-existence rather than change; and structures are the "real things" that lie beneath the surface or the appearance of meaning. In linguistics In Ferdinand de Saussure's Course in General Linguistics, the analysis focuses not on the use of language (parole, 'speech'), but rather on the underlying system of language (langue). This approach examines how the elements of language relate to each other in the present, synchronically rather than diachronically. Saussure argued that linguistic signs were composed of two parts: a signifiant ('signifier'): the "sound pattern" of a word, either in mental projection—e.g., as when one silently recites lines from signage, a poem to one's self—or in actual, any kind of text, physical realization as part of a speech act. a signifié '(signified'): the concept or meaning of the word. This differed from previous approaches that focused on the relationship between words and the things in the world that they designate. Although not fully developed by Saussure, other key notions in structural linguistics can be found in structural "idealism." A structural idealism is a class of linguistic units (lexemes, morphemes, or even constructions) that are possible in a certain position in a given syntagm, or linguistic environment (such as a given sentence). The different functional role of each of these members of the paradigm is called 'value' (French: ). Prague School In France, Antoine Meillet and Émile Benveniste continued Saussure's project, and members of the Prague school of linguistics such as Roman Jakobson and Nikolai Trubetzkoy conducted influential research. The clearest and most important example of Prague school structuralism lies in phonemics. Rather than simply compiling a list of which sounds occur in a language, the Prague school examined how they were related. They determined that the inventory of sounds in a language could be analysed as a series of contrasts. Thus, in English, the sounds /p/ and /b/ represent distinct phonemes because there are cases (minimal pairs) where the contrast between the two is the only difference between two distinct words (e.g. 'pat' and 'bat'). Analyzing sounds in terms of contrastive features also opens up comparative scope—for instance, it makes clear the difficulty Japanese speakers have differentiating /r/ and /l/ in English and other languages is because these sounds are not contrastive in Japanese. Phonology would become the paradigmatic basis for structuralism in a number of different fields. Based on the Prague school concept, André Martinet in France, J. R. Firth in the UK and Louis Hjelmslev in Denmark developed their own versions of structural and functional linguistics. In anthropology According to structural theory in anthropology and social anthropology, meaning is produced and reproduced within a culture through various practices, phenomena, and activities that serve as systems of signification. A structuralist approach may study activities as diverse as food-preparation and serving rituals, religious rites, games, literary and non-literary texts, and other forms of entertainment to discover the deep structures by which meaning is produced and reproduced within the culture. For example, Lévi-Strauss analysed in the 1950s cultural phenomena including mythology, kinship (the alliance theory and the incest taboo), and food preparation. In addition to these studies, he produced more linguistically-focused writings in which he applied Saussure's distinction between langue and parole in his search for the fundamental structures of the human mind, arguing that the structures that form the "deep grammar" of society originate in the mind and operate in people unconsciously. Lévi-Strauss took inspiration from mathematics. Another concept used in structural anthropology came from the Prague school of linguistics, where Roman Jakobson and others analysed sounds based on the presence or absence of certain features (e.g., voiceless vs. voiced). Lévi-Strauss included this in his conceptualization of the universal structures of the mind, which he held to operate based on pairs of binary oppositions such as hot-cold, male-female, culture-nature, cooked-raw, or marriageable vs. tabooed women. A third influence came from Marcel Mauss (1872–1950), who had written on gift-exchange systems. Based on Mauss, for instance, Lévi-Strauss argued an alliance theory—that kinship systems are based on the exchange of women between groups—as opposed to the 'descent'-based theory described by Edward Evans-Pritchard and Meyer Fortes. While replacing Mauss at his Ecole Pratique des Hautes Etudes chair, the writings of Lévi-Strauss became widely popular in the 1960s and 1970s and gave rise to the term "structuralism" itself. In Britain, authors such as Rodney Needham and Edmund Leach were highly influenced by structuralism. Authors such as Maurice Godelier and Emmanuel Terray combined Marxism with structural anthropology in France. In the United States, authors such as Marshall Sahlins and James Boon built on structuralism to provide their own analysis of human society. Structural anthropology fell out of favour in the early 1980s for a number of reasons. D'Andrade suggests that this was because it made unverifiable assumptions about the universal structures of the human mind. Authors such as Eric Wolf argued that political economy and colonialism should be at the forefront of anthropology. More generally, criticisms of structuralism by Pierre Bourdieu led to a concern with how cultural and social structures were changed by human agency and practice, a trend which Sherry Ortner has referred to as 'practice theory'. One example is Douglas E. Foley's Learning Capitalist Culture (2010), in which he applied a mixture of structural and Marxist theories to his ethnographic fieldwork among high school students in Texas. Foley analyzed how they reach a shared goal through the lens of social solidarity when he observed "Mexicanos" and "Anglo-Americans" come together on the same football team to defeat the school's rivals. However, he also continually applies a marxist lens and states that he," wanted to wow peers with a new cultural marxist theory of schooling." Some anthropological theorists, however, while finding considerable fault with Lévi-Strauss's version of structuralism, did not turn away from a fundamental structural basis for human culture. The Biogenetic Structuralism group for instance argued that some kind of structural foundation for culture must exist because all humans inherit the same system of brain structures. They proposed a kind of neuroanthropology which would lay the foundations for a more complete scientific account of cultural similarity and variation by requiring an integration of cultural anthropology and neuroscience—a program that theorists such as Victor Turner also embraced. In literary criticism and theory In literary theory, structuralist criticism relates literary texts to a larger structure, which may be a particular genre, a range of intertextual connections, a model of a universal narrative structure, or a system of recurrent patterns or motifs. The field of structuralist semiotics argues that there must be a structure in every text, which explains why it is easier for experienced readers than for non-experienced readers to interpret a text. Everything that is written seems to be governed by rules, or "grammar of literature", that one learns in educational institutions and that are to be unmasked. A potential problem for a structuralist interpretation is that it can be highly reductive; as scholar Catherine Belsey puts it: "the structuralist danger of collapsing all difference." An example of such a reading might be if a student concludes the authors of West Side Story did not write anything "really" new, because their work has the same structure as Shakespeare's Romeo and Juliet. In both texts a girl and a boy fall in love (a "formula" with a symbolic operator between them would be "Boy + Girl") despite the fact that they belong to two groups that hate each other ("Boy's Group - Girl's Group" or "Opposing forces") and conflict is resolved by their deaths. Structuralist readings focus on how the structures of the single text resolve inherent narrative tensions. If a structuralist reading focuses on multiple texts, there must be some way in which those texts unify themselves into a coherent system. The versatility of structuralism is such that a literary critic could make the same claim about a story of two friendly families ("Boy's Family + Girl's Family") that arrange a marriage between their children despite the fact that the children hate each other ("Boy - Girl") and then the children commit suicide to escape the arranged marriage; the justification is that the second story's structure is an 'inversion' of the first story's structure: the relationship between the values of love and the two pairs of parties involved have been reversed. Structuralist literary criticism argues that the "literary banter of a text" can lie only in new structure, rather than in the specifics of character development and voice in which that structure is expressed. Literary structuralism often follows the lead of Vladimir Propp, Algirdas Julien Greimas, and Claude Lévi-Strauss in seeking out basic deep elements in stories, myths, and more recently, anecdotes, which are combined in various ways to produce the many versions of the ur-story or ur-myth. There is considerable similarity between structural literary theory and Northrop Frye's archetypal criticism, which is also indebted to the anthropological study of myths. Some critics have also tried to apply the theory to individual works, but the effort to find unique structures in individual literary works runs counter to the structuralist program and has an affinity with New Criticism. In economics Yifu Lin criticizes early structural economic systems and theories, discussing the failures of it. He writes:"The structuralism believes that the failure to develop advanced capital-intensive industries spontaneously in a developing country is due to market failures caused by various structural rigidities..." "According to neoliberalism, the main reason for the failure of developing countries to catch up with developed countries was too much state intervention in the market, causing misallocation of resources, rent seeking and so forth."Rather these failures are more so centered around the unlikelihood of such quick development of these advanced industries within developing countries. New Structural Economics (NSE) New structural economics is an economic development strategy developed by World Bank Chief Economist Justin Yifu Lin. The strategy combines ideas from both neoclassical economics and structural economics. NSE studies two parts: the base and the superstructure. A base is a combination of forces and relations of production, consisting of, but not limited to, industry and technology, while the superstructure consists of hard infrastructure and institutions. This results in an explanation of how the base impacts the superstructure which then determines transaction costs. Interpretations and general criticisms Structuralism is less popular today than other approaches, such as post-structuralism and deconstruction. Structuralism has often been criticized for being ahistorical and for favouring deterministic structural forces over the ability of people to act. As the political turbulence of the 1960s and 1970s (particularly the student uprisings of May 1968) began affecting academia, issues of power and political struggle moved to the center of public attention. In the 1980s, deconstruction—and its emphasis on the fundamental ambiguity of language rather than its logical structure—became popular. By the end of the century, structuralism was seen as a historically important school of thought, but the movements that it spawned, rather than structuralism itself, commanded attention. Several social theorists and academics have strongly criticized structuralism or even dismissed it. French hermeneutic philosopher Paul Ricœur (1969) criticized Lévi-Strauss for overstepping the limits of validity of the structuralist approach, ending up in what Ricœur described as "a Kantianism without a transcendental subject." Anthropologist Adam Kuper (1973) argued that:'Structuralism' came to have something of the momentum of a millennial movement and some of its adherents felt that they formed a secret society of the seeing in a world of the blind. Conversion was not just a matter of accepting a new paradigm. It was, almost, a question of salvation. Philip Noel Pettit (1975) called for an abandoning of "the positivist dream which Lévi-Strauss dreamed for semiology," arguing that semiology is not to be placed among the natural sciences. Cornelius Castoriadis (1975) criticized structuralism as failing to explain symbolic mediation in the social world; he viewed structuralism as a variation on the "logicist" theme, arguing that, contrary to what structuralists advocate, language—and symbolic systems in general—cannot be reduced to logical organizations on the basis of the binary logic of oppositions. Critical theorist Jürgen Habermas (1985) accused structuralists like Foucault of being positivists; Foucault, while not an ordinary positivist per se, paradoxically uses the tools of science to criticize science, according to Habermas. (See Performative contradiction and Foucault–Habermas debate.) Sociologist Anthony Giddens (1993) is another notable critic; while Giddens draws on a range of structuralist themes in his theorizing, he dismisses the structuralist view that the reproduction of social systems is merely "a mechanical outcome." See also Antihumanism Engaged theory Genetic structuralism Holism Isomorphism Post-structuralism Russian formalism Structuralist film theory Structuration theory Émile Durkheim Structural functionalism Structuralism (philosophy of science) Structuralism (philosophy of mathematics) Structuralism (psychology) Structural change Structuralist economics References Further reading Angermuller, Johannes. 2015. Why There Is No Poststructuralism in France: The Making of an Intellectual Generation. London: Bloomsbury. Roudinesco, Élisabeth. 2008. Philosophy in Turbulent Times: Canguilhem, Sartre, Foucault, Althusser, Deleuze, Derrida. New York: Columbia University Press. Primary sources Althusser, Louis. Reading Capital. Barthes, Roland. S/Z. Deleuze, Gilles. 1973. "À quoi reconnaît-on le structuralisme?" Pp. 299–335 in Histoire de la philosophie, Idées, Doctrines. Vol. 8: Le XXe siècle, edited by F. Châtelet. Paris: Hachette de Saussure, Ferdinand. 1916. Course in General Linguistics. Foucault, Michel. The Order of Things. Jakobson, Roman. Essais de linguistique générale. Lacan, Jacques. The Seminars of Jacques Lacan. Lévi-Strauss, Claude. The Elementary Structures of Kinship. —— 1958. Structural Anthropology [Anthropologie structurale] —— 1964–1971. Mythologiques Wilcken, Patrick, ed. Claude Levi-Strauss: The Father of Modern Anthropology. Linguistic theories and hypotheses Literary criticism Philosophical anthropology Psychoanalytic theory Sociological theories Theories of language

Social determinants of health

The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual risk factors (such as behavioral risk factors or genetics) that influence the risk or vulnerability for a disease or injury. The distribution of social determinants is often shaped by public policies that reflect prevailing political ideologies of the area. The World Health Organization says that "the social determinants can be more important than health care or lifestyle choices in influencing health." and "This unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer], and bad politics." Some commonly accepted social determinants include gender, race, economics, education, employment, housing, and food access/security. There is debate about which of these are most important. Health starts where we live, learn, work, and play. SDOH are the conditions and environments in which people are born, live, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risk. They are non-medical factors that influence health outcomes and have a direct correlation with health equity. This includes: Access to health education, community and social context, access to quality healthcare, food security, neighborhood and physical environment, and economic stability. Up to 80% of a person's health is determined by SDOH, not clinical care and genetics. Health disparities exist in countries around the world. There are various theoretical approaches to social determinants, including the life-course perspective. Chronic stress, which is experienced more frequently by those living with adverse social and economic conditions, has been linked to poor health outcomes. Various interventions have been made to improve health conditions worldwide, although measuring the efficacy of such interventions is difficult. Social determinants are important considerations within clinical settings. Public policy has shaped and continues to shape social determinants of health. Related topics are social determinants of mental health, social determinants of health in poverty, social determinants of obesity and commercial determinants of health. Commonly accepted social determinants The United States Centers for Disease Control and Prevention (CDC) defines social determinants of health as "life-enhancing resources. In the realm of public health, the concept of social determinants of health (SDOH) has emerged as a crucial framework for comprehending the myriad factors that influence an individual’s well-being. While medical care and genetics play significant roles, a person’s health outcomes are also profoundly shaped by their social, economic, and environmental conditions. Understanding these determinants is imperative for devising effective strategies to address health disparities and promote equitable access to healthcare. Some of the main social factors that shape one's health include Socioeconomic Status (SES), education, neighborhood and physical environment, social support networks, healthcare access and quality, and economic stability. As per findings from the Center for Migration Studies of New York, there exists a strong correlation among various social determinants of health. Individuals residing in regions marked by one specific determinant often experience the impact of other determinants as well. These social determinants significantly shape health-promoting behaviors, emphasizing that achieving health equity across populations necessitates a fair distribution of these social determinants among different groups. A commonly used model that illustrates the relationship between biological, individual, community, and societal determinants is Whitehead and Dahlgren's model originally presented in 1991 and subsequently adapted by the CDC. Additionally, within the United States, Healthy People 2030 is an objective-driven framework which can guide public health practitioners and healthcare providers on how to address social determinants of health at the community level. In Canada, these social determinants of health have gained wide usage: Income and income distribution; Education; Unemployment and job security; Employment and working conditions; Early childhood development; Food insecurity; Housing; Social exclusion/inclusion; Social safety network; Health services; Aboriginal status; Gender; Race; Disability. The list of social determinants of health can be much longer. A 2019 article identified several other social determinants, including culture or social norms; media, stigma, and discrimination; immigration; religion; and access to broadband internet service. Additional research indicates that social determinants of health can be directly tied to degrees of health literacy. Unfortunately, there is no agreed-upon taxonomy or criteria as to what should be considered a social determinant of health. In the literature, a subjective assessment—whether social factors impacting health are avoidable through structural changes in policy and practice—seems to be the dominant way of identifying a social determinant of health. The increase of artificial intelligence (AI) being used in clinical care raises numerous opportunities for addressing health equity issues, yet clear models and procedures for data characteristics and design have not been embraced consistently across health systems and providers. Socioeconomic status At the core of SDOH lies socioeconomic status (SES). Income, education, and occupation significantly impact health outcomes. Individuals with higher incomes generally have better access to healthcare, healthier lifestyles, and improved living conditions. Conversely, those with lower incomes often face barriers to accessing quality healthcare, nutritious food, safe housing, and educational opportunities. The stress of financial instability can also exacerbate health issues. This incovenience can be further passed down to generations, as parents teach their children these habits. Education Education serves as a cornerstone of health. Higher levels of education are associated with better health outcomes due to increased health literacy, better employment prospects, and access to resources for healthier lifestyles. Moreover, education fosters critical thinking skills, enabling individuals to make informed decisions about their health and navigate complex healthcare systems more effectively. Individuals with higher education are more likely to have habits that contribute to active lifestyle and in overall, better health. Neighborhood and physical environment Where people live profoundly impacts their health. Access to green spaces, safe housing, clean air, and reliable public transportation all contribute to overall well-being. Conversely, living in areas with environmental pollution, limited access to fresh foods, high crime rates, or inadequate infrastructure can lead to higher rates of chronic diseases, injuries, and mental health issues. Social support networks Strong social connections and support systems are vital for maintaining good health. Friends, family, and community networks provide emotional support, practical assistance, and a sense of belonging, which buffer against stress and contribute to mental and physical well-being. Conversely, social isolation and lack of social support are linked to increased mortality rates and poorer health outcomes across various age groups. Healthcare access and quality Access to healthcare services is a critical determinant of health outcomes. Factors such as health insurance coverage, proximity to healthcare facilities, availability of primary care providers, and affordability of services significantly influence an individual’s ability to seek timely medical care, preventive services, and treatment for chronic conditions. Disparities in healthcare access contribute to inequities in health outcomes among different populations. The quality of healthare system of a state is also dependent on how developed a country is. The government should ensure a suitable working conditions for workers working in the health industry. If the state fails to ensure these conditions, there is a high chance of qualified people to leave the country. Economic stability Financial stability plays a pivotal role in shaping health outcomes. Stable employment, living wages, and social safety nets contribute to better physical and mental health by reducing stress, enabling access to healthcare, and facilitating healthy lifestyle choices. Conversely, economic instability, unemployment, and poverty are associated with higher rates of chronic diseases, mental health disorders, and overall poorer health status. According to Child Welfare League of America (CWLA), Economic stability is described as the ability to obtain the resources that is necessary to one's life and well-being. Gender Race Work Work is a defined social determinant of health, meaning that the conditions at work are a key aspect in determining the health of an individual. This was demonstrated notably during the COVID-19 pandemic when members of the essential workforce were exposed to a much higher risk of the disease by the necessity of being at work. Other examples include the relatively higher risk of injury in construction jobs or the relatively higher risk of toxic substances in many industrial jobs. Because many of the jobs associated with higher health risks are essential to society, it is important to implement policies to mitigate the inequities experienced by these workers. A "good job" is defined by the CDC as one that is safe and healthy; has sufficient income and benefits; allows for work-life balance; provides employment security; considers employees' voices in decision-making; offers opportunities to gain skills; and has positive employment-related relationships. Ongoing debates Steven H. Woolf of the Virginia Commonwealth University Center on Human Needs states, "The degree to which social conditions affect health is illustrated by the association between education and mortality rates." Reports in 2005 revealed the mortality rate was 206.3 per 100,000 for adults aged 25 to 64 years with little education beyond high school, but was twice as great (477.6 per 100,000) for those with only a high school education and three times as great (650.4 per 100,000) for those less educated. Based on the data collected, the social conditions such as education, income, and race were dependent on one another, but these social conditions also apply to independent health influences. Marmot and Bell of the University College London found that in wealthy countries, income and mortality are correlated as a marker of relative position within society, and this relative position is related to social conditions that are important for health including good early childhood development, access to high quality education, rewarding work with some degree of autonomy, decent housing, and a clean and safe living environment. The social condition of autonomy, control, and empowerment turns are important influences on health and disease, and individuals who lack social participation and control over their lives are at a greater risk for heart disease and mental illness. Early childhood development can be promoted or disrupted as a result of the social and environmental factors affecting the mother, while the child is still in the womb. Janet Currie's research finds that women in New York City receiving assistance from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), in comparison to their previous or future childbirth, are 5.6% less likely to give birth to a child who is underweight, an indication that a child will have better short term, and long term physical, and cognitive development. Several other social determinants are related to health outcomes and public policy, and are easily understood by the public to impact health. They tend to cluster together – for example, those living in poverty experience a number of negative health determinants. International health inequalities Even in the wealthiest countries, there are health inequalities between the rich and the poor. Researchers Labonte and Schrecker from the Department of Epidemiology and Community Medicine at the University of Ottawa emphasize that globalization is key to understanding the social determinants of health, and as Bushra (2011) posits, the impacts of globalization are unequal. Globalization has caused an uneven distribution of wealth and power both within and across national borders, and where and in what situation a person is born has an enormous impact on their health outcomes. The Organization for Economic Cooperation and Development found significant differences among developed nations in health status indicators such as life expectancy, infant mortality, incidence of disease, and death from injuries. Migrants and their family members also experience significant negatives health impacts. These inequalities may exist in the context of the health care system, or in broader social approaches. According to the WHO's Commission on Social Determinants of Health, access to health care is essential for equitable health, and it argued that health care should be a common good rather than a market commodity. However, there is substantial variation in health care systems and coverage from country to country. The commission also calls for government action on such things as access to clean water and safe, equitable working conditions, and it notes that dangerous working conditions exist even in some wealthy countries. In the Rio Political Declaration on Social Determinants of Health, several key areas of action were identified to address inequalities, including promotion of participatory policy-making processes, strengthening global governance and collaboration, and encouraging developed countries to reach a target of 0.7% of gross national product (GNP) for official development assistance. Theoretical approaches The UK Black and The Health Divide reports considered two primary mechanisms for understanding how social determinants influence health: cultural/behavioral and materialist/structuralist The cultural/behavioral explanation is that individuals' behavioral choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their development and deaths from a variety of diseases. However, both the Black and Health Divide reports found that behavioral choices are determined by one's material conditions of life, and these behavioral risk factors account for a relatively small proportion of variation in the incidence and death from various diseases. The materialist/structuralist explanation emphasizes the people's material living conditions. These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. Within this view, three frameworks have been developed to explain how social determinants influence health. These frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist view explains how living conditions – and the social determinants of health that constitute these living conditions – shape health. The neo-materialist explanation extends the materialist analysis by asking how these living conditions occur. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing. A nation's wealth is a strong indicator of the health of its population. Within nations, however, individual socio-economic position is a powerful predictor of health. Material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. Material conditions of life lead to differing likelihood of physical (infections, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems. Material conditions of life also lead to differences in psychosocial stress. When the fight-or-flight reaction is chronically elicited in response to constant threats to income, housing, and food availability, the immune system is weakened, insulin resistance is increased, and lipid and clotting disorders appear more frequently. The effects of chronic fight-or-flight is described in the allostatic load model The materialist approach offers insight into the sources of health inequalities among individuals and nations. Adoption of health-threatening behaviors is also influenced by material deprivation and stress. Environments influence whether individuals take up tobacco, use alcohol, consume poor diets, and have low levels of physical activity. Tobacco use, excessive alcohol consumption, and carbohydrate-dense diets are also used to cope with difficult circumstances. The materialist approach seeks to understand how these social determinants occur. The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population. This distribution of resources can vary widely from country to country. The neo-materialist view focuses on both the social determinants of health and the societal factors that determine the distribution of these social determinants, and especially emphasizes how resources are distributed among members of a society. The social comparison approach holds that the social determinants of health play their role through citizens' interpretations of their standings in the social hierarchy. There are two mechanisms by which this occurs. At the individual level, the perception and experience of one's status in unequal societies lead to stress and poor health. Feelings of shame, worthlessness, and envy can lead to harmful effects upon neuro-endocrine, autonomic and metabolic, and immune systems. Comparisons to those of a higher social class can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviors such as overeating and using alcohol and tobacco. At the communal level, widening and strengthening of hierarchy weakens social cohesion, which is a determinant of health. The social comparison approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. However, these effects may be secondary to how societies distribute material resources and provide security to its citizens, which are described in the materialist and neo-materialist approaches. Life-course perspective Life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. The economic and social conditions – the social determinants of health – under which individuals live their lives have a cumulative effect upon the probability of developing any number of diseases, including heart disease and stroke. Studies into the childhood and adulthood antecedents of adult-onset diabetes show that adverse economic and social conditions across the life span predispose individuals to this disorder. Hertzman outlines three health effects that have relevance for a life-course perspective. Latent effects are biological or developmental early life experiences that influence health later in life. Low birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. Nutritional deprivation during childhood has lasting health effects as well. Pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. As one example, children who enter school with delayed vocabulary are set upon a path that leads to lower educational expectations, poor employment prospects, and greater likelihood of illness and disease across the lifespan. Deprivation associated with poor-quality neighborhoods, schools, and housing sets children off on paths that are not conducive to health and well-being. Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health, in particular between women and men. These involve the combination of latent and pathways effects. Adopting a life-course perspective directs attention to how social determinants of health operate at every level of development – in utero, infancy, early childhood, childhood, adolescence, and adulthood – to both immediately influence health and influence it in the future. Vaccination Social and economic conditions also influence how many people take vaccines. Factors such as income, socioeconomic status, ethnicity, age, and education can determine the uptake of vaccines and their impact, especially among vulnerable communities. Social factors like whether one lives with others may affect vaccine uptake. For example, older individuals who live alone are much more likely not to take up vaccines compared to those living with other people. Other factors may be racial, with minority groups being affected by low vaccine uptake. Chronic stress and health Stress is hypothesized to be a major influence in the social determinants of health. There is a relationship between experience of chronic stress and negative health outcomes. This relationship is explained through both direct and indirect effects of chronic stress on health outcomes. The direct relationship between stress and health outcomes is the effect of stress on human physiology. The long term stress hormone, cortisol, is believed to be the key driver in this relationship. Chronic stress has been found to be significantly associated with chronic low-grade inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to vaccines. Meta-analysis of healing studies has found that there is a robust relationship between elevated stress levels and slower healing for many different acute and chronic conditions However, it is also important to note that certain factors, such as coping styles and social support, can mitigate the relationship between chronic stress and health outcomes. Stress can also be seen to have an indirect effect on health status. One way this happens is due to the strain on the psychological resources of the stressed individual. Chronic stress is common in those of a low socio-economic status, who are having to balance worries about financial security, how they will feed their families, housing status, and many other concerns. Therefore, individuals with these kinds of worries may lack the emotional resources to adopt positive health behaviors. Chronically stressed individuals may therefore be less likely to prioritize their health. In addition to this, the way that an individual responds to stress can influence their health status. Often, individuals responding to chronic stress will develop potentially positive or negative coping behaviors. People who cope with stress through positive behaviors such as exercise or social connections may not be as affected by the relationship between stress and health, whereas those with a coping style more prone to over-consumption (i.e. emotional eating, drinking, smoking or drug use) are more likely to see negative health effects of stress. Vape shops are also found more in low socioeconomic status areas. The owners target these areas in particular to gain profit. Since people with low-income status are not highly educated, they are more prone to make poor health behavior choices. Socioeconomic status also has a huge impact in lives of people of color. According to Kids Count Data Center, Children in Poverty 2014, in the United States 39% of African American children and adolescents, and 33% of Latino children and adolescents are living in poverty (Kids Count Data Center, Children in Poverty 2014). The stress these racial groups with low socioeconomic status face, is higher than the same race group from a high-income community. According to the research done on socioeconomic disparities in vape shop density and proximity to public schools, the researchers found that vape shops were located a lot more in the areas with schools where African-Americans/Latinos/Hispanic students were in higher population than the areas with schools where White population was more. The detrimental effects of stress on health outcomes are hypothesized to partly explain why countries that have high levels of income inequality have poorer health outcomes compared to more equal countries. Wilkinson and Picket hypothesized in their book The Spirit Level that the stressors associated with low social status are amplified in societies where others are clearly far better off. A landmark study conducted by the World Health Organization and the International Labour Organization found that exposure to long working hours, operating through psychosocial stress, is the occupational risk factor with the largest attributable burden of disease, i.e. an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016. Improving health conditions worldwide Reducing the health gap requires that governments build systems that allow a healthy standard of living for every resident. Interventions Three common interventions for improving social determinant outcomes as identified by the WHO are education, social security and urban development. However, evaluation of interventions has been difficult due to the nature of the interventions, their impact and the fact that the interventions strongly affect children's health outcomes. Education: Many scientific studies have been conducted and strongly suggests that increased quantity and quality of education leads to benefits to both the individual and society (e.g. improved labor productivity). Health and economic outcome improvements can be seen in health measures such as blood pressure, crime, and market participation trends. Examples of interventions include decreasing size of classes and providing additional resources to low-income school districts. However, there is currently insufficient evidence to support education as a social determinants intervention with a cost-benefit analysis. Social Protection: Interventions such as "health-related cash transfers", maternal education, and nutrition-based social protections have been shown to have a positive impact on health outcomes. However, the full economic costs and impacts generated of social security interventions are difficult to evaluate, especially as many social protections primarily affect children of recipients. The landmark Cochrane Collaboration Review of the health impact of unconditional cash transfers in low- and middle-income countries found a large body of evidence that these cash transfers clinically meaningfully reduce in the likelihood of being sick (by an estimated 27%), may also improve food security and dietary diversity, and may also reduce extreme poverty and improve school attendance, as well as increase healthcare spending. Urban Development: Urban development interventions include a wide variety of potential targets such as housing, transportation, and infrastructure improvements. The health benefits are considerable (especially for children), because housing improvements such as smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct impact on health. In addition, there is a fair amount of evidence to prove that external urban development interventions such as transportation improvements or improved walkability of neighborhoods (which is highly effective in developed countries) can have health benefits. Affordable housing options (including public housing) can make large contributions to both social determinants of health, as well as the local economy, and access to public natural areas -including green and blue spaces- is also associated with improved health benefits. The Commission on Social Determinants of Health made recommendations in 2005 for action to promote health equity based on three principles: "improve the circumstances in which people are born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources, the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the problem, evaluate action, and expand the knowledge base." These recommendations would involve providing resources such as quality education, decent housing, access to affordable health care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence. Expansion of knowledge of the social determinants of health, including among healthcare workers, can improve the quality and standard of care for people who are marginalized, poor or living in developing nations by preventing early death and disability while working to improve quality of life. Challenges of measuring value of interventions Many economic studies have been conducted to measure the effectiveness and value of social determinant interventions but are unable to accurately reflect effects on public health due to the multi-faceted nature of the topic. While neither cost-effectiveness nor cost-utility analysis is able to be used on social determinant interventions, cost-benefit analysis is able to better capture the effects of an intervention on multiple sectors of the economy. For example, tobacco interventions have shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. Another issue with research in this area is that most of the current scientific papers focus on rich, developed countries, and there is a lack of research in developing countries. Policy changes that affect children also present the challenge that it takes a significant amount of time to gather this type of data. In addition, policies to reduce child poverty are particularly important, as elevated stress hormones in children interfere with the development of brain circuitry and connections, causing long term chemical damage. In most wealthy countries, the relative child poverty rate is 10 percent or less; in the United States, it is 21.9 percent. The lowest poverty rates are more common in smaller well-developed and high-spending welfare states like Sweden and Finland, with about 5 or 6 percent. Middle-level rates are found in major European countries where unemployment compensation is more generous and social policies provide more generous support to single mothers and working women (through paid family leave, for example), and where social assistance minimums are high. For instance, the Netherlands, Austria, Belgium and Germany have poverty rates that are in the 7 to 8 percent range. Within clinical settings Connecting patients with the necessary social services during their visits to hospitals or medical clinics is an important factor in preventing patients from experiencing decreased health outcomes as a result of social or environmental factors. This can take the form of community health workers who can support patients with their care plans developed in conjunction with their primary care physicians. A clinical study done by researchers at the University of California San Francisco, indicated that connecting patients with the resources to utilize and contact social services during clinical visits, significantly decreased families social needs and significantly improved children's overall health. In addition, within the clinical setting, it was noted that in order to better health outcomes for the patients in any clinical setting, a collection of SHD data should be documented. This helps maintain the connection between healthcare systems and organizations that address these needs that were documented. Public policy The Rio Political Declaration on Social Determinants of Health embraces a transparent, participatory model of policy development that, among other things, addresses the social determinants of health leading to persistent health inequalities for indigenous peoples. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity. The United States Department of Health and Human Services includes social determinants in its model of population health, and one of its missions is to strengthen policies which are backed by the best available evidence and knowledge in the field. Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of public policy decisions made by governing authorities. For example, early life is shaped by availability of sufficient material resources that assure adequate educational opportunities, food, and housing among others. Much of this has to do with the employment security and the quality of working conditions and wages. The availability of quality, regulated childcare is an especially important policy option in support of early life. These are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses. A policy-oriented approach places such findings within a broader policy context. In this context, Health in All Policies has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health. Yet it is not uncommon to see governmental and other authorities individualize these issues. Governments may view early life as being primarily about parental behaviors towards their children. They then focus upon promoting better parenting, assist in having parents read to their children, or urge schools to foster exercise among children rather than raising the amount of financial or housing resources available to families. Indeed, for every social determinant of health, an individualized manifestation of each is available. There is little evidence to suggest the efficacy of such approaches in improving the health status of those most vulnerable to illness in the absence of efforts to modify their adverse living conditions. A team of the Cochrane Collaboration conducted the first comprehensive systematic review of the health impact of unconditional cash transfers, as an increasingly common up-stream, structural social determinant of health. The review of 21 studies, including 16 randomized controlled trials, found that unconditional cash transfers may not improve health services use. However, they lead to a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%. Unconditional cash transfers may also improve food security and dietary diversity. Children in recipient families are more likely to attend school, and the cash transfers may increase money spent on health care. One of the recommendations by the Commission on the Social Determinants of Health is expanding knowledge – particularly to health care workers. Although not addressed by the WHO Commission on Social Determinants of Health, sexual orientation and gender identity are increasingly recognized as social determinants of health. With all the different health inequities and differences in quality of care addressed in social determinants of health, the American Hospital Association created the Value Initiative project which helps make healthcare more affordable to people of all types. It does this four different ways: It frames issues regarding the healthcare system and its pricing and affordability. It provides knowledge, resources, and tools for hospitals to supply affordable healthcare and increase value The initiative collects data of hospital experiences to develop new federal policy solutions Builds a platform for the American Hospital Association to discuss with policymakers to find solutions to the lack of affordable care. This initiative educates the public and makes sure there is transparency in pricing of hospital bills, making sure patients are not billed more than they should be. It also addresses the cost drivers in the healthcare system, and urges for legislators to take action to make healthcare affordable and to prioritize health over profit. This organization asks congress to control the rising costs of pharmaceuticals by encouraging competition between manufacturers, and improving transparency in drug pricing. In this value initiative, they have started the Affordability Advocacy Agenda (AAA) which improves the ongoing policy and advocacy activities. With the Covid-19 pandemic health care spending increased and there was a rise in hospitalizations and therefore a rise in demand for health care providers. The price for care has increased and there aren't enough workers to meet the demand for care. The AAA and congress are working together to provide relief from the pandemic in order to make healthcare more affordable to all. As of January 1, 2022 there are regulations placed for healthcare providers about no surprise billing. This is the "No Surprises Act" of division BB of the Consolidated Appropriations Act, 2021 and this rule was made by the Biden-Harris administration. Patients should not be billed more than they expected to pay, it is often noticed with emergency services and this rule will stop patients from getting worried about any bills out of their budget, and they will be able to get the proper care they need for their health with peace of mind. The act was passed by congress at the end of 2020 and offers protection against insured Americans getting surprise bills from out-of-network providers. They struggled to find an amount that an insurer should pay to the out-of-network provider, but eventually found an amount and the law is now in effect as of January 2022. When it comes to out-of-network providers, patients often rely on these services in an emergency and then get stuck with the bill afterwards. Air Ambulance bills are a big problem for consumers, not just because they are out of network and cost a lot, but also for their lack of billing transparency. Since the Airline Deregulation Act, which allows air ambulance to make their own prices, federal solutions to this increasing cost of emergency care is needed. A possible solution is to allow air ambulance services to be administered and financed in a way that combines competitive bidding and public utility regulation. History Starting in the early 2000s, the World Health Organization facilitated the academic and political work on social determinants in a way that provided a deep understanding of health disparities in a global perspective. In 2003, the World Health Organization (WHO) Europe suggested that the social determinants of health included: the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transportation. In 2008, the WHO Commission on Social Determinants of Health published a report entitled "Closing the Gap in a Generation", which aimed to understand, from a social justice perspective, how health inequity could be remedied, and what actions could combat factors that exacerbated injustices. The work of the commission was based on development goals, and thus, connected social determinants of health discourse to economic growth and bridging gaps in the healthcare system. This report made three broad recommendations regarding social determinants of health that needed to be addressed. The first imperative was to improve daily living conditions, including work and home physical environments, early childhood development and education, and social protection across the lifespan. The second recommendation was to disrupt the distribution of power, money, and resources, including social inequities such as gender disparities; this recommendation involves a more active role on the part of government. Third, the report calls for a global acknowledgement of the problem so as to take its full measure, as well as assess the impact of any planned interventions. The 2010 Affordable Care Act (ACA) established by the Obama administration in the United States, embodied the ideas put in place by the WHO by bridging the gap between community-based health and healthcare as a medical treatment, meaning that a larger consideration of social determinants of health was emerging in the policy. The ACA established community change through initiatives like providing Community Transformation Grants to community organizations, which opened up further debates and talks about increased integration of policies to create change on a larger scale. The 2011 World Conference on Social Determinants of Health, in which 125 delegations participated, created the Rio Political Declaration on Social Determinants of Health. With a series of affirmations and announcements, the Declaration aimed to communicate that the social conditions in which an individual exists were key to understanding health disparities that individual may face, and it called for new policies across the world to fight health disparities, along with global collaborations. See also Adverse Childhood Experiences Study Causal inference Center for Minority Health Commercial determinants of health Dennis Raphael Diseases of affluence Diseases of poverty Environmental racism in the United States Epidemiology Etiology EuroHealthNet Exercise Global health Health behaviour Health equity Health literacy Health policy Healthy People Hopkins Center for Health Disparities Solutions Inequality in disease Medical anthropology Medical sociology Michael Marmot Molecular pathological epidemiology Pathogenesis Pathology Population health Population Health Forum Race and health Richard G. Wilkinson Slavery hypertension hypothesis Social determinants of health in Mexico Social determinants of obesity Social determinants of health in poverty Social epidemiology Unnatural Causes: Is Inequality Making Us Sick? Weathering hypothesis Whitehall Study Notes and references External links Social determinants of health (World Health Organization) Commission on Social Determinants of Health (World Health Organization) A glossary for social epidemiology – N Krieger Key determinants of health (Public Health Agency of Canada) NPTEL – Socio-economic Status and Health Income Inequality and Health Social Determinants of Health: The Canadian Facts Social Determinants of Health, Social Determinants of Health Task Force, Centers for Disease Control and Prevention, USA The Social Context of Health Behaviors – Paula Braveman World Health Organization: Equity, Social Determinants and Public Health Programmes Public Health Agency of Canada: What determines health? – Key determinants Olomouc University Social Health Institute Occupational Health Equity Program, The National Institute for Occupational Safety and Health (NIOSH), 2022. Public health Social inequality Determinants of health Cultural competence Social problems in medicine

Postpartum psychosis

Postpartum psychosis (PPP), also known as puerperal psychosis or peripartum psychosis, involves the abrupt onset of psychotic symptoms shortly following childbirth, typically within two weeks of delivery but less than 4 weeks postpartum. PPP is a condition currently represented under "Brief Psychotic Disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Volume V (DSM-V). Symptoms may include delusions, hallucinations, disorganized speech (e.g., incoherent speech), and/or abnormal motor behavior (e.g., catatonia). Other symptoms frequently associated with PPP include confusion, disorganized thought, severe difficulty sleeping, variations of mood disorders (including depression, agitation, mania, or a combination of the above), as well as cognitive features such as consciousness that comes and goes (waxing and waning) or disorientation. The cause of PPP is currently unknown, though growing evidence for the broad category of postpartum psychiatric disorders (e.g., postpartum depression) suggests hormonal and immune changes as potential factors contributing to their onset, as well as genetics and circadian rhythm disruption. There is no agreement in the evidence about risk factors, though a number of studies have suggested that sleep loss, first pregnancies (primiparity), and previous episodes of PPP may play a role. More recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or her family may raise the risk of a new-onset psychosis triggered by childbirth. There are currently no screening or assessment tools available to diagnose PPP; a diagnosis must be made by the attending physician based on the patient's presenting symptoms, guided by diagnostic criteria in the DSM-V (see Diagnosis). While PPP is seen only in 1 to 2 of every 1000 childbirths, the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia, raises concerns for the safety of the patient and the infant; thus, PPP is considered a psychiatric emergency, usually requiring urgent hospitalization. Treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ECT). In some cases where pregnant women have a known history of bipolar disorder or previous episodes of PPP, prophylactic use of medication (especially lithium) either throughout or immediately after delivery has been demonstrated to reduce the incidence of psychotic or bipolar episodes in the postpartum period. PPP is not an independently recognized diagnosis in the DSM-V; instead, the specifier "with peripartum onset" is used for both "Brief psychotic disorder" and "Unspecified bipolar and related disorders." Recent literature suggests that, more frequently, this syndrome occurs in the context of known or new-onset bipolar illness (see Postpartum Bipolar Disorder). Given the variety of symptoms associated with PPP, a thorough consideration of other psychiatric and non-psychiatric (or organic) causes must be ruled out through a combination of diagnostic labwork and imaging, as well as clinical presentation - a non-exhaustive sample of these other causes is examined below (see Organic postpartum psychoses and Other non-organic postpartum psychoses). Clinical presentation By its diagnostic definition (under the name "brief psychotic disorder with peripartum onset"), PPP occurs either during pregnancy or within 4 weeks of delivering the infant. Generally, PPP symptoms have been observed within 3–10 days of childbirth, though women with a past history of bipolar disorder may experience symptoms even sooner. The persistence of symptoms varies; while the average reported length of an episode may last weeks to several months, there is currently no strong literature documenting the course of individual episodes. Recurrence rates for psychotic episodes, on the other hand, have stronger supporting studies and are covered in more detail below (see Prognosis and Outcomes). Diagnostic criteria per the DSM-V require the presence of at least one psychotic symptom, defined as delusions, hallucinations, bizarre or incoherent speech (disorganized speech), or abnormal movements (psychomotor behavior) such as catatonia. Delusions, particularly about the infant, are the most commonly reported psychotic symptom associated with PPP. Paranoid delusions are a frequently noted theme in cases of PPP, but a small review noted infrequent cases of delusional misidentification syndromes, such as Capgras syndrome (the belief that someone or something familiar has been replaced with an impostor), Fregoli syndrome (the belief that a stranger is actually a known person in disguise), and others. The latter types of delusions may have a significant negative impact on the bond between a mother and child, raising concerns for the safety of both (see Prognosis and Outcomes). Both postpartum obsessive-compulsive disorder (OCD) and PPP may present with concerning thoughts about the infant; typically, the thoughts associated with OCD are unwanted and distressing to the individual (who does not wish to act on their thoughts), whereas persons with PPP are often less distressed by their beliefs and may even feel the need to act on them. Compared to schizophrenia, PPP tends to feature less bizarre delusions, and associated hallucinations are more likely to be visual rather than auditory. The sensation of being outside one's body or feeling that one's surroundings are unreal (i.e., derealization) has also been described in cases of PPP. Additional distinctions in PPP compared to classical schizophrenia include the presence of mood and cognitive (or neurological) symptoms. Rapid mood changes or the presence of abnormal moods such as depression or mania (increased energy, decreased need for sleep, etc.) tend to be seen in a large percentage of patients experiencing PPP. Irritability, anxiety, and general difficulties with sleep may also be present. Confusion or disorientation, disorganized thoughts, incoherent speech, or abrupt changes in a person's mental capacity may also be seen in individuals experiencing PPP, though one small study observed these neurological symptoms in only one-quarter of PPP cases. Like delirium, these symptoms may come and go in unpredictable patterns. Thoughts of committing suicide or harming one's infant or children have also been reported as common occurrences in PPP, with as many as half of PPP cases exhibiting these features. In many cases where harmful thoughts exist, the person experiencing these thoughts does not consider their intended action to be harmful; rather, they believe that their actions are in the best interest of the child. In addition to the rapid onset of symptoms (less than two weeks) with the presence of a psychotic symptom, further diagnostic criteria defined by the DSM-V for "brief psychotic disorder with peripartum onset" include that the symptomatic episode ends within one month and involves a return to the individual's previous functional ability, as well as confidence that the episode is not a different psychiatric illness (e.g., depressive or bipolar disorder with psychotic features) or the result of substance-induced psychosis. Risk factors Childbirth is the primary cause of PPP; other causes and risk factors remain largely under investigation. The largest known risks for the occurrence of PPP include a history of PPP in a previous pregnancy, or a personal or family history of bipolar disorder. A significant number of PPP cases, however, occur in individuals with no prior history of psychosis. (For this reason, first-time pregnancy is itself sometimes considered to be a risk factor for PPP.) A review of pregnancy-related complications demonstrated some association between emergency caesarean sections (C-sections), excess bleeding, uterine rupture, and stillbirth (amongst other complications) and the subsequent development of PPP; however, several of the reviewed studies were contradictory and thus no consensus can confirm the relationship between problems related to pregnancy and PPP. Lifestyle and psychological factors, such as previous trauma or single parenthood, have likewise been inconclusive as factors contributing to PPP, though a number of patients have reported a perception that social and pregnancy-related challenges were the cause of their PPP episodes. Pathophysiology Currently, the pathophysiology of PPP is not well understood and remains an open field of ongoing research. The leading theories under investigation involve areas of genetics, hormones, immunology, and sleep disturbance processes. Genetics Some findings suggest an association between PPP and variation in serotonin transporter genes and signaling or changes at specific chromosomes (e.g., 16p13 or METTL13). However, the majority of research devoted to genetic understanding of PPP has evaluated patients who have known bipolar disorder, so these associations may not be specific to PPP. Hormones Despite significant hormone changes that occur around pregnancy and childbirth, there is little evidence supporting hormonal causes behind PPP. Changes in corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH), as well as rapid changes in estrogen and progesterone, are known effects associated with delivering a child, and they are present in both those affected and unaffected by PPP; therefore, a relationship between hormonal change and the onset of psychosis is not well-supported, though some researchers continue to explore whether postpartum disorders might be related to differences in sensitivity to rapid hormone changes. Estrogen has known impacts on various neurotransmitters, including serotonin and dopamine), which prominent theories associate with schizophrenia; however, investigations of estrogen concentrations and dopamine receptor sensitivity, and trials of estrogen replacement following birth, do not support an association between estrogen changes and PPP onset. Immune system alteration Due to above-average rates of PPP in individuals experiencing immunologic complications such as anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and autoimmune thyroid disorders, as well as the known heightened immune response post-childbirth, some theories suggest a connection between PPP and the immune system. There is some evidence connecting PPP with changes to levels of peripheral immune cells (e.g., lymphocytes and NK or natural killer cells) traveling in the bloodstream, but more research is required to identify the specific mechanisms and cell types involved which might be related to PPP onset. No direct evidence has shown a link between cytokine levels and PPP. Sleep disturbance A link between sleep difficulty and PPP is not strongly supported by current evidence; however, some studies have demonstrated an increased risk for postpartum psychosis in women with bipolar disorder who have had manic episodes triggered by sleep disturbance. Diagnosis and screening Diagnosis Not recognized as its own distinct disorder, PPP is instead classified by the DSM-V as a "Brief Psychotic Disorder with peripartum onset." Clinical requirements for the diagnosis of a brief psychotic disorder require the presence of at least one of the following psychotic symptoms: delusions, hallucinations, disorganized speech, and/or grossly disorganized or catatonic behavior. Additional requirements include that the psychotic symptom lasts between one day and one month, eventually resulting in the person recovering their previous level of functional ability, and that the symptoms are not better related to a different psychiatric illness (including the result of ingesting substances such as alcohol or drugs). The specifier, "with peripartum onset," requires the development of the above within 4 weeks of delivering a child. There are no laboratory or imaging tools available to diagnose PPP, though a work-up of different laboratory analyses and imaging of the brain may be conducted to ensure other potential confounding diagnoses (e.g., vascular disorders, infective delirium, etc.) are not the cause of the patient's presentation (see Differential, Other non-organic postpartum psychoses, and Organic postpartum psychoses). These may include, but are not limited to, a complete blood count, comprehensive metabolic panel, urinalysis and urine drug screen, and tests for thyroid functioning; further workup in the setting of classically neurological symptoms (such as delirium-like confusion) may include magnetic resonance imaging (MRI), a test of cerebrospinal fluid (CSF), or electroencephalogram (EEG). Screening Currently, no screening tools exist to evaluate for PPP, though providers may choose to use standard screens for postpartum depression and mania to evaluate the presence of these particular symptoms. It may be difficult for providers and family-members to identify PPP, due to the presence of several symptoms that are classically associated with other postpartum conditions such as postpartum depression, as well as overlap with often-benign changes that accompany new parenthood (anxiety, irritability, poor sleep). Therefore, clinical recommendations advise healthcare providers to directly ask new mothers about thoughts of harming themselves or their children. Differential The presentation of PPP includes a large differential overlapping neurological and psychiatric diseases and syndromes. Neurological, or cognitive, symptoms like disorientation and confusion raise concerns for conditions that organically affect the brain: this may include autoimmune processes resulting in various forms of encephalitis, embolism (and other vascular disorders), and infectious processes. Physical causes as a result of chronic hormonal disease (e.g., thyroid diseases, hyperparathyroidism) or complications resulting from childbirth, such as Sheehan's syndrome or other complications resulting from excess blood loss, should also be evaluated. Other psychiatric conditions must also be considered: postpartum blues, postpartum depression, anxiety disorders, and postpartum OCD may have many overlapping symptoms with PPP. Finally, psychosis as a result of various substances (including medications such as steroids), should be ruled out. If this is a first-onset episode of psychosis, new-onset bipolar disorder and schizophrenia cannot be ruled out; the diagnosis of these disorders is based on time and recurrence of episodes. Treatment While each case is considered by individual circumstances, generally, PPP is assessed as a psychiatric emergency and requires admission to a psychiatric hospital for close care. This admission may be to a mother-baby psychiatric unit or a general adult psychiatric unit, depending upon the availability in one's country and area. Because few units, especially in the United States, offer mother-baby services, patients may be discharged home as soon as the worst concerns for the safety of the patient and infant are cleared, even though the patient may still be experiencing some symptoms of PPP; in this way, patients receive care to prevent harm to self and others but return home to care for their children and promote bonding as soon as they are able. Treatment plans are made up of a combination of education, medication, and close follow-up care and support; the major goals of care include improving sleep and psychotic symptoms while helping to minimize major shifts in mood, such as depression and mania. Medical treatment typically involves ECT, benzodiazepines, lithium, and/or antipsychotics. Electroconvulsive therapy (ECT) ECT has a long and well-documented history as a psychiatric treatment, starting in 1938, with a large body of literature supporting its effectiveness and safety in various psychiatric conditions, including psychosis. However, while it has been used for PPP for over 50 years, the data on its efficacy in PPP specifically is limited to a significant number of case series and various retrospective matched-cohort studies. There are few adverse effects associated with ECT, though short-term memory disturbance (< 6 months) has been reported. Patients who are adverse to long-term psychiatric medications may prefer ECT, particularly given the minimal and short-term impact that ECT-related medications (e.g., drugs for muscle relaxation and anesthesia) appear to have on breastfeeding (as compared to psychiatric medications). Per current recommendations, ECT is considered an option for PPP when medications are ineffective. Lithium Lithium is a psychiatric medication commonly classified as a "mood stabilizer" and often used for the treatment of bipolar disorder. For PPP, lithium can be administered as a medication by itself ("monotherapy") or as an additional medication with other psychiatric drugs ("adjunctive therapy"). Research has shown strong evidence for the effectiveness of lithium as monotherapy in preventing repeat episodes of psychosis, particularly when compared to antipsychotic use alone, and current recommendations suggest it as a first-line treatment for PPP in patients for whom this is safe (lithium is not advised for patients with severe kidney or heart disease, thyroid dysfunction, Brugada syndrome, or who have known allergies to the drug). Lithium has been associated with side effects to the fetus when taken during pregnancy, including body and heart abnormalities (e.g., Ebstein's anomaly); these effects have been documented in all trimesters, but higher risks, particularly for structural heart problems and spontaneous abortion, are typically seen with exposure in the first trimester. Lithium is also currently the recommended medication for prevention of psychotic episodes in individuals who have a known history of bipolar disorder and/or previous episodes of PPP. The preferred strategy for preventative medication is to begin lithium immediately following delivery of the infant, minimizing the exposure of the fetus to lithium while in the womb. Treatment throughout pregnancy, however, may be warranted as appropriate for treatment of bipolar disorder, and is dosed according to appropriate medical advisory for the patient's trimester. Lithium effectiveness is based on reaching an optimum level in the individual's blood, which usually requires more frequent bloodwork and adjustment of medication dosage to find and maintain an appropriate level. Stopping lithium requires slow and gradual discontinuation; sudden removal of the medication may lead to symptom relapse and suicidal thoughts. Benzodiazepines Benzodiazepines are a class of drug commonly used for anxiety disorders and insomnia, though they also play a role as an additive medication for psychosis and delirium. According to a small study of 64 women, benzodiazepines had a minor but positive effect in reducing psychosis as a sequentially added medication for treatment of PPP (on top of lithium and antipsychotic medications); due to little supporting data, benzodiazepines are currently only recommended as an add-on medication to lithium and/or antipsychotic drugs, usually in the setting of continued sleep disturbance despite the use of the other medications. Antipsychotic medications Antipsychotic medications are the preferred class of drug used to treat general psychosis, including schizophrenia spectrum disorders. Few studies provide evidence for the efficacy of antipsychotic use in PPP, with the exception of one study of 64 women which examined antipsychotic use as a drug by itself and combined with lithium. In this study, antipsychotic use was effective in both scenarios, but not as effective as lithium used by itself. Despite this limited evidence in PPP specifically, current recommendations include antipsychotic use as an additional medication for patients receiving lithium, or antipsychotic use on its own for those who are unable to tolerate lithium. Antipsychotic choice is physician- and case-dependent, with a large number of available medications offering a range of nuanced effects. Treatment guidance is largely based on recommendations and data from patients with schizophrenia who become pregnant. First-generation antipsychotics have a longer history of use, efficacy and safety in pregnancy, particularly chlorpromazine and haloperidol. Still, second-generation antipsychotics may be preferred over first-generation antipsychotics due to the reduced risk for extrapyramidal symptoms (e.g., uncontrollable movements, tremors or muscle contractions). Breastfeeding Disruption of continued contact with the infant may occur during hospitalization and treatment, which may impact breastfeeding capacity; hospital units may provide the use of a breast pump to mitigate this concern. Strategies and concerns should also be discussed regarding breastfeeding and its impact on sleep, as poor sleep related to night feedings may worsen or delay patient recovery; alternatives may include social support and bottle-feeding through the night to allow the patient time for adequate rest. The effects of various medications during breastfeeding are poorly studied. According to one systematic review evaluating 37 different reports of antipsychotic use in 206 infants, olanzapine has the strongest supporting evidence for low infant exposure through breastmilk, while fewer reports support a similarly low exposure for quetiapine and ziprasidone use. Chlorpromazine also demonstrates minimal transference to the infant through breastmilk. There is currently no consensus to the safety or level of lithium present in breastmilk, though several guidelines and reviews do not consider it an absolute danger to the infant which should exclude its use. Several reports describe safe use of lithium during breastfeeding with no noticeable effects in the infant, though any lasting effects have not been well-studied. As in adults, lithium use with breastfeeding infants requires careful monitoring of the child for serum levels, dose adjustment, and any side effects; thus, the ability of the patient to maintain follow-up care should also be taken into consideration when lithium may be used. Short-acting benzodiazepines, like lorazepam, are preferred from this class of drugs as they demonstrate lower levels passed through breastmilk and no reported side effects in infants. Prognosis and outcomes Symptoms may last for a variable length of time (up to one year in 25% of cases) despite adequate treatment. Despite most individuals (50-80%) experiencing a relapse episode and development of chronic psychiatric disorders (such as bipolar spectrum disorder), these same individuals are expected to be able to resume normal activities of their daily life with the same level of function as previously experienced. Of the minority of persons who experience PPP and choose to have another pregnancy, evidence has shown that about 33% will have a repeat psychotic episode. Other factors that contribute to poorer prognosis include an experience of PPP that's limited to the postpartum period (rather than a diagnosis of bipolar disorder, for example), longer initial psychotic episodes, and a higher severity in the initial episode. Infanticide (or filicide) is thought to occur in 1 to 4% of PPP cases, and some evidence suggests that these incidents are more commonly related to PPP episodes that feature more depressive symptoms. Epidemiology PPP is rare, reported to occur in about 1 to 2 of every 1000 childbirths (0.9 to 2.6 per 1,000). Reported cases are thought to underestimate the actual occurrence of PPP due to the probability of some individuals avoiding hospitalized care to avoid separation from their child (particularly in locations with no mother-baby units) or fear of stigma, as well as the likelihood of misdiagnosis with other postpartum disorders. The first month following childbirth is associated with a higher relative risk for hospital admission due to psychosis when compared to other times in an individual's life. While no specific genetic factors have been linked to PPP, a family history or personal history of bipolar disorder has been strongly associated with higher risk for PPP episodes (see Risk Factors). History Postpartum psychosis had been recognized in earlier editions of the DSM (I and II), first as Involutional Psychotic Reaction and later as Psychosis with Childbirth. It was removed in the DSMIII following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses; it has only been more recently recognized again with the 1994 release of the DSM-IV, when the specifier "with postpartum onset" was included for various diagnoses. Between the 16th and 18th centuries, about 50 brief reports regarding postpartum psychosis were published; among them is the observation that these psychoses could recur, and that they occur both in breast-feeding and non-lactating women. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length that contributed significantly to the knowledge of this disorder during that time. In 1819, Esquirol conducted a survey of cases admitted to the Salpêtrière, and pioneered long-term studies. From that time, puerperal psychosis became widely known to the medical profession. In the next 200 years, over 2,500 theses, articles and books were published. Among these many contributions were Delay's unique investigation using serial curettage and Kendell's record-linkage study comparing 2 years before and 2 years after the birth. In the last few years, two monographs reviewed over 2,400 works, detailing more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases. Postpartum bipolar disorder Signs and symptoms About 40% of patients experiencing postpartum bipolar disorder have puerperal mania, with increased energy or activity and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness and grandiosity (including religious and expansive delusions); puerperal mania is considered to be particularly severe, with highly disorganized speech, extreme excitement and eroticism. Delusions have been associated with this disorder (including delusional parasitosis, delusional misidentification syndrome, and denial of pregnancy or birth), as well as hallucinations, disorders of the will and self, catalepsy and other symptoms of catatonia, self-mutilation and other severe disturbances of mood. Historically, literature from the 18th century also describes symptoms not typically documented today, such as rhyming speech, enhanced intellect, and enhanced perception. Another 25% have an acute polymorphic (cycloid) syndrome, which is a changing clinical state, with transient delusions, fragments of other syndromes, extreme fear or ecstasy, perplexity, confusion, and motility disturbances. In the past, some experts regarded this as pathognomonic (specific) for puerperal psychosis, but this syndrome is found in other settings, not just the reproductive process, and in men. These psychoses are placed in the World Health Organization's ICD-10 under the rubric of acute and transient psychotic disorders. In general psychiatry, manic and cycloid syndromes are regarded as distinct, but, studied long-term among childbearing women, the bipolar and cycloid variants are intermingled in a wide variety of combinations; in this context, it seems best to regard them as members of the same 'bipolar/cycloid' group. Together, the manic and cycloid variants make up about two thirds of childbearing psychoses. Diagnosis Postpartum bipolar disorders must be distinguished from a long list of organic psychoses that can present in the puerperium, and from other non-organic psychoses; both of these groups are described below. It is also necessary to distinguish them from other psychiatric disorders associated with childbirth, such as anxiety disorders, depression, post-traumatic stress disorder, complaining disorders and bonding disorders (emotional rejection of the infant), which occasionally cause diagnostic difficulties. Clinical assessment requires obtaining the history from the mother herself and, because she is often severely ill, lacking in insight and unable to give a clear account of events, from at least one close relative. A social work report and, in mothers admitted to hospital, nursing observations are information sources of great value. A physical examination and laboratory investigations may disclose somatic illness complicating the obstetric events, which sometimes provokes psychosis. It is important to obtain the case records of previous episodes of mental illness, and, in patients with multiple episodes, to construct a summary of the whole course of her psychiatric history in relation to her life. In the 10th edition of the International Classification of Diseases, published in 1992, the recommendation is to classify these cases by the form of the illness, without highlighting the postpartum state. There is, however, a category F53.1, entitled 'severe mental and behavioural disorders associated with the puerperium', which can be used when it is not possible to diagnose some variety of affective disorder or schizophrenia. The American Psychiatric Association's Diagnostic and Statistical Manual, whose 5th edition was published in May 2013, allows the use of a 'peripartum onset specifier' in episodes of mania, hypomania or major depression if the symptoms occur during pregnancy or the first four weeks of the puerperium. The failure to recognize postpartum psychosis, and its complexity, is unhelpful to clinicians, epidemiologists, and other researchers. Onset groups Postpartum bipolar disease belongs to the bipolar spectrum, whose disorders exist in two contrasting forms – mania and depression. They are highly heritable, and affected individuals (less than 1% of the population) have a lifelong tendency (diathesis) to develop psychotic episodes in certain circumstances. The 'triggers' include a number of pharmaceutical agents, surgical operations, adrenal corticosteroids, seasonal changes, menstruation and childbearing. Research into puerperal mania is, therefore, not the study of a 'disease-in-its-own right', but an investigation into the childbearing triggers of bipolar disorder. Psychoses triggered in the first two weeks after the birth – between the first postpartum day (or even during parturition until about the 15th day – complicate approximately 1/1,000 pregnancies. The impression is sometimes given that this is the only trigger associated with childbearing. But there is evidence of four other triggers – late postpartum, prepartum, post-abortion and weaning. Marcé, widely considered an authority on puerperal psychoses, claimed that they could be divided into early and late forms; the late form begins about six weeks after childbirth, associated with the return of the menses. His view is supported by the large number of cases in the literature with onset 4–13 weeks after the birth, mothers with serial 4-13 week onsets and some survey evidence. The evidence for a trigger acting in pregnancy is also based on the large number of reported cases, and particularly on the frequency of mothers experiencing two or more prepartum episodes. There is evidence, especially from surveys, of bipolar episodes triggered by abortion (miscarriage or termination). The evidence for a weaning trigger rests on 32 cases in the literature, of which 14 were recurrent. The relative frequency of these five triggers is given by the number of cases in the literature – just over half early postpartum onset, 20% each late postpartum and prepartum onset, and the rest post-abortion and weaning onset. In addition, episodes starting after childbirth may be triggered by adrenal corticosteroids, surgical operations (such as Caesarean section) or bromocriptine as an alternative to, or in addition to, the postpartum trigger. Course With modern treatment, a full recovery can be expected within 6–10 weeks. After recovery from the psychosis, some mothers have depression, which can last for weeks or months. About one third have a relapse, with a return of psychotic symptoms a few weeks after recovery; these relapses are not due to a failure to comply with medication, because they were often described before pharmaceutical treatment was discovered. A minority have a series of periodic relapses related to the menstrual cycle. Complete recovery, with a resumption of normal life and a normal mother-infant relationship is the rule. Many of these mothers experience other bipolar episodes, on the average about one every six years. Although suicide is almost unknown in an acute puerperal manic or cycloid episode, depressive episodes later in life carry an increased risk, and it is wise for mothers to maintain contact with psychiatric services in the long term. In the event of a further pregnancy, the recurrence rate is high – in the largest series, about three quarters had a recurrence, but not always in the early puerperium; the recurrence could occur during pregnancy, or later in the postpartum period. Management, treatment and prevention Pre-conception counseling Women with a personal or family history of puerperal psychosis or bipolar disorder are at higher risk of a puerperal episode. The highest risk of all (82%) is a combination of a previous postpartum episode and at least one earlier non-puerperal episode. Counseling regarding risks of recurrence should be discussed with patients who have these risk factors, and may include the potential side effects to the fetus associated with certain psychiatric medications, the frequency of episode recurrence, and the risks and benefits of various treatments during pregnancy and breast-feeding. The teratogenic risks of antipsychotic agents are small, but are higher with lithium and anti-convulsant agents. Carbamazepine, an anticonvulsant, when taken in early pregnancy, has some teratogenic effects, but valproate, a different member of the anticonvulsant class, is associated with spina bifida and other major malformations, and a foetal valproate syndrome; it is not usually recommended in women who may become pregnant. More recent reviews demonstrate varying effects of different anticonvulsants (or antiepileptic medications) when given during pregnancy: the type of medication, dosage, and timing of the medication during pregnancy has different levels of safety for the fetus. Given late in pregnancy, antipsychotic agents and lithium can have adverse effects on the infant. Stopping mood-stabilisers carries a higher risk for bipolar episode recurrence during pregnancy. Home treatment and hospitalization It has been recognized since the 19th century that it is optimal for a woman with puerperal psychosis to be treated at home, where she can maintain her role as homemaker and mother to her other children, and develop her relationship with the new-born. But there are many risks, and it is essential that she is monitored by a competent adult round the clock, and visited frequently by professional staff. Home treatment is a counsel of perfection and most women will be admitted to a psychiatric hospital, many as an emergency, and usually without their babies. In a few countries, especially Australia, Belgium, France, India, the Netherlands, Switzerland and the United Kingdom, special units allow the admission of both woman and infant. Conjoint admission has many advantages, but the risks to the infant of admission to a ward full of severely ill mothers should not be understated, and the high ratio of nursing staff, required to safeguard the infants, make these among the most expensive psychiatric units. Treatment of the acute episode These mothers require sedation with anti-psychotic (neuroleptic) agents, but are liable to extrapyramidal symptoms, including neuroleptic malignant syndrome. Since the link with bipolar disorder was recognized (about 1970), treatment with mood-stabilizing agents, such as lithium and anti-convulsant drugs, has been employed with success. Electroconvulsive therapy has the reputation of efficacy in this disorder, and it can be given during pregnancy (avoiding the risk of pharmaceutical treatment), with due precautions. But there have been no trials, and Dutch experience has shown that almost all mothers recover quickly without it. After recovery the mother may need antidepressant treatment and/or prophylactic mood stabilizers; she will need counselling about the risk of recurrence and will often appreciate psychotherapeutic support. Prevention There is much evidence that lithium can at least partly prevent episodes in mothers at high risk. It is dangerous during parturition, when pressure in the pelvis can obstruct the ureters and raise blood levels. Started after the birth its adverse effects are minimal, even in breast-fed infants. Causes The cause of postpartum bipolar disorder breaks down into two parts – the nature of the brain anomalies that predispose to manic and depressive symptoms, and the triggers that provoke these symptoms in those with the bipolar diathesis. The genetic, anatomical and neurochemical basis of bipolar disorder is at present unknown, and is one of the most important projects in psychiatry; but is not the main concern here. The challenge and opportunity presented by the childbearing psychoses is to identify the triggers of early postpartum onset and other onset groups. Considering that these psychoses have been known for centuries, little effort has so far been made to understand the underlying biology. Research has lagged far behind other areas of medicine and psychiatry. There is a dearth of knowledge and of theories. There is evidence of heritability, both from family studies and molecular genetics. Early onset cases occur more frequently in first time mothers, but this is not true of late postpartum or pregnancy onset. There are not many other predictors. Sleep deprivation has been suggested. Inhibition of steroid sulphatase caused behavioural abnormalities in mice. A recent hypothesis, supported by collateral studies, invokes the re-awakening of auto-immunity after its suppression during pregnancy, on the model of multiple sclerosis or autoimmune thyroiditis; a related hypothesis has proposed that abnormal immune system processes (regulatory T cell biology) and consequent changes in myelinogenesis may increase postpartum psychosis risk. Aberrant steroid hormone–dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important in conferring biological risk. Another promising lead is based on the similarity of bipolar-cycloid puerperal and menstrual psychosis; many women have had both. Late-onset puerperal psychoses, and relapses may be linked to menstruation. Since almost all reproductive onsets occur when the menstrual cycle is released from a long period of inhibition, this may be a common factor, but it can hardly explain episodes starting in the 2nd and 3rd trimesters of pregnancy. Research directions The lack of a formal diagnosis in the DSM and ICD has hindered research. Research is needed to improve the care and treatment of affected mothers, but it is of paramount importance to investigate the causes, because this can lead to long term control and elimination of the disease. The opportunities come under the heading of clinical observation, the study of the acute episode, long-term studies, epidemiology, genetics and neuroscience. In a disorder with a strong genetic element and links to the reproductive process, costly imaging, molecular-genetic and neuroendocrinological investigations will be decisive. These depend on expert laboratory methods. It is important that the clinical study is also 'state-of-the-art'– that scientists understand the complexity of these psychoses, and the need for multiple and reliable information sources to establish the diagnosis. Other non-organic postpartum psychoses It is much less common to encounter other acute psychoses in the puerperium. Psychogenic psychosis This is the name given to a psychosis whose theme, onset and course are all related to an extremely stressful event. The psychotic symptom is usually a delusion. Over 50 cases have been described, but usually in unusual circumstances, such as abortion or adoption, or in fathers at the time of the birth of one of their children. They are occasionally seen after normal childbirth. Paranoid and schizophrenic psychoses These are so uncommon in the puerperium that it seems reasonable to regard them as sporadic events, not puerperal complications. Early postpartum stupor Brief states of stupor have rarely been described in the first few hours or days after the birth. They are similar to parturient delirium and stupor, which are among the psychiatric disorders of childbirth. Organic postpartum psychoses There are at least a dozen organic (neuropsychiatric) psychoses that can present in pregnancy or soon after childbirth. The clinical picture is usually delirium – a global disturbance of cognition, affecting consciousness, attention, comprehension, perception and memory – but amnesic syndromes and a mania-like state also occur. The two most recent were described in 1980 and 2010, and it is quite likely that others will be described. Organic psychoses, especially those due to infection, may be more common in nations with high parturient morbidity. Infective delirium The most common organic postpartum psychosis is infective delirium. This was mentioned by Hippocrates: there are 8 cases of puerperal or post-abortion sepsis among the 17 women in the 1st and 3rd books of epidemics, all complicated by delirium. In Europe and North America the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. The peak was about 1870, after which antisepsis and asepsis gradually brought them under control. These severe infections were often complicated by delirium, but it was not until the nosological advances of Chaslin and Bonhöffer that they could be distinguished from other causes of postpartum psychosis. Infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. The onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients continue to have chronic confusional states after recovery from the infection. Recurrences after another pregnancy are rare. Their frequency began to decline at the end of the 19th century, and fell steeply after the discovery of the sulphonamides. Puerperal sepsis is still common in Bangladesh, Nigeria and Zambia. Even in the United Kingdom, cases are still occasionally seen. It would be a mistake to forget this cause of puerperal psychosis. Eclamptic and Donkin psychoses Eclampsia is the sudden eruption of convulsions in a pregnant woman, usually around the time of delivery. It is the late complication of pre-eclamptic toxaemia (gestosis). Although its frequency in nations with excellent obstetric services has fallen below 1/500 pregnancies, it is still common in many other countries. The primary pathology is in the placenta, which secretes an anti-angiogenic factor in response to ischaemia, leading to endothelial dysfunction. In fatal cases, there are arterial lesions in many organs including the brain. This is the second most frequent organic psychosis, and the second to be described. Psychoses occur in about 5% of cases, and about 240 detailed cases have been reported. It particularly affects first time mothers. Seizures may begin before, during or after labour, but the onset of psychosis is almost always postpartum. These mothers usually experience delirium but some have manic features. The duration is remarkably short, with a median duration of 8 days. This, together with the absence of a family history and of recurrences, contrasts with puerperal bipolar/cycloid psychoses. After recovery, amnesia and sometimes retrograde memory loss may occur, as well as other permanent cerebral lesions such as dysphasia, hemiplegia or blindness. A variant was described by Donkin. He had been trained by Simpson (one of those who first recognized the importance of albuminuria) in Edinburgh, and recognized that some cases of eclamptic psychosis occurred without seizures; this explains the interval between seizures (or coma) and psychosis, a gap that has occasionally exceeded 4 days: seizures and psychosis are two different consequences of severe gestosis. Donkin psychosis may not be rare: a British series included 13 possible cases; but clarifying its distinction from postpartum bipolar disorder requires prospective investigations in collaboration with obstetricians. Wernicke–Korsakoff psychosis This was described by Wernicke and Korsakoff. The pathology is damage to the core of the brain including the thalamus and mamillary bodies. Its most striking clinical feature is loss of memory, which can be permanent. It is usually found in severe alcoholics, but can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum), because the requirement for thiamine is much increased in pregnancy; nearly 200 cases have been reported. The cause is vitamin B1 (thiamine) deficiency. This has been available for treatment and prevention since 1936, so the occurrence of this syndrome in pregnancy should be extinct. But these cases continue to be reported – more than 50 in this century – from all over the world, including some from countries with advanced medical services; most are due to rehydration without vitamin supplements. A pregnant woman who presents in a dehydrated state due to pernicious vomiting urgently needs thiamine, as well as intravenous fluids. Vascular disorders Various vascular disorders occasionally cause psychosis, especially cerebral venous thrombosis. Puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins; aseptic thrombi can also form in the dural venous sinuses and the cerebral veins draining into them. Most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation. The incidence is about 1 in 1,000 births in Europe and North America, but much higher in India, where large series have been collected. Psychosis is occasionally associated with other arterial or venous lesions: epidural anaesthesia can, if the dura is punctured, lead to leakage of cerebrospinal fluid and subdural haematoma. Arterial occlusion may be due to thrombi, amniotic fragments or air embolism. Postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. Subarachnoid haemorrhage can occur after miscarriage or childbirth. All these usually present with neurological symptoms, and occasionally with delirium. Epilepsy Women with a lifelong epileptic history are liable to psychoses during pregnancy, labour and the puerperium. Women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described. There are over 30 cases in the literature. Hypopituitarism Pituitary necrosis following postpartum haemorrhage (Sheehan's syndrome) leads to failure and atrophy of the gonads, adrenal and thyroid. Chronic psychoses can supervene many years later, based on myxoedema, hypoglycaemia or Addisonian crisis. But these patients can also develop acute and recurrent psychoses, even as early as the puerperium. Water intoxication Hyponatraemia (which leads to delirium) can complicate oxytocin treatment, usually when given to induce an abortion. By 1975, 29 cases had been reported, of which three were severe or fatal. Urea cycle disorders Inborn errors of the Krebs-Henseleit urea cycle lead to hyperammonaemia. In carriers and heterozygotes, encephalopathy can develop in pregnancy or the puerperium. Cases have been described in carbamoyl phosphate synthetase 1, argino-succinate synthetase and ornithine carbamoyltransferase deficiency. Anti-NMDA receptor encephalitis The most recent form of organic childbearing psychosis to be described is encephalitis associated with antibodies to the NMDA receptor; these women often have ovarian teratomas. A Japanese review found ten reported during pregnancy and five after delivery. Other organic psychoses with a specific link to childbearing Sydenham's chorea, of which chorea gravidarum is a severe variant, has a number of psychiatric complications, which include psychosis. This usually develops during pregnancy, and occasionally after the birth or abortion. Its symptoms include severe hypnagogic hallucinations (hypnagogia), possibly the result of the extreme sleep disorder. This form of chorea was caused by streptococcal infections, which at present respond to antibiotics; it still occurs as a result of systemic lupus or anti-phospholipid syndromes. Only about 50 chorea psychoses have been reported, and only one this century; but it could return if the streptococcus escapes control. Alcohol withdrawal states (delirium tremens) occur in addicts whose intake has been interrupted by trauma or surgery; this can happen after childbirth. Postpartum confusional states have also been reported during withdrawal from opium and barbiturates. One would expect acquired immunodeficiency syndrome (HIV/AIDS) encephalitis to present in pregnancy or the puerperium, because it is a venereal disease that can progress rapidly; one case of AIDS encephalitis, presenting in the 28th week of gestation, has been reported from Haiti, and there may be others in countries where AIDS is rife. Anaemia is common in pregnancy and the puerperium, and folate deficiency has been linked to psychosis. Incidental organic psychoses The psychoses, mentioned above, all had a recognized connection with childbearing. But medical disorders with no specific link have presented with psychotic symptoms in the puerperium; in them the association seems to be fortuitous. They include neurosyphilis, encephalitis including von Economo's, meningitis, cerebral tumours, thyroid disease and ischaemic heart disease. Society and culture Support In the UK, a series of workshops called "Unravelling Eve" were held in 2011, where women who had experienced postpartum depression shared their stories. Cases Harriet Sarah, Lady Mordaunt (1848–1906), formerly Harriet Moncreiffe, was the Scottish wife of an English baronet and Member of Parliament, Sir Charles Mordaunt. She was the defendant in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled; after a controversial trial lasting seven days, the jury determined that Lady Mordaunt had "puerperal mania" and her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum. Andrea Yates had depression and, four months after the birth of her fifth child, relapsed, with psychotic features. Several weeks later she drowned all five children. Under the law in Texas, she was sentenced to life imprisonment, but, after a retrial, was committed to a mental hospital. Lindsay Clancy Lindsay Marie Clancy (née Musgrove; born August 11, 1990) is an American woman from Duxbury, Massachusetts who strangled her three children on the evening of January 24, 2023. Two of the children, 5-year-old Cora Clancy and 3-year-old Dawson Clancy, were pronounced dead at the hospital on January 24, 2023, while a third child, 8-month-old Callan Clancy, died on January 27, 2023. After she strangled the children she attempted to kill herself by jumping from a window. She is now permanently paralyzed from the waist down. Experts for the defense believe Clancy suffered from postpartum psychosis and that she may have been "overmedicated." Her attorneys reported that, in the 4 months leading up to the incident, Lindsay had been prescribed 13 different psychiatric medications. Clancy worked as a labor and delivery nurse at Massachusetts General Hospital. She also made videos for newborn mothers. Prior to the incident, she struggled with various facets of her mental health, seeking treatment from one psychiatrist and a psychiatric nurse practitioner. She was admitted to McLean Hospital less than three weeks before the killings. The incident ignited a discussion on social media platforms such as TikTok about postpartum psychosis and various others struggles mothers face after a birth. This had led to many mothers speaking out about their own stories, opening up on social media or to various press outlets about their experiences. Several bills were introduced to the Massachusetts state legislature in an attempt to better address postpartum illnesses in the state. In fiction Guy de Maupassant, in his novel Mont-Oriol (1887) described a brief postpartum psychotic episode. Charlotte Perkins Gilman, in her short story "The Yellow Wallpaper" (1892) described severe depression with psychotic features starting after childbirth, perhaps similar to that experienced by the author herself. Stacey Slater, a fictional character in the long-running BBC soap-opera EastEnders had postpartum psychosis in 2016, and was one of the show's biggest storylines that year. In the House, M.D. episode Forever, House takes the case of a mother with postpartum psychosis. Legal status Postpartum psychosis, especially when there is a marked component of depression, has a small risk of filicide. In acute manic or cycloid cases, this risk is about 1%. Most of these incidents have occurred before the mother came under treatment, and some have been accidental. Several nations including Canada, United Kingdom, Australia, and Italy recognize postpartum mental illness as a mitigating factor in cases where mothers kill their children. In the United States, such a legal distinction was not made as of 2009, and an insanity defense is not available in all states. The United Kingdom has had the Infanticide Act since 1922. Books written about postpartum psychosis and postpartum bipolar disorder The following books have been published about these psychoses: Ripping, Dr (1877) Die Geistesstörungen der Schwangeren, Wöchnerinnen und Säugenden. Stuttgart, Enke. Knauer O (1897) Über Puerperale Psychose für practische Ärzte. Berlin, Karger. Twomey T (2009) Understanding Postpartum Psychosis: A Temporary Madness. Westport, Praeger. Harwood D (2017) Birth of a New Brain - Healing from Postpartum Bipolar Disorder. Brentwood, Post Hill Press. References External links Pathology of pregnancy, childbirth and the puerperium Mood disorders Psychosis Bipolar disorder Mental disorders associated with pregnancy, childbirth or the puerperium de:Postpartale Stimmungskrisen#Postpartale Psychose (PPP)

Insanity defense

The insanity defense, also known as the mental disorder defense, is an affirmative defense by excuse in a criminal case, arguing that the defendant is not responsible for their actions due to a psychiatric disease at the time of the criminal act. This is contrasted with an excuse of provocation, in which the defendant is responsible, but the responsibility is lessened due to a temporary mental state. It is also contrasted with the justification of self defense or with the mitigation of imperfect self-defense. The insanity defense is also contrasted with a finding that a defendant cannot stand trial in a criminal case because a mental disease prevents them from effectively assisting counsel, from a civil finding in trusts and estates where a will is nullified because it was made when a mental disorder prevented a testator from recognizing the natural objects of their bounty, and from involuntary civil commitment to a mental institution, when anyone is found to be gravely disabled or to be a danger to themself or to others. Legal definitions of insanity or mental disorder are varied, and include the M'Naghten Rule, the Durham rule, the 1953 British Royal Commission on Capital Punishment report, the ALI rule (American Legal Institute Model Penal Code rule), and other provisions, often relating to a lack of mens rea ("guilty mind"). In the criminal laws of Australia and Canada, statutory legislation enshrines the M'Naghten Rules, with the terms defense of mental disorder, defense of mental illness or not criminally responsible by reason of mental disorder employed. Being incapable of distinguishing right from wrong is one basis for being found to be legally insane as a criminal defense. It originated in the M'Naghten Rule, and has been reinterpreted and modernized through more recent cases, such as People v. Serravo. In the United Kingdom, Ireland, and the United States, use of the defense is rare. Mitigating factors, including things not eligible for the insanity defense such as intoxication and partial defenses such as diminished capacity and provocation, are used more frequently. The defense is based on evaluations by forensic mental health professionals with the appropriate test according to the jurisdiction. Their testimony guides the jury, but they are not allowed to testify to the accused's criminal responsibility, as this is a matter for the jury to decide. Similarly, mental health practitioners are restrained from making a judgment on the "ultimate issue"—whether the defendant is insane. Some jurisdictions require the evaluation to address the defendant's ability to control their behavior at the time of the offense (the volitional limb). A defendant claiming the defense is pleading "not guilty by reason of insanity" (NGRI) or "guilty but insane or mentally ill" in some jurisdictions which, if successful, may result in the defendant being committed to a psychiatric facility for an indeterminate period. Non compos mentis Non compos mentis (Latin) is a legal term meaning "not of sound mind". Non compos mentis derives from the Latin non meaning "not", compos meaning "control" or "command", and mentis (genitive singular of mens), meaning "of mind". It is the direct opposite of Compos mentis (of a sound mind). Although typically used in law, this term can also be used metaphorically or figuratively; e.g. when one is in a confused state, intoxicated, or not of sound mind. The term may be applied when a determination of competency needs to be made by a physician for purposes of obtaining informed consent for treatments and, if necessary, assigning a surrogate to make health care decisions. While the proper sphere for this determination is in a court of law, this is practically, and most frequently, made by physicians in the clinical setting. In English law, the rule of non compos mentis was most commonly used when the defendant invoked religious or magical explanations for behaviour. History The concept of defense by insanity has existed since ancient Greece and Rome. During the Roman and Greek eras, insanity was used as a way to help provide a defense for those with mental disorders. However, in colonial America a delusional Dorothy Talbye was hanged in 1638 for murdering her daughter, as at the time Massachusetts's common law made no distinction between insanity (or mental illness) and criminal behavior. Edward II, under English common law, declared that a person was insane if their mental capacity was no more than that of a "wild beast" (in the sense of a dumb animal, rather than being frenzied). The first complete transcript of an insanity trial dates to 1724. It is likely that the insane, like those under 14, were spared trial by ordeal. When that was replaced by trial by jury, members were expected to find the insane guilty but then to refer the case to the king for a royal pardon. From 1500 onwards, juries could acquit the insane, and detention required a separate civil procedure. The Criminal Lunatics Act 1800, passed with retrospective effect following the acquittal of James Hadfield, mandated detention at the regent's pleasure (indefinitely) even for those who, although insane at the time of the offence, were now sane. The M'Naghten Rules of 1843 were not a codification or definition of insanity but rather the responses of a panel of judges to hypothetical questions posed by Parliament in the wake of Daniel M'Naghten's acquittal for the homicide of Edward Drummond, whom he mistook for British Prime Minister Robert Peel. The rules define the defense as "at the time of committing the act the party accused was labouring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing, or as not to know that what he was doing was wrong." The key is that the defendant could not appreciate the nature of their actions during the commission of the crime. In Ford v. Wainwright 477 U.S. 399 (1986), the US Supreme Court upheld the common law rule that the insane cannot be executed. It further stated that a person under the death penalty is entitled to a competency evaluation and to an evidentiary hearing in court on the question of their competency to be executed. In Wainwright v. Greenfield (1986), the Court ruled that it was fundamentally unfair for the prosecutor to comment during the court proceedings on the petitioner's silence invoked as a result of a Miranda warning. The prosecutor had argued that the respondent's silence after receiving Miranda warnings was evidence of his sanity. In 2006, the US Supreme Court decided Clark v. Arizona, upholding Arizona's restrictions on the insanity defense. Kahler v. Kansas, 589 U.S. ___ (2020), is a case in which the US Supreme Court justices ruled that the Eighth and the Fourteenth Amendments of the US Constitution do not require states to adopt the insanity defense in criminal cases that are based on the defendant's ability to recognize right from wrong. Application The defense of insanity takes different guises in different jurisdictions, and there are differences between legal systems with regard to the availability, definition and burden of proof, as well as the role of judges, juries and medical experts. In jurisdictions where there are jury trials, it is common for the decision about the sanity of an accused to be determined by the jury. Incompetency and mental illness An important distinction to be made is the difference between competency and criminal responsibility. The issue of competency is whether a defendant is able to adequately assist their attorney in preparing a defense, make informed decisions about trial strategy and whether to plead guilty, accept a plea agreement or plead not guilty. This issue is dealt with in UK law as "fitness to plead". Competency largely deals with the defendant's present condition, while criminal responsibility addresses the condition at the time the crime was committed. In the United States, a trial in which the insanity defense is invoked typically involves the testimony of psychiatrists or psychologists who will, as expert witnesses, present opinions on the defendant's state of mind at the time of the offense. Therefore, a person whose mental disorder is not in dispute is determined to be sane if the court decides that despite a "mental illness" the defendant was responsible for the acts committed and will be treated in court as a normal defendant. If the person has a mental illness and it is determined that the mental illness interfered with the person's ability to determine right from wrong (and other associated criteria a jurisdiction may have) and if the person is willing to plead guilty or is proven guilty in a court of law, some jurisdictions have an alternative option known as either a Guilty but Mentally Ill (GBMI) or a Guilty but Insane verdict. The GBMI verdict is available as an alternative to, rather than in lieu of, a "not guilty by reason of insanity" verdict. Michigan (1975) was the first state to create a GBMI verdict, after two prisoners released after being found NGRI committed violent crimes within a year of release, one raping two women and the other killing his wife. Temporary insanity The notion of temporary insanity argues that a defendant was insane during the commission of a crime, but they later regained their sanity after the criminal act was carried out. This legal defense developed in the 19th century and became especially associated with the defense of individuals committing crimes of passion. The defense was first successfully used by U.S. Congressman Daniel Sickles of New York in 1859 after he had killed his wife's lover, Philip Barton Key II. The temporary insanity defense was unsuccessfully pleaded by Charles J. Guiteau who assassinated president James A. Garfield in 1881. Mitigating factors and diminished capacity The United States Supreme Court (in Penry v. Lynaugh) and the United States Court of Appeals for the Fifth Circuit (in Bigby v. Dretke) have been clear in their decisions that jury instructions in death penalty cases that do not ask about mitigating factors regarding the defendant's mental health violate the defendant's Eighth Amendment rights, saying that the jury is to be instructed to consider mitigating factors when answering unrelated questions. This ruling suggests specific explanations to the jury are necessary to weigh mitigating factors. Diminished responsibility or diminished capacity can be employed as a mitigating factor or partial defense to crimes. In the United States, diminished capacity is applicable to more circumstances than the insanity defense. The Homicide Act 1957 is the statutory basis for the defense of diminished responsibility in England and Wales, whereas in Scotland it is a product of case law. The number of findings of diminished responsibility has been matched by a fall in unfitness to plead and insanity findings. A plea of diminished capacity is different from a plea of insanity in that "reason of insanity" is a full defense while "diminished capacity" is merely a plea to a lesser crime. Intoxication Depending on jurisdiction, circumstances and crime, intoxication may be a defense, a mitigating factor or an aggravating factor. However, most jurisdictions differentiate between voluntary intoxication and involuntary intoxication. In some cases, intoxication (usually involuntary intoxication) may be covered by the insanity defense. Withdrawal or refusal of defense Several cases have ruled that persons found not guilty by reason of insanity may not withdraw the defense in a habeas petition to pursue an alternative, although there have been exceptions in other rulings. In Colorado v. Connelly, 700 A.2d 694 (Conn. App. Ct. 1997), the petitioner who had originally been found not guilty by reason of insanity and committed for ten years to the jurisdiction of a Psychiatric Security Review Board, filed a pro se writ of habeas corpus and the court vacated his insanity acquittal. He was granted a new trial and found guilty of the original charges, receiving a prison sentence of 40 years. In the landmark case of Frendak v. United States in 1979, the court ruled that the insanity defense cannot be imposed upon an unwilling defendant if an intelligent defendant voluntarily wishes to forgo the defense. Usage This increased coverage gives the impression that the defense is widely used, but this is not the case. According to an eight-state study, the insanity defense is used in less than 1% of all court cases and, when used, has only a 26% success rate. Of those cases that were successful, 90% of the defendants had been previously diagnosed with mental illness. Psychiatric treatment In the United States, those found to have been not guilty by reason of mental disorder or insanity are generally then required to undergo psychiatric treatment in a mental institution, except in the case of temporary insanity. In England and Wales, under the Criminal Procedure (Insanity and Unfitness to Plead) Act of 1991 (amended by the Domestic Violence, Crime and Victims Act, 2004 to remove the option of a guardianship order), the court can mandate a hospital order, a restriction order (where release from hospital requires the permission of the Home Secretary), a "supervision and treatment" order, or an absolute discharge. Unlike defendants who are found guilty of a crime, they are not institutionalized for a fixed period, but rather held in the institution until they are determined not to be a threat. Authorities making this decision tend to be cautious, and as a result, defendants can often be institutionalized for longer than they would have been incarcerated in prison. Worldwide Australia In Australia there are nine law units, each of which may have different rules governing mental impairment defenses. South Australia In South Australia, the Criminal Law Consolidation Act 1935 (SA) provides that: 269C—Mental competence A person is mentally incompetent to commit an offence if, at the time of the conduct alleged to give rise to the offence, the person is suffering from a mental impairment and, in consequence of the mental impairment— (a) does not know the nature and quality of the conduct; or (b) does not know that the conduct is wrong; or (c) is unable to control the conduct. 269H — Mental unfitness to stand trial A person is mentally unfit to stand trial on a charge of an offence if the person's mental processes are so disordered or impaired that the person is — (a) unable to understand, or to respond rationally to, the charge or the allegations on which the charge is based; or (b) unable to exercise (or to give rational instructions about the exercise of) procedural rights (such as, for example, the right to challenge jurors); or (c) unable to understand the nature of the proceedings, or to follow the evidence or the course of the proceedings. Victoria In Victoria the current defence of mental impairment was introduced in the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 which replaced the common law defence of insanity and indefinite detention at the governor's pleasure with the following: the accused was suffering from a mental impairment; and the mental impairment affected the accused so they either did not understand the nature and quality of the conduct, or did not know that it was wrong. These requirements are almost identical to the M'Naghten Rules, substituting "mental impairment" for "disease of the mind". New South Wales In New South Wales, the defence has been renamed the 'Defence of Mental Illness' in Part 4 of the Mental Health (Forensic Provisions) Act 1990. However, definitions of the defence are derived from M'Naghten's case and have not been codified. Whether a particular condition amounts to a disease of the mind is not a medical but a legal question to be decided in accordance with the ordinary rules of interpretation. This defence is an exception to the Woolmington v DPP (1935) 'golden thread', as the party raising the issue of the defence of mental illness bears the burden of proving this defence on the balance of probabilities. Generally, the defence will raise the issue of insanity. However, the prosecution can raise it in exceptional circumstances: R v Ayoub (1984). Australian cases have further qualified and explained the M'Naghten Rules. The NSW Supreme Court has held there are two limbs to the M'Naghten Rules, that the accused did not know what he was doing, or that the accused did not appreciate that what he was doing was morally wrong, in both cases the accused must be operating under a 'defect of reason, from a disease of the mind'. The High Court in R v Porter stated that the condition of the accused's mind is relevant only at the time of the actus reus. In Woodbridge v The Queen the court stated that a symptom indicating a disease of the mind must be prone to recur and be the result of an underlying pathological infirmity. A 'defect of reason' is the inability to think rationally and pertains to incapacity to reason, rather than having unsound ideas or difficulty with such a task. Examples of disease of the mind include Arteriosclerosis (considered so because the hardening of the arteries affects the mind. Canada Criminal Code provisions The defence of mental disorder is codified in section 16 of the Criminal Code which states, in part: 16. (1) No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong. To establish a claim of mental disorder the party raising the issue must show on a balance of probabilities first that the person who committed the act was suffering from a "disease of the mind", and second, that at the time of the offence they were either 1) unable to appreciate the "nature and quality" of the act, or 2) did not know it was "wrong". The meaning of the word "wrong" was determined in the Supreme Court case of R. v. Chaulk [1990] 3 S.C.R. which held that "wrong" was NOT restricted to "legally wrong" but to "morally wrong" as well. Post-verdict conditions The current legislative scheme was created by the Parliament of Canada after the previous scheme was found unconstitutional by the Supreme Court of Canada in R. v. Swain. The new provisions also replaced the old insanity defense with the current mental disorder defence. Once a person is found not criminally responsible ("NCR"), they will have a hearing by a Review Board within 45 days (90 days if the court extends the delay). A Review Board is established under Part XX.1 of the Criminal Code and is composed of at least three members, a person who is a judge or eligible to be a judge, a psychiatrist and another expert in a relevant field, such as social work, criminology or psychology. Parties at a Review Board hearing are usually the accused, the Crown and the hospital responsible for the supervision or assessment of the accused. A Review Board is responsible for both accused persons found NCR or accused persons found unfit to stand trial on account of mental disorder. A Review Board dealing with an NCR offender must consider two questions: whether the accused is a "significant threat to the safety of the public" and, if so, what the "least onerous and least restrictive" restrictions on the liberty of the accused should be in order to mitigate such a threat. Proceedings before a Review Board are inquisitorial rather than adversarial. Often the Review Board will be active in conducting an inquiry. Where the Review Board is unable to conclude that the accused is a significant threat to the safety of the public, the review board must grant the accused an absolute discharge, an order essentially terminating the jurisdiction of the criminal law over the accused. Otherwise, the Review Board must order that the accused be either discharged subject to conditions or detained in a hospital, both subject to conditions. The conditions imposed must be the least onerous and least restrictive necessary to mitigate any danger the accused may pose to others. Since the Review Board is empowered under criminal law powers under s. 91(27) of the Constitution Act, 1867 the sole justification for its jurisdiction is public safety. Therefore, the nature of the inquiry is the danger the accused may pose to public safety rather than whether the accused is "cured". For instance, many "sick" accused persons are discharged absolutely on the basis that they are not a danger to the public while many "sane" accused are detained on the basis that they are dangerous. Moreover, the notion of "significant threat to the safety of the public" is a "criminal threat". This means that the Review Board must find that the threat posed by the accused is of a criminal nature. While proceedings before a Review Board are less formal than in court, there are many procedural safeguards available to the accused given the potential indefinite nature of Part XX.1. Any party may appeal against the decision of a Review Board. In 1992 when the new mental disorder provisions were enacted, Parliament included "capping" provisions which were to be enacted at a later date. These capping provisions limited the jurisdiction of a Review Board over an accused based on the maximum potential sentence had the accused been convicted (e.g. there would be a cap of 5 years if the maximum penalty for the index offence is 5 years). However, these provisions were never proclaimed into force and were subsequently repealed. A Review Board must hold a hearing every 12 months (unless extended to 24 months) until the accused is discharged absolutely. Accused unfit to stand trial The issue of mental disorder may also come into play before a trial even begins if the accused's mental state prevents the accused from being able to appreciate the nature of a trial and to conduct a defence. An accused who is found to be unfit to stand trial is subject to the jurisdiction a Review Board. While the considerations are essentially the same, there are a few provisions which apply only to unfit accused. A Review Board must determine whether the accused is fit to stand trial. Regardless of the determination, the Review Board must then determine what conditions should be imposed on the accused, considering both the protection of the public and the maintenance of the fitness of the accused (or conditions which would render the accused fit). Previously an absolute discharge was unavailable to an unfit accused. However, in R. v. Demers, the Supreme Court of Canada struck down the provision restricting the availability of an absolute discharge to an accused person who is deemed both "permanently unfit" and not a significant threat to the safety of the public. Presently a Review Board may recommend a judicial stay of proceedings in the event that it finds the accused both "permanently unfit" and non-dangerous. The decision is left to the court having jurisdiction over the accused. An additional requirement for an unfit accused is the holding of a "prima facie case" hearing every two years. The Crown must demonstrate to the court having jurisdiction over the accused that it still has sufficient evidence to try the accused. If the Crown fails to meet this burden then the accused is discharged and proceedings are terminated. The nature of the hearing is virtually identical to that of a preliminary hearing. Denmark In Denmark a psychotic person who commits a criminal defense is declared guilty but is sentenced to mandatory treatment instead of prison. Section 16 of the penal code states that "Persons, who, at the time of the act, were irresponsible owing to mental illness or similar conditions or to a pronounced mental deficiency, are not punishable". This means that in Denmark, 'insanity' is a legal term rather than a medical term and that the court retains the authority to decide whether an accused person is irresponsible. Finland In Finland, punishments can only be administered if the accused is compos mentis, of sound mind; not if the accused is insane (syyntakeeton, literally "unable to guarantee [shoulder the responsibility of] guilt"). Thus, an insane defendant may be found guilty based on the facts and their actions just as a sane defendant, but the insanity will only affect the punishment. The definition of insanity is similar to the M'Naught criterion above: "the accused is insane, if during the act, due to a mental illness, profound mental retardation or a severe disruption of mental health or consciousness, he cannot understand the actual nature of his act or its illegality, or that his ability to control his behavior is critically weakened". If an accused is suspected to be insane, the court must consult the National Institute for Health and Welfare (THL), which is obliged to place the accused in involuntary commitment if they are found insane. The offender receives no judicial punishment; they become a patient under the jurisdiction of THL, and must be released immediately once the conditions of involuntary commitment are no longer fulfilled. Diminished responsibility is also available, resulting in lighter sentences. Germany According to section 20 of the German criminal code, those who commit an illegal act because a mental disorder makes them unable to see the wrong of the act or to act on this insight is considered not guilty. Section 63 stipulates that if the offender is deemed at risk of committing further offences that will harm others or cause grave economic damage, and if they therefore pose a continuing threat to public safety, they shall be committed to a psychiatric hospital in lieu of a custodial or suspended prison sentence. Japan If the ability to recognize the right or wrong of action or the ability to act accordingly is lost due to a mental disorder, then the defendant cannot be pursued under Japanese criminal law so if this is recognized during a trial then an innocent judgment will be given. This is, however, rare, happening in only around 1 in 500,000 cases. Netherlands Section 39 of the Dutch criminal code stipulates: "Not culpable is he who performs an act that he cannot be imputed with due to the deficient development or pathological disorder of his mental faculties". Obviously critical are the definitions of "deficient development" and/or "pathological [mental] disorder". These are to be verified by somatomedical and/or psychiatric specialists. An inculpability defense needs to conform to the following criteria: The defendant suffered from deficient development or pathological disorder of his mental faculties at the time at which the crime took place; There is a probable causal relationship between deficient development or pathological (mental) disorder and the crime [i.e. not every disorder or developmental deficit excuses every crime]; and Based on the criteria above, there is a reasonable assumption the deficient development or pathological disorder of his mental faculties excuses culpability of the crime. If the inculpability defense succeeds, the defendant cannot be ordered to incarceration proper. If the defendant is deemed to be criminally insane (i.e. deemed to pose a risk to himself or others), the court instead may order involuntary admission to a mental institution for further evaluation and/or treatment. The court can opt for a definite period of time (when complete or at least sufficient recovery of mental faculties on a relatively short time scale is probable) or an indefinite period of time (when the defendant's ailment is deemed to be difficult or impossible to treat, or can be supposed to be refractory to treatment). If the inculpability defense succeeds only partly ([i.e. if the crime cannot be completely excused because of a minor degree of deficient development or pathological (mental) disorder), there may still be a legal basis for a diminished culpability of the defendant; in such case, a diminished prison sentence should be ordered. This can also be combined with the aforementioned involuntary admission to a mental institution, although in these cases the two 'sentences' often run/are served in parallel. Norway In Norway, psychotic perpetrators are declared guilty but not punished and, instead of prison, they are sentenced to mandatory treatment. Section 44 of the penal code states specifically that "a person who at the time of the crime was insane or unconscious is not punished". Poland Insanity is determined through a judicial decision issued on the basis of expert opinions of psychiatrists and psychologists. Russia A forensic psychiatric examination is used to establish insanity. The result of the forensic examination is then subjected to a legal assessment, taking into account other circumstances of the case, from which a conclusion is drawn about the defendant's sanity or insanity. The Criminal Code of Russia establishes that a person who during the commission of an illegal act was in a state of insanity, that is, could not be aware of the actual nature and social danger of their actions or was unable to control them due to a chronic mental disorder, a temporary mental disorder, or dementia is not subject to criminal liability. Sweden In Sweden, psychotic perpetrators are seen as accountable, but the sanction is, if they are psychotic at the time of the trial, forensic mental care. United Kingdom Although use of the insanity defense is rare, since the Criminal Procedure (Insanity and Unfitness to Plead) Act 1991, insanity pleas have steadily increased in the UK. Scotland The Scottish Law Commission, in its Discussion Paper No 122 on Insanity and Diminished Responsibility (2003) confirms that the law has not substantially changed from the position stated in Hume's Commentaries in 1797: The phrase "absolute alienation of reason" is still regarded as at the core of the defense in the modern law (see HM Advocate v Kidd (1960) JC 61 and Brennan v HM Advocate (1977) United States In the United States, variances in the insanity defense between states, and in the federal court system, are attributable to differences with respect to three key issues: Availability: whether the jurisdiction allows a defendant to raise the insanity defense, Definition: when the defense is available, what facts will support a finding of insanity, and Burden of proof: whether the defendant has the duty of proving insanity or the prosecutor has the duty of disproving insanity, and by what standard of proof. In Foucha v. Louisiana (1992) the Supreme Court of the United States ruled that a person could not be held "indefinitely" for psychiatric treatment following a finding of not guilty by reason of insanity. Availability In the United States, a criminal defendant may plead insanity in federal court, and in the state courts of every state except for Idaho, Kansas, Montana, and Utah. However, defendants in states that disallow the insanity defense may still be able to demonstrate that a defendant was not capable of forming intent to commit a crime as a result of mental illness. In Kahler v. Kansas (2020), the U.S. Supreme Court held, in a 6–3 ruling, that a state does not violate the Due Process Clause by abolishing an insanity defense based on a defendant's incapacity to distinguish right from wrong. The Court emphasized that state governments have broad discretion to choose laws defining "the precise relationship between criminal culpability and mental illness." Definition Each state and the federal court system currently uses one of the following "tests" to define insanity for purposes of the insanity defense. Over its decades of use the definition of insanity has been modified by statute, with changes to the availability of the insanity defense, what constitutes legal insanity, whether the prosecutor or defendant has the burden of proof, the standard of proof required at trial, trial procedures, and to commitment and release procedures for defendants who have been acquitted based on a finding of insanity. M'Naghten test The guidelines for the M'Naghten Rules, state, among other things, and evaluating the criminal responsibility for defendants claiming to be insane were settled in the British courts in the case of Daniel M'Naghten in 1843. M'Naghten was a Scottish woodcutter who killed the secretary to the prime minister, Edward Drummond, in a botched attempt to assassinate the prime minister himself. M'Naghten apparently believed that the prime minister was the architect of the myriad of personal and financial misfortunes that had befallen him. During his trial, nine witnesses testified to the fact that he was insane, and the jury acquitted him, finding him "not guilty by reason of insanity". The House of Lords asked the judges of the common law courts to answer five questions on insanity as a criminal defence, and the formulation that emerged from their review—that a defendant should not be held responsible for their actions only if, as a result of their mental disease or defect, they (i) did not know that their act would be wrong; or (ii) did not understand the nature and quality of their actions—became the basis of the law governing legal responsibility in cases of insanity in England. Under the rules, loss of control because of mental illness was no defense. The M'Naghten rule was embraced with almost no modification by American courts and legislatures for more than 100 years, until the mid-20th century. It was first used as a defense in the United States in the case of People v. Freeman in 1847, where an Afro-Native man from Auburn, New York was tried for a quadruple murder. William H. Seward represented William Freeman and argued that Freeman was mentally insane after being committed to the Auburn State Prison for a crime Freeman insisted he did not commit. This was a novel defense at the time, and produced much controversy in the town of Auburn, New York, and throughout the United States at large. Durham/New Hampshire test The strict M'Naghten standard for the insanity defense was widely used until the 1950s and the case of Durham v. United States case. In the Durham case, the court ruled that a defendant is entitled to acquittal if the crime was the product of their mental illness (i.e., crime would not have been committed but for the disease). The Durham rule, also called the Product Test, is broader than either the M'Naghten test or the irresistible impulse test. The test has more lenient guidelines for the insanity defense, but it addressed the issue of convicting mentally ill defendants, which was allowed under the M'Naghten Rule. However, the Durham standard drew much criticism because of its expansive definition of legal insanity. It was abandoned in the 1970s, after the case of United States v. Brawner (1972). Model Penal Code test The Model Penal Code, published by the American Law Institute, provides the ALI rule - a standard for legal insanity that serves as a compromise between the strict M'Naghten Rule, the lenient Durham ruling, and the irresistible impulse test. Under the MPC standard, which represents the modern trend, a defendant is not responsible for criminal conduct "if at the time of such conduct as a result of mental disease or defect he lacks substantial capacity either to appreciate the criminality of their conduct or to conform their conduct to the requirements of the law." The test thus takes into account both the cognitive and volitional capacity of insanity. Federal courts After the perpetrator of President Reagan's assassination attempt was found not guilty by reason of insanity, Congress passed the Insanity Defense Reform Act of 1984. Under this act, the burden of proof was shifted from the prosecution to the defense and the standard of evidence in federal trials was increased from a preponderance of evidence to clear and convincing evidence. The ALI test was discarded in favor of a new test that more closely resembled M'Naghten's. Under this new test only perpetrators suffering from severe mental illnesses at the time of the crime could successfully employ the insanity defense. The defendant's ability to control himself or herself was no longer a consideration. The Act also curbed the scope of expert psychiatric testimony and adopted stricter procedures regarding the hospitalization and release of those found not guilty by reason of insanity. Those acquitted of a federal offense by reason of insanity have not been able to challenge their psychiatric confinement through a writ of habeas corpus or other remedies. In Archuleta v. Hedrick, 365 F.3d 644 (8th Cir. 2004), the U.S. Court of Appeals for the Eighth Circuit the court ruled persons found not guilty by reason of insanity and later want to challenge their confinement may not attack their initial successful insanity defense: Guilty but mentally ill As an alternative to the insanity defense, some jurisdictions permit a defendant to plead guilty but mentally ill. A defendant who is found guilty but mentally ill may be sentenced to mental health treatment, at the conclusion of which the defendant will serve the remainder of their sentence in the same manner as any other defendant. Burden of proof In a majority of states, the burden of proving insanity is placed on the defendant, who must prove insanity by a preponderance of the evidence. In a minority of states, the burden is placed on the prosecution, who must prove sanity beyond reasonable doubt. In federal court the burden is placed on the defendant, who must prove insanity by clear and convincing evidence. See 18 U.S.C.S. Sec. 17(b); see also A.R.S. Sec. 13-502(C). Controversy The insanity plea is used in the U.S. Criminal Justice System in less than 1% of all criminal cases. Little is known about the criminal justice system and the mentally ill: Some U.S. states have begun to ban the use of the insanity defense, and in 1994 the Supreme Court denied a petition of certiorari seeking review of a Montana Supreme Court case that upheld Montana's abolition of the defense. Idaho, Kansas, and Utah have also banned the defense. However, a mentally ill defendant/patient can be found unfit to stand trial in these states. In 2001, the Nevada Supreme Court found that their state's abolition of the defense was unconstitutional as a violation of Federal due process. In 2006, the Supreme Court decided Clark v. Arizona upholding Arizona's limitations on the insanity defense. In that same ruling, the Court noted "We have never held that the Constitution mandates an insanity defense, nor have we held that the Constitution does not so require." In 2020, the Supreme Court decided Kahler v. Kansas upholding Kansas' abolition of the insanity defense, stating that the Constitution does not require Kansas to adopt an insanity test that turns on a defendant's ability to recognize that their crime was morally wrong. The insanity defense is also complicated because of the underlying differences in philosophy between psychiatrists/psychologists and legal professionals. In the United States, a psychiatrist, psychologist or other mental health professional is often consulted as an expert witness in insanity cases, but the ultimate legal judgment of the defendant's sanity is determined by a jury, not by a mental health professional. In other words, mental health professionals provide testimony and professional opinion but are not ultimately responsible for answering legal questions. See also Archuleta v. Hedrick By Reason of Insanity, a documentary about a hospital in Ohio housing the guilty-but-insane Diminished responsibility (or "Limited Sanity") Frendak v. United States Intoxication defence Mentally ill people in American prisons M'Naghten rules NCR: Not Criminally Responsible, a Canadian documentary film about the mental disorder defense Non compos mentis Nulla poena sine culpa People v. Drew Sanity Settled insanity State v. Strasburg Twinkie defense United States federal laws governing offenders with mental diseases or defects List of people acquitted by reason of insanity References Further reading Boland, F. (1996). "Insanity, the Irish Constitution and the European Convention on Human Rights". 47 Northern Ireland Legal Quarterly 260. Brown, M. (2007). "The John Hinckley Trial & Its Effect on the Insanity Defense". Butler Committee. (1975). The Butler Committee on Mentally Abnormal Offenders, London: HMSO, Cmnd 6244 . Ellis, J. W. (1986). "The Consequences of the Insanity Defense: Proposals to reform post-acquittal commitment laws". 35 Catholic University Law Review 961. Gostin, L. (1982). "Human Rights, Judicial Review and the Mentally Disordered Offender". (1982) Crim. LR 779. Vatz, R. (December 19, 2013). "Affluenza: just the latest way to shirk legal responsibility". The Baltimore Sun op-ed page. at p. 30 External links Frontline—From Daniel M'Naughten to John Hinckley: A Brief History of the Insanity Defense Evolution of the Insanity Plea Survey of US states' insanity defense criteria Criminal defenses Criminology Forensic psychiatry Forensic psychology Defense Legal ethics it:Capacità di intendere e di volere ja:責任能力#刑法上の責任能力

Executive functions

In cognitive science and neuropsychology, executive functions (collectively referred to as executive function and cognitive control) are a set of cognitive processes that support goal-directed behavior, by regulating thoughts and actions through cognitive control, selecting and successfully monitoring actions that facilitate the attainment of chosen objectives. Executive functions include basic cognitive processes such as attentional control, cognitive inhibition, inhibitory control, working memory, and cognitive flexibility. Higher-order executive functions require the simultaneous use of multiple basic executive functions and include planning and fluid intelligence (e.g., reasoning and problem-solving). Executive functions gradually develop and change across the lifespan of an individual and can be improved at any time over the course of a person's life. Similarly, these cognitive processes can be adversely affected by a variety of events which affect an individual. Both neuropsychological tests (e.g., the Stroop test) and rating scales (e.g., the Behavior Rating Inventory of Executive Function) are used to measure executive functions. They are usually performed as part of a more comprehensive assessment to diagnose neurological and psychiatric disorders. Cognitive control and stimulus control, which is associated with operant and classical conditioning, represent opposite processes (internal vs external or environmental, respectively) that compete over the control of an individual's elicited behaviors; in particular, inhibitory control is necessary for overriding stimulus-driven behavioral responses (stimulus control of behavior). The prefrontal cortex is necessary but not solely sufficient for executive functions; for example, the caudate nucleus and subthalamic nucleus also have a role in mediating inhibitory control. Cognitive control is impaired in addiction, attention deficit hyperactivity disorder, autism, and a number of other central nervous system disorders. Stimulus-driven behavioral responses that are associated with a particular rewarding stimulus tend to dominate one's behavior in an addiction. Neuroanatomy Historically, the executive functions have been seen as regulated by the prefrontal regions of the frontal lobes, but it is still a matter of ongoing debate if that really is the case. Even though articles on prefrontal lobe lesions commonly refer to disturbances of executive functions and vice versa, a review found indications for the sensitivity but not for the specificity of executive function measures to frontal lobe functioning. This means that both frontal and non-frontal brain regions are necessary for intact executive functions. Probably the frontal lobes need to participate in basically all of the executive functions, but they are not the only brain structure involved. Neuroimaging and lesion studies have identified the functions which are most often associated with the particular regions of the prefrontal cortex and associated areas. The dorsolateral prefrontal cortex (DLPFC) is involved with "on-line" processing of information such as integrating different dimensions of cognition and behavior. As such, this area has been found to be associated with verbal and design fluency, ability to maintain and shift set, planning, response inhibition, working memory, organisational skills, reasoning, problem-solving, and abstract thinking. The anterior cingulate cortex (ACC) is involved in emotional drives, experience and integration. Associated cognitive functions include inhibition of inappropriate responses, decision making and motivated behaviors. Lesions in this area can lead to low drive states such as apathy, abulia or akinetic mutism and may also result in low drive states for such basic needs as food or drink and possibly decreased interest in social or vocational activities and sex. The orbitofrontal cortex (OFC) plays a key role in impulse control, maintenance of set, monitoring ongoing behavior and socially appropriate behaviors. The orbitofrontal cortex also has roles in representing the value of rewards based on sensory stimuli and evaluating subjective emotional experiences. Lesions can cause disinhibition, impulsivity, aggressive outbursts, sexual promiscuity and antisocial behavior. Furthermore, in their review, Alvarez and Emory state that:The frontal lobes have multiple connections to cortical, subcortical and brain stem sites. The basis of "higher-level" cognitive functions such as inhibition, flexibility of thinking, problem solving, planning, impulse control, concept formation, abstract thinking, and creativity often arise from much simpler, "lower-level" forms of cognition and behavior. Thus, the concept of executive function must be broad enough to include anatomical structures that represent a diverse and diffuse portion of the central nervous system.The cerebellum also appears to be involved in mediating certain executive functions, as do the ventral tegmental area and the substantia nigra. In humans, high contents of cannabinoid receptor 1 (CB1) is found in frontal neocortical areas, subserving higher cognitive and executive functions, and in the posterior cingulate, a region pivotal for consciousness and higher cognitive processing by its activation. Hypothesized role The executive system is thought to be heavily involved in handling novel situations outside the domain of some of our 'automatic' psychological processes that could be explained by the reproduction of learned schemas or set behaviors. Psychologists Don Norman and Tim Shallice have outlined five types of situations in which routine activation of behavior would not be sufficient for optimal performance: Those that involve planning or decision-making Those that involve error correction or troubleshooting Situations where responses are not well-rehearsed or contain novel sequences of actions Dangerous or technically difficult situations Situations that require the overcoming of a strong habitual response or resisting temptation. A prepotent response is a response for which immediate reinforcement (positive or negative) is available or has been previously associated with that response. Executive functions are often invoked when it is necessary to override prepotent responses that might otherwise be automatically elicited by stimuli in the external environment. For example, on being presented with a potentially rewarding stimulus, such as a tasty piece of chocolate cake, a person might have the automatic response to take a bite. However, where such behavior conflicts with internal plans (such as having decided not to eat chocolate cake while on a diet), the executive functions might be engaged to inhibit that response. Although suppression of these prepotent responses is ordinarily considered adaptive, problems for the development of the individual and the culture arise when feelings of right and wrong are overridden by cultural expectations or when creative impulses are overridden by executive inhibitions. Historical perspective Although research into the executive functions and their neural basis has increased markedly over recent years, the theoretical framework in which it is situated is not new. In the 1940s, the British psychologist Donald Broadbent drew a distinction between "automatic" and "controlled" processes (a distinction characterized more fully by Shiffrin and Schneider in 1977), and introduced the notion of selective attention, to which executive functions are closely allied. In 1975, the US psychologist Michael Posner used the term "cognitive control" in his book chapter entitled "Attention and cognitive control". The work of influential researchers such as Michael Posner, Joaquin Fuster, Tim Shallice, and their colleagues in the 1980s (and later Trevor Robbins, Bob Knight, Don Stuss, and others) laid much of the groundwork for recent research into executive functions. For example, Posner proposed that there is a separate "executive" branch of the attentional system, which is responsible for focusing attention on selected aspects of the environment. The British neuropsychologist Tim Shallice similarly suggested that attention is regulated by a "supervisory system", which can override automatic responses in favour of scheduling behaviour on the basis of plans or intentions. Throughout this period, a consensus emerged that this control system is housed in the most anterior portion of the brain, the prefrontal cortex (PFC). Psychologist Alan Baddeley had proposed a similar system as part of his model of working memory and argued that there must be a component (which he named the "central executive") that allows information to be manipulated in short-term memory (for example, when doing mental arithmetic). Development The executive functions are among the last mental functions to reach maturity. This is due to the delayed maturation of the prefrontal cortex, which is not completely myelinated until well into a person's third decade of life. Development of executive functions tends to occur in spurts, when new skills, strategies, and forms of awareness emerge. These spurts are thought to reflect maturational events in the frontal areas of the brain. Attentional control appears to emerge in infancy and develop rapidly in early childhood. Cognitive flexibility, goal setting, and information processing usually develop rapidly during ages 7–9 and mature by age 12. Executive control typically emerges shortly after a transition period at the beginning of adolescence. It is not yet clear whether there is a single sequence of stages in which executive functions appear, or whether different environments and early life experiences can lead people to develop them in different sequences. Early childhood Inhibitory control and working memory act as basic executive functions that make it possible for more complex executive functions like problem-solving to develop. Inhibitory control and working memory are among the earliest executive functions to appear, with initial signs observed in infants, 7 to 12 months old. Then in the preschool years, children display a spurt in performance on tasks of inhibition and working memory, usually between the ages of 3 and 5 years. Also during this time, cognitive flexibility, goal-directed behavior, and planning begin to develop. Nevertheless, preschool children do not have fully mature executive functions and continue to make errors related to these emerging abilities – often not due to the absence of the abilities, but rather because they lack the awareness to know when and how to use particular strategies in particular contexts. Preadolescence Preadolescent children continue to exhibit certain growth spurts in executive functions, suggesting that this development does not necessarily occur in a linear manner, along with the preliminary maturing of particular functions as well. During preadolescence, children display major increases in verbal working memory; goal-directed behavior (with a potential spurt around 12 years of age); response inhibition and selective attention; and strategic planning and organizational skills. Additionally, between the ages of 8 and 10, cognitive flexibility in particular begins to match adult levels. However, similar to patterns in childhood development, executive functioning in preadolescents is limited because they do not reliably apply these executive functions across multiple contexts as a result of ongoing development of inhibitory control. Adolescence Many executive functions may begin in childhood and preadolescence, such as inhibitory control. Yet, it is during adolescence when the different brain systems become better integrated. At this time, youth implement executive functions, such as inhibitory control, more efficiently and effectively and improve throughout this time period. Just as inhibitory control emerges in childhood and improves over time, planning and goal-directed behavior also demonstrate an extended time course with ongoing growth over adolescence. Likewise, functions such as attentional control, with a potential spurt at age 15, along with working memory, continue developing at this stage. Adulthood The major change that occurs in the brain in adulthood is the constant myelination of neurons in the prefrontal cortex. At age 20–29, executive functioning skills are at their peak, which allows people of this age to participate in some of the most challenging mental tasks. These skills begin to decline in later adulthood. Working memory and spatial span are areas where decline is most readily noted. Cognitive flexibility, however, has a late onset of impairment and does not usually start declining until around age 70 in normally functioning adults. Impaired executive functioning has been found to be the best predictor of functional decline in the elderly. Models Top-down inhibitory control Aside from facilitatory or amplificatory mechanisms of control, many authors have argued for inhibitory mechanisms in the domain of response control, memory, selective attention, theory of mind, emotion regulation, as well as social emotions such as empathy. A recent review on this topic argues that active inhibition is a valid concept in some domains of psychology/cognitive control. Working memory model One influential model is Baddeley's multicomponent model of working memory, which is composed of a central executive system that regulates three subsystems: the phonological loop, which maintains verbal information; the visuospatial sketchpad, which maintains visual and spatial information; and the more recently developed episodic buffer that integrates short-term and long-term memory, holding and manipulating a limited amount of information from multiple domains in temporal and spatially sequenced episodes. Researchers have found significant positive effects of biofeedback-enhanced relaxation on memory and inhibition in children. Biofeedback is a mind-body tool where people can learn to control and regulate their body to improve and control their executive functioning skills. To measure one's processes, researchers use their heart rate and or respiratory rates. Biofeedback-relaxation includes music therapy, art, and other mindfulness activities. Executive functioning skills are important for many reasons, including children's academic success and social emotional development. According to the study "The Efficacy of Different Interventions to Foster Children's Executive Function Skills: A Series of Meta-Analyses", researchers found that it is possible to train executive functioning skills. Researchers conducted a meta-analytic study that looked at the combined effects of prior studies in order to find the overarching effectiveness of different interventions that promote the development of executive functioning skills in children. The interventions included computerized and non-computerized training, physical exercise, art, and mindfulness exercises. However, researchers could not conclude that art activities or physical activities could improve executive functioning skills. Supervisory attentional system (SAS) Another conceptual model is the supervisory attentional system (SAS). In this model, contention scheduling is the process where an individual's well-established schemas automatically respond to routine situations while executive functions are used when faced with novel situations. In these new situations, attentional control will be a crucial element to help generate new schema, implement these schema, and then assess their accuracy. Self-regulatory model Russell Barkley proposed a widely known model of executive functioning that is based on self-regulation. Primarily derived from work examining behavioral inhibition, it views executive functions as composed of four main abilities. One element is working memory that allows individuals to resist interfering information. A second component is the management of emotional responses in order to achieve goal-directed behaviors. Thirdly, internalization of self-directed speech is used to control and sustain rule-governed behavior and to generate plans for problem-solving. Lastly, information is analyzed and synthesized into new behavioral responses to meet one's goals. Changing one's behavioral response to meet a new goal or modify an objective is a higher level skill that requires a fusion of executive functions including self-regulation, and accessing prior knowledge and experiences. According to this model, the executive system of the human brain provides for the cross-temporal organization of behavior towards goals and the future and coordinates actions and strategies for everyday goal-directed tasks. Essentially, this system permits humans to self-regulate their behavior so as to sustain action and problem-solving toward goals specifically and the future more generally. Thus, executive function deficits pose serious problems for a person's ability to engage in self-regulation over time to attain their goals and anticipate and prepare for the future. Teaching children self-regulation strategies is a way to improve their inhibitory control and their cognitive flexibility. These skills allow children to manage their emotional responses. These interventions include teaching children executive function-related skills that provide the steps necessary to implement them during classroom activities and educating children on how to plan their actions before acting upon them. Executive functioning skills are how the brain plans and reacts to situations. Offering new self-regulation strategies allow children to improve their executive functioning skills by practicing something new. It is also concluded that mindfulness practices are shown to be a significantly effective intervention for children to self-regulate. This includes biofeedback-enhanced relaxation. These strategies support the growth of children's executive functioning skills. Problem-solving model Yet another model of executive functions is a problem-solving framework where executive functions are considered a macroconstruct composed of subfunctions working in different phases to (a) represent a problem, (b) plan for a solution by selecting and ordering strategies, (c) maintain the strategies in short-term memory in order to perform them by certain rules, and then (d) evaluate the results with error detection and error correction. Lezak's conceptual model One of the most widespread conceptual models on executive functions is Lezak's model. This framework proposes four broad domains of volition, planning, purposive action, and effective performance as working together to accomplish global executive functioning needs. While this model may broadly appeal to clinicians and researchers to help identify and assess certain executive functioning components, it lacks a distinct theoretical basis and relatively few attempts at validation. Miller and Cohen's model In 2001, Earl Miller and Jonathan Cohen published their article "An integrative theory of prefrontal cortex function", in which they argue that cognitive control is the primary function of the prefrontal cortex (PFC), and that control is implemented by increasing the gain of sensory or motor neurons that are engaged by task- or goal-relevant elements of the external environment. In a key paragraph, they argue: Miller and Cohen draw explicitly upon an earlier theory of visual attention that conceptualises perception of visual scenes in terms of competition among multiple representations – such as colors, individuals, or objects. Selective visual attention acts to 'bias' this competition in favour of certain selected features or representations. For example, imagine that you are waiting at a busy train station for a friend who is wearing a red coat. You are able to selectively narrow the focus of your attention to search for red objects, in the hope of identifying your friend. Desimone and Duncan argue that the brain achieves this by selectively increasing the gain of neurons responsive to the color red, such that output from these neurons is more likely to reach a downstream processing stage, and, as a consequence, to guide behaviour. According to Miller and Cohen, this selective attention mechanism is in fact just a special case of cognitive control – one in which the biasing occurs in the sensory domain. According to Miller and Cohen's model, the PFC can exert control over input (sensory) or output (response) neurons, as well as over assemblies involved in memory, or emotion. Cognitive control is mediated by reciprocal PFC connectivity with the sensory and motor cortices, and with the limbic system. Within their approach, thus, the term "cognitive control" is applied to any situation where a biasing signal is used to promote task-appropriate responding, and control thus becomes a crucial component of a wide range of psychological constructs such as selective attention, error monitoring, decision-making, memory inhibition, and response inhibition. Miyake and Friedman's model Miyake and Friedman's theory of executive functions proposes that there are three aspects of executive functions: updating, inhibition, and shifting. A cornerstone of this theoretical framework is the understanding that individual differences in executive functions reflect both unity (i.e., common EF skills) and diversity of each component (e.g., shifting-specific). In other words, aspects of updating, inhibition, and shifting are related, yet each remains a distinct entity. First, updating is defined as the continuous monitoring and quick addition or deletion of contents within one's working memory. Second, inhibition is one's capacity to supersede responses that are prepotent in a given situation. Third, shifting is one's cognitive flexibility to switch between different tasks or mental states. Miyake and Friedman also suggest that the current body of research in executive functions suggest four general conclusions about these skills. The first conclusion is the unity and diversity aspects of executive functions. Second, recent studies suggest that much of one's EF skills are inherited genetically, as demonstrated in twin studies. Third, clean measures of executive functions can differentiate between normal and clinical or regulatory behaviors, such as ADHD. Last, longitudinal studies demonstrate that EF skills are relatively stable throughout development. Banich's "cascade of control" model This model from 2009 integrates theories from other models, and involves a sequential cascade of brain regions involved in maintaining attentional sets in order to arrive at a goal. In sequence, the model assumes the involvement of the posterior dorsolateral prefrontal cortex (DLPFC), the mid-DLPFC, and the posterior and anterior dorsal anterior cingulate cortex (ACC). The cognitive task used in the article is selecting a response in the Stroop task, among conflicting color and word responses, specifically a stimulus where the word "green" is printed in red ink. The posterior DLPFC creates an appropriate attentional set, or rules for the brain to accomplish the current goal. For the Stroop task, this involves activating the areas of the brain involved in color perception, and not those involved in word comprehension. It counteracts biases and irrelevant information, like the fact that the semantic perception of the word is more salient to most people than the color in which it is printed. Next, the mid-DLPFC selects the representation that will fulfill the goal. The task-relevant information must be separated from other sources of information in the task. In the example, this means focusing on the ink color and not the word. The posterior dorsal ACC is next in the cascade, and it is responsible for response selection. This is where the decision is made whether the Stroop task participant will say "green" (the written word and the incorrect answer) or "red" (the font color and correct answer). Following the response, the anterior dorsal ACC is involved in response evaluation, deciding whether one's response were correct or incorrect. Activity in this region increases when the probability of an error is higher. The activity of any of the areas involved in this model depends on the efficiency of the areas that came before it. If the DLPFC imposes a lot of control on the response, the ACC will require less activity. Recent work using individual differences in cognitive style has shown exciting support for this model. Researchers had participants complete an auditory version of the Stroop task, in which either the location or semantic meaning of a directional word had to be attended to. Participants that either had a strong bias toward spatial or semantic information (different cognitive styles) were then recruited to participate in the task. As predicted, participants that had a strong bias toward spatial information had more difficulty paying attention to the semantic information and elicited increased electrophysiological activity from the ACC. A similar activity pattern was also found for participants that had a strong bias toward verbal information when they tried to attend to spatial information. Assessment Assessment of executive functions involves gathering data from several sources and synthesizing the information to look for trends and patterns across time and settings. Apart from standardized neuropsychological tests, other measures can and should be used, such as behaviour checklists, observations, interviews, and work samples. From these, conclusions may be drawn on the use of executive functions. There are several different kinds of instruments (e.g., performance based, self-report) that measure executive functions across development. These assessments can serve a diagnostic purpose for a number of clinical populations. Experimental evidence The executive system has been traditionally quite hard to define, mainly due to what psychologist Paul W. Burgess calls a lack of "process-behaviour correspondence". That is, there is no single behavior that can in itself be tied to executive function, or indeed executive dysfunction. For example, it is quite obvious what reading-impaired patients cannot do, but it is not so obvious what exactly executive-impaired patients might be incapable of. This is largely due to the nature of the executive system itself. It is mainly concerned with the dynamic, "online" co-ordination of cognitive resources, and, hence, its effect can be observed only by measuring other cognitive processes. In similar manner, it does not always fully engage outside of real-world situations. As neurologist Antonio Damasio has reported, a patient with severe day-to-day executive problems may still pass paper-and-pencil or lab-based tests of executive function. Theories of the executive system were largely driven by observations of patients with frontal lobe damage. They exhibited disorganized actions and strategies for everyday tasks (a group of behaviors now known as dysexecutive syndrome) although they seemed to perform normally when clinical or lab-based tests were used to assess more fundamental cognitive functions such as memory, learning, language, and reasoning. It was hypothesized that, to explain this unusual behaviour, there must be an overarching system that co-ordinates other cognitive resources. Much of the experimental evidence for the neural structures involved in executive functions comes from laboratory tasks such as the Stroop task or the Wisconsin Card Sorting Task (WCST). In the Stroop task, for example, human subjects are asked to name the color that color words are printed in when the ink color and word meaning often conflict (for example, the word "RED" in green ink). Executive functions are needed to perform this task, as the relatively overlearned and automatic behaviour (word reading) has to be inhibited in favour of a less practiced task – naming the ink color. Recent functional neuroimaging studies have shown that two parts of the PFC, the anterior cingulate cortex (ACC) and the dorsolateral prefrontal cortex (DLPFC), are thought to be particularly important for performing this task. Context-sensitivity of PFC neurons Other evidence for the involvement of the PFC in executive functions comes from single-cell electrophysiology studies in non-human primates, such as the macaque monkey, which have shown that (in contrast to cells in the posterior brain) many PFC neurons are sensitive to a conjunction of a stimulus and a context. For example, PFC cells might respond to a green cue in a condition where that cue signals that a leftwards fast movement of the eyes and the head should be made, but not to a green cue in another experimental context. This is important, because the optimal deployment of executive functions is invariably context-dependent. One example from Miller & Cohen involves a pedestrian crossing the street. In the United States, where cars drive on the right side of the road, an American learns to look left when crossing the street. However, if that American visits a country where cars drive on the left, such as the United Kingdom, then the opposite behavior would be required (looking to the right). In this case, the automatic response needs to be suppressed (or augmented) and executive functions must make the American look to the right while in the UK. Neurologically, this behavioural repertoire clearly requires a neural system that is able to integrate the stimulus (the road) with a context (US or UK) to cue a behaviour (look left or look right). Current evidence suggests that neurons in the PFC appear to represent precisely this sort of information. Other evidence from single-cell electrophysiology in monkeys implicates ventrolateral PFC (inferior prefrontal convexity) in the control of motor responses. For example, cells that increase their firing rate to NoGo signals as well as a signal that says "don't look there!" have been identified. Attentional biasing in sensory regions Electrophysiology and functional neuroimaging studies involving human subjects have been used to describe the neural mechanisms underlying attentional biasing. Most studies have looked for activation at the 'sites' of biasing, such as in the visual or auditory cortices. Early studies employed event-related potentials to reveal that electrical brain responses recorded over left and right visual cortex are enhanced when the subject is instructed to attend to the appropriate (contralateral) side of space. The advent of bloodflow-based neuroimaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) has more recently permitted the demonstration that neural activity in a number of sensory regions, including color-, motion-, and face-responsive regions of visual cortex, is enhanced when subjects are directed to attend to that dimension of a stimulus, suggestive of gain control in sensory neocortex. For example, in a typical study, Liu and coworkers presented subjects with arrays of dots moving to the left or right, presented in either red or green. Preceding each stimulus, an instruction cue indicated whether subjects should respond on the basis of the colour or the direction of the dots. Even though colour and motion were present in all stimulus arrays, fMRI activity in colour-sensitive regions (V4) was enhanced when subjects were instructed to attend to the colour, and activity in motion-sensitive regions was increased when subjects were cued to attend to the direction of motion. Several studies have also reported evidence for the biasing signal prior to stimulus onset, with the observation that regions of the frontal cortex tend to come active prior to the onset of an expected stimulus. Connectivity between the PFC and sensory regions Despite the growing currency of the 'biasing' model of executive functions, direct evidence for functional connectivity between the PFC and sensory regions when executive functions are used, is to date rather sparse. Indeed, the only direct evidence comes from studies in which a portion of frontal cortex is damaged, and a corresponding effect is observed far from the lesion site, in the responses of sensory neurons. However, few studies have explored whether this effect is specific to situations where executive functions are required. Other methods for measuring connectivity between distant brain regions, such as correlation in the fMRI response, have yielded indirect evidence that the frontal cortex and sensory regions communicate during a variety of processes thought to engage executive functions, such as working memory, but more research is required to establish how information flows between the PFC and the rest of the brain when executive functions are used. As an early step in this direction, an fMRI study on the flow of information processing during visuospatial reasoning has provided evidence for causal associations (inferred from the temporal order of activity) between sensory-related activity in occipital and parietal cortices and activity in posterior and anterior PFC. Such approaches can further elucidate the distribution of processing between executive functions in PFC and the rest of the brain. Bilingualism and executive functions A growing body of research demonstrates that bilinguals might show advantages in executive functions, specifically inhibitory control and task switching. A possible explanation for this is that speaking two languages requires controlling one's attention and choosing the correct language to speak. Across development, bilingual infants, children, and elderly show a bilingual advantage when it comes to executive functioning. The advantage does not seem to manifest in younger adults. Bimodal bilinguals, or people who speak one oral language and one sign language, do not demonstrate this bilingual advantage in executive functioning tasks. This may be because one is not required to actively inhibit one language in order to speak the other. Bilingual individuals also seem to have an advantage in an area known as conflict processing, which occurs when there are multiple representations of one particular response (for example, a word in one language and its translation in the individual's other language). Specifically, the lateral prefrontal cortex has been shown to be involved with conflict processing. However, there are still some doubts. In a meta-analytic review, researchers concluded that bilingualism did not enhance executive functioning in adults. In disease or disorder The study of executive function in Parkinson's disease suggests subcortical areas such as the amygdala, hippocampus and basal ganglia are important in these processes. Dopamine modulation of the prefrontal cortex is responsible for the efficacy of dopaminergic drugs on executive function, and gives rise to the Yerkes–Dodson Curve. The inverted U represents decreased executive functioning with excessive arousal (or increased catecholamine release during stress), and decreased executive functioning with insufficient arousal. The low activity polymorphism of catechol-O-methyltransferase is associated with slight increase in performance on executive function tasks in healthy persons. Executive functions are impaired in multiple disorders including anxiety disorder, major depressive disorder, bipolar disorder, attention deficit hyperactivity disorder, schizophrenia and autism. Lesions to the prefrontal cortex, such as in the case of Phineas Gage, may also result in deficits of executive function. Damage to these areas may also manifest in deficits of other areas of function, such as motivation, and social functioning. Future directions Other important evidence for executive functions processes in the prefrontal cortex have been described. One widely cited review article emphasizes the role of the medial part of the PFC in situations where executive functions are likely to be engaged – for example, where it is important to detect errors, identify situations where stimulus conflict may arise, make decisions under uncertainty, or when a reduced probability of obtaining favourable performance outcomes is detected. This review, like many others, highlights interactions between medial and lateral PFC, whereby posterior medial frontal cortex signals the need for increased executive functions and sends this signal on to areas in dorsolateral prefrontal cortex that actually implement control. Yet there has been no compelling evidence at all that this view is correct, and, indeed, one article showed that patients with lateral PFC damage had reduced ERNs (a putative sign of dorsomedial monitoring/error-feedback) – suggesting, if anything, that the direction of flow of the control could be in the reverse direction. Another prominent theory emphasises that interactions along the perpendicular axis of the frontal cortex, arguing that a 'cascade' of interactions between anterior PFC, dorsolateral PFC, and premotor cortex guides behaviour in accordance with past context, present context, and current sensorimotor associations, respectively. Advances in neuroimaging techniques have allowed studies of genetic links to executive functions, with the goal of using the imaging techniques as potential endophenotypes for discovering the genetic causes of executive function. More research is required to develop interventions that can improve executive functions and help people generalize those skills to daily activities and settings See also Cognitive neuropsychology Executive dysfunction Metacognition Nonverbal learning disorder Purkinje cell Self-control Conscientiousness References External links The National Center for Learning Disabilities Amphetamine Cognition Motor control Neuropsychological assessment Neuropsychology Self

Biomedical model

The biomedical model of medicine care is the medical model used in most Western healthcare settings, and is built from the perception that a state of health is defined purely in the absence of illness. The biomedical model contrasts with sociological theories of care. Forms of the biomedical model have existed since before 400 BC, with Hippocrates advocating for physical etiologies of illness. Despite this, the model did not form the dominant view of health until the nineteenth century during the Scientific Revolution. Criticism of the model generally surrounds its perception that health is independent of the social environment in which it occurs, and can be defined one way across all populations. The model is also criticised for its view of the health system as socially and politically neutral, and not as a source of social and political power or as embedded into the structure of society. Features In their book Society, Culture and Health: an Introduction to Sociology for Nurses, health sociologists Dr. Karen Willis and Dr. Shandell Elmer outline eight 'features' of the biomedical model's approach to illness and health: doctrine of specific aetiology: that all illness and disease is attributable to a specific, physiological dysfunction body as a machine: that the body is formed of machinery to be fixed by medical doctors mind-body distinction: that the mind and body are separate entities that do not interrelate reductionism narrow definition of health: that a state of health is always the absence of a definable illness individualistic: that sources of ill health are always in the individual, and not the environment which health occurs treatment versus prevention: that the focus of health is on diagnosis and treatment of illness, not prevention treatment imperative: that medicine can 'fix the broken machinery' of ill-health neutral scientific process: that health care systems and agents of health are socially and culturally detached See also Biopsychosocial model Medical model Medical model of disability Social model of disability Trauma model of mental disorders References Medical models

Drug rehabilitation

Drug rehabilitation is the process of medical or psychotherapeutic treatment for dependency on psychoactive substances such as alcohol, prescription drugs, and street drugs such as cannabis, cocaine, heroin, and amphetamines. The general intent is to enable the patient to confront substance dependence, if present, and stop substance misuse to avoid the psychological, legal, financial, social, and medical consequences that can be caused. Treatment includes medication for comorbidities, counseling by experts, and sharing of experience with other recovering individuals. Psychological dependency Psychological dependency is addressed in many drug rehabilitation programs by attempting to teach patients new methods of interacting in a drug-free environment. In particular, patients are generally encouraged, or possibly even required, to not associate with peers who still use addictive substances. Twelve-step programs encourage addicts not only to stop using alcohol or other drugs but to examine and change habits related to their addictions. Many programs emphasize that recovery is an ongoing process without culmination. For legal drugs such as alcohol, complete abstention—rather than attempts at moderation, which may lead to relapse—is also emphasized ("One is too many, and a thousand is never enough.") Whether moderation is achievable by those with a history of misuse remains a controversial point. The brain's chemical structure is altered by addictive substances and these changes are present long after an individual stops using. This change in brain structure increases the risk of relapse, making treatment an important part of the rehabilitation process. Types Various types of programs offer help in drug rehabilitation, including residential treatment (in-patient/out-patient), local support groups, extended care centers, recovery or sober houses, addiction counselling, mental health, and medical care. Some rehab centers offer age- and gender-specific programs. In an American survey by three separate institutions (the National Association of Alcoholism and Drug Abuse Counselors, Rational Recovery Systems and the Society of Psychologists in Addictive Behaviors) measuring treatment responses on the Spiritual Belief Scale (a scale measuring belief in the four spiritual characteristics Alcoholics Anonymous identified by Ernest Kurtz); the scores were found to explain 41% of the variance in the treatment provider's responses on the Addiction Belief Scale (a scale measuring adherence to the disease model or the free-will model addiction). Effective treatment addresses the multiple needs of the patient rather than treating addiction alone. In addition, medically assisted drug detoxification or alcohol detoxification alone is ineffective as a treatment for addiction. The National Institute on Drug Abuse (NIDA) recommends detoxification followed by both medication (where applicable) and behavioral therapy, followed by relapse prevention. According to NIDA, effective treatment must address medical and mental health services as well as follow-up options, such as community or family-based recovery support systems. Whatever the methodology, patient motivation is an important factor in treatment success. For individuals addicted to prescription drugs, treatments tend to be similar to those who are addicted to drugs affecting the same brain systems. Medication like methadone and buprenorphine can be used to treat addiction to prescription opiates, and behavioral therapies can be used to treat addiction to prescription stimulants, benzodiazepines, and other drugs. Types of behavioral therapy include: Cognitive-behavioral therapy, which seeks to help patients to recognize, avoid and cope with situations in which they are most likely to relapse. Multidimensional family therapy, which is designed to support the recovery of the patient by improving family functioning. Motivational interviewing, which is designed to increase patient motivation to change behavior and enter treatment. Motivational incentives, which uses positive reinforcement to encourage abstinence from the addictive substance. EEG Biofeedback augmented treatment improves abstinence rates of 12-step, faith-based, and medically assisted addiction for cocaine, methamphetamine, alcohol use disorder, and opioid addictions. Treatment can be a long process and the duration is dependent upon the patient's needs and history of substance use. Research has shown that most patients need at least three months of treatment and longer durations are associated with better outcomes. Prescription drug addiction does not discriminate. It affects people from all walks of life and can be a devastatingly destructive force. Medications Certain opioid medications such as methadone and more buprenorphine are widely used to treat addiction and dependence on other opioids such as heroin, morphine or oxycodone. Methadone and buprenorphine are maintenance therapies intended to reduce cravings for opiates, thereby reducing illegal drug use, and the risks associated with it, such as disease, arrest, incarceration, and death, in line with the philosophy of harm reduction. Both drugs may be used as maintenance medications (taken for an indefinite period of time), or used as detoxification aids. All available studies collected in the 2005 Australian National Evaluation of Pharmacotherapies for Opioid Dependence suggest that maintenance treatment is preferable, with very high rates (79–100%) of relapse within three months of detoxification from levo-α-acetylmethadol (LAAM), buprenorphine, and methadone. According to the National Institute on Drug Abuse (NIDA), patients stabilized on adequate, sustained doses of methadone or buprenorphine can keep their jobs, avoid crime and violence, and reduce their exposure to HIV and Hepatitis C by stopping or reducing injection drug use and drug-related high risk sexual behavior. Naltrexone is a long-acting opioid antagonist with few side effects. It is usually prescribed in outpatient medical conditions. Naltrexone blocks the euphoric effects of alcohol and opiates. Naltrexone cuts relapse risk in the first three months by about 36%. However, it is far less effective in helping patients maintain abstinence or retaining them in the drug-treatment system (retention rates average 12% at 90 days for naltrexone, average 57% at 90 days for buprenorphine, average 61% at 90 days for methadone). Ibogaine is a hallucinogenic drug promoted by certain fringe groups to interrupt both physical dependence and psychological craving to a broad range of drugs including narcotics, stimulants, alcohol, and nicotine. To date, there have never been any controlled studies showing it to be effective, and it is not accepted as a treatment by physicians, pharmacists, or addictionologist. There have also been several deaths related to ibogaine use, which causes tachycardia and long QT syndrome. The drug is an illegal Schedule I controlled substance in the United States, and the foreign facilities in which it is administered tend to have little oversight and range from motel rooms to one moderately-sized rehabilitation center. A few antidepressants have been proven to be helpful in the context of smoking cessation/nicotine addiction. These medications include bupropion and nortriptyline. Bupropion inhibits the re-uptake of nor-epinephrine and dopamine and has been FDA approved for smoking cessation, while nortriptyline is a tricyclic antidepressant which has been used to aid in smoking cessation it has not been FDA approved for this indication. Acamprosate, disulfiram and topiramate (a novel anticonvulsant sulphonated sugar) are also used to treat alcohol addiction. Acamprosate has shown effectiveness for patients with severe dependence, helping them to maintain abstinence for several weeks, even months. Disulfiram produces a very unpleasant reaction when drinking alcohol that includes flushing, nausea and palpitations. It is more effective for patients with high motivation and some addicts use it only for high-risk situations. Patients who wish to continue drinking or may be likely to relapse should not take disulfiram as it can result in the disulfiram-alcohol reaction mentioned previously, which is very serious and can even be fatal. Nitrous oxide, also sometimes known as laughing gas, is a legally available gas used for anesthesia during certain dental and surgical procedures, in food preparation, and for the fueling of rocket and racing engines. People who use substances also sometimes use gas as an inhalant. Like all other inhalants, it is popular because it provides consciousness-altering effects while allowing users to avoid some of the legal issues surrounding illicit substances. Misuse of nitrous oxide can produce significant short-term and long-term damage to human health, including a form of oxygen starvation called hypoxia, brain damage and a serious vitamin B12 deficiency that can lead to nerve damage. Although dangerous and addictive in its own right, nitrous oxide has been shown to be an effective treatment for a number of addictions. Residential treatment In-patient residential treatment for people with an alcohol use disorder is usually quite expensive without insurance. Most American programs follow a 28–30 day program length. The length is based solely upon providers' experience. During the 1940s, clients stayed about one week to get over the physical changes, another week to understand the program, and another week or two to become stable. 70% to 80% of American residential alcohol treatment programs provide 12-step support services. These include, but are not limited to AA, Narcotics Anonymous, Cocaine Anonymous and Al-Anon. One recent study suggests the importance of family participation in residential treatment patient retention, finding "increased program completion rate for those with a family member or significant other involved in a seven-day family program". Brain implants Patients with severe opioid addiction are being given brain implants to help reduce their cravings, in the first trial of its kind in the US. Treatment starts with a series of brain scans. Surgery follows with doctors making a small hole in the skull to insert a tiny 1mm electrode in the specific area of the brain that regulates impulses such as addiction and self-control. This treatment is for those who have failed every other treatment, whether that is medicine, behavioral therapy, and/or social interventions. It is a very rigorous trial with oversight from ethicists and regulators and many other governing bodies. Recovery The definition of recovery remains divided and subjective in drug rehabilitation, as there are no set standards for measuring recovery. The Betty Ford Institute defined recovery as achieving complete abstinence as well as personal well-being while other studies have considered "near abstinence" as a definition. The Recovery Model originates in the psychiatric survivor movement in the US, which argues that receiving a certain diagnoses can be stigmatizing and disempowering. Some characteristics of the Recovery Model are social inclusion, empowerment to overcome substance use, focusing on strengths of the client instead of their deficits and providing help living more fulfilling lives in the presence of symptoms of addiction. Another key component of the Recovery Model is the collaborative relationship between client and provider in developing the client's path to abstinence. Under the Recovery Model a program is personally designed to meet an individual clients needs, and does not include a standard set of steps one must go through. The Recovery Model uses integral theory: a four-part approach focusing on the individual, the collective society, along with individual and external factors. The four quadrants corresponding with each in Integral Theory are Consciousness, Behavior, Culture and Systems. Quadrant One deals with the neurological aspect of addiction. Quadrant Two focuses on building self-esteem and a feeling of connectedness, sometimes through spirituality. Quadrant three works on mending the "eroded relationships" caused by active addiction. Quadrant Four often involves facing the harsh consequences of drug use such as unemployment, legal discrepancies, or eviction. The use of integral theory aims to break the dichotomy of "using" or "not using" and focuses instead on emotional, spiritual, and intellectual growth, along with physical wellness. Criminal justice Drug rehabilitation is sometimes part of the criminal justice system. People convicted of minor drug offenses may be sentenced to rehabilitation instead of prison, and those convicted of driving while intoxicated are sometimes required to attend Alcoholics Anonymous meetings. There are a great number of ways to address an alternative sentence in a drug possession or DUI case; increasingly, American courts are willing to explore outside-the-box methods for delivering this service. There have been lawsuits filed, and won, regarding the requirement of attending Alcoholics Anonymous and other twelve-step meetings as being inconsistent with the Establishment Clause of the First Amendment of the U.S. Constitution, mandating separation of church and state. In some cases, individuals can be court-ordered to drug rehabilitation by the state through legislation like the Marchman Act. Counseling Traditional addiction treatment is based primarily on counseling. Counselors help individuals with identifying behaviors and problems related to their addiction. It can be done on an individual basis, but it's more common to find it in a group setting and can include crisis counseling, weekly or daily counseling, and drop-in counseling supports. Counselors are trained to develop recovery programs that help to reestablish healthy behaviors and provide coping strategies whenever a situation of risk happens. It's very common to see them also work with family members who are affected by the addictions of the individual, or in a community to prevent addiction and educate the public. Counselors should be able to recognize how addiction affects the whole person and those around him or her. Counseling is also related to "Intervention"; a process in which the addict's family and loved ones request help from a professional to get an individual into drug treatment. This process begins with a professionals' first goal: breaking down denial of the person with the addiction. Denial implies a lack of willingness from the patients or fear to confront the true nature of the addiction and to take any action to improve their lives, instead of continuing the destructive behavior. Once this has been achieved, the counselor coordinates with the addict's family to support them in getting the individual to drug rehabilitation immediately, with concern and care for this person. Otherwise, this person will be asked to leave and expect no support of any kind until going into drug rehabilitation or alcoholism treatment. An intervention can also be conducted in the workplace environment with colleagues instead of family. One approach with limited applicability is the sober coach. In this approach, the client is serviced by the provider(s) in his or her home and workplace—for any efficacy, around-the-clock—who functions much like a nanny to guide or control the patient's behavior. Twelve-step programs The disease model of addiction has long contended the maladaptive patterns of alcohol and substance use displays addicted individuals are the result of a lifelong disease that is biological in origin and exacerbated by environmental contingencies. This conceptualization renders the individual essentially powerless over his or her problematic behaviors and unable to remain sober by himself or herself, much as individuals with a terminal illness are unable to fight the disease by themselves without medication. Behavioral treatment, therefore, necessarily requires individuals to admit their addiction, renounce their former lifestyle, and seek a supportive social network that can help them remain sober. Such approaches are the quintessential features of Twelve-step programs, originally published in the book Alcoholics Anonymous in 1939. These approaches have met considerable amounts of criticism, coming from opponents who disapprove of the spiritual-religious orientation on both psychological and legal grounds. Opponents also contend that it lacks valid scientific evidence for claims of efficacy. However, there is survey-based research that suggests there is a correlation between attendance and alcohol sobriety. Different results have been reached for other drugs, with the twelve steps being less beneficial for addicts to illicit substances, and least beneficial to those addicted to the physiologically and psychologically addicting opioids, for which maintenance therapies are the gold standard of care. SMART Recovery SMART Recovery was founded by Joe Gerstein in 1994 by basing REBT as a foundation. It gives importance to the human agency in overcoming addiction and focuses on self-empowerment and self-reliance. It does not subscribe to disease theory and powerlessness. The group meetings involve open discussions, questioning decisions and forming corrective measures through assertive exercises. It does not involve a lifetime membership concept, but people can opt to attend meetings, and choose not to after gaining recovery. Objectives of the SMART Recovery programs are: Building and Maintaining Motivation, Coping with Urges, Managing Thoughts, Feelings, and Behaviors, Living a Balanced Life. This is considered to be similar to other self-help groups who work within mutual aid concepts. Client-centered approaches In his influential book, Client-Centered Therapy, in which he presented the client-centered approach to therapeutic change, psychologist Carl Rogers proposed there are three necessary and sufficient conditions for personal change: unconditional positive regard, accurate empathy, and genuineness. Rogers believed the presence of these three items, in the therapeutic relationship, could help an individual overcome any troublesome issue, including but not limited to alcohol use disorder. To this end, a 1957 study compared the relative effectiveness of three different psychotherapies in treating alcoholics who had been committed to a state hospital for sixty days: a therapy based on two-factor learning theory, client-centered therapy, and psychoanalytic therapy. Though the authors expected the two-factor theory to be the most effective, it actually proved to be deleterious in the outcome. Surprisingly, client-centered therapy proved most effective. It has been argued, however, these findings may be attributable to the profound difference in therapist outlook between the two-factor and client-centered approaches, rather than to client-centered techniques. The authors note two-factor theory involves stark disapproval of the clients' "irrational behavior" (p. 350); this notably negative outlook could explain the results. A variation of Rogers' approach has been developed in which clients are directly responsible for determining the goals and objectives of the treatment. Known as Client-Directed Outcome-Informed therapy (CDOI), this approach has been utilized by several drug treatment programs, such as Arizona's Department of Health Services. Psychoanalysis Psychoanalysis, a psychotherapeutic approach to behavior change developed by Sigmund Freud and modified by his followers, has also explained substance use. This orientation suggests the main cause of the addiction syndrome is the unconscious need to entertain and to enact various kinds of homosexual and perverse fantasies, and at the same time to avoid taking responsibility for this. It is hypothesized specific drugs facilitate specific fantasies and using drugs is considered to be a displacement from, and a concomitant of, the compulsion to masturbate while entertaining homosexual and perverse fantasies. The addiction syndrome is also hypothesized to be associated with life trajectories that have occurred within the context of teratogenic processes, the phases of which include social, cultural, and political factors, encapsulation, traumatophobia, and masturbation as a form of self-soothing. Such an approach lies in stark contrast to the approaches of social cognitive theory to addiction—and indeed, to behavior in general—which holds human beings to regulate and control their own environmental and cognitive environments, and are not merely driven by internal, driving impulses. Additionally, homosexual content is not implicated as a necessary feature in addiction. Relapse prevention An influential cognitive-behavioral approach to addiction recovery and therapy has been Alan Marlatt's (1985) Relapse Prevention approach. Marlatt describes four psycho-social processes relevant to the addiction and relapse processes: self-efficacy, outcome expectancy, attributions of causality, and decision-making processes. Self-efficacy refers to one's ability to deal competently and effectively with high-risk, relapse-provoking situations. Outcome expectancy refers to an individual's expectations about the psychoactive effects of an addictive substance. Attributions of causality refer to an individual's pattern of beliefs that relapse to drug use is a result of internal, or rather external, transient causes (e.g., allowing oneself to make exceptions when faced with what are judged to be unusual circumstances). Finally, decision-making processes are implicated in the relapse process as well. Substance use is the result of multiple decisions whose collective effects result in the consumption of the intoxicant. Furthermore, Marlatt stresses some decisions—referred to as apparently irrelevant decisions—may seem inconsequential to relapse, but may actually have downstream implications that place the user in a high-risk situation. For example: As a result of heavy traffic, a recovering alcoholic may decide one afternoon to exit the highway and travel on side roads. This will result in the creation of a high-risk situation when he realizes he is inadvertently driving by his old favorite bar. If this individual can employ successful coping strategies, such as distracting himself from his cravings by turning on his favorite music, then he will avoid the relapse risk (PATH 1) and heighten his efficacy for future abstinence. If, however, he lacks coping mechanisms—for instance, he may begin ruminating on his cravings (PATH 2)—then his efficacy for abstinence will decrease, his expectations of positive outcomes will increase, and he may experience a lapse—an isolated return to substance intoxication. So doing results in what Marlatt refers to as the Abstinence Violation Effect, characterized by guilt for having gotten intoxicated and low efficacy for future abstinence in similar tempting situations. This is a dangerous pathway, Marlatt proposes, to full-blown relapse. Cognitive therapy An additional cognitively-based model of substance use recovery has been offered by Aaron Beck, the father of cognitive therapy and championed in his 1993 book Cognitive Therapy of Substance Abuse. This therapy rests upon the assumption addicted individuals possess core beliefs, often not accessible to immediate consciousness (unless the patient is also depressed). These core beliefs, such as "I am undesirable," activate a system of addictive beliefs that result in imagined anticipatory benefits of substance use and, consequentially, craving. Once craving has been activated, permissive beliefs ("I can handle getting high just this one more time") are facilitated. Once a permissive set of beliefs have been activated, then the individual will activate drug-seeking and drug-ingesting behaviors. The cognitive therapist's job is to uncover this underlying system of beliefs, analyze it with the patient, and thereby demonstrate its dysfunction. As with any cognitive-behavioral therapy, homework assignments and behavioral exercises serve to solidify what is learned and discussed during treatment. Emotion regulation and mindfulness A growing literature is demonstrating the importance of emotion regulation in the treatment of substance use. Considering that nicotine and other psychoactive substances such as cocaine activate similar psycho-pharmacological pathways, an emotion regulation approach may be applicable to a wide array of substance use. Proposed models of affect-driven tobacco use have focused on negative reinforcement as the primary driving force for addiction; according to such theories, tobacco is used because it helps one escape from the undesirable effects of nicotine withdrawal or other negative moods. Acceptance and commitment therapy (ACT), is showing evidence that it is effective in treating substance use, including the treatment of polysubstance use disorder and tobacco smoking. Mindfulness programs that encourage patients to be aware of their own experiences in the present moment and of emotions that arise from thoughts, appear to prevent impulsive/compulsive responses. Research also indicates that mindfulness programs can reduce the consumption of substances such as alcohol, cocaine, amphetamines, marijuana, cigarettes and opiates. Dual diagnosis People who are diagnosed with a mental health disorder and a simultaneous substance use disorder are known as having a dual diagnosis. For example, someone with bipolar disorder who also has an alcohol use disorder would have dual diagnosis. On such occasions, two treatment plans are needed with the mental health disorder requiring treatment first. According to the National Survey on Drug Use and Health (NSDUH), 45 percent of people with addiction have a co-occurring mental health disorder. Behavioral models Behavioral models make use of principles of functional analysis of drinking behavior. Behavior models exist for both working with the person using the substance (community reinforcement approach) and their family (community reinforcement approach and family training). Both these models have had considerable research success for both efficacy and effectiveness. This model lays much emphasis on the use of problem-solving techniques as a means of helping the addict to overcome his/her addiction. The way researchers think about how addictions are formed shapes the models we have. Four main Behavioral Models of addiction exist: the Moral Model, Disease Model, Socio-Cultural Model and Psycho-dynamic Model. The Moral Model of addiction theorizes that addiction is a moral weakness and that it is the sole fault of the person for becoming addicted. Supporters of the Moral Model view drug use as a choice, even for those who are addicted, and addicts as people of bad character. Disease Model of addiction frames substance abuse as 'a chronic relapsing disease that changes the structure and function of the brain'. Research conducted on the neurobiological factors of addiction has proven to have mixed results, and the only treatment idea it offers is abstinence. The Socio-Cultural Model tries to provide an explanation of how certain populations are more susceptible to substance abuse than others. It focuses on how discrimination, poor quality of life, lack of opportunity and other problems common in marginalized communities can make them vulnerable to addiction. The Psycho-Dynamic Model looks at trauma and mental illness as a precursor to addiction. Many rehabilitation centers treat "co-occurring" disorders, which refer to substance abuse disorder paired with a mental health diagnosis. Barriers to treatment in the US Barriers to accessing drug treatment may worsen negative health outcomes and further exacerbate health inequalities in the United States. Stigmatization of drug use, the War on Drugs and criminalization, and the social determinants of health should all be considered when discussing access to drug treatment and potential barriers. Broad categories of barriers to drug treatment are: absences of problem, negative social support, fear of treatment, privacy concerns, time conflict, poor treatment availability, and admission difficulty. Other barriers to treatment include high costs, lack of tailored programs to address specific needs, and prerequisites that require participants to be house, abstinent from all substances, and/or employed. (See low-threshold treatment and housing first for more context on the latter point.) Loss of Child/Dependent Access In certain states, providers due to mandatory reporting methods and guidelines inform Child Protective Services of substance abusing parents for Schedule 1 substances including cannabis/marijuana. If a mother tests positive for using the substance during pregnancy in South Carolina she may be required to forfeit her child. Further, barriers to treatment can vary depending on the geographical location, gender, race, socioeconomic status, and status of past or current criminal justice system involvement of the person seeking treatment. Criticism Despite ongoing efforts to combat addiction, there has been evidence of clinics billing patients for treatments that may not guarantee their recovery. This is a major problem as there are numerous claims of fraud in drug rehabilitation centers, where these centers are billing insurance companies for under-delivering much-needed medical treatment while exhausting patients' insurance benefits. In California, there are movements and laws regarding this matter, particularly the California Insurance Fraud Prevention Act (IFPA) which declares it unlawful to unknowingly conduct such businesses. Under the Affordable Care Act and the Mental Health Parity Act, rehabilitation centers are able to bill insurance companies for substance use treatment. With long wait lists in limited state-funded rehabilitation centers, controversial private centers rapidly emerged. One popular model, known as the Florida Model for rehabilitation centers, is often criticized for fraudulent billing to insurance companies. Under the guise of helping patients with opioid addiction, these centers would offer addicts free rent or up to $500 per month to stay in their "sober homes", then charge insurance companies as high as $5,000 to $10,000 per test for simple urine tests. Little attention is paid to patients in terms of addiction intervention as these patients have often been known to continue drug use during their stay in these centers. Since 2015, these centers have been under federal and state criminal investigation. As of 2017 in California, there are only 16 investigators in the CA Department of Health Care Services investigating over 2,000 licensed rehab centers. By country Afghanistan In Afghanistan since the Taliban took power in 2021, they have forced drug addicts into compulsory drug rehab. China As of 2013 China has compulsory drug rehabilitation centers. It was reported in 2018 1.3 million drug addicts were treated in China's compulsory detox centers. Compulsory drug rehabilitation has a long history in China: The Mao Zedong government is credited with eradicating both consumption and production of opium during the 1950s using unrestrained repression and social reform. Ten million addicts were forced into compulsory treatment, dealers were executed, and opium-producing regions were planted with new crops. Remaining opium production shifted south of the Chinese border into the Golden Triangle region. Indonesia In 2015 the National Narcotics Board (Indonesia) was pushing for compulsory drug treatment for people with drug dependence. Iran According to statistics best case scenario less than a 25% of addicts go back to being healthy. There are two types of rehab one is Revolutionary Guard Corp or FARAJA run article 16 quarantine which is part of operations cleaning the cities from addicts and homeless just as well, the others article 15 and article 17 run by others including State Welfare Organization of Iran and also those run by Ministry of health and medical education. There are also places called Trust houses since July 2023 run by IRGC. Italy In 1963, Pierino Gelmini founded Comunità Incontro, a drug rehabilitation center in Amelia, Italy. In Italy, drug-related treatment is managed by the heads of the local drug department or drug services. The drug system includes two complementary options that consist of public drug dependency service units and social-rehabilitative facilities. One of Italy's most prominent drug rehabilitation facilities is San Patrignano in Cariano, which offers a free, long-term residential program. See also Coerced abstinence Drug policy of the Soviet Union Dual diagnosis Florida shuffle Low-threshold treatment programs Self-medication Sober living environment Sober Coach Baclofen References Further reading Substance dependence Substance-related disorders Alcohol and health Addiction

Medical Subject Headings

Medical Subject Headings (MeSH) is a comprehensive controlled vocabulary for the purpose of indexing journal articles and books in the life sciences. It serves as a thesaurus that facilitates searching. Created and updated by the United States National Library of Medicine (NLM), it is used by the MEDLINE/PubMed article database and by NLM's catalog of book holdings. MeSH is also used by ClinicalTrials.gov registry to classify which diseases are studied by trials registered in ClinicalTrials. MeSH was introduced in the 1960s, with the NLM's own index catalogue and the subject headings of the Quarterly Cumulative Index Medicus (1940 edition) as precursors. The yearly printed version of MeSH was discontinued in 2007; MeSH is now available only online. It can be browsed and downloaded free of charge through PubMed. Originally in English, MeSH has been translated into numerous other languages and allows retrieval of documents from different origins. Structure MeSH vocabulary is divided into four types of terms. The main ones are the "headings" (also known as MeSH headings or descriptors), which describe the subject of each article (e.g., "Body Weight", "Brain Edema" or "Critical Care Nursing"). Most of these are accompanied by a short description or definition, links to related descriptors, and a list of synonyms or very similar terms (known as entry terms). MeSH contains approximately 30,000 entries and is updated annually to reflect changes in medicine and medical terminology. MeSH terms are arranged in alphabetic order and in a hierarchical structure by subject categories with more specific terms arranged beneath broader terms. When we search for a MeSH term, the most specific MeSH terms are automatically included in the search. This is known as the extended search or explode of that MeSH term. This additional information and the hierarchical structure (see below) make the MeSH essentially a thesaurus, rather than a plain subject headings list. The second type of term, MeSH subheadings or qualifiers (see below), can be used with MeSH terms to more completely describe a particular aspect of a subject, such as adverse, diagnostic or genetic effects. For example, the drug therapy of asthma is displayed as asthma/drug therapy. The remaining two types of term are those that describe the type of material that the article represents (publication types), and supplementary concept records (SCR) which describes substances such as chemical products and drugs that are not included in the headings (see below as "Supplements"). Descriptor hierarchy The descriptors or subject headings are arranged in a hierarchy. A given descriptor may appear at several locations in the hierarchical tree. The tree locations carry systematic labels known as tree numbers, and consequently one descriptor can carry several tree numbers. For example, the descriptor "Digestive System Neoplasms" has the tree numbers C06.301 and C04.588.274; C stands for Diseases, C06 for Digestive System Diseases and C06.301 for Digestive System Neoplasms; C04 for Neoplasms, C04.588 for Neoplasms By Site, and C04.588.274 also for Digestive System Neoplasms. The tree numbers of a given descriptor are subject to change as MeSH is updated. Every descriptor also carries a unique alphanumerical ID that will not change. Descriptions Most subject headings come with a short description or definition. See the MeSH description for diabetes type 2 as an example. The explanatory text is written by the MeSH team based on their standard sources if not otherwise stated. References are mostly encyclopaedias and standard textbooks of the subject areas. References for specific statements in the descriptions are not given; instead, readers are referred to the bibliography. Qualifiers In addition to the descriptor hierarchy, MeSH contains a small number of standard qualifiers (also known as subheadings), which can be added to descriptors to narrow down the topic. For example, "Measles" is a descriptor and "epidemiology" is a qualifier; "Measles/epidemiology" describes the subheading of epidemiological articles about Measles. The "epidemiology" qualifier can be added to all other disease descriptors. Not all descriptor/qualifier combinations are allowed since some of them may be meaningless. In all there are 83 different qualifiers. Supplements In addition to the descriptors, MeSH also contains some 318,000 supplementary concept records. These do not belong to the controlled vocabulary as such; instead they enlarge the thesaurus and contain links to the closest fitting descriptor to be used in a MEDLINE search. Many of these records describe chemical substances. Use in Medline/PubMed In MEDLINE/PubMed, every journal article is indexed with about 10–15 subject headings, subheadings and supplementary concept records, with some of them designated as major and marked with an asterisk, indicating the article's major topics. When performing a MEDLINE search via PubMed, entry terms are automatically translated into (i.e., mapped to) the corresponding descriptors with a good degree of reliability; it is recommended to check the 'Details tab' in PubMed to see how a search formulation was translated. By default, a search for a descriptor will include all the descriptors in the hierarchy below the given one. PubMed does not apply automatic mapping of the term in the following circumstances: by writing the quoted phrase (e.g. "kidney allograft"), when truncated on the asterisk (e.g. ), and when looking with field labels (e.g. ). Use at ClinicalTrials.gov At ClinicalTrials.gov, each trial has keywords that describe the trial. The ClinicalTrials.gov team assigns each trial two sets of MeSH terms. One set is for the conditions studied by the trial and the other for the set of interventions used in the trial. The XML file that can be downloaded for each trial contains these MeSH keywords. The XML file also has a comment that says: "the assignment of MeSH keywords is done by imperfect algorithm". Categories The top-level categories in the MeSH descriptor hierarchy are: Anatomy [A] Organisms [B] Diseases [C] Chemicals and Drugs [D] Analytical, Diagnostic and Therapeutic Techniques, and Equipment [E] Psychiatry and Psychology [F] Phenomena and Processes [G] Disciplines and Occupations [H] Anthropology, Education, Sociology and Social Phenomena [I] Technology, Industry, and Agriculture [J] Humanities [K] Information Science [L] Named Groups [M] Health Care [N] Publication Characteristics [V] Geographicals [Z] See also Medical classification Medical literature retrieval References External links Medical Subject Heading Home provided by National Library of Medicine, National Institutes of Health (U.S.) MeSH tutorials Automatic Term Mapping Browsing MeSH: Entrez MeSH Browser Visual MeSH Browser mapping drug-disease relationships in research Reference.MD of qualifiers – 2009 Biological databases Library cataloging and classification Medical classification Thesauri United States National Library of Medicine

Psychological adaptation

A psychological adaptation is a functional, cognitive or behavioral trait that benefits an organism in its environment. Psychological adaptations fall under the scope of evolved psychological mechanisms (EPMs), however, EPMs refer to a less restricted set. Psychological adaptations include only the functional traits that increase the fitness of an organism, while EPMs refer to any psychological mechanism that developed through the processes of evolution. These additional EPMs are the by-product traits of a species’ evolutionary development (see spandrels), as well as the vestigial traits that no longer benefit the species’ fitness. It can be difficult to tell whether a trait is vestigial or not, so some literature is more lenient and refers to vestigial traits as adaptations, even though they may no longer have adaptive functionality. For example, xenophobic attitudes and behaviors, some have claimed, appear to have certain EPM influences relating to disease aversion, however, in many environments these behaviors will have a detrimental effect on a person's fitness. The principles of psychological adaptation rely on Darwin's theory of evolution and are important to the fields of evolutionary psychology, biology, and cognitive science. Darwinian theory Charles Darwin proposed his theory of evolution in On the Origin of Species (1859). His theory dictates that adaptations are traits that arise from the selective pressures a species faces in its environment. Adaptations must benefit either an organism's chance of survival or reproduction to be considered adaptive, and are then passed down to the next generation through this process of natural selection. Psychological adaptations are those adaptive traits that we consider cognitive or behavioral. These can include conscious social strategies, subconscious emotional responses (guilt, fear, etc.), or the most innate instincts. Evolutionary psychologists consider a number of factors in what determines a psychological adaptation, such as functionality, complexity, efficiency, and universality. The Adapted Mind is considered a foundational text on evolutionary psychology, further integrating Darwinian theory into modern psychology. Evolved adaptation vs learned behaviour An area of disagreement arises between evolutionary psychologists, cognitive scientists and behaviourists on where to draw the line on what is considered a psychological adaptation, and what is considered a learned behaviour. Where behaviourism explains certain behaviours as conditioned responses, cognitivism may push that these behaviours arise from a psychological adaptation that institutes a preference for that behaviour. Evolutionary psychology proposes that the human psychology consists primarily of psychological adaptations, which is opposed by the tabula rasa or blank slate model of human psychology. Early behaviourists, like B.F. Skinner, tended to the blank slate model and argued that innate behaviors and instincts were few, some behaviourists suggesting that the only innate behavior was the ability to learn. On the other hand, Steven Pinker presents the cognitivist perspective in his book, The Blank Slate, in which he challenges the tabula rasa models and argues that human behaviour is shaped by psychological adaptations. This difference in theory can be seen in research on modern human sexual preferences, with behaviourists arguing that attraction has conditioning influences, such as from the media or cultural norms, while others arguing it is based on psychological adaptations. However, sexual preferences are a difficult subject to test due to the amount of variance and flexibility exhibited in human mate choice. A hybrid resolution to psychological adaptations and learned behaviours refers to an adaptation as the species’ capacity for a certain behavior, while each individual organism still needs to be conditioned to exhibit that behaviour. This approach can explain language acquisition in relation to linguist and cognitive scientist Noam Chomsky's model of human language. His model supports that the capacity for language is a psychological adaptation (involving both the language necessary brain structures and disposition for language acquisition), however, children lack any particular instantiation of language at birth, and must instead learn one in their environment. Sexual selection The mating strategies of both sexes can be simplified into different psychological adaptations. There is extensive evidence that incest avoidance, which is the tendency to avoid sexual intercourse with close relatives is an evolved behavioural adaptation. Incest avoidance can be seen cross-culturally in humans, and is evident in wild animals. Evolutionary psychologists argue that incest avoidance adapted due to the greater chance of producing children with severe disabilities when mating with relatives, and because genetic variability offers an increase in fitness regarding offspring survival. Sexual jealousy is another behavior observed in human and non-human animals that appears to be instinctual. Heuristic problem solving and consistent preference for behavioral patterns are considered by some evolutionary psychologists to be psychological adaptations. For example, the tendency for females to change their sexual strategies when faced with developmental pressures such as an absent father may be the result of a psychological adaptation. Psychological adaptation in males Human males have developed psychological adaptations, which make them attractive to the opposite sex in order to increase their reproductive success. Evolutionarily, it pays for a male to be polygynous – to have a number of female partners at once – because it means he can create more offspring at once, as they don't have to invest any time in carrying a foetus. Examples of some of these other adaptations include strategies to entice females, strategies to retain a partner and the desire for short-term relationships. Humour It has been researched that humour is sexually selected and acts as a fitness indicator. According to this research it was concluded the production of humour increases mate value in men, and some women seek men with a good sense of humour. In turn, some men are believed to have developed an adaptation in which they endeavour to produce humour with the aim to attract female mates. Waist-to-hip ratio Human males have developed an adaptation in which they find women more attractive if they show cues of fertility, such as a good waist–hip ratio. Women with a waist-to-hip ratio of 0.7 are considered more attractive to males than those with a ratio of 0.8, who are considered to have a more masculine figure. This is because they are perceived to be able to have children more and to be more fertile and healthy. Mate retention Males have developed behaviours that help them to retain a mate, also known as mate guarding, in order to enhance reproductive success in long-term relationships. Examples are intersexual manipulations which involves the male manipulating the way his partner views their current relationship and to repulse her from other relationships. He could do this by enhancing his own value or decreasing the value of other males. In extreme cases, some men have developed intersexual adaptations that restrict their partner from interacting with other men, including the use of violence. By doing this, women may be less able to leave that relationship, even if it is due to fear. On the other hand, intrasexual manipulations are used to reduce any other options for the women, which could include decreasing their partner's value or make it clear to other males that a woman is 'theirs' by using possessive techniques such as holding her hand in public. Parental investment With regards to parental investment, males are much more wary when investing in offspring as they cannot guarantee that the child is theirs. Therefore, as an adaptation, males tend to only invest in offspring if there are high levels of commitment and if they were produced in a long-term relationship as opposed to short-term relationships. Short-term mating Some human males have also developed an adaptation in which they have a desire for short-term relationships more than some human females do. This is because men hardly have any investment obligation, whereas a female has to carry a child for nine months if she was to fall pregnant after the sexual encounter. Evolutionarily, it is thought that males have a desire to reproduce as much as they can, and short-term relationships are a good way to inseminate many women with his sperm in order for his genes to continue through generations. There is much evidence for how this short-term mating has evolved psychologically for males, beginning with the desire for a variety of sex partners. It seems that a larger percentage of men, in every culture of the world, desire more than one sex partner in one month compared to women. Furthermore, men are more likely than women to have sexual intercourse with someone having known them for only one hour, one day, one week or one month. Problems However, there are some adaptive problems in short-term mating that men must solve; one of these is avoiding commitment and women who might not have sex with the male until they have a signal of commitment or investment. This would reduce the number of partners a male could pursue and succeed with. Psychological adaptation in females Female sex-specific adaptations provide evidence of special design for the purpose of increasing fitness and in turn, reproductive success. For example, mate choice, rape aversion tactics and pregnancy sickness are all female-specific psychological adaptations, identified through empirical research, found to increase genetic contributions through survival and reproduction. Mate-choice as an adaptation A psychological adaptation for the purpose of reproductive success can be seen in female mate choice. David Buss, an evolutionary psychologist, examines the fundamental principles of selection pressures that create human mate preferences in his contribution to the publication The Adapted Mind. Females have evolved psychological procedures that affect mating decisions in relation to certain male physical attributes and behaviours. Robert Trivers, an evolutionary biologist, outlines the evolutionary basis of these preferences in relation to parental investment and sexual selection. He proposes that females have adapted a preference to mate with males who display both an ability and willingness to invest vital resources for the survival of the female and her offspring. Research suggests females are able to use external cues displayed by males such as territory or physical possessions. For example, women are able to evaluate the long-term presence of testosterone in men by observing facial testosterone cues. Testosterone stimulates craniofacial development and results in a squarer jaw and consequently, a more masculine appearance. Women in the fertile phase of their menstrual cycle perceive masculine faces as healthier and more attractive than feminine male faces. Females show a psychological adaptation to detect mate quality using these hormonal cues which display the male's fitness and reproductive value. Males who display testosterone cues show a female that they are able to offset the high physiological costs such as immunosuppressant effects. Rape avoidance Research proposes that women have evolved psychological mechanisms specifically designed to motivate rape-avoidance behaviours or strategies. This is because rape poses severe costs for the female such as pregnancy, physical harm, injury or death, relationship abandonment and self-esteem depletion. The greatest cost to the female is the circumvention of her mate choice, which threatens reproductive success, resulting in the possession of adaptations in response. Evidence suggests that a number of female-specific traits have evolved in order to reduce the risks associated with experiencing rape. The body-guard hypothesis proposes that rape-avoidance drives women's mate preferences for physically strong or dominant males. Women may also form groups with men and women as a protective alliance against potential rapists. Psychological pain experienced following rape is also identified as an adaptive process designed to focus the female on the social circumstances surrounding the rape for future prevention. Evidence for this as an adaptation can be seen in reproductive-aged women who are found to experience more psychological pain following rape due to an increased risk of conception. Research also suggests that women in the fertile phase of their menstrual cycle perform fewer risky behaviours that could potentially result in the risk of rape. Women's capacity to resist rape also changes relative to their menstrual cycle; females in the fertile phase show an increase in handgrip strength when placed in a threatening, sexually coercive scenario. Susceptibility to signs of a male's coerciveness is also identified to be better in fertile women. Pregnancy sickness One psychological adaptation found solely in women is pregnancy sickness. This is an adaptation resulting from natural selection for the purpose of avoiding toxic-containing foods during pregnancy. Margaret Profet, an evolutionary biologist, provides evidence for this adaptation in a literature review on pregnancy sickness. Particular plant foods, whilst unharmful to adults, can contain toxins (e.g. teratogens) that are dangerous for developing embryos and can potentially cause birth defects such as facial asymmetry. Evidence lies in the finding that women who experience more extreme cases of pregnancy sickness tend to be less likely to miscarry or have babies with birth defects. This fits the criteria for an adaptation as it enhances fitness and increases reproductive success – it results in greater fertility of the mother and contributes to the health of the developing embryo. Researchers dispute whether this is actually a psychological adaptation, however evidence advocates it is the result of strong selective pressures in our hereditary past. For example, the toxins are found only in natural wild plant foods, not processed foods in our modern-day environment. Furthermore, pregnant women experiencing sickness have been found to avoid particular bitter or pungent smelling foods, potentially containing toxins. Pregnancy induced sickness only typically occurs 3 weeks after conception, around the time when the embryo has started forming major organs and is therefore at the highest risk. It is also a cross-cultural universal adaptation, a suggestion it is an innate mechanism. See also Adaptive behavior (ecology) Adaptive bias Adjustment (psychology) Cognitive module Dual inheritance theory Evolutionary developmental psychology Evolutionary psychology Human behavioral ecology Instinct Modularity of mind References External links Evolutionary psychology

Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by executive dysfunction occasioning symptoms of inattention, hyperactivity, impulsivity and emotional dysregulation that are excessive and pervasive, impairing in multiple contexts, and developmentally-inappropriate. ADHD symptoms arise from executive dysfunction, and emotional dysregulation is often considered a core symptom. Difficulties in self-regulation such as time management, inhibition, and sustained attention may cause poor professional performance, relationship difficulties, and numerous health risks, collectively predisposing to a diminished quality of life and a direct average reduction in life expectancy of 13 years. The disorder costs society hundreds of billions of US dollars each year, worldwide. It is associated with other neurodevelopmental and mental disorders as well as non-psychiatric disorders, which can cause additional impairment. Although people with ADHD struggle to persist on tasks with delayed consequences, they may be able to do so on tasks they find intrinsically interesting or immediately rewarding; this is known as hyperfocus (more colloquially) or perseverative responding. This mental state is often hard to disengage from and can be related to risks such as for internet addiction and types of offending behaviour. ADHD represents the extreme lower end of the continuous dimensional trait (bell curve) of executive functioning and self-regulation, which is supported by twin, brain imaging and molecular genetic studies. The precise causes of ADHD are unknown in the majority of cases. For most people with ADHD, many genetic and environmental risk factors accumulate to cause the disorder. The environmental risks are not related to social or familial factors; they exert their effects very early in life, in the prenatal or early postnatal period. However, in rare cases, ADHD may be caused by a single event such as traumatic brain injury, exposure to biohazards during pregnancy, or a major genetic mutation. There is no biologically distinct adult-onset ADHD except for when ADHD occurs after traumatic brain injury. Signs and symptoms Inattention, hyperactivity (restlessness in adults), disruptive behaviour, and impulsivity are common in ADHD. Academic difficulties are frequent, as are problems with relationships. The signs and symptoms can be difficult to define, as it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and significant levels requiring interventions begin. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its text revision (DSM-5-TR), symptoms must be present for six months or more to a degree that is much greater than others of the same age. This requires at least six symptoms of either inattention or hyperactivity/impulsivity for those under 17 and at least five symptoms for those 17 years or older. The symptoms must be present in at least two settings (e.g., social, school, work, or home), and must directly interfere with or reduce quality of functioning. Additionally, several symptoms must have been present before age twelve. The DSM-5 's required age of onset of symptoms is 12 years. However, research indicates the age of onset should not be interpreted as a prerequisite for diagnosis given contextual exceptions. Presentations ADHD is divided into three primary presentations: predominantly inattentive (ADHD-PI or ADHD-I) predominantly hyperactive-impulsive (ADHD-PH or ADHD-HI) combined presentation (ADHD-C). The table "Symptoms" lists the symptoms for ADHD-I and ADHD-HI from two major classification systems. Symptoms which can be better explained by another psychiatric or medical condition which an individual has are not considered to be a symptom of ADHD for that person. In DSM-5, subtypes were discarded and reclassified as presentations of the disorder that change over time. Girls and women with ADHD tend to display fewer hyperactivity and impulsivity symptoms but more symptoms of inattention and distractibility. Symptoms are expressed differently and more subtly as the individual ages. Hyperactivity tends to become less overt with age and turns into inner restlessness, difficulty relaxing or remaining still, talkativeness or constant mental activity in teens and adults with ADHD. Impulsivity in adulthood may appear as thoughtless behaviour, impatience, irresponsible spending and sensation-seeking behaviours, while inattention may appear as becoming easily bored, difficulty with organization, remaining on task and making decisions, and sensitivity to stress. Although not listed as an official symptom, emotional dysregulation or mood lability is generally understood to be a common symptom of ADHD. People with ADHD of all ages are more likely to have problems with social skills, such as social interaction and forming and maintaining friendships. This is true for all presentations. About half of children and adolescents with ADHD experience social rejection by their peers compared to 10–15% of non-ADHD children and adolescents. People with attention deficits are prone to having difficulty processing verbal and nonverbal language which can negatively affect social interaction. They may also drift off during conversations, miss social cues, and have trouble learning social skills. Difficulties managing anger are more common in children with ADHD as are delays in speech, language and motor development. Poorer handwriting is more common in children with ADHD. Poor handwriting can be a symptom of ADHD in itself due to decreased attentiveness. When this is a pervasive problem, it may also be attributable to dyslexia or dysgraphia. There is significant overlap in the symptomatologies of ADHD, dyslexia, and dysgraphia, and 3 in 10 people diagnosed with dyslexia experience co-occurring ADHD. Although it causes significant difficulty, many children with ADHD have an attention span equal to or greater than that of other children for tasks and subjects they find interesting. IQ test performance Certain studies have found that people with ADHD tend to have lower scores on intelligence quotient (IQ) tests. The significance of this is controversial due to the differences between people with ADHD and the difficulty determining the influence of symptoms, such as distractibility, on lower scores rather than intellectual capacity. In studies of ADHD, higher IQs may be over-represented because many studies exclude individuals who have lower IQs despite those with ADHD scoring on average nine points lower on standardised intelligence measures. However, other studies contradict this, saying that in individuals with high intelligence, there is an increased risk of a missed ADHD diagnosis, possibly because of compensatory strategies in said individuals. Studies of adults suggest that negative differences in intelligence are not meaningful and may be explained by associated health problems. Comorbidities Psychiatric comorbidities In children, ADHD occurs with other disorders about two-thirds of the time. Other neurodevelopmental conditions are common comorbidities. Autism spectrum disorder (ASD), co-occurring at a rate of 21% in those with ADHD, affects social skills, ability to communicate, behaviour, and interests. Learning disabilities have been found to occur in about 20–30% of children with ADHD. Learning disabilities can include developmental speech and language disorders, and academic skills disorders. ADHD, however, is not considered a learning disability, but it very frequently causes academic difficulties. Intellectual disabilities and Tourette's syndrome are also common. ADHD is often comorbid with disruptive, impulse control, and conduct disorders. Oppositional defiant disorder (ODD) occurs in about 25% of children with an inattentive presentation and 50% of those with a combined presentation. It is characterised by angry or irritable mood, argumentative or defiant behaviour and vindictiveness which are age-inappropriate. Conduct disorder (CD) occurs in about 25% of adolescents with ADHD. It is characterised by aggression, destruction of property, deceitfulness, theft and violations of rules. Adolescents with ADHD who also have CD are more likely to develop antisocial personality disorder in adulthood. Brain imaging supports that CD and ADHD are separate conditions: conduct disorder was shown to reduce the size of one's temporal lobe and limbic system, and increase the size of one's orbitofrontal cortex, whereas ADHD was shown to reduce connections in the cerebellum and prefrontal cortex more broadly. Conduct disorder involves more impairment in motivation control than ADHD. Intermittent explosive disorder is characterised by sudden and disproportionate outbursts of anger and co-occurs in individuals with ADHD more frequently than in the general population. Anxiety and mood disorders are frequent comorbidities. Anxiety disorders have been found to occur more commonly in the ADHD population, as have mood disorders (especially bipolar disorder and major depressive disorder). Boys diagnosed with the combined ADHD subtype are more likely to have a mood disorder. Adults and children with ADHD sometimes also have bipolar disorder, which requires careful assessment to accurately diagnose and treat both conditions. Sleep disorders and ADHD commonly co-exist. They can also occur as a side effect of medications used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder with behavioural therapy being the preferred treatment. Problems with sleep initiation are common among individuals with ADHD but often they will be deep sleepers and have significant difficulty getting up in the morning. Melatonin is sometimes used in children who have sleep onset insomnia. Restless legs syndrome has been found to be more common in those with ADHD and is often due to iron deficiency anemia. However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders. Delayed sleep phase disorder is also a common comorbidity. Individuals with ADHD are at increased risk of substance use disorders. This is most commonly seen with alcohol or cannabis. The reason for this may be an altered reward pathway in the brains of ADHD individuals, self-treatment and increased psychosocial risk factors. This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks. Other psychiatric conditions include reactive attachment disorder, characterised by a severe inability to appropriately relate socially, and cognitive disengagement syndrome, a distinct attention disorder occurring in 30–50% of ADHD cases as a comorbidity, regardless of the presentation; a subset of cases diagnosed with ADHD-PIP have been found to have CDS instead. Individuals with ADHD are three times more likely to be diagnosed with an eating disorder compared to those without ADHD; conversely, individuals with eating disorders are two times more likely to have ADHD than those without eating disorders. Trauma ADHD, trauma, and adverse childhood experiences are also comorbid, which could in part be potentially explained by the similarity in presentation between different diagnoses. The symptoms of ADHD and PTSD can have significant behavioural overlap—in particular, motor restlessness, difficulty concentrating, distractibility, irritability/anger, emotional constriction or dysregulation, poor impulse control, and forgetfulness are common in both. This could result in trauma-related disorders or ADHD being mis-identified as the other. Additionally, traumatic events in childhood are a risk factor for ADHD; they can lead to structural brain changes and the development of ADHD behaviours. Finally, the behavioural consequences of ADHD symptoms cause a higher chance of the individual experiencing trauma (and therefore ADHD leads to a concrete diagnosis of a trauma-related disorder). Non-psychiatric Some non-psychiatric conditions are also comorbidities of ADHD. This includes epilepsy, a neurological condition characterised by recurrent seizures. There are well established associations between ADHD and obesity, asthma and sleep disorders, and an association with celiac disease. Children with ADHD have a higher risk for migraine headaches, but have no increased risk of tension-type headaches. Children with ADHD may also experience headaches as a result of medication. A 2021 review reported that several neurometabolic disorders caused by inborn errors of metabolism converge on common neurochemical mechanisms that interfere with biological mechanisms also considered central in ADHD pathophysiology and treatment. This highlights the importance of close collaboration between health services to avoid clinical overshadowing. In June 2021, Neuroscience & Biobehavioral Reviews published a systematic review of 82 studies that all confirmed or implied elevated accident-proneness in ADHD patients and whose data suggested that the type of accidents or injuries and overall risk changes in ADHD patients over the lifespan. In January 2014, Accident Analysis & Prevention published a meta-analysis of 16 studies examining the relative risk of traffic collisions for drivers with ADHD, finding an overall relative risk estimate of 1.36 without controlling for exposure, a relative risk estimate of 1.29 when controlling for publication bias, a relative risk estimate of 1.23 when controlling for exposure, and a relative risk estimate of 1.86 for ADHD drivers with oppositional defiant disorder and/or conduct disorder comorbidities. Problematic digital media use Suicide risk Systematic reviews in 2017 and 2020 found strong evidence that ADHD is associated with increased suicide risk across all age groups, as well as growing evidence that an ADHD diagnosis in childhood or adolescence represents a significant future suicidal risk factor. Potential causes include ADHD's association with functional impairment, negative social, educational and occupational outcomes, and financial distress. A 2019 meta-analysis indicated a significant association between ADHD and suicidal spectrum behaviours (suicidal attempts, ideations, plans, and completed suicides); across the studies examined, the prevalence of suicide attempts in individuals with ADHD was 18.9%, compared to 9.3% in individuals without ADHD, and the findings were substantially replicated among studies which adjusted for other variables. However, the relationship between ADHD and suicidal spectrum behaviours remains unclear due to mixed findings across individual studies and the complicating impact of comorbid psychiatric disorders. There is no clear data on whether there is a direct relationship between ADHD and suicidality, or whether ADHD increases suicide risk through comorbidities. Causes ADHD arises from brain maldevelopment especially in the prefrontal executive networks that can arise either from genetic factors (different gene variants and mutations for building and regulating such networks) or from acquired disruptions to the development of these networks and regions; involved in executive functioning and self-regulation. Their reduced size, functional connectivity, and activation contribute to the pathophysiology of ADHD, as well as imbalances in the noradrenergic and dopaminergic systems that mediate these brain regions. Genetic factors play an important role; ADHD has a heritability rate of 70-80%. The remaining 20-30% of variance is mediated by de-novo mutations and non-shared environmental factors that provide for or produce brain injuries; there is no significant contribution of the rearing family and social environment. Very rarely, ADHD can also be the result of abnormalities in the chromosomes. Genetics In November 1999, Biological Psychiatry published a literature review by psychiatrists Joseph Biederman and Thomas Spencer found the average heritability estimate of ADHD from twin studies to be 0.8, while a subsequent family, twin, and adoption studies literature review published in Molecular Psychiatry in April 2019 by psychologists Stephen Faraone and Henrik Larsson that found an average heritability estimate of 0.74. Additionally, evolutionary psychiatrist Randolph M. Nesse has argued that the 5:1 male-to-female sex ratio in the epidemiology of ADHD suggests that ADHD may be the end of a continuum where males are overrepresented at the tails, citing clinical psychologist Simon Baron-Cohen's suggestion for the sex ratio in the epidemiology of autism as an analogue. Natural selection has been acting against the genetic variants for ADHD over the course of at least 45,000 years, indicating that it was not an adaptative trait in ancient times. The disorder may remain at a stable rate by the balance of genetic mutations and removal rate (natural selection) across generations; over thousands of years, these genetic variants become more stable, decreasing disorder prevalence. Throughout human evolution, the EFs involved in ADHD likely provide the capacity to bind contingencies across time thereby directing behaviour toward future over immediate events so as to maximise future social consequences for humans. ADHD has a high heritability of 74%, meaning that 74% of the presence of ADHD in the population is due to genetic factors. There are multiple gene variants which each slightly increase the likelihood of a person having ADHD; it is polygenic and thus arises through the accumulation of many genetic risks each having a very small effect. The siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of children without the disorder. The association of maternal smoking observed in large population studies disappears after adjusting for family history of ADHD, which indicates that the association between maternal smoking during pregnancy and ADHD is due to familial or genetic factors that increase the risk for the confluence of smoking and ADHD. ADHD presents with reduced size, functional connectivity and activation as well as low noradrenergic and dopaminergic functioning in brain regions and networks crucial for executive functioning and self-regulation. Typically, a number of genes are involved, many of which directly affect brain functioning and neurotransmission. Those involved with dopamine include DAT, DRD4, DRD5, TAAR1, MAOA, COMT, and DBH. Other genes associated with ADHD include SERT, HTR1B, SNAP25, GRIN2A, ADRA2A, TPH2, and BDNF. A common variant of a gene called latrophilin 3 is estimated to be responsible for about 9% of cases and when this variant is present, people are particularly responsive to stimulant medication. The 7 repeat variant of dopamine receptor D4 (DRD4–7R) causes increased inhibitory effects induced by dopamine and is associated with ADHD. The DRD4 receptor is a G protein-coupled receptor that inhibits adenylyl cyclase. The DRD4–7R mutation results in a wide range of behavioural phenotypes, including ADHD symptoms reflecting split attention. The DRD4 gene is both linked to novelty seeking and ADHD. The genes GFOD1 and CDH13 show strong genetic associations with ADHD. CDH13's association with ASD, schizophrenia, bipolar disorder, and depression make it an interesting candidate causative gene. Another candidate causative gene that has been identified is ADGRL3. In zebrafish, knockout of this gene causes a loss of dopaminergic function in the ventral diencephalon and the fish display a hyperactive/impulsive phenotype. For genetic variation to be used as a tool for diagnosis, more validating studies need to be performed. However, smaller studies have shown that genetic polymorphisms in genes related to catecholaminergic neurotransmission or the SNARE complex of the synapse can reliably predict a person's response to stimulant medication. Rare genetic variants show more relevant clinical significance as their penetrance (the chance of developing the disorder) tends to be much higher. However their usefulness as tools for diagnosis is limited as no single gene predicts ADHD. ASD shows genetic overlap with ADHD at both common and rare levels of genetic variation. Environment In addition to genetics, some environmental factors might play a role in causing ADHD. Alcohol intake during pregnancy can cause fetal alcohol spectrum disorders which can include ADHD or symptoms like it. Children exposed to certain toxic substances, such as lead or polychlorinated biphenyls, may develop problems which resemble ADHD. Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not conclusive. Exposure to tobacco smoke during pregnancy can cause problems with central nervous system development and can increase the risk of ADHD. Nicotine exposure during pregnancy may be an environmental risk. Extreme premature birth, very low birth weight, and extreme neglect, abuse, or social deprivation also increase the risk as do certain infections during pregnancy, at birth, and in early childhood. These infections include, among others, various viruses (measles, varicella zoster encephalitis, rubella, enterovirus 71). At least 30% of children with a traumatic brain injury later develop ADHD and about 5% of cases are due to brain damage. Some studies suggest that in a small number of children, artificial food dyes or preservatives may be associated with an increased prevalence of ADHD or ADHD-like symptoms, but the evidence is weak and may apply to only children with food sensitivities. The European Union has put in place regulatory measures based on these concerns. In a minority of children, intolerances or allergies to certain foods may worsen ADHD symptoms. Individuals with hypokalemic sensory overstimulation are sometimes diagnosed as having ADHD, raising the possibility that a subtype of ADHD has a cause that can be understood mechanistically and treated in a novel way. The sensory overload is treatable with oral potassium gluconate. Research does not support popular beliefs that ADHD is caused by eating too much refined sugar, watching too much television, bad parenting, poverty or family chaos; however, they might worsen ADHD symptoms in certain people. In some cases, an inappropriate diagnosis of ADHD may reflect a dysfunctional family or a poor educational system, rather than any true presence of ADHD in the individual. In other cases, it may be explained by increasing academic expectations, with a diagnosis being a method for parents in some countries to get extra financial and educational support for their child. Behaviours typical of ADHD occur more commonly in children who have experienced violence and emotional abuse. Pathophysiology Current models of ADHD suggest that it is associated with functional impairments in some of the brain's neurotransmitter systems, particularly those involving dopamine and norepinephrine. The dopamine and norepinephrine pathways that originate in the ventral tegmental area and locus coeruleus project to diverse regions of the brain and govern a variety of cognitive processes. The dopamine pathways and norepinephrine pathways which project to the prefrontal cortex and striatum are directly responsible for modulating executive function (cognitive control of behaviour), motivation, reward perception, and motor function; these pathways are known to play a central role in the pathophysiology of ADHD. Larger models of ADHD with additional pathways have been proposed. Brain structure In children with ADHD, there is a general reduction of volume in certain brain structures, with a proportionally greater decrease in the volume in the left-sided prefrontal cortex. The posterior parietal cortex also shows thinning in individuals with ADHD compared to controls. Other brain structures in the prefrontal-striatal-cerebellar and prefrontal-striatal-thalamic circuits have also been found to differ between people with and without ADHD. The subcortical volumes of the accumbens, amygdala, caudate, hippocampus, and putamen appears smaller in individuals with ADHD compared with controls. Structural MRI studies have also revealed differences in white matter, with marked differences in inter-hemispheric asymmetry between ADHD and typically developing youths. Functional MRI (fMRI) studies have revealed a number of differences between ADHD and control brains. Mirroring what is known from structural findings, fMRI studies have showed evidence for a higher connectivity between subcortical and cortical regions, such as between the caudate and prefrontal cortex. The degree of hyperconnectivity between these regions correlated with the severity of inattention or hyperactivity Hemispheric lateralization processes have also been postulated as being implicated in ADHD, but empiric results showed contrasting evidence on the topic. Neurotransmitter pathways Previously, it had been suggested that the elevated number of dopamine transporters in people with ADHD was part of the pathophysiology, but it appears the elevated numbers may be due to adaptation following exposure to stimulant medication. Current models involve the mesocorticolimbic dopamine pathway and the locus coeruleus-noradrenergic system. ADHD psychostimulants possess treatment efficacy because they increase neurotransmitter activity in these systems. There may additionally be abnormalities in serotonergic, glutamatergic, or cholinergic pathways. Executive function and motivation ADHD arises from a core deficit in executive functions (e.g., attentional control, inhibitory control, and working memory), which are a set of cognitive processes that are required to successfully select and monitor behaviours that facilitate the attainment of one's chosen goals. The executive function impairments that occur in ADHD individuals result in problems with staying organised, time keeping, procrastination control, maintaining concentration, paying attention, ignoring distractions, regulating emotions, and remembering details. People with ADHD appear to have unimpaired long-term memory, and deficits in long-term recall appear to be attributed to impairments in working memory. Due to the rates of brain maturation and the increasing demands for executive control as a person gets older, ADHD impairments may not fully manifest themselves until adolescence or even early adulthood. Conversely, brain maturation trajectories, potentially exhibiting diverging longitudinal trends in ADHD, may support a later improvement in executive functions after reaching adulthood. ADHD has also been associated with motivational deficits in children. Children with ADHD often find it difficult to focus on long-term over short-term rewards, and exhibit impulsive behaviour for short-term rewards. Paradoxical reaction to neuroactive substances Another sign of the structurally altered signal processing in the central nervous system in this group of people is the conspicuously common paradoxical reaction ( of patients). These are unexpected reactions in the opposite direction as with a normal effect, or otherwise significant different reactions. These are reactions to neuroactive substances such as local anesthetic at the dentist, sedative, caffeine, antihistamine, weak neuroleptics and central and peripheral painkillers. Since the causes of paradoxical reactions are at least partly genetic, it may be useful in critical situations, for example before operations, to ask whether such abnormalities may also exist in family members. Diagnosis ADHD is diagnosed by an assessment of a person's behavioural and mental development, including ruling out the effects of drugs, medications, and other medical or psychiatric problems as explanations for the symptoms. ADHD diagnosis often takes into account feedback from parents and teachers with most diagnoses begun after a teacher raises concerns. While many tools exist to aid in the diagnosis of ADHD, their validity varies in different populations, and a reliable and valid diagnosis requires confirmation by a clinician while supplemented by standardized rating scales and input from multiple informants across various settings. The diagnosis of ADHD has been criticised as being subjective because it is not based on a biological test. The International Consensus Statement on ADHD concluded that this criticism is unfounded, on the basis that ADHD meets standard criteria for validity of a mental disorder established by Robins and Guze. They attest that the disorder is considered valid because: 1) well-trained professionals in a variety of settings and cultures agree on its presence or absence using well-defined criteria and 2) the diagnosis is useful for predicting a) additional problems the patient may have (e.g., difficulties learning in school); b) future patient outcomes (e.g., risk for future drug abuse); c) response to treatment (e.g., medications and psychological treatments); and d) features that indicate a consistent set of causes for the disorder (e.g., findings from genetics or brain imaging), and that professional associations have endorsed and published guidelines for diagnosing ADHD. The most commonly used rating scales for diagnosing ADHD are the Achenbach System of Empirically Based Assessment (ASEBA) and include the Child Behavior Checklist (CBCL) used for parents to rate their child's behaviour, the Youth Self Report Form (YSR) used for children to rate their own behaviour, and the Teacher Report Form (TRF) used for teachers to rate their pupil's behaviour. Additional rating scales that have been used alone or in combination with other measures to diagnose ADHD include the Behavior Assessment System for Children (BASC), Behavior Rating Inventory of Executive Function - Second Edition (BRIEF2), Revised Conners Rating Scale (CRS-R), Conduct-Hyperactive-Attention Problem-Oppositional Symptom scale (CHAOS), Developmental Behavior Checklist Hyperactivity Index (DBC-HI), Parent Disruptive Behavior Disorder Ratings Scale (DBDRS), Diagnostic Infant and Preschool Assessment (DIPA-L), Pediatric Symptom Checklist (PSC), Social Communication Questionnaire (SCQ), Social Responsiveness Scale (SRS), Strengths and Weaknesses of ADHD Symptoms and Normal Behavior Rating Scale (SWAN). and the Vanderbilt ADHD diagnostic rating scale. The ASEBA, BASC, CHAOS, CRS, and Vanderbilt diagnostic rating scales allow for both parents and teachers as raters in the diagnosis of childhood and adolescent ADHD. Adolescents may also self report their symptoms using self report scales from the ASEBA, SWAN, and the Dominic Interactive for Adolescents-Revised (DIA-R). Self-rating scales, such as the ADHD rating scale and the Vanderbilt ADHD diagnostic rating scale, are used in the screening and evaluation of ADHD. Based on a 2024 systematic literature review and meta analysis commissioned by the Patient-Centered Outcomes Research Institute (PCORI), rating scales based on parent report, teacher report, or self-assessment from the adolescent have high internal consistency as a diagnostic tool meaning that the items within the scale are highly interrelated. The reliability of the scales between raters (i.e. their degree of agreement) however is poor to moderate making it important to include information from multiple raters to best inform a diagnosis. Imaging studies of the brain do not give consistent results between individuals; thus, they are only used for research purposes and not a diagnosis. Electroencephalography is not accurate enough to make an ADHD diagnosis. A 2024 systematic review concluded that the use of biomarkers such as blood or urine samples, electroencephalogram (EEG) markers, and neuroimaging such as MRIs, in diagnosis for ADHD remains unclear; studies showed great variability, did not assess test-retest reliability, and were not independently replicable. In North America and Australia, DSM-5 criteria are used for diagnosis, while European countries usually use the ICD-10. The DSM-IV criteria for diagnosis of ADHD is more likely to diagnose ADHD than is the ICD-10 criteria. ADHD is alternately classified as neurodevelopmental disorder or a disruptive behaviour disorder along with ODD, CD, and antisocial personality disorder. A diagnosis does not imply a neurological disorder. Very few studies have been conducted on diagnosis of ADHD on children younger than 7 years of age, and those that have were found in a 2024 systematic review to be of low or insufficient strength of evidence. Classification Diagnostic and Statistical Manual As with many other psychiatric disorders, a formal diagnosis should be made by a qualified professional based on a set number of criteria. In the United States, these criteria are defined by the American Psychiatric Association in the DSM. Based on the DSM-5 criteria published in 2013 and the DSM-5-TR criteria published in 2022, there are three presentations of ADHD: ADHD, predominantly inattentive presentation, presents with symptoms including being easily distracted, forgetful, daydreaming, disorganization, poor sustained attention, and difficulty completing tasks. ADHD, predominantly hyperactive-impulsive presentation, presents with excessive fidgeting and restlessness, hyperactivity, and difficulty waiting and remaining seated. ADHD, combined presentation, is a combination of the first two presentations. This subdivision is based on presence of at least six (in children) or five (in older teenagers and adults) out of nine long-term (lasting at least six months) symptoms of inattention, hyperactivity–impulsivity, or both. To be considered, several symptoms must have appeared by the age of six to twelve and occur in more than one environment (e.g. at home and at school or work). The symptoms must be inappropriate for a child of that age and there must be clear evidence that they are causing impairment in multiple domains of life. The DSM-5 and the DSM-5-TR also provide two diagnoses for individuals who have symptoms of ADHD but do not entirely meet the requirements. Other Specified ADHD allows the clinician to describe why the individual does not meet the criteria, whereas Unspecified ADHD is used where the clinician chooses not to describe the reason. International Classification of Diseases In the eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) by the World Health Organization, the disorder is classified as Attention deficit hyperactivity disorder (code 6A05). The defined subtypes are predominantly inattentive presentation (6A05.0); predominantly hyperactive-impulsive presentation(6A05.1); and combined presentation (6A05.2). However, the ICD-11 includes two residual categories for individuals who do not entirely match any of the defined subtypes: other specified presentation (6A05.Y) where the clinician includes detail on the individual's presentation; and presentation unspecified (6A05.Z) where the clinician does not provide detail. In the tenth revision (ICD-10), the symptoms of hyperkinetic disorder were analogous to ADHD in the ICD-11. When a conduct disorder (as defined by ICD-10) is present, the condition was referred to as hyperkinetic conduct disorder. Otherwise, the disorder was classified as disturbance of activity and attention, other hyperkinetic disorders or hyperkinetic disorders, unspecified. The latter was sometimes referred to as hyperkinetic syndrome. Social construct theory The social construct theory of ADHD suggests that, because the boundaries between normal and abnormal behaviour are socially constructed (i.e. jointly created and validated by all members of society, and in particular by physicians, parents, teachers, and others), it then follows that subjective valuations and judgements determine which diagnostic criteria are used and thus, the number of people affected. Thomas Szasz, a supporter of this theory, has argued that ADHD was "invented and then given a name". Adults Adults with ADHD are diagnosed under the same criteria, including that their signs must have been present by the age of six to twelve. The individual is the best source for information in diagnosis, however others may provide useful information about the individual's symptoms currently and in childhood; a family history of ADHD also adds weight to a diagnosis. While the core symptoms of ADHD are similar in children and adults, they often present differently in adults than in children: for example, excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults. Worldwide, it is estimated that 2.58% of adults have persistent ADHD (where the individual currently meets the criteria and there is evidence of childhood onset), and 6.76% of adults have symptomatic ADHD (meaning that they currently meet the criteria for ADHD, regardless of childhood onset). In 2020, this was 139.84 million and 366.33 million affected adults respectively. Around 15% of children with ADHD continue to meet full DSM-IV-TR criteria at 25 years of age, and 50% still experience some symptoms. , most adults remain untreated. Many adults with ADHD without diagnosis and treatment have a disorganised life, and some use non-prescribed drugs or alcohol as a coping mechanism. Other problems may include relationship and job difficulties, and an increased risk of criminal activities. Associated mental health problems include depression, anxiety disorders, and learning disabilities. Some ADHD symptoms in adults differ from those seen in children. While children with ADHD may climb and run about excessively, adults may experience an inability to relax, or may talk excessively in social situations. Adults with ADHD may start relationships impulsively, display sensation-seeking behaviour, and be short-tempered. Addictive behaviour such as substance abuse and gambling are common. This led to those who presented differently as they aged having outgrown the DSM-IV criteria. The DSM-5 criteria does specifically deal with adults unlike that of DSM-IV, which does not fully take into account the differences in impairments seen in adulthood compared to childhood. For diagnosis in an adult, having symptoms since childhood is required. Nevertheless, a proportion of adults who meet the criteria for ADHD in adulthood would not have been diagnosed with ADHD as children. Most cases of late-onset ADHD develop the disorder between the ages of 12–16 and may therefore be considered early adult or adolescent-onset ADHD. Differential diagnosis The DSM provides differential diagnoses – potential alternate explanations for specific symptoms. Assessment and investigation of clinical history determines which is the most appropriate diagnosis. The DSM-5 suggests oppositional defiant disorder, intermittent explosive disorder, and other disorders such as stereotypic movement disorder and Tourette syndrome, in addition to specific learning disorder, intellectual disability, autism, reactive attachment disorder, anxiety disorders, depressive disorders, bipolar disorder, disruptive mood dysregulation disorder, substance use disorder, personality disorders, psychotic disorders, medication-induced symptoms, and neurocognitive disorders. Many but not all of these are also common comorbidities of ADHD. The DSM-5-TR also suggests post-traumatic stress disorder. Symptoms of ADHD, such as low mood and poor self-image, mood swings, and irritability can be confused with dysthymia and bipolar disorder as well as with borderline personality disorder. Some symptoms that are due to anxiety disorders, personality disorder, developmental disabilities, or intellectual disability or the effects of substance abuse such as intoxication and withdrawal can overlap with ADHD. These disorders can also sometimes occur along with ADHD. Medical conditions which can cause ADHD-type symptoms include: hyperthyroidism, seizure disorder, lead toxicity, hearing deficits, hepatic disease, sleep apnea, drug interactions, untreated celiac disease, and head injury. Primary sleep disorders may affect attention and behaviour and the symptoms of ADHD may affect sleep. It is thus recommended that children with ADHD be regularly assessed for sleep problems. Sleepiness in children may result in symptoms ranging from the classic ones of yawning and rubbing the eyes, to hyperactivity and inattentiveness. Obstructive sleep apnea can also cause ADHD-like symptoms. Management The management of ADHD typically involves counseling or medications, either alone or in combination. While there are various options of treatment to improve ADHD symptoms, medication therapies substantially improve long-term outcomes, and while completely eliminating some elevated risks such as obesity, they do come with some risks of adverse events. Medications used include stimulants, atomoxetine, alpha-2 adrenergic receptor agonists, and sometimes antidepressants. In those who have trouble focusing on long-term rewards, a large amount of positive reinforcement improves task performance. Medications are the most effective treatment, and any side effects are typically mild and easy to resolve although any improvements will be reverted if medication is ceased. ADHD stimulants also improve persistence and task performance in children with ADHD. To quote one systematic review, "recent evidence from observational and registry studies indicates that pharmacological treatment of ADHD is associated with increased achievement and decreased absenteeism at school, a reduced risk of trauma-related emergency hospital visits, reduced risks of suicide and attempted suicide, and decreased rates of substance abuse and criminality". Data also suggest that combining medication with CBT is a good idea: although CBT is substantially less effective, it can help address problems that reside after medication has been optimised. The nature and range of desirable endpoints of ADHD treatment vary among diagnostic standards for ADHD. In most studies, the efficacy of treatment is determined by reductions in symptoms. However, some studies have included subjective ratings from teachers and parents as part of their assessment of treatment efficacies. Behavioural therapies There is good evidence for the use of behavioural therapies in ADHD. They are the recommended first-line treatment in those who have mild symptoms or who are preschool-aged. Psychological therapies used include: psychoeducational input, behavior therapy, cognitive behavioral therapy, interpersonal psychotherapy, family therapy, school-based interventions, social skills training, behavioural peer intervention, organization training, and parent management training. Neurofeedback has greater treatment effects than non-active controls for up to 6 months and possibly a year following treatment, and may have treatment effects comparable to active controls (controls proven to have a clinical effect) over that time period. Despite efficacy in research, there is insufficient regulation of neurofeedback practice, leading to ineffective applications and false claims regarding innovations. Parent training may improve a number of behavioural problems including oppositional and non-compliant behaviours. There is little high-quality research on the effectiveness of family therapy for ADHD—but the existing evidence shows that it is similar to community care, and better than placebo. ADHD-specific support groups can provide information and may help families cope with ADHD. Social skills training, behavioural modification, and medication may have some limited beneficial effects in peer relationships. Stable, high-quality friendships with non-deviant peers protect against later psychological problems. Digital interventions Several clinical trials have investigated the efficacy of digital therapeutics, particularly Akili Interactive Labs's video game-based digital therapeutic AKL-T01, marketed as EndeavourRx. The pediatric STARS-ADHD randomized, double-blind, parallel-group, controlled trial demonstrated that AKL-T01 significantly improved performance on the Test of Variables of Attention, an objective measure of attention and inhibitory control, compared to a control group after four weeks of at-home use. A subsequent pediatric open-label study, STARS-Adjunct, published in Nature Portfolio's npj Digital Medicine evaluated AKL-T01 as an adjunctive treatment for children with ADHD who were either on stimulant medication or not on stimulant pharmacotherapy. Results showed improvements in ADHD-related impairment (measured by the Impairment Rating Scale) and ADHD symptoms after 4 weeks of treatment, with effects persisting during a 4-week pause and further improving with an additional treatment period. Notably, the magnitude of the measured improvement was similar for children both on and off stimulants. In 2020, AKL-T01 received marketing authorization for pediatric ADHD from the FDA, becoming "the first game-based therapeutic granted marketing authorization by the FDA for any type of condition." In addition to pediatric populations, a 2023 study in the Journal of the American Academy of Child & Adolescent Psychiatry investigated the efficacy and safety of AKL-T01 in adults with ADHD. After six weeks of at-home treatment with AKL-T01, participants showed significant improvements in objective measures of attention (TOVA - Attention Comparison Score), reported ADHD symptoms (ADHD-RS-IV inattention subscale and total score), and reported quality of life (AAQoL). The magnitude of improvement in attention was nearly seven times greater than that reported in pediatric trials. The treatment was well-tolerated, with high compliance and no serious adverse events. Medication The medications for ADHD appear to alleviate symptoms via their effects on the pre-frontal executive, striatal and related regions and networks in the brain; usually by increasing neurotransmission of norepinephrine and dopamine. Stimulants Methylphenidate and amphetamine or its derivatives are often first-line treatments for ADHD. About 70 per cent respond to the first stimulant tried and as few as 10 per cent respond to neither amphetamines nor methylphenidate. Stimulants may also reduce the risk of unintentional injuries in children with ADHD. Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD. A 2018 review found the greatest short-term benefit with methylphenidate in children, and amphetamines in adults. Studies and meta-analyses show that amphetamine is slightly-to-modestly more effective than methylphenidate at reducing symptoms, and they are more effective pharmacotherapy for ADHD than α2-agonists but methylphenidate has comparable efficacy to non-stimulants such as atomoxetine. In a Cochrane clinical synopsis, Dr Storebø and colleagues summarised their meta-review on methylphenidate for ADHD in children and adolescents. The meta-analysis raised substantial doubts about the drug's efficacy relative to a placebo. This led to a strong critical reaction from the European ADHD Guidelines Group and individuals in the scientific community, who identified a number of flaws in the review. Since at least September 2021, there is a unanimous and global scientific consensus that methylphenidate is safe and highly effective for treating ADHD. The same journal released a subsequent systematic review (2022) of extended-release methylphenidate for adults, concluding similar doubts about the certainty of evidence. Other recent systematic reviews and meta-analyses, however, find certainty in the safety and high efficacy of methylphenidate for reducing ADHD symptoms, for alleviating the underlying executive functioning deficits, and for substantially reducing the adverse consequences of untreated ADHD with continuous treatment. Clinical guidelines internationally are also consistent in approving the safety and efficacy of methylphenidate and recommending it as a first-line treatment for the disorder. Safety and efficacy data have been reviewed extensively by medical regulators (e.g., the US Food and Drug Administration and the European Medicines Agency), the developers of evidence-based international guidelines (e.g., the UK National Institute for Health and Care Excellence and the American Academy of Pediatrics), and government agencies who have endorsed these guidelines (e.g., the Australian National Health and Medical Research Council). These professional groups unanimously conclude, based on the scientific evidence, that methylphenidate is safe and effective and should be considered as a first-line treatment for ADHD. The likelihood of developing insomnia for ADHD patients taking stimulants has been measured at between 11 and 45 per cent for different medications, and may be a main reason for discontinuation. Other side effects, such as tics, decreased appetite and weight loss, or emotional lability, may also lead to discontinuation. Stimulant psychosis and mania are rare at therapeutic doses, appearing to occur in approximately 0.1% of individuals, within the first several weeks after starting amphetamine therapy. The safety of these medications in pregnancy is unclear. Symptom improvement is not sustained if medication is ceased. The long-term effects of ADHD medication have yet to be fully determined, although stimulants are generally beneficial and safe for up to two years for children and adolescents. A 2022 meta-analysis found no statistically significant association between ADHD medications and the risk of cardiovascular disease (CVD) across age groups, although the study suggests further investigation is warranted for patients with preexisting CVD as well as long-term medication use. Regular monitoring has been recommended in those on long-term treatment. There are indications suggesting that stimulant therapy for children and adolescents should be stopped periodically to assess continuing need for medication, decrease possible growth delay, and reduce tolerance. Although potentially addictive at high doses, stimulants used to treat ADHD have low potential for abuse. Treatment with stimulants is either protective against substance abuse or has no effect. The majority of studies on nicotine and other nicotinic agonists as treatments for ADHD have shown favorable results; however, no nicotinic drug has been approved for ADHD treatment. Caffeine was formerly used as a second-line treatment for ADHD but research indicates it has no significant effects in reducing ADHD symptoms. Caffeine appears to help with alertness, arousal and reaction time but not the type of inattention implicated in ADHD (sustained attention/persistence). Pseudoephedrine and ephedrine do not affect ADHD symptoms. Modafinil has shown some efficacy in reducing the severity of ADHD in children and adolescents. It may be prescribed off-label to treat ADHD. Non-stimulants Two non-stimulant medications, atomoxetine and viloxazine, are approved by the FDA and in other countries for the treatment of ADHD. Atomoxetine, due to its lack of addiction liability, may be preferred in those who are at risk of recreational or compulsive stimulant use, although evidence is lacking to support its use over stimulants for this reason. Atomoxetine alleviates ADHD symptoms through norepinephrine reuptake and by indirectly increasing dopamine in the pre-frontal cortex, sharing 70-80% of the brain regions with stimulants in their produced effects. Atomoxetine has been shown to significantly improve academic performance. Meta-analyses and systematic reviews have found that atomoxetine has comparable efficacy, equal tolerability and response rate (75%) to methylphenidate in children and adolescents. In adults, efficacy and discontinuation rates are equivalent. Analyses of clinical trial data suggests that viloxazine is about as effective as atomoxetine and methylphenidate but with fewer side effects. Amantadine was shown to induce similar improvements in children treated with methylphenidate, with less frequent side effects. A 2021 retrospective study showed that amantadine may serve as an effective adjunct to stimulants for ADHD–related symptoms and appears to be a safer alternative to second- or third-generation antipsychotics. Bupropion is also used off-label by some clinicians due to research findings. It is effective, but modestly less than atomoxetine and methylphenidate. There is little evidence on the effects of medication on social behaviours. Antipsychotics may also be used to treat aggression in ADHD. Alpha-2a agonists Two alpha-2a agonists, extended-release formulations of guanfacine and clonidine, are approved by the FDA and in other countries for the treatment of ADHD (effective in children and adolescents but effectiveness has still not been shown for adults). They appear to be modestly less effective than the stimulants (amphetamine and methylphenidate) and non-stimulants (atomoxetine and viloxazine) at reducing symptoms, but can be useful alternatives or used in conjunction with a stimulant. These medications act by adjusting the alpha-2a ports on the outside of noradrenergic nerve cells in the pre-frontal executive networks, so the information (electrical signal) is less confounded by noise. Guidelines Guidelines on when to use medications vary by country. The United Kingdom's National Institute for Health and Care Excellence recommends use for children only in severe cases, though for adults medication is a first-line treatment. Conversely, most United States guidelines recommend medications in most age groups. Medications are especially not recommended for preschool children. Underdosing of stimulants can occur, and can result in a lack of response or later loss of effectiveness. This is particularly common in adolescents and adults as approved dosing is based on school-aged children, causing some practitioners to use weight-based or benefit-based off-label dosing instead. Exercise Exercise does not reduce the symptoms of ADHD. The conclusion by the International Consensus Statement is based on two meta-analyses: one of 10 studies with 300 children and the other of 15 studies and 668 participants, which showed that exercise yields no statistically significant reductions on ADHD symptoms. A 2024 systematic review and meta analysis commissioned by the Patient-Centered Outcomes Research Institute (PCORI) identified seven studies on the effectiveness of physical exercise for treating ADHD symptoms. The type and amount of exercise varied widely across studies from martial arts interventions to treadmill training, to table tennis or aerobic exercise. Effects reported were not replicated, causing the authors to conclude that there is insufficient evidence that exercise intervention is an effective form of treatment for ADHD symptoms. Diet Dietary modifications are not recommended by the American Academy of Pediatrics, the National Institute for Health and Care Excellence, or the Agency for Healthcare Research and Quality due to insufficient evidence. A 2013 meta-analysis found less than a third of children with ADHD see some improvement in symptoms with free fatty acid supplementation or decreased consumption of artificial food colouring. These benefits may be limited to children with food sensitivities or those who are simultaneously being treated with ADHD medications. This review also found that evidence does not support removing other foods from the diet to treat ADHD. A 2014 review found that an elimination diet results in a small overall benefit in a minority of children, such as those with allergies. A 2016 review stated that the use of a gluten-free diet as standard ADHD treatment is not advised. A 2017 review showed that a few-foods elimination diet may help children too young to be medicated or not responding to medication, while free fatty acid supplementation or decreased eating of artificial food colouring as standard ADHD treatment is not advised. Chronic deficiencies of iron, magnesium and iodine may have a negative impact on ADHD symptoms. There is a small amount of evidence that lower tissue zinc levels may be associated with ADHD. In the absence of a demonstrated zinc deficiency (which is rare outside of developing countries), zinc supplementation is not recommended as treatment for ADHD. However, zinc supplementation may reduce the minimum effective dose of amphetamine when it is used with amphetamine for the treatment of ADHD. Prognosis ADHD persists into adulthood in about 30–50% of cases. Those affected are likely to develop coping mechanisms as they mature, thus compensating to some extent for their previous symptoms. Children with ADHD have a higher risk of unintentional injuries. Effects of medication on functional impairment and quality of life (e.g. reduced risk of accidents) have been found across multiple domains. Rates of smoking among those with ADHD are higher than in the general population at about 40%. About 30–50% of people diagnosed in childhood continue to have ADHD in adulthood, with 2.58% of adults estimated to have ADHD which began in childhood. In adults, hyperactivity is usually replaced by inner restlessness, and adults often develop coping skills to compensate for their impairments. The condition can be difficult to tell apart from other conditions, as well as from high levels of activity within the range of normal behaviour. ADHD has a negative impact on patient health-related quality of life that may be further exacerbated by, or may increase the risk of, other psychiatric conditions such as anxiety and depression. Individuals with ADHD may also face misconceptions and stigma. Individuals with ADHD are significantly overrepresented in prison populations. Although there is no generally accepted estimate of ADHD prevalence among inmates, a 2015 meta-analysis estimated a prevalence of 25.5%, and a larger 2018 meta-analysis estimated the frequency to be 26.2%. Epidemiology ADHD is estimated to affect about 6–7% of people aged 18 and under when diagnosed via the DSM-IV criteria. When diagnosed via the ICD-10 criteria, rates in this age group are estimated around 1–2%. Rates are similar between countries and differences in rates depend mostly on how it is diagnosed. Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East; this is believed to be due to differing methods of diagnosis rather than a difference in underlying frequency. (The same publication which describes this difference also notes that the difference may be rooted in the available studies from these respective regions, as far more studies were from North America than from Africa and the Middle East.) it was estimated to affect 84.7 million people globally. ADHD is diagnosed approximately twice as often in boys as in girls, and 1.6 times more often in men than in women, although the disorder is overlooked in girls or diagnosed in later life because their symptoms sometimes differ from diagnostic criteria. In 2014, Keith Conners, one of the early advocates for recognition of the disorder, spoke out against overdiagnosis in a New York Times article. In contrast, a 2014 peer-reviewed medical literature review indicated that ADHD is underdiagnosed in adults. Studies from multiple countries have reported that children born closer to the start of the school year are more frequently diagnosed with and medicated for ADHD than their older classmates. Boys who were born in December where the school age cut-off was 31 December were shown to be 30% more likely to be diagnosed and 41% more likely to be treated than those born in January. Girls born in December had a diagnosis and treatment percentage increase of 70% and 77% respectively compared to those born in January. Children who were born at the last three days of a calendar year were reported to have significantly higher levels of diagnosis and treatment for ADHD than children born at the first three days of a calendar year. The studies suggest that ADHD diagnosis is prone to subjective analysis. Rates of diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s. Prior to 1970, it was rare for children to be diagnosed with ADHD, while in the 1970s rates were about 1%. This is believed to be primarily due to changes in how the condition is diagnosed and how readily people are willing to treat it with medications rather than a true change in incidence. With widely differing rates of diagnosis across countries, states within countries, races, and ethnicities, some suspect factors other than symptoms of ADHD are playing a role in diagnosis, such as cultural norms. Despite showing a higher frequency of symptoms associated with ADHD, non-White children in the US are less likely than White children to be diagnosed or treated for ADHD, a finding that is often explained by bias among health professionals, as well as parents who may be reluctant to acknowledge that their child has ADHD. Crosscultural differences in diagnosis of ADHD can also be attributed to the long-lasting effects of harmful, racially targeted medical practices. Medical pseudosciences, particularly those that targeted Black populations during the period of slavery in the US, lead to a distrust of medical practices within certain communities. The combination of ADHD symptoms often being regarded as misbehaviour rather than as a psychiatric condition, and the use of drugs to regulate ADHD, result in a hesitancy to trust a diagnosis of ADHD. Cases of misdiagnosis in ADHD can also occur due to stereotyping of people of color. Due to ADHD's subjectively determined symptoms, medical professionals may diagnose individuals based on stereotyped behaviour or misdiagnose due to cultural differences in symptom presentation. A 2024 study in CDC’s Morbidity and Mortality Weekly Report reports around 15.5 million U.S. adults have attention-deficit hyperactivity disorder, with many facing challenges in accessing treatment. One-third of diagnosed individuals had received a prescription for a stimulant drug in the past year but nearly three-quarters of them reported difficulties filling the prescription due to medication shortages. History ADHD was officially known as attention deficit disorder (ADD) from 1980 to 1987; prior to the 1980s, it was known as hyperkinetic reaction of childhood. Symptoms similar to those of ADHD have been described in medical literature dating back to the 18th century. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798. He made observations about children showing signs of being inattentive and having the "fidgets". The first clear description of ADHD is credited to George Still in 1902 during a series of lectures he gave to the Royal College of Physicians of London. The terminology used to describe the condition has changed over time and has included: minimal brain dysfunction in the DSM-I (1952), hyperkinetic reaction of childhood in the DSM-II (1968), and attention-deficit disorder with or without hyperactivity in the DSM-III (1980). In 1987, this was changed to ADHD in the DSM-III-R, and in 1994 the DSM-IV in split the diagnosis into three subtypes: ADHD inattentive type, ADHD hyperactive-impulsive type, and ADHD combined type. These terms were kept in the DSM-5 in 2013 and in the DSM-5-TR in 2022. Prior to the DSM, terms included minimal brain damage in the 1930s. ADHD, its diagnosis, and its treatment have been controversial since the 1970s. Positions range from the view that ADHD is within the normal range of behaviour to the hypothesis that ADHD is a genetic condition. Other areas of controversy include the use of stimulant medications in children, the method of diagnosis, and the possibility of overdiagnosis. In 2009, the National Institute for Health and Care Excellence states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature. Once neuroimaging studies were possible, studies in the 1990s provided support for the pre-existing theory that neurological differences (particularly in the frontal lobes) were involved in ADHD. A genetic component was identified and ADHD was acknowledged to be a persistent, long-term disorder which lasted from childhood into adulthood. ADHD was split into the current three sub-types because of a field trial completed by Lahey and colleagues and published in 1994. In 2021, global teams of scientists curated the International Consensus Statement compiling evidence-based findings about the disorder. In 1934, Benzedrine became the first amphetamine medication approved for use in the United States. Methylphenidate was introduced in the 1950s, and enantiopure dextroamphetamine in the 1970s. The use of stimulants to treat ADHD was first described in 1937. Charles Bradley gave the children with behavioural disorders Benzedrine and found it improved academic performance and behaviour. Research directions Possible positive traits Possible positive traits of ADHD are a new avenue of research, and therefore limited. A 2020 review found that creativity may be associated with ADHD symptoms, particularly divergent thinking and quantity of creative achievements, but not with the disorder of ADHD itself – i.e. it has not been found to be increased in people diagnosed with the disorder, only in people with subclinical symptoms or those that possess traits associated with the disorder. Divergent thinking is the ability to produce creative solutions which differ significantly from each other and consider the issue from multiple perspectives. Those with ADHD symptoms could be advantaged in this form of creativity as they tend to have diffuse attention, allowing rapid switching between aspects of the task under consideration; flexible associative memory, allowing them to remember and use more distantly-related ideas which is associated with creativity; and impulsivity, allowing them to consider ideas which others may not have. Possible biomarkers for diagnosis Reviews of ADHD biomarkers have noted that platelet monoamine oxidase expression, urinary norepinephrine, urinary MHPG, and urinary phenethylamine levels consistently differ between ADHD individuals and non-ADHD controls. These measurements could serve as diagnostic biomarkers for ADHD, but more research is needed to establish their diagnostic utility. Urinary and blood plasma phenethylamine concentrations are lower in ADHD individuals relative to controls. The two most commonly prescribed drugs for ADHD, amphetamine and methylphenidate, increase phenethylamine biosynthesis in treatment-responsive individuals with ADHD. Lower urinary phenethylamine concentrations are associated with symptoms of inattentiveness in ADHD individuals. See also Attention deficit hyperactivity disorder controversies Directed attention fatigue – a temporary state sharing many of the symptoms of ADHD Self-medication References Further reading External links National Institute of Mental Health. NIMH Pages About Attention-Deficit/Hyperactivity Disorder (ADHD). National Institutes of Health (NIH), U.S. Department of Health and Human Services. 1987 neologisms Ailments of unknown cause Amphetamine Attention disorders Learning disabilities Methylphenidate Wikipedia medicine articles ready to translate (full) Wikipedia neurology articles ready to translate

Colloquialism

Colloquialism (also called colloquial language, everyday language, or general parlance) is the linguistic style used for casual (informal) communication. It is the most common functional style of speech, the idiom normally employed in conversation and other informal contexts. Colloquialism is characterized by wide usage of interjections and other expressive devices; it makes use of non-specialist terminology, and has a rapidly changing lexicon. It can also be distinguished by its usage of formulations with incomplete logical and syntactic ordering. A specific instance of such language is termed a colloquialism. The most common term used in dictionaries to label such an expression is colloquial. Explanation Colloquialism or general parlance is distinct from formal speech or formal writing. It is the form of language that speakers typically use when they are relaxed and not especially self-conscious. An expression is labeled colloq. for "colloquial" in dictionaries when a different expression is preferred in formal usage, but this does not mean that the colloquial expression is necessarily slang or non-standard. Some colloquial language contains a great deal of slang, but some contains no slang at all. Slang is often used in colloquial speech, but this particular register is restricted to particular in-groups, and it is not a necessary element of colloquialism. Other examples of colloquial usage in English include contractions or profanity. "Colloquial" should also be distinguished from "non-standard". The difference between standard and non-standard is not necessarily connected to the difference between formal and colloquial. Formal, colloquial, and vulgar language are more a matter of stylistic variation and diction, rather than of the standard and non-standard dichotomy. The term "colloquial" is also equated with "non-standard" at times, in certain contexts and terminological conventions. A colloquial name or familiar name is a name or term commonly used to identify a person or thing in non-specialist language, in place of another usually more formal or technical name. In the philosophy of language, "colloquial language" is ordinary natural language, as distinct from specialized forms used in logic or other areas of philosophy. In the field of logical atomism, meaning is evaluated in a different way than with more formal propositions. Distinction from other styles Colloquialisms are distinct from slang or jargon. Slang refers to words used only by specific social groups, such as demographics based on region, age, or socio-economic identity. In contrast, jargon is most commonly used within specific occupations, industries, activities, or areas of interest. Colloquial language includes slang, along with abbreviations, contractions, idioms, turns-of-phrase, and other informal words and phrases known to most native speakers of a language or dialect. Jargon is terminology that is explicitly defined in relationship to a specific activity, profession, or group. The term refers to the language used by people who work in a particular area or who have a common interest. Similar to slang, it is shorthand used to express ideas, people, and things that are frequently discussed between members of a group. Unlike slang, it is often developed deliberately. While a standard term may be given a more precise or unique usage amongst practitioners of relevant disciplines, it is often reported that jargon is a barrier to communication for those people unfamiliar with the respective field. See also Eye dialect Oral history Vernacular References External links Colloquial Spanish – Dictionary of Colloquial Spanish. Tractatus Logico-Philosophicus, Ludwig Wittgenstein (archived 17 May 1997) Youth culture Language varieties and styles

Resignation syndrome

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal or abandonment syndrome; ) is a hypothesized condition that induces a state of reduced consciousness, not recognized by the World Health Organization as a valid psychiatric condition. It was first described in Sweden in the 1990s. The condition affects predominately psychologically traumatized children and adolescents in the midst of a strenuous and lengthy migration process. Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family. Signs and symptoms Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function. Nosology Resignation syndrome (RS) and pervasive refusal syndrome share common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems. Pervasive refusal syndrome (also called pervasive arousal-withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness, such as parents drugging children for increased chance of being granted asylum. It was also suggested to be on the 'refusal-withdrawal-regression spectrum'. Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognized the novel diagnostic entity resignation syndrome in 2014. Others, however, argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder. Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking. Causes Resignation syndrome appears to be a very specialized response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years. Experts have proposed multifactorial explanatory models involving individual vulnerability, traumatization, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver's expectations to interplay in pathogenesis. Some differential diagnoses to be excluded include severe depression, dissociative disorders and conversion disorders. However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden's experience raises concerns about "contagion". Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma. A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioral systems in particularly vulnerable individuals. Epidemiology Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005 and 2.8% of all 6,547 asylum applications submitted for children were diagnosed in 2004. It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may have traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven had RS, and three had psychosis. Concerns The phenomenon has been called into question, with two children reporting that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam and witnessed parents who actively refused aid for their children but remained silent at the time. Later, Sveriges Television, Sweden's national public television broadcaster, was severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said "There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works". See also Asylum seekers with apathetic refugee children Life Overtakes Me Quiet Life (film) Mass psychogenic illness References External links Psychopathological syndromes Culture-bound syndromes

Functional illiteracy

Functional illiteracy consists of reading and writing skills that are inadequate "to manage daily living and employment tasks that require reading skills beyond a basic level". Those who read and write only in a language other than the predominant language of their environs may also be considered functionally illiterate. Functional illiteracy is contrasted with illiteracy in the strict sense, meaning the inability to read or write complete, correctly spelled sentences in any language. The characteristics of functional illiteracy vary from one culture to another, as some cultures require more advanced reading and writing skills than do others. In languages with phonemic spelling, functional illiteracy might be defined simply as reading too slowly for practical use, an inability to effectively use dictionaries and written manuals, and other factors. Sociological research has demonstrated that countries with lower levels of functional illiteracy among their adult populations tend to be those with the highest levels of scientific literacy among the lower stratum of young people nearing the end of their formal academic studies. This correspondence suggests that the capacity of schools to ensure students attain the functional literacy required to comprehend the basic texts and documents associated with competent citizenship contributes to a society's level of civic literacy. A reading level that might be sufficient to make a farmer functionally literate in a rural area of a developing country might qualify as functional illiteracy in an urban area of a technologically advanced country. In developed countries, the level of functional literacy of an individual is proportional to income level and inversely proportional to the risk of committing certain kinds of crime. In Russia, where more than 99% of the population is technically literate, only one-third of high school graduates can comprehend the content of scientific and literary texts, according to a 2015 study. The UK government's Department for Education reported in 2006 that 47% of school children left school at age 16 without having achieved a basic level in functional mathematics, and 42% fail to achieve a basic level of functional English. Every year, 100,000 pupils leave school functionally illiterate in the UK. In the United States, according to Business magazine, an estimated 15 million functionally illiterate adults held jobs at the beginning of the 21st century. According to the National Center for Educational Statistics in the United States: About 70% of adults in the U.S. prison system read at or below the fourth-grade level, according to the 2003 National Adult Literacy Survey, noting that a "link between academic failure and delinquency, violence and crime is welded to reading failure." 85% of US juvenile inmates are functionally illiterate 43% of adults at the lowest level of literacy lived below the poverty line, as opposed to 4% of those with the highest levels of literacy. The National Center for Education Statistics provides more detail. Literacy is broken down into three parameters: prose, document, and quantitative literacy. Each parameter has four levels: below basic, basic, intermediate, and proficient. For prose literacy, for example, a below basic level of literacy means that a person can look at a short piece of text to get a small piece of uncomplicated information, while a person who is below basic in quantitative literacy would be able to do simple addition. In the US, 14% of the adult population is at the "below basic" level for prose literacy; 12% are at the "below basic" level for document literacy, and 22% are at that level for quantitative literacy. Only 13% of the population is proficient in each of these three areas—able to compare viewpoints in two editorials; interpret a table about blood pressure, age, and physical activity; or compute and compare the cost per ounce of food items. A Literacy at Work study, published by the Northeast Institute in 2001, found that business losses attributed to basic skill deficiencies run into billions of dollars a year due to low productivity, errors, and accidents attributed to functional illiteracy. The American Council of Life Insurers reported that 75% of the Fortune 500 companies provide some level of remedial training for their workers. , 30 million (14% of adults) were unable to perform simple and everyday literacy activities. UNESCO definition Illiteracy, as well as functional illiteracy, were defined on the 20th session of UNESCO in 1978 as follows: See also Aliteracy Functional English Health literacy Literacy Literacy in the United States Post-literate society Reading Scientific literacy References Knowledge Reading (process) Sociolinguistics Literacy de:Analphabetismus#Definitionen und Differenzierungen

Downshifting (lifestyle)

In social behavior, downshifting is a trend where individuals adopt simpler lives from what critics call the "rat race". The long-term effect of downshifting can include an escape from what has been described as economic materialism, as well as reduce the "stress and psychological expense that may accompany economic materialism". This new social trend emphasizes finding an improved balance between leisure and work, while also focusing life goals on personal fulfillment, as well as building personal relationships instead of the all-consuming pursuit of economic success. Downshifting, as a concept, shares characteristics with simple living. However, it is distinguished as an alternative form by its focus on moderate change and concentration on an individual comfort level and a gradual approach to living. In the 1990s, this new form of simple living began appearing in the mainstream media, and has continually grown in popularity among populations living in industrial societies, especially the United States, the United Kingdom, New Zealand, and Australia, as well as Russia. Values and motives "Down-shifters" refers to people who adopt long-term voluntary simplicity in their lives. A few of the main practices of down-shifters include accepting less money for fewer hours worked, while placing an emphasis on consuming less in order to reduce their ecological footprint. One of the main results of these practices is being able to enjoy more leisure time in the company of others, especially loved ones. The primary motivations for downshifting are gaining leisure time, escaping from work-and-spend cycle, and removing the clutter of unnecessary possessions. The personal goals of downshifting are simple: To reach a holistic self-understanding and satisfying meaning in life. Because of its personalized nature and emphasis on many minor changes, rather than complete lifestyle overhaul, downshifting attracts participants from across the socioeconomic spectrum. An intrinsic consequence of downshifting is increased time for non-work-related activities, which, combined with the diverse demographics of downshifters, cultivates higher levels of civic engagement and social interaction. The scope of participation is limitless, because all members of society—adults, children, businesses, institutions, organizations, and governments—are able to downshift even if many demographic strata do not start "high" enough to "down"-shift. In practice, down-shifting involves a variety of behavioral and lifestyle changes. The majority of these down-shifts are voluntary choices. Natural life course events, such as the loss of a job, or birth of a child can prompt involuntary down-shifting. There is also a temporal dimension, because a down-shift could be either temporary or permanent. Methods Work and income The most common form of down-shifting is work (or income) down-shifting. Down-shifting is fundamentally based on dissatisfaction with the conditions and consequences of the workplace environment. The philosophy of work-to-live replaces the social ideology of live-to-work. Reorienting economic priorities shifts the work–life balance away from the workplace. Economically, work downshifts are defined in terms of reductions in either actual or potential income, work hours, and spending levels. Following a path of earnings that is lower than the established market path is a downshift in potential earnings in favor of gaining other non-material benefits. On an individual level, work downshifting is a voluntary reduction in annual income. Downshifters desire meaning in life outside of work and, therefore, will opt to decrease the amount of time spent at work or work hours. Reducing the number of hours of work, consequently, lowers the amount earned. Simply not working overtime or taking a half-day a week for leisure time, are work downshifts. Career downshifts are another way of downshifting economically and entail lowering previous aspirations of wealth, a promotion or higher social status. Quitting a job to work locally in the community, from home or to start a business are examples of career downshifts. Although more radical, these changes do not mean stopping work altogether. Many reasons are cited by workers for this choice and usually center on a personal cost–benefit analysis of current working situations and desired extracurricular activities. High stress, pressure from employers to increase productivity, and long commutes can be factors that contribute to the costs of being employed. If the down-shifter wants more non-material benefits like leisure time, a healthy family life, or personal freedom then switching jobs could be a desirable option. Work down-shifting may also be a key to considerable health benefits as well as a healthy retirement. People are retiring later in life than previous generations. As can be seen by looking at The Health and Retirement Study, done by the Health and Retirement Study Survey Research Center, women can show the long term health benefits of down-shifting their work lives by working part time hours over a long period of years. Men however prove to be more unhealthy if they work part time from middle age till retirement. Men who down-shift their work life to part time hours at the age of 60 to 65 however benefit from continuing to work a part-time job through a semi retirement even over the age of 70. This is an example of how flexible working policies can be a key to being healthy while in retirement. Spending habits Another aspect of down-shifting is being a conscious consumer or actively practicing alternative forms of consumption. Proponents of down-shifting point to consumerism as a primary source of stress and dissatisfaction because it creates a society of individualistic consumers who measure both social status and general happiness by an unattainable quantity of material possessions. Instead of buying goods for personal satisfaction, consumption down-shifting, purchasing only the necessities, is a way to focus on quality of life rather than quantity. This realignment of spending priorities promotes the functional utility of goods over their ability to convey status which is evident in downshifters being generally less brand-conscious. These consumption habits also facilitate the option of working and earning less because annual spending is proportionally lower. Reducing spending is less demanding than more extreme downshifts in other areas, like employment, as it requires only minor lifestyle changes. Policies that enable downshifting Unions, business, and governments could implement more flexible working hours, part-time work, and other non-traditional work arrangements that enable people to work less, while still maintaining employment. Small business legislation, reduced filing requirements and reduced tax rates encourage small-scale individual entrepreneurship and therefore help individuals quit their jobs altogether and work for themselves on their own terms. Environmental consequences The catch-phrase of International Downshifting Week is "Slow Down and Green Up". Whether intentional or unintentional, generally, the choices and practices of down-shifters nurture environmental health because they reject the fast-paced lifestyle fueled by fossil fuels and adopt more sustainable lifestyles. The latent function of consumption down-shifting is to reduce, to some degree, the carbon footprint of the individual down-shifter. An example is to shift from a corporate suburban rat race lifestyle to a small eco friendly farming lifestyle. Down-shifting geographically Downshifting geographically is a relocation to a smaller, rural, or more slow-paced community. This is often a response to the hectic pace of life and stresses in urban areas. It is a significant change but does not bring total removal from mainstream culture. Sociopolitical implications Although downshifting is primarily motivated by personal desire and not by a conscious political stance, it does define societal overconsumption as the source of much personal discontent. By redefining life satisfaction in non-material terms, downshifters assume an alternative lifestyle but continue to coexist in a society and political system preoccupied with the economy. In general, downshifters are politically apathetic because mainstream politicians mobilize voters by proposing governmental solutions to periods of financial hardship and economic recessions. This economic rhetoric is meaningless to downshifters who have forgone worrying about money. In the United States, the UK, and Australia, a significant minority, approximately 20 to 25 percent, of these countries' citizens identify themselves in some respect as downshifters. Downshifting is not an isolated or unusual choice. Politics still centers around consumerism and unrestricted growth, but downshifting values, such as family priorities and workplace regulation, appear in political debates and campaigns. Like downshifters, the Cultural Creatives is another social movement whose ideology and practices diverge from mainstream consumerism and according to Paul Ray, are followed by at least a quarter of U.S. citizens. In his book In Praise of Slowness, Carl Honoré relates followers of downshifting and simple living to the global slow movement. The significant number and diversity of downshifters are a challenge to economic approaches to improving society. The rise in popularity of downshifting and similar, post-materialist ideologies represents unorganized social movements without political aspirations or motivating grievances. This is a result of their grassroots nature and relatively inconspicuous, non-confrontational subcultures. See also Anti-consumerism Conspicuous consumption Degrowth Demotion Downsizing Eco-communalism Ecological economics Ecovillage Ethical consumerism FIRE movement Frugality Homesteading Intentional community Intentional living Minimalism / Simple living Permaculture Slow living Sustainable living Transition towns Workaholic References Further reading Blanchard, Elisa A. (1994). Beyond Consumer Culture: A Study of Revaluation and Voluntary Action. Unpublished thesis, Tufts University. Bull, Andy. (1998). Downshifting: The Ultimate Handbook. London: Thorsons Etziomi, Amitai. (1998). Voluntary simplicity: Characterization, select psychological implications, and societal consequences. Journal of Economic Psychology 19:619–43. Hamilton, Clive (November 2003). Downshifting in Britain: A sea-change in the pursuit of happiness. The Australia Institute Discussion Paper No. 58. 42p. Hamilton, C., Mail, E. (January 2003). Downshifting in Australia: A sea-change in the pursuit of happiness. The Australia Institute Discussion Paper No. 50. 12p. ISSN 1322-5421 Juniu, Susana (2000). Downshifting: Regaining the Essence of Leisure, Journal of Leisure Research, 1st Quarter, Vol. 32 Issue 1, p69, 5p. Levy, Neil (2005). Downshifting and Meaning in Life, Ratio, Vol. 18, Issue 2, 176–89. J. B. MacKinnon (2021). The Day the World Stops Shopping: How ending consumerism gives us a better life and a greener world, Penguin Random House. Mazza, P. (1997). Keeping it simple. Reflections 36 (March): 10–12. Nelson, Michelle R., Paek, Hye-Jin, Rademacher, Mark A. (2007). Downshifting Consumer = Upshifting Citizen?: An Examination of a Local Freecycle Community. The Annals of the American Academy of Political and Social Science, 141–56. Saltzman, Amy. (1991). Downshifting: Reinventing Success on a Slower Track. New York: Harper Collins. Schor, Juliet B (1998). Voluntary Downshifting in the 1990s. In E. Houston, J. Stanford, & L. Taylor (Eds.), Power, Employment, and Accumulation: Social Structures in Economic Theory and Practice (pp. 66–79). Armonk, NY: M. E. Sharpe, 2003. Text from University of Chapel Hill Library Collections. External links The Homemade Life, a web forum aimed at promoting simple living Official website for the Slow Movement How To Be Rich Today – downloadable guide to Downshifting (UK) Personal finance Simple living Subcultures Waste minimisation Work–life balance fr:Simplicité volontaire

High-functioning alcoholic

A high-functioning alcoholic (HFA) is a person who maintains jobs and relationships while exhibiting alcoholism. Many HFAs are not viewed as alcoholics by society because they do not fit the common alcoholic stereotype. Unlike the stereotypical alcoholic, HFAs have either succeeded or over-achieved throughout their lifetimes. This can lead to denial of alcoholism by the HFA, co-workers, family members, and friends. Functional alcoholics account for 19.5 percent of total U.S. alcoholics, with 50 percent also being smokers and 33 percent having a multigenerational family history of alcoholism. Statistics from the Harvard School of Public Health indicated that 31 percent of college students show signs of alcohol abuse and 6 percent are dependent on alcohol. Doctors hope that the new definition will help identify severe cases of alcoholism early, rather than when the problem is fully developed. High-functioning alcoholics may exhibit signs of alcohol dependence while still managing to fulfill their professional and personal responsibilities. Some common characteristics include denial, maintaining responsibilities, high alcohol tolerance, physical and mental health issues, and social isolation. Causes Social drinking Social drinking refers to consuming alcohol in casual settings like bars, nightclubs, or parties, focusing on the company rather than the amount of alcohol. However, unlike "responsible drinking" it doesn't necessarily specify moderation or safety practices, but on socializing and spending quality time with others. While social drinking is a common part of our culture, it's different from "responsible drinking" which emphasizes moderation and safety. Occasional social drinking might not be a problem. However, regular social drinking can lead to dependence, including the development of high-functioning alcoholism. This means someone may appear to function normally in daily life while struggling with alcohol dependence. See also Alcohol (drug) Holiday heart syndrome References Alcohol abuse

Premorbidity

Premorbidity refers to the state of functionality prior to the onset of a disease or illness. It is most often used in relation to psychological function (e.g. premorbid personality or premorbid intelligence), but can also be used in relation to other medical conditions (e.g. premorbid lung function or premorbid heart rate). Psychology In psychology, premorbidity is most often used in relation to changes in personality, intelligence or cognitive function. Changes in personality are common in cases of traumatic brain injury involving the frontal lobes, the most famous example of this is the case of Phineas Gage who survived having a tamping iron shot through his head in a railway construction accident. Declines from premorbid levels of intelligence and other cognitive functions are observed in stroke, traumatic brain injury, and dementia as well as in mental illnesses such as depression and schizophrenia. Other usage in psychology include premorbid adjustment which has important implications for the prognosis of mental illness such as schizophrenia. Efforts are also being made to identify premorbid personality profiles for certain illness, such as schizophrenia to determine at risk populations. Clinical and diagnostic usage In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), paranoid, schizoid, and schizotypal personality disorders may be diagnosed as conditions premorbid to the onset of schizophrenia. See also Prodrome References Symptoms

Industrial and organizational psychology

Industrial and organizational psychology (I-O psychology) "focuses the lens of psychological science on a key aspect of human life, namely, their work lives. In general, the goals of I-O psychology are to better understand and optimize the effectiveness, health, and well-being of both individuals and organizations." It is an applied discipline within psychology and is an international profession. I-O psychology is also known as occupational psychology in the United Kingdom, organisational psychology in Australia and New Zealand, and work and organizational (WO) psychology throughout Europe and Brazil. Industrial, work, and organizational (IWO) psychology is the broader, more global term for the science and profession. I-O psychologists are trained in the scientist–practitioner model. As an applied psychology field, the discipline involves both research and practice and I-O psychologists apply psychological theories and principles to organizations and the individuals within them. They contribute to an organization's success by improving the job performance, wellbeing, motivation, job satisfaction and the health and safety of employees. An I-O psychologist conducts research on employee attitudes, behaviors, emotions, motivation, and stress. The field is concerned with how these things can be improved through recruitment processes, training, and development programs, 360-degree feedback, change management, and other management systems and other interventions. I-O psychology research and practice also includes the work–nonwork interface such as selecting and transitioning into a new career, occupational burnout, unemployment, retirement, and work–family conflict and balance. I-O psychology is one of the 17 recognized professional specialties by the American Psychological Association (APA). In the United States the profession is represented by Division 14 of the APA and is formally known as the Society for Industrial and Organizational Psychology (SIOP). Similar I-O psychology societies can be found in many countries. In 2009 the Alliance for Organizational Psychology was formed and is a federation of Work, Industrial, & Organizational Psychology societies and "network partners" from around the world. International I-O psychology is an international science and profession and depending on the region of the world, it is referred to by different names. In North America, Canada and South Africa the title "I-O" psychology is used; in the United Kingdom, the field is known as occupational psychology. Occupational psychology in the UK is one of nine "protected titles" within the "practitioner psychologist" professions. The profession is regulated by the Health and Care Professions Council. In the UK, graduate programs in psychology, including occupational psychology, are accredited by the British Psychological Society. In Europe, someone with a specialist EuroPsy Certificate in Work and Organisational Psychology is a fully qualified psychologist and a specialist in the work psychology field. Industrial and organizational psychologists reaching the EuroPsy standard are recorded in the Register of European Psychologists. I-O psychology is one of the three main psychology specializations in Europe. In Australia, the title "organisational psychologist" is protected by law and regulated by the Australian Health Practitioner Regulation Agency (AHPRA). Organizational psychology is one of nine areas of specialist endorsement for psychology practice in Australia. In South Africa, industrial psychology is a registration category for the profession of psychologist as regulated by the Health Professions Council of South Africa (HPCSA). In 2009 The Alliance for Organizational psychology was formed and is a federation of Work, Industrial, & Organizational Psychology societies and "network partners" from around the world. In 2021 The British Psychological Society (BPS) Division of Occupational Psychology (DOP) and the Australian Psychological Society's (APS) College of Organizational Psychology joined the Alliance. The Alliance currently has member organizations representing Industrial, Work and Organisational psychology and IWO psychologists from Australia, Britain, Brazil, Canada, Chile, Europe, Germany, Hong Kong, Japan, Netherlands, New Zealand, Singapore, South Africa and the United States. Historical overview The historical development of I-O psychology was paralleled in the US, the UK, Australia, Germany, the Netherlands, and Eastern European countries such as Romania. The roots of I-O psychology trace back to almost the beginning of psychology as a science, when Wilhelm Wundt founded one of the first psychological laboratories in 1879 in Leipzig, Germany. In the mid–1880s, Wundt trained two psychologists, Hugo Münsterberg and James McKeen Cattell, who went on to have a major influence on the emergence of I-O psychology. World War I was an impetus for the development of the field simultaneously in the UK and US. Munsterberg, one of the founders of I-O psychology, wrote, "Our aim is to sketch the outlines of a new science which is intermediate between the modern laboratory psychology and the problems of economics: the psychological experiment is systematically to be placed at the service of commerce and industry" (p. 3). Instead of viewing performance differences as human "errors," Cattell was one of the first to recognize the importance of differences among individuals as a way of better understanding work behavior. Walter Dill Scott, who was a contemporary of Cattell and was elected President of the American Psychological Association (APA) in 1919, was arguably the most prominent I-O psychologist of his time. Scott, along with Walter Van Dyke Bingham, worked at what was then Carnegie Institute of Technology, developing methods for selecting and training sales personnel. The "industrial" side of I-O psychology originated in research on individual differences, assessment, and the prediction of work performance. Industrial psychology crystallized during World War I, in response to the need to rapidly assign new troops to duty. Scott and Bingham volunteered to help with the testing and placement of more than a million U.S. Army recruits. In 1917, together with other prominent psychologists, they adapted a well-known intelligence test the Stanford–Binet, which was designed for testing one individual at a time, to make it suitable for group testing. The new test was called the Army Alpha. After the War, increasing employment in the U.S. created opportunities for I-O psychology practitioners who called themselves "industrial psychologists" The "organizational" side of the field was focused on employee behavior, feelings, and well-being. During World War I, with the U.K. government's interest in worker productivity in munitions factories, Charles Myers studied worker fatigue and well-being. Following the war, Elton Mayo found that rest periods improved morale and reduced turnover in a Philadelphia textile factory. He later joined the ongoing Hawthorne studies, where he became interested in how workers' emotions and informal relationships affected productivity. The results of these studies ushered in the human relations movement. World War II brought renewed interest in ability testing. The U.S. military needed to accurately place recruits in new technologically advanced jobs. There was also concern with morale and fatigue in war-industry workers. In the 1960s Arthur Kornhauser examined the impact on productivity of hiring mentally unstable workers. Kornhauser also examined the link between industrial working conditions and worker mental health as well as the spillover into a worker's personal life of having an unsatisfying job. Zickar noted that most of Kornhauser's I-O contemporaries favored management and Kornhauser was largely alone in his interest in protecting workers. Vinchur and Koppes (2010) observed that I-O psychologists' interest in job stress is a relatively recent development (p. 22). The industrial psychology division of the former American Association of Applied Psychology became a division within APA, becoming Division 14 of APA. It was initially called the Industrial and Business Psychology Division. In 1962, the name was changed to the Industrial Psychology Division. In 1973, it was renamed again, this time to the Division of Industrial and Organizational Psychology. In 1982, the unit become more independent of APA, and its name was changed again, this time to the Society for Industrial and Organizational Psychology. The name change of the division from "industrial psychology" to "industrial and organizational psychology" reflected the shift in the work of industrial psychologists who had originally addressed work behavior from the individual perspective, examining performance and attitudes of individual workers. Their work became broader. Group behavior in the workplace became a worthy subject of study. The emphasis on the "organizational" underlined the fact that when an individual joins an organization (e.g., the organization that hired him or her), he or she will be exposed to a common goal and a common set of operating procedures. In the 1970s in the UK, references to occupational psychology became more common than references to I-O psychology. According to Bryan and Vinchur, "while organizational psychology increased in popularity through [the 1960s and 1970s], research and practice in the traditional areas of industrial psychology continued, primarily driven by employment legislation and case law".p. 53 There was a focus on fairness and validity in selection efforts as well as in the job analyses that undergirded selection instruments. For example, I-O psychology showed increased interest in behaviorally anchored rating scales. What critics there were of I-O psychology accused the discipline of being responsive only to the concerns of management. From the 1980s to 2010s, other changes in I-O psychology took place. Researchers increasingly adopted a multi-level approach, attempting to understand behavioral phenomena from both the level of the organization and the level of the individual worker. There was also an increased interest in the needs and expectations of employees as individuals. For example, an emphasis on organizational justice and the psychological contract took root, as well as the more traditional concerns of selection and training. Methodological innovations (e.g., meta-analyses, structural equation modeling) were adopted. With the passage of the American with Disabilities Act in 1990 and parallel legislation elsewhere in the world, I-O psychology saw an increased emphasis on "fairness in personnel decisions." Training research relied increasingly on advances in educational psychology and cognitive science. Research methods I-O researchers employ both qualitative and quantitative methods, although quantitative methods are far more common. Basic Quantitative methods used in I-O psychology include correlation, multiple regression, and analysis of variance. More advanced statistical methods include logistic regression, structural equation modeling, and hierarchical linear modeling (HLM; also known as multilevel modeling). I-O researchers have also employed meta-analysis. I-O psychologists also employ psychometric methods including methods associated with classical test theory, generalizability theory, and item response theory (IRT). I-O psychologists have also employed qualitative methods, which largely involve focus groups, interviews, and case studies. I-O psychologists conducting research on organizational culture have employed ethnographic techniques and participant observation. A qualitative technique associated with I-O psychology is Flanagan's critical incident technique. I-O psychologists have also coordinated the use of quantitative and qualitative methods in the same study, Topics I-O psychologists deal with a wide range of topics concerning people in the workplace. Job analysis Job analysis encompasses a number of different methods including, but not limited to, interviews, questionnaires, task analysis, and observation. A job analysis primarily involves the systematic collection of information about a job. A task-oriented job analysis involves an assessment of the duties, tasks, and/or competencies a job requires. By contrast, a worker-oriented job analysis involves an examination of the knowledge, skills, abilities, and other characteristics (KSAOs) required to successfully perform the work. Information obtained from job analyses are used for many purposes, including the creation job-relevant selection procedures, the development of criteria for performance appraisals, the conducting of performance appraisals, and the development and implementation of training programs. Personnel recruitment and selection I-O psychologists design (a) recruitment processes and (b) personnel selection systems. Personnel recruitment is the process of identifying qualified candidates in the workforce and getting them to apply for jobs within an organization. Personnel recruitment processes include developing job announcements, placing ads, defining key qualifications for applicants, and screening out unqualified applicants. Personnel selection is the systematic process of hiring and promoting personnel. Personnel selection systems employing I-O methods use quantitative data to determine the most qualified candidates. This can involve the use of psychological tests, Biographical Information Blanks, interviews, work samples, and assessment centers. Personnel selection procedures are usually validated, i.e., shown to be job relevant to personnel selection, using one or more of the following types of validity: content validity, construct validity, and/or criterion-related validity. I-O psychologists must adhere to professional standards in personnel selection efforts. SIOP (e.g., Principles for validation and use of personnel selection procedures) and APA together with the National Council on Measurement in Education (e.g., Standards for educational and psychological testing are sources of those standards. The Equal Employment Opportunity Commission's Uniform guidelines are also influential in guiding personnel selection decisions. A meta-analysis of selection methods found that general mental ability (g factor) was the best overall predictor of job performance and attainment in training. Performance appraisal/management Performance appraisal or performance evaluation is the process in which an individual's or a group's work behaviors and outcomes are assessed against managers' and others' expectations for the job. Performance appraisal is used for a variety of purposes including alignment with organizational objectives, the basis for employment decisions (promotion, raises and termination), feedback to employees, and training needs assessment. Performance management is the process of providing performance feedback relative to expectations and information relevant to helping a worker improve his or her performance (e.g., coaching, mentoring). Performance management may also include documenting and tracking performance information for organizational evaluation purposes. Individual assessment and psychometrics Individual assessment involves the measurement of individual differences. I-O psychologists perform individual assessments in order to evaluate differences among candidates for employment as well as differences among employees. The constructs measured pertain to job performance. With candidates for employment, individual assessment is often part of the personnel selection process. These assessments can include written tests, aptitude tests, physical tests, psycho-motor tests, personality tests, integrity and reliability tests, work samples, simulations, and assessment centres. Occupational health, safety and well-being A more recent focus of I-O field is the health, safety, and well-being of employees. Topics include occupational safety, occupational stress, and workplace bullying, aggression and violence. Occupational stress There are many features of work that can be stressful to employees. Research has identified a number of job stressors (environmental conditions at work) that contribute to strains (adverse behavioral, emotional, physical, and psychological reactions). Occupational stress can have implications for organizational performance because of the emotions job stress evokes. For example, a job stressor such as conflict with a supervisor can precipitate anger that in turn motivates counterproductive workplace behaviors. A number of prominent models of job stress have been developed to explain the job stress process, including the person-environment (P-E) fit model, which was developed by University of Michigan social psychologists, and the demand-control(-support) and effort-reward imbalance models, which were developed by sociologists. Research has also examined occupational stress in specific occupations, including police, general practitioners, and dentists. Another concern has been the relation of occupational stress to family life. Other I-O researchers have examined gender differences in leadership style and job stress and strain in the context of male- and female-dominated industries, and unemployment-related distress. Occupational stress has also been linked to lack of fit between people and their jobs. Occupational safety Accidents and safety in the workplace are important because of the serious injuries and fatalities that are all too common. Research has linked accidents to psychosocial factors in the workplace including overwork that leads to fatigue, workplace violence, and working night shifts. "Stress audits" can help organizations remain compliant with various occupational safety regulations. Psychosocial hazards can affect musculoskeletal disorders. A psychosocial factor related to accident risk is safety climate, which refers to employees' perceptions of the extent to which their work organization prioritizes safety. By contrast, psychosocial safety climate refers to management's "policies, practices, and procedures" aimed at protecting workers' psychological health. Research on safety leadership is also relevant to understanding employee safety performance. Research suggests that safety-oriented transformational leadership is associated with a positive safety climate and safe worker practices. Workplace bullying, aggression and violence I-O psychologists are concerned with the related topics of workplace bullying, aggression, and violence. For example, I-O research found that exposure to workplace violence elicited ruminative thinking. Ruminative thinking is associated with poor well-being. Research has found that interpersonal aggressive behaviour is associated with worse team performance. Relation to occupational health psychology A new discipline, occupational health psychology (OHP), emerged from both health psychology and I-O psychology as well as occupational medicine. OHP concerns itself with such topic areas as the impact of occupational stressors on mental and physical health, the health impact of involuntary unemployment, violence and bullying in the workplace, psychosocial factors that influence accident risk and safety, work–family balance, and interventions designed to improve/protect worker health. Spector observed that one of the problems facing I-O psychologists in the late 20 century who were interested in the health of working people was resistance within the field to publishing papers on worker health. In the 21 century, OHP topics have become popular at the Society for Industrial and Organizational Psychology conference. Work design Work design concerns the "content and organisation of one's work tasks, activities, relationships, and responsibilities." Research has demonstrated that work design has important implications for individual employees (e.g., level of engagement, job strain, chance of injury), teams (e.g., how effectively teams co-ordinate their activities), organisations (e.g., productivity, safety, efficiency targets), and society (e.g., whether a nation utilises the skills of its population or promotes effective aging). I-O psychologists review job tasks, relationships, and an individual's way of thinking about their work to ensure that their roles are meaningful and motivating, thus creating greater productivity and job satisfaction. Deliberate interventions aimed at altering work design are sometimes referred to as work redesign. Such interventions can be initiated by the management of an organization (e.g., job rotation, job enlargement, job enrichment) or by individual workers (e.g., job crafting, role innovation, idiosyncratic ideals). Remuneration and compensation Training and training evaluation Training involves the systematic teaching of skills, concepts, or attitudes that results in improved performance in another environment. Because many people hired for a job are not already versed in all the tasks the job requires, training may be needed to help the individual perform the job effectively. Evidence indicates that training is often effective, and that it succeeds in terms of higher net sales and gross profitability per employee. Similar to performance management (see above), an I-O psychologist would employ a job analysis in concert with the application of the principles of instructional design to create an effective training program. A training program is likely to include a summative evaluation at its conclusion in order to ensure that trainees have met the training objectives and can perform the target work tasks at an acceptable level. Kirkpatrick describes four levels of criteria by which to evaluate training: Reactions are the extent to which trainees enjoyed the training and found it worthwhile. Learning is the knowledge and skill trainees acquired from the training. Behavior is the change in behavior trainees exhibit on the job after training, for example, did they perform trained tasks more quickly? Results are the effect of the change in knowledge or behavior on the job, for example, was overall productivity increased or costs decreased? Training programs often include formative evaluations to assess the effect of the training as the training proceeds. Formative evaluations can be used to locate problems in training procedures and help I-O psychologists make corrective adjustments while training is ongoing. The foundation for training programs is learning. Learning outcomes can be organized into three broad categories: cognitive, skill-based, and affective outcomes. Cognitive training is aimed at instilling declarative knowledge or the knowledge of rules, facts, and principles (e.g., police officer training covers laws and court procedures). Skill-based training aims to impart procedural knowledge (e.g., skills needed to use a special tool) or technical skills (e.g., understanding the workings of software program). Affective training concerns teaching individuals to develop specific attitudes or beliefs that predispose trainees to behave a certain way (e.g., show commitment to the organization, appreciate diversity). A needs assessment, an analysis of corporate and individual goals, is often undertaken prior to the development of a training program. In addition, a careful training needs analysis is required in order to develop a systematic understanding of where training is needed, what should be taught, and who will be trained. A training needs analysis typically involves a three-step process that includes organizational analysis, task analysis, and person analysis. An organizational analysis is an examination of organizational goals and resources as well as the organizational environment. The results of an organizational analysis help to determine where training should be directed. The analysis identifies the training needs of different departments or subunits. It systematically assesses manager, peer, and technological support for transfer of training. An organizational analysis also takes into account the climate of the organization and its subunits. For example, if a climate for safety is emphasized throughout the organization or in subunits of the organization (e.g., production), then training needs will likely reflect an emphasis on safety. A task analysis uses the results of a job analysis to determine what is needed for successful job performance, contributing to training content. With organizations increasingly trying to identify "core competencies" that are required for all jobs, task analysis can also include an assessment of competencies. A person analysis identifies which individuals within an organization should receive training and what kind of instruction they need. Employee needs can be assessed using a variety of methods that identify weaknesses that training can address. Motivation in the workplace Work motivation reflects the energy an individual applies "to initiate work-related behavior, and to determine its form, direction, intensity, and duration" Understanding what motivates an organization's employees is central to I-O psychology. Motivation is generally thought of as a theoretical construct that fuels behavior. An incentive is an anticipated reward that is thought to incline a person to behave a certain way. Motivation varies among individuals. Studying its influence on behavior, it must be examined together with ability and environmental influences. Because of motivation's role in influencing workplace behavior and performance, many organizations structure the work environment to encourage productive behaviors and discourage unproductive behaviors. Motivation involves three psychological processes: arousal, direction, and intensity. Arousal is what initiates action. It is often fueled by a person's need or desire for something that is missing from his or her life, either totally or partially. Direction refers to the path employees take in accomplishing the goals they set for themselves. Intensity is the amount of energy employees put into goal-directed work performance. The level of intensity often reflects the importance and difficulty of the goal. These psychological processes involve four factors. First, motivation serves to direct attention, focusing on particular issues, people, tasks, etc. Second, it serves to stimulate effort. Third, motivation influences persistence. Finally, motivation influences the choice and application of task-related strategies. Organizational climate Organizational climate is the perceptions of employees about what is important in an organization, that is, what behaviors are encouraged versus discouraged. It can be assessed in individual employees (climate perceptions) or averaged across groups of employees within a department or organization (organizational climate). Climates are usually focused on specific employee outcomes, or what is called “climate for something”. There are more than a dozen types of climates that have been assessed and studied. Some of the more popular include: Customer service climate: The emphasis placed on providing good service. It has been shown to relate to employee service performance. Diversity climate: The extent to which organizations value differences among employees and expect employees to treat everyone with respect. It has been linked to job satisfaction. Ethical climate: The extent to which organizational emphasize ethical practices. Innovation climate: The extent to which organizations encourage employees to use new approaches. Psychosocial safety climate: Organizations with such climates emphasize the importance of psychological health and well-being. Safety climate: Such organizations emphasize safety and have fewer accidents and injuries. Climate concerns organizational policies and practices that encourage or discourage specific behaviors by employees. Shared perceptions of what the organization emphasizes (organizational climate) is part of organizational culture, but culture concerns far more than shared perceptions, as discussed in the next section. Organizational culture While there is no universal definition for organizational culture, a collective understanding shares the following assumptions: Organizational culture has been shown to affect important organizational outcomes such as performance, attraction, recruitment, retention, employee satisfaction, and employee well-being. There are three levels of organizational culture: artifacts, shared values, and basic beliefs and assumptions. Artifacts comprise the physical components of the organization that relay cultural meaning. Shared values are individuals' preferences regarding certain aspects of the organization's culture (e.g., loyalty, customer service). Basic beliefs and assumptions include individuals' impressions about the trustworthiness and supportiveness of an organization, and are often deeply ingrained within the organization's culture. In addition to an overall culture, organizations also have subcultures. Subcultures can be departmental (e.g. different work units) or defined by geographical distinction. While there is no single "type" of organizational culture, some researchers have developed models to describe different organizational cultures. Group behavior Group behavior involves the interactions among individuals in a collective. Most I-O group research is about teams which is a group in which people work together to achieve the same task goals. The individuals' opinions, attitudes, and adaptations affect group behavior, with group behavior in turn affecting those opinions, etc. The interactions are thought to fulfill some need satisfaction in an individual who is part of the collective. Team effectiveness Organizations often organize teams because teams can accomplish a much greater amount of work in a short period of time than an individual can accomplish. I-O research has examined the harm workplace aggression does to team performance. Team composition Team composition, or the configuration of team member knowledge, skills, abilities, and other characteristics, fundamentally influences teamwork. Team composition can be considered in the selection and management of teams to increase the likelihood of team success. To achieve high-quality results, teams built with members having higher skill levels are more likely to be effective than teams built around members having lesser skills; teams that include members with a diversity of skills are also likely to show improved team performance. Team members should also be compatible in terms of personality traits, values, and work styles. There is substantial evidence that personality traits and values can shape the nature of teamwork, and influence team performance. Team task design A fundamental question in team task design is whether or not a task is even appropriate for a team. Those tasks that require predominantly independent work are best left to individuals, and team tasks should include those tasks that consist primarily of interdependent work. When a given task is appropriate for a team, task design can play a key role in team effectiveness. Job characteristic theory identifies core job dimensions that affect motivation, satisfaction, performance, etc. These dimensions include skill variety, task identity, task significance, autonomy and feedback. The dimensions map well to the team environment. Individual contributors who perform team tasks that are challenging, interesting, and engaging are more likely to be motivated to exert greater effort and perform better than team members who are working on tasks that lack those characteristics. Organizational resources Organizational support systems affect the team effectiveness and provide resources for teams operating in the multi-team environment. During the chartering of new teams, organizational enabling resources are first identified. Examples of enabling resources include facilities, equipment, information, training, and leadership. Team-specific resources (e.g., budgetary resources, human resources) are typically made available. Team-specific human resources represent the individual contributors who are selected to be team members. Intra-team processes (e.g., task design, task assignment) involve these team-specific resources. Teams also function in dynamic multi-team environments. Teams often must respond to shifting organizational contingencies. Team rewards Organizational reward systems drive the strengthening and enhancing of individual team member efforts; such efforts contribute towards reaching team goals. In other words, rewards that are given to individual team members should be contingent upon the performance of the entire team. Several design elements are needed to enable organizational reward systems to operate successfully. First, for a collective assessment to be appropriate for individual team members, the group's tasks must be highly interdependent. If this is not the case, individual assessment is more appropriate than team assessment. Second, individual-level reward systems and team-level reward systems must be compatible. For example, it would be unfair to reward the entire team for a job well done if only one team member did most of the work. That team member would most likely view teams and teamwork negatively, and would not want to work on a team in the future. Third, an organizational culture must be created such that it supports and rewards employees who believe in the value of teamwork and who maintain a positive attitude towards team-based rewards. Team goals Goals potentially motivate team members when goals contain three elements: difficulty, acceptance, and specificity. Under difficult goal conditions, teams with more committed members tend to outperform teams with less committed members. When team members commit to team goals, team effectiveness is a function of how supportive members are with each other. The goals of individual team members and team goals interact. Team and individual goals must be coordinated. Individual goals must be consistent with team goals in order for a team to be effective. Job satisfaction and commitment Job satisfaction is often thought to reflect the extent to which a worker likes his or her job, or individual aspects or facets of jobs. It is one of the most heavily researched topics in I-O psychology. Job satisfaction has theoretical and practical utility for the field. It has been linked to important job outcomes including absenteeism, accidents, counterproductive work behavior, customer service, cyberloafing, job performance, organizational citizenship behavior, physical and psychological health, and turnover. A meta-analyses found job satisfaction to be related to life satisfaction, happiness, positive affect, and the absence of negative affect. Productive behavior Productive behavior is defined as employee behavior that contributes positively to the goals and objectives of an organization. When an employee begins a new job, there is a transition period during which he or she may not contribute significantly. To assist with this transition an employee typically requires job-related training. In financial terms, productive behavior represents the point at which an organization begins to achieve some return on the investment it has made in a new employee. IO psychologists are ordinarily more focused on productive behavior than job or task performance, including in-role and extra-role performance. In-role performance tells managers how well an employee performs the required aspects of the job; extra-role performance includes behaviors not necessarily required by job but nonetheless contribute to organizational effectiveness. By taking both in-role and extra-role performance into account, an I-O psychologist is able to assess employees' effectiveness (how well they do what they were hired to do), efficiency (outputs to relative inputs), and productivity (how much they help the organization reach its goals). Three forms of productive behavior that IO psychologists often evaluate include job performance, organizational citizenship behavior (see below), and innovation. Job performance Job performance represents behaviors employees engage in while at work which contribute to organizational goals. These behaviors are formally evaluated by an organization as part of an employee's responsibilities. In order to understand and ultimately predict job performance, it is important to be precise when defining the term. Job performance is about behaviors that are within the control of the employee and not about results (effectiveness), the costs involved in achieving results (productivity), the results that can be achieved in a period of time (efficiency), or the value an organization places on a given level of performance, effectiveness, productivity or efficiency (utility). To model job performance, researchers have attempted to define a set of dimensions that are common to all jobs. Using a common set of dimensions provides a consistent basis for assessing performance and enables the comparison of performance across jobs. Performance is commonly broken into two major categories: in-role (technical aspects of a job) and extra-role (non-technical abilities such as communication skills and being a good team member). While this distinction in behavior has been challenged it is commonly made by both employees and management. A model of performance by Campbell breaks performance into in-role and extra-role categories. Campbell labeled job-specific task proficiency and non-job-specific task proficiency as in-role dimensions, while written and oral communication, demonstrating effort, maintaining personal discipline, facilitating peer and team performance, supervision and leadership and management and administration are labeled as extra-role dimensions. Murphy's model of job performance also broke job performance into in-role and extra-role categories. However, task-orientated behaviors composed the in-role category and the extra-role category included interpersonally-oriented behaviors, down-time behaviors and destructive and hazardous behaviors. However, it has been challenged as to whether the measurement of job performance is usually done through pencil/paper tests, job skills tests, on-site hands-on tests, off-site hands-on tests, high-fidelity simulations, symbolic simulations, task ratings and global ratings. These various tools are often used to evaluate performance on specific tasks and overall job performance. Van Dyne and LePine developed a measurement model in which overall job performance was evaluated using Campbell's in-role and extra-role categories. Here, in-role performance was reflected through how well "employees met their performance expectations and performed well at the tasks that made up the employees' job." Dimensions regarding how well the employee assists others with their work for the benefit of the group, if the employee voices new ideas for projects or changes to procedure and whether the employee attends functions that help the group composed the extra-role category. To assess job performance, reliable and valid measures must be established. While there are many sources of error with performance ratings, error can be reduced through rater training and through the use of behaviorally-anchored rating scales. Such scales can be used to clearly define the behaviors that constitute poor, average, and superior performance. Additional factors that complicate the measurement of job performance include the instability of job performance over time due to forces such as changing performance criteria, the structure of the job itself and the restriction of variation in individual performance by organizational forces. These factors include errors in job measurement techniques, acceptance and the justification of poor performance, and lack of importance of individual performance. The determinants of job performance consist of factors having to do with the individual worker as well as environmental factors in the workplace. According to Campbell's Model of The Determinants of Job Performance, job performance is a result of the interaction between declarative knowledge (knowledge of facts or things), procedural knowledge (knowledge of what needs to be done and how to do it), and motivation (reflective of an employee's choices regarding whether to expend effort, the level of effort to expend, and whether to persist with the level of effort chosen). The interplay between these factors show that an employee may, for example, have a low level of declarative knowledge, but may still have a high level of performance if the employee has high levels of procedural knowledge and motivation. Regardless of the job, three determinants stand out as predictors of performance: (1) general mental ability (especially for jobs higher in complexity); (2) job experience (although there is a law of diminishing returns); and (3) the personality trait of conscientiousness (people who are dependable and achievement-oriented, who plan well). These determinants appear to influence performance largely through the acquisition and usage of job knowledge and the motivation to do well. Further, an expanding area of research in job performance determinants includes emotional intelligence. Organizational citizenship behavior Organizational citizenship behaviors (OCBs) are another form of workplace behavior that IO psychologists are involved with. OCBs tend to be beneficial to both the organization and other workers. Dennis Organ (1988) defines OCBs as "individual behavior that is discretionary, not directly or explicitly recognized by the formal reward system, and that in the aggregate promotes the effective functioning of the organization." Behaviors that qualify as OCBs can fall into one of the following five categories: altruism, courtesy, sportsmanship, conscientiousness, and civic virtue. OCBs have also been categorized in other ways too, for example, by their intended targets individuals, supervisors, and the organization as a whole. Other alternative ways of categorizing OCBs include "compulsory OCBs", which are engaged in owing to coercive persuasion or peer pressure rather than out of good will. The extent to which OCBs are voluntary has been the subject of some debate. Other research suggests that some employees perform OCBs to influence how they are viewed within the organization. While these behaviors are not formally part of the job description, performing them can influence performance appraisals. Researchers have advanced the view that employees engage in OCBs as a form of "impression management," a term coined by Erving Goffman. Goffman defined impression management as "the way in which the individual ... presents himself and his activity to others, the ways in which he guides and controls the impression they form of him, and the kinds of things he may and may not do while sustaining his performance before them. Some researchers have hypothesized that OCBs are not performed out of good will, positive affect, etc., but instead as a way of being noticed by others, including supervisors. Innovation Four qualities are generally linked to creative and innovative behaviour by individuals: Task-relevant skills (general mental ability and job specific knowledge). Task specific and subject specific knowledge is most often gained through higher education; however, it may also be gained by mentoring and experience in a given field. Creativity-relevant skills (ability to concentrate on a problem for long periods of time, to abandon unproductive searches, and to temporarily put aside stubborn problems). The ability to put aside stubborn problems is referred to by Jex and Britt as productive forgetting. Creativity-relevant skills also require the individual contributor to evaluate a problem from multiple vantage points. One must be able to take on the perspective of various users. For example, an Operation Manager analyzing a reporting issue and developing an innovative solution would consider the perspective of a sales person, assistant, finance, compensation, and compliance officer. Task motivation (internal desire to perform task and level of enjoyment). At the organizational level, a study by Damanpour identified four specific characteristics that may predict innovation: A population with high levels of technical knowledge The organization's level of specialization The level an organization communicates externally Functional differentiation. Counterproductive work behavior Counterproductive work behavior (CWB) can be defined as employee behavior that goes against the goals of an organization. These behaviors can be intentional or unintentional and result from a wide range of underlying causes and motivations. Some CWBs have instrumental motivations (e.g., theft). It has been proposed that a person-by-environment interaction can be utilized to explain a variety of counterproductive behaviors. For instance, an employee who sabotages another employee's work may do so because of lax supervision (environment) and underlying psychopathology (person) that work in concert to result in the counterproductive behavior. There is evidence that an emotional response (e.g., anger) to job stress (e.g., unfair treatment) can motivate CWBs. The forms of counterproductive behavior with the most empirical examination are ineffective job performance, absenteeism, job turnover, and accidents. Less common but potentially more detrimental forms of counterproductive behavior have also been investigated including violence and sexual harassment. Leadership Leadership can be defined as a process of influencing others to agree on a shared purpose, and to work towards shared objectives. A distinction should be made between leadership and management. Managers process administrative tasks and organize work environments. Although leaders may be required to undertake managerial duties as well, leaders typically focus on inspiring followers and creating a shared organizational culture and values. Managers deal with complexity, while leaders deal with initiating and adapting to change. Managers undertake the tasks of planning, budgeting, organizing, staffing, controlling, and problem solving. In contrast, leaders undertake the tasks of setting a direction or vision, aligning people to shared goals, communicating, and motivating. Approaches to studying leadership can be broadly classified into three categories: Leader-focused approaches, contingency-focused approaches, and follower-focused approaches. Leader-focused approaches Leader-focused approaches look to organizational leaders to determine the characteristics of effective leadership. According to the trait approach, more effective leaders possess certain traits that less effective leaders lack. More recently, this approach is being used to predict leader emergence. The following traits have been identified as those that predict leader emergence when there is no formal leader: high intelligence, high needs for dominance, high self-motivation, and socially perceptive. Another leader-focused approached is the behavioral approach, which focuses on the behaviors that distinguish effective from ineffective leaders. There are two categories of leadership behaviors: consideration and initiating structure. Behaviors associated with the category of consideration include showing subordinates they are valued and that the leader cares about them. An example of a consideration behavior is showing compassion when problems arise in or out of the office. Behaviors associated with the category of initiating structure include facilitating the task performance of groups. One example of an initiating structure behavior is meeting one-on-one with subordinates to explain expectations and goals. The final leader-focused approach is power and influence. To be most effective, a leader should be able to influence others to behave in ways that are in line with the organization's mission and goals. How influential a leader can be depends on their social power – their potential to influence their subordinates. There are six bases of power: French and Raven's classic five bases of coercive, reward, legitimate, expert, and referent power, plus informational power. A leader can use several different tactics to influence others within an organization. These include: rational persuasion, inspirational appeal, consultation, ingratiation, exchange, personal appeal, coalition, legitimating, and pressure. Contingency-focused approaches Of the 3 approaches to leadership, contingency-focused approaches have been the most prevalent over the past 30 years. Contingency-focused theories base a leader's effectiveness on their ability to assess a situation and adapt their behavior accordingly. These theories assume that an effective leader can accurately "read" a situation and skillfully employ a leadership style that meets the needs of the individuals involved and the task at hand. A brief introduction to the most prominent contingency-focused theories will follow. The Fiedler contingency model holds that a leader's effectiveness depends on the interaction between their characteristics and the characteristics of the situation. Path–goal theory asserts that the role of the leader is to help his or her subordinates achieve their goals. To effectively do this, leaders must skillfully select from four different leadership styles to meet the situational factors. The situational factors are a product of the characteristics of subordinates and the characteristics of the environment. The leader–member exchange theory (LMX) focuses on how leader–subordinate relationships develop. Generally speaking, when a subordinate performs well or when there are positive exchanges between a leader and a subordinate, their relationship is strengthened, performance and job satisfaction are enhanced, and the subordinate will feel more commitment to the leader and the organization as a whole. Vroom-Yetton-Jago model focuses on decision-making with respect to a feasibility set. Organizational development I-O psychologists may also become involved with organizational change, a process which some call organizational development (OD). Tools used to advance organization development include the survey-feedback technique. The technique involves the periodic assessment (via surveys) of employee attitudes and feelings. The results are conveyed to organizational stakeholders, who may want to take the organization in a particular direction. Another tool is the team-building technique. Because many if not most tasks within an organization are completed by small groups and/or teams, team building can become important for organizational success. In order to enhance a team's morale and problem-solving skills, I-O psychologists help the groups to improve their self-confidence, group cohesiveness, and working effectiveness. Work–nonwork interface An important topic in I-O is the connection between people’s working and nonworking lives. Two concepts are particularly relevant. Work–family conflict is the incompatibility between the job and family life. Conflict can occur when stressful experiences in one domain spillover into the other, such as someone coming home in a bad mood after having a difficult day at work. It can also occur when there are time conflicts, such as having a work meeting at the same time as a child’s doctor’s appointment. Work–family enrichment (also called work–family facilitation) occurs when one domain provides benefits to the other. For example, a spouse might assist with a work task or a supervisor might offer assistance with a family problem. Relation to organizational behavior and human resource management I-O psychology and organizational behavior researchers have sometimes investigated similar topics. The overlap has led to some confusion regarding how the two disciplines differ. Sometimes there has been confusion within organizations regarding the practical duties of I-O psychologists and human resource management specialists. As an occupation Training The minimum requirement for working as an IO psychologist is a master's degree. Normally, this degree requires about two to three years of postgraduate work to complete. Of all the degrees granted in IO psychology each year, approximately two-thirds are at the master's level. A comprehensive list of US and Canadian master's and doctoral programs can be found at the web site of the Society for Industrial and Organizational Psychology (SIOP). Admission into IO psychology PhD programs is highly competitive; many programs accept only a small number of applicants each year. There are graduate degree programs in IO psychology outside of the US and Canada. The SIOP web site lists some of them. In Australia, organisational psychologists must be accredited by the Australian Psychological Society (APS). To become an organisational psychologist, one must meet the criteria for a general psychologist's licence: three years studying bachelor's degree in psychology, 4th-year honours degree or postgraduate diploma in psychology, and two-year full-time supervised practice plus 80 hours of professional development. There are other avenues available, such as a two-year supervised training program after honours (i.e. 4+2 pathway), or one year of postgraduate coursework and practical placements followed by a one-year supervised training program (i.e. 5+1 pathway). After this, psychologists can elect to specialise as Organisational Psychologists in Australia. Competencies There are many different sets of competencies for different specializations within IO psychology and IO psychologists are versatile behavioral scientists. For example, an IO psychologist specializing in selection and recruiting should have expertise in finding the best talent for the organization and getting everyone on board while he or she might not need to know much about executive coaching. Some IO psychologists specialize in specific areas of consulting whereas others tend to generalize their areas of expertise. There are basic skills and knowledge an individual needs in order to be an effective IO psychologist, which include being an independent learner, interpersonal skills (e.g., listening skills), and general consultation skills (e.g., skills and knowledge in the problem area). Job outlook U.S. News & World Report lists I-O Psychology as the third best science job, with a strong job market in the U.S. In the 2020 SIOP salary survey, the median annual salary for a PhD in IO psychology was $125,000; for a master's level IO psychologist was $88,900. The highest paid PhD IO psychologists were self-employed consultants who had a median annual income of $167,000. The highest paid in private industry worked in IT ($153,000), retail ($151,000) and healthcare ($147,000). The lowest earners were found in state and local government positions, averaging approximately $100,000, and in academic positions in colleges and universities that do not award doctoral degrees, with median salaries between $80,000 and $94,000. Ethical principles An IO psychologist, whether an academic, consultant or an employee of an organization, is expected to maintain high ethical standards. SIOP encourages its members to follow the APA Ethics Code. With more organizations becoming global, it is important that when an IO psychologist works outside her or his home country, the psychologist is aware of rules, regulations, and cultures of the organizations and countries in which the psychologist works, while also adhering to the ethical standards set at home. See also References Footnotes Further reading Anderson, N.; Ones, D. S.; Sinangil, H. K.; Viswesvaran, C. (eds.). (2002). Handbook of Industrial, Work and Organizational Psychology, Volume 1: Personnel Psychology. Thousand Oaks, California: SAGE Publications Anderson, N.; Ones, D. S.; Sinangil, H. K.; Viswesvaran, C. (eds.). (2002). Handbook of Industrial, Work and Organizational Psychology, Volume 2: Organizational Psychology. SAGE Publications Borman, W. C.; Ilgen, D. R.; Klimoski, R. J. (eds.). (2003). Handbook of psychology: Vol 12 Industrial and organizational psychology. Hoboken, New Jersey: John Wiley & Sons. Borman, W. C.; Motowidlo, S. J. (1993). "Expanding the criterion domain to include elements of contextual performance". In: Schmitt, N.; Borman, W. C. (eds.). Personnel Selection. San Francisco: Jossey-Bass (pp. 71–98). Bryan, L. L. K.; Vinchur, A. J. (2012). "A history of industrial and organizational psychology". Kozlowski, S. W. J. (ed.). The Oxford Handbook of Organizational Psychology (pp. 22–75). New York: Oxford University Press. Campbell, J. P.; Gasser, M. B.; Oswald, F. L. (1996). "The substantive nature of job performance variability". In Murphy, K. R. (ed.). Individual Differences and Behavior in Organizations (pp. 258–299). Jossey-Bass. Copley, F. B. (1923). Frederick W. Taylor: Father of Scientific Management, Vols. I and II. New York: Taylor Society. Dunnette, M. D. (ed.). (1976). Handbook of Industrial and Organizational Psychology. Chicago: Rand McNally. Dunnette, M. D.; Hough, L. M. (eds.). (1991). Handbook of Industrial/Organizational Psychology (4 Volumes). Palo Alto, California: Consulting Psychologists Press. Eunson, Baden: Behaving – Managing Yourself and Others. McGraw-Hill, Sidney 1987. Guion, R.M. (1998). Assessment, Measurement and Prediction for Personnel Decisions. Mahwah, New Jersey: Lawrence Erlbaum Associates. Hunter, J. E.; Schmidt, F. L. (1990). Methods of Meta-analysis: Correcting Error and Bias in Research Findings. Newbury Park, California: SAGE Publications. Jones, Ishmael (2008). The Human Factor: Inside the CIA's Dysfunctional Intelligence Culture. New York: Encounter Books. Koppes, L. L. (ed.). (2007). Historical Perspectives in Industrial and Organizational Psychology. Lawrence Erlbaum Associates. Lant, T. K. "Organizational Cognition and Interpretation". In Baum (ed)., The Blackwell Companion to Organizations. Oxford: Blackwell Publishers. Lowman, R. L. (ed.). (2002). The California School of Organizational Studies Handbook of Organizational Consulting Psychology: A Comprehensive Guide to Theory, Skills and Techniques. Jossey-Bass. Rogelberg, S. G. (ed.). (2002). Handbook of Research Methods in Industrial and Organizational Psychology. Malden, Massachusetts: Blackwell. Sackett, P. R.; Wilk, S. L. (1994). "Within group norming and other forms of score adjustment in pre-employment testing". American Psychologist, 49, 929–954. Schmidt, F. L.; Hunter, J. E. (1998). "The validity and utility of selection methods in personnel psychology: Practical and theoretical implications of 85 years of research findings". Psychological Bulletin, 124, 262–274. External links Canadian Society for Industrial and Organizational Psychology British Psychological Society's Division of Occupational Psychology's (DOP) website Society for Industrial and Organisational Psychology of South Africa European Academy of Occupational Health Psychology European Association of Work and Organizational Psychology Society for Industrial and Organizational Psychology Alliance for Organizational Psychology Applied psychology Behavioural sciences Systems psychology psych

Minimisation (psychology)

Minimisation or minimization is a tactic where an individual intentionally downplays a situation or a thing. Minimisation, or downplaying the significance of an event or emotion, is a common strategy in dealing with feelings of guilt. Manipulative abuse Minimisation may take the form of a manipulative technique: observed in abusers and manipulators to downplay their misdemeanors when confronted with irrefutable facts. observed in abusers and manipulators to downplay positive attributes (talents and skills etc.) of their victims. Typical psychological defences exhibited by stalkers and guilty criminal suspects include denial, rationalisation, minimisation and projection of blame onto the victim. A variation on minimisation as a manipulative technique is "claiming altruistic motives" such as saying "I don't do this because I am selfish, and for gain, but because I am a socially aware person interested in the common good". Cognitive distortion Minimisation may also take the form of cognitive distortion: that avoids acknowledging and dealing with negative emotions by reducing the importance and impact of events that give rise to those emotions. that avoids conscious confrontation with the negative impacts of one's behavior on others by reducing the perception of such impacts. that avoids interpersonal confrontation by reducing the perception of the impact of others' behavior on oneself. School bullying School bullying is one form of victimisation or physical abuse which has sometimes been unofficially encouraged, ritualised or even minimised as a sort of prank by teachers or peers. The main difference between pranks and bullying is establishment of power inequity between the bully and the victim that lasts beyond the duration of the act. Understatements Understatement is a form of speech which contains an expression of less strength than what would be expected. A related term is euphemism, where a polite phrase is used in place of a harsher or more offensive expression. Self-esteem/depression Redefining events to downplay their significance can be an effective way of preserving one's self-esteem. One of the problems of depression (found in those with clinical, bipolar, and chronic depressive mood disorders, as well as cyclothymia) is the tendency to do the reverse: minimising the positive, discounting praise, and dismissing one's own accomplishments. On the other hand, one technique used by Alfred Adler to combat neurosis was to minimise the excessive significance the neurotic attaches to his own symptoms—the narcissistic gains derived from pride in one's own illness. Social minimisation Display rules expressing a group's general consensus about the display of feeling often involve minimising the amount of emotion one displays, as with a poker face. Social interchanges involving minor infringements often end with the 'victim' minimising the offence with a comment like 'Think nothing of it', using so-called 'reduction words', such as 'no big deal,' 'only a little,' 'merely,' or 'just', the latter particularly useful in denying intent. On a wider scale, renaming things in a more benign or neutral form—'collateral damage' for death—is a form of minimisation. See also References Further reading Henning, K & Holdford, R Minimization, Denial, and Victim Blaming by Batterers Criminal Justice and Behavior, Vol. 33, No. 1, 110–130 (2006) Rogers, Richard & Dickey, Rob (March 1991) Denial and minimization among sex offenders Journal Sexual Abuse Vol 4, No 1: 49–63 Scott K Denial, Minimization, Partner Blaming, and Intimate Aggression in Dating Partners Journal of Interpersonal Violence, Vol. 22, No. 7, 851–871 (2007) Defence mechanisms Cognitive biases Error Public relations techniques

Health

Health has a variety of definitions, which have been used for different purposes over time. In general, it refers to physical and emotional well-being, especially that associated with normal functioning of the human body, absent of disease, pain (including mental pain), or injury. Health can be promoted by encouraging healthful activities, such as regular physical exercise and adequate sleep, and by reducing or avoiding unhealthful activities or situations, such as smoking or excessive stress. Some factors affecting health are due to individual choices, such as whether to engage in a high-risk behavior, while others are due to structural causes, such as whether the society is arranged in a way that makes it easier or harder for people to get necessary healthcare services. Still, other factors are beyond both individual and group choices, such as genetic disorders. History The meaning of health has evolved over time. In keeping with the biomedical perspective, early definitions of health focused on the theme of the body's ability to function; health was seen as a state of normal function that could be disrupted from time to time by disease. An example of such a definition of health is: "a state characterized by anatomic, physiologic, and psychological integrity; ability to perform personally valued family, work, and community roles; ability to deal with physical, biological, psychological, and social stress". Then, in 1948, in a radical departure from previous definitions, the World Health Organization (WHO) proposed a definition that aimed higher, linking health to well-being, in terms of "physical, mental, and social well-being, and not merely the absence of disease and infirmity". Although this definition was welcomed by some as being innovative, it was also criticized for being vague and excessively broad and was not construed as measurable. For a long time, it was set aside as an impractical ideal, with most discussions of health returning to the practicality of the biomedical model. Just as there was a shift from viewing disease as a state to thinking of it as a process, the same shift happened in definitions of health. Again, the WHO played a leading role when it fostered the development of the health promotion movement in the 1980s. This brought in a new conception of health, not as a state, but in dynamic terms of resiliency, in other words, as "a resource for living". In 1984, WHO revised the definition of health defined it as "the extent to which an individual or group is able to realize aspirations and satisfy needs and to change or cope with the environment. Health is a resource for everyday life, not the objective of living; it is a positive concept, emphasizing social and personal resources, as well as physical capacities." Thus, health referred to the ability to maintain homeostasis and recover from adverse events. Mental, intellectual, emotional and social health referred to a person's ability to handle stress, to acquire skills, to maintain relationships, all of which form resources for resiliency and independent living. This opens up many possibilities for health to be taught, strengthened and learned. Since the late 1970s, the federal Healthy People Program has been a visible component of the United States' approach to improving population health. In each decade, a new version of Healthy People is issued, featuring updated goals and identifying topic areas and quantifiable objectives for health improvement during the succeeding ten years, with assessment at that point of progress or lack thereof. Progress has been limited to many objectives, leading to concerns about the effectiveness of Healthy People in shaping outcomes in the context of a decentralized and uncoordinated US health system. Healthy People 2020 gives more prominence to health promotion and preventive approaches and adds a substantive focus on the importance of addressing social determinants of health. A new expanded digital interface facilitates use and dissemination rather than bulky printed books as produced in the past. The impact of these changes to Healthy People will be determined in the coming years. Systematic activities to prevent or cure health problems and promote good health in humans are undertaken by health care providers. Applications with regard to animal health are covered by the veterinary sciences. The term "healthy" is also widely used in the context of many types of non-living organizations and their impacts for the benefit of humans, such as in the sense of healthy communities, healthy cities or healthy environments. In addition to health care interventions and a person's surroundings, a number of other factors are known to influence the health status of individuals. These are referred to as the "determinants of health", which include the individual's background, lifestyle, economic status, social conditions and spirituality; Studies have shown that high levels of stress can affect human health. In the first decade of the 21st century, the conceptualization of health as an ability opened the door for self-assessments to become the main indicators to judge the performance of efforts aimed at improving human health. It also created the opportunity for every person to feel healthy, even in the presence of multiple chronic diseases or a terminal condition, and for the re-examination of determinants of health (away from the traditional approach that focuses on the reduction of the prevalence of diseases). Determinants In general, the context in which an individual lives is of great importance for both his health status and quality of life. It is increasingly recognized that health is maintained and improved not only through the advancement and application of health science, but also through the efforts and intelligent lifestyle choices of the individual and society. According to the World Health Organization, the main determinants of health include the social and economic environment, the physical environment, and the person's individual characteristics and behaviors. More specifically, key factors that have been found to influence whether people are healthy or unhealthy include the following: Education and literacy Employment/working conditions Income and social status Physical environments Social environments Social support networks Biology and genetics Culture Gender Health care services Healthy child development Personal health practices and coping skills An increasing number of studies and reports from different organizations and contexts examine the linkages between health and different factors, including lifestyles, environments, health care organization and health policy, one specific health policy brought into many countries in recent years was the introduction of the sugar tax. Beverage taxes came into light with increasing concerns about obesity, particularly among youth. Sugar-sweetened beverages have become a target of anti-obesity initiatives with increasing evidence of their link to obesity.—such as the 1974 Lalonde report from Canada; the Alameda County Study in California; and the series of World Health Reports of the World Health Organization, which focuses on global health issues including access to health care and improving public health outcomes, especially in developing countries. The concept of the "health field," as distinct from medical care, emerged from the Lalonde report from Canada. The report identified three interdependent fields as key determinants of an individual's health. These are: Biomedical: all aspects of health, physical and mental, developed within the human body as influenced by genetic make-up. Environmental: all matters related to health external to the human body and over which the individual has little or no control; Lifestyle: the aggregation of personal decisions (i.e., over which the individual has control) that can be said to contribute to, or cause, illness or death; The maintenance and promotion of health is achieved through different combination of physical, mental, and social well-being—a combination sometimes referred to as the "health triangle." The WHO's 1986 Ottawa Charter for Health Promotion further stated that health is not just a state, but also "a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities." Focusing more on lifestyle issues and their relationships with functional health, data from the Alameda County Study suggested that people can improve their health via exercise, enough sleep, spending time in nature, maintaining a healthy body weight, limiting alcohol use, and avoiding smoking. Health and illness can co-exist, as even people with multiple chronic diseases or terminal illnesses can consider themselves healthy. The environment is often cited as an important factor influencing the health status of individuals. This includes characteristics of the natural environment, the built environment and the social environment. Factors such as clean water and air, adequate housing, and safe communities and roads all have been found to contribute to good health, especially to the health of infants and children. Some studies have shown that a lack of neighborhood recreational spaces including natural environment leads to lower levels of personal satisfaction and higher levels of obesity, linked to lower overall health and well-being. It has been demonstrated that increased time spent in natural environments is associated with improved self-reported health, suggesting that the positive health benefits of natural space in urban neighborhoods should be taken into account in public policy and land use. Genetics, or inherited traits from parents, also play a role in determining the health status of individuals and populations. This can encompass both the predisposition to certain diseases and health conditions, as well as the habits and behaviors individuals develop through the lifestyle of their families. For example, genetics may play a role in the manner in which people cope with stress, either mental, emotional or physical. For example, obesity is a significant problem in the United States that contributes to poor mental health and causes stress in the lives of many people. One difficulty is the issue raised by the debate over the relative strengths of genetics and other factors; interactions between genetics and environment may be of particular importance. Potential issues A number of health issues are common around the globe. Disease is one of the most common. According to GlobalIssues.org, approximately 36 million people die each year from non-communicable (i.e., not contagious) diseases, including cardiovascular disease, cancer, diabetes and chronic lung disease. Among communicable diseases, both viral and bacterial, AIDS/HIV, tuberculosis, and malaria are the most common, causing millions of deaths every year. Another health issue that causes death or contributes to other health problems is malnutrition, especially among children. One of the groups malnutrition affects most is young children. Approximately 7.5 million children under the age of 5 die from malnutrition, usually brought on by not having the money to find or make food. Bodily injuries are also a common health issue worldwide. These injuries, including bone fractures and burns, can reduce a person's quality of life or can cause fatalities including infections that resulted from the injury (or the severity injury in general). Lifestyle choices are contributing factors to poor health in many cases. These include smoking cigarettes, and can also include a poor diet, whether it is overeating or an overly constrictive diet. Inactivity can also contribute to health issues and also a lack of sleep, excessive alcohol consumption, and neglect of oral hygiene. There are also genetic disorders that are inherited by the person and can vary in how much they affect the person (and when they surface). Although the majority of these health issues are preventable, a major contributor to global ill health is the fact that approximately 1 billion people lack access to health care systems. Arguably, the most common and harmful health issue is that a great many people do not have access to quality remedies. Mental health The World Health Organization describes mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community". Mental health is not just the absence of mental illness. Mental illness is described as 'the spectrum of cognitive, emotional, and behavioral conditions that interfere with social and emotional well-being and the lives and productivity of people. Having a mental illness can seriously impair, temporarily or permanently, the mental functioning of a person. Other terms include: 'mental health problem', 'illness', 'disorder', 'dysfunction'. Approximately twenty percent of all adults in the US are considered diagnosable with a mental disorder. Mental disorders are the leading cause of disability in the United States and Canada. Examples of these disorders include schizophrenia, ADHD, major depressive disorder, bipolar disorder, anxiety disorder, post-traumatic stress disorder and autism.  Many factors contribute to mental health problems, including: Biological factors, such as genes or brain chemistry Family history of mental health problems Life experiences, such as trauma or abuse Maintaining Achieving and maintaining health is an ongoing process, shaped by both the evolution of health care knowledge and practices as well as personal strategies and organized interventions for staying healthy. Diet An important way to maintain one's personal health is to have a healthy diet. A healthy diet includes a variety of plant-based and animal-based foods that provide nutrients to the body. Such nutrients provide the body with energy and keep it running. Nutrients help build and strengthen bones, muscles, and tendons and also regulate body processes (i.e., blood pressure). Water is essential for growth, reproduction and good health. Macronutrients are consumed in relatively large quantities and include proteins, carbohydrates, and fats and fatty acids. Micronutrients – vitamins and minerals – are consumed in relatively smaller quantities, but are essential to body processes. The food guide pyramid is a pyramid-shaped guide of healthy foods divided into sections. Each section shows the recommended intake for each food group (i.e., protein, fat, carbohydrates and sugars). Making healthy food choices can lower one's risk of heart disease and the risk of developing some types of cancer, and can help one maintain their weight within a healthy range. The Mediterranean diet is commonly associated with health-promoting effects. This is sometimes attributed to the inclusion of bioactive compounds such as phenolic compounds, isoprenoids and alkaloids. Exercise Physical exercise enhances or maintains physical fitness and overall health and wellness. It strengthens one's bones and muscles and improves the cardiovascular system. According to the National Institutes of Health, there are four types of exercise: endurance, strength, flexibility, and balance. The CDC states that physical exercise can reduce the risks of heart disease, cancer, type 2 diabetes, high blood pressure, obesity, depression, and anxiety. For the purpose of counteracting possible risks, it is often recommended to start physical exercise gradually as one goes. Participating in any exercising, whether it is housework, yardwork, walking or standing up when talking on the phone, is often thought to be better than none when it comes to health. Sleep Sleep is an essential component to maintaining health. In children, sleep is also vital for growth and development. Ongoing sleep deprivation has been linked to an increased risk for some chronic health problems. In addition, sleep deprivation has been shown to correlate with both increased susceptibility to illness and slower recovery times from illness. In one study, people with chronic insufficient sleep, set as six hours of sleep a night or less, were found to be four times more likely to catch a cold compared to those who reported sleeping for seven hours or more a night. Due to the role of sleep in regulating metabolism, insufficient sleep may also play a role in weight gain or, conversely, in impeding weight loss. Additionally, in 2007, the International Agency for Research on Cancer, which is the cancer research agency for the World Health Organization, declared that "shiftwork that involves circadian disruption is probably carcinogenic to humans", speaking to the dangers of long-term nighttime work due to its intrusion on sleep. In 2015, the National Sleep Foundation released updated recommendations for sleep duration requirements based on age, and concluded that "Individuals who habitually sleep outside the normal range may be exhibiting signs or symptoms of serious health problems or, if done volitionally, may be compromising their health and well-being." Role of science Health science is the branch of science focused on health. There are two main approaches to health science: the study and research of the body and health-related issues to understand how humans (and animals) function, and the application of that knowledge to improve health and to prevent and cure diseases and other physical and mental impairments. The science builds on many sub-fields, including biology, biochemistry, physics, epidemiology, pharmacology, medical sociology. Applied health sciences endeavor to better understand and improve human health through applications in areas such as health education, biomedical engineering, biotechnology and public health. Organized interventions to improve health based on the principles and procedures developed through the health sciences are provided by practitioners trained in medicine, nursing, nutrition, pharmacy, social work, psychology, occupational therapy, physical therapy and other health care professions. Clinical practitioners focus mainly on the health of individuals, while public health practitioners consider the overall health of communities and populations. Workplace wellness programs are increasingly being adopted by companies for their value in improving the health and well-being of their employees, as are school health services to improve the health and well-being of children. Role of medicine and medical science Contemporary medicine is in general conducted within health care systems. Legal, credentialing and financing frameworks are established by individual governments, augmented on occasion by international organizations, such as churches. The characteristics of any given health care system have significant impact on the way medical care is provided. From ancient times, Christian emphasis on practical charity gave rise to the development of systematic nursing and hospitals and the Catholic Church today remains the largest non-government provider of medical services in the world. Advanced industrial countries (with the exception of the United States) and many developing countries provide medical services through a system of universal health care that aims to guarantee care for all through a single-payer health care system, or compulsory private or co-operative health insurance. This is intended to ensure that the entire population has access to medical care on the basis of need rather than ability to pay. Delivery may be via private medical practices or by state-owned hospitals and clinics, or by charities, most commonly by a combination of all three. Most tribal societies provide no guarantee of healthcare for the population as a whole. In such societies, healthcare is available to those that can afford to pay for it or have self-insured it (either directly or as part of an employment contract) or who may be covered by care financed by the government or tribe directly. Transparency of information is another factor defining a delivery system. Access to information on conditions, treatments, quality, and pricing greatly affects the choice by patients/consumers and, therefore, the incentives of medical professionals. While the US healthcare system has come under fire for lack of openness, new legislation may encourage greater openness. There is a perceived tension between the need for transparency on the one hand and such issues as patient confidentiality and the possible exploitation of information for commercial gain on the other. Delivery Provision of medical care is classified into primary, secondary, and tertiary care categories. Primary care medical services are provided by physicians, physician assistants, nurse practitioners, or other health professionals who have first contact with a patient seeking medical treatment or care. These occur in physician offices, clinics, nursing homes, schools, home visits, and other places close to patients. About 90% of medical visits can be treated by the primary care provider. These include treatment of acute and chronic illnesses, preventive care and health education for all ages and both sexes. Secondary care medical services are provided by medical specialists in their offices or clinics or at local community hospitals for a patient referred by a primary care provider who first diagnosed or treated the patient. Referrals are made for those patients who required the expertise or procedures performed by specialists. These include both ambulatory care and inpatient services, Emergency departments, intensive care medicine, surgery services, physical therapy, labor and delivery, endoscopy units, diagnostic laboratory and medical imaging services, hospice centers, etc. Some primary care providers may also take care of hospitalized patients and deliver babies in a secondary care setting. Tertiary care medical services are provided by specialist hospitals or regional centers equipped with diagnostic and treatment facilities not generally available at local hospitals. These include trauma centers, burn treatment centers, advanced neonatology unit services, organ transplants, high-risk pregnancy, radiation oncology, etc. Modern medical care also depends on information – still delivered in many health care settings on paper records, but increasingly nowadays by electronic means. In low-income countries, modern healthcare is often too expensive for the average person. International healthcare policy researchers have advocated that "user fees" be removed in these areas to ensure access, although even after removal, significant costs and barriers remain. Separation of prescribing and dispensing is a practice in medicine and pharmacy in which the physician who provides a medical prescription is independent from the pharmacist who provides the prescription drug. In the Western world there are centuries of tradition for separating pharmacists from physicians. In Asian countries, it is traditional for physicians to also provide drugs. Role of public health Public health has been described as "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals." It is concerned with threats to the overall health of a community based on population health analysis. The population in question can be as small as a handful of people or as large as all the inhabitants of several continents (for instance, in the case of a pandemic). Public health has many sub-fields, but typically includes the interdisciplinary categories of epidemiology, biostatistics and health services. environmental health, community health, behavioral health, and occupational health are also important areas of public health. The focus of public health interventions is to prevent and manage diseases, injuries and other health conditions through surveillance of cases and the promotion of healthy behavior, communities, and (in aspects relevant to human health) environments. Its aim is to prevent health problems from happening or re-occurring by implementing educational programs, developing policies, administering services and conducting research. In many cases, treating a disease or controlling a pathogen can be vital to preventing it in others, such as during an outbreak. Vaccination programs and distribution of condoms to prevent the spread of communicable diseases are examples of common preventive public health measures, as are educational campaigns to promote vaccination and the use of condoms (including overcoming resistance to such). Public health also takes various actions to limit the health disparities between different areas of the country and, in some cases, the continent or world. One issue is the access of individuals and communities to health care in terms of financial, geographical or socio-cultural constraints. Applications of the public health system include the areas of maternal and child health, health services administration, emergency response, and prevention and control of infectious and chronic diseases. The great positive impact of public health programs is widely acknowledged. Due in part to the policies and actions developed through public health, the 20th century registered a decrease in the mortality rates for infants and children and a continual increase in life expectancy in most parts of the world. For example, it is estimated that life expectancy has increased for Americans by thirty years since 1900, and worldwide by six years since 1990. Self-care strategies Personal health depends partially on the active, passive, and assisted cues people observe and adopt about their own health. These include personal actions for preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care. They also include personal hygiene practices to prevent infection and illness, such as bathing and washing hands with soap; brushing and flossing teeth; storing, preparing and handling food safely; and many others. The information gleaned from personal observations of daily living – such as about sleep patterns, exercise behavior, nutritional intake and environmental features – may be used to inform personal decisions and actions (e.g., "I feel tired in the morning so I am going to try sleeping on a different pillow"), as well as clinical decisions and treatment plans (e.g., a patient who notices his or her shoes are tighter than usual may be having exacerbation of left-sided heart failure, and may require diuretic medication to reduce fluid overload). Personal health also depends partially on the social structure of a person's life. The maintenance of strong social relationships, volunteering, and other social activities have been linked to positive mental health and also increased longevity. One American study among seniors over age 70, found that frequent volunteering was associated with reduced risk of dying compared with older persons who did not volunteer, regardless of physical health status. Another study from Singapore reported that volunteering retirees had significantly better cognitive performance scores, fewer depressive symptoms, and better mental well-being and life satisfaction than non-volunteering retirees. Prolonged psychological stress may negatively impact health, and has been cited as a factor in cognitive impairment with aging, depressive illness, and expression of disease. Stress management is the application of methods to either reduce stress or increase tolerance to stress. Relaxation techniques are physical methods used to relieve stress. Psychological methods include cognitive therapy, meditation, and positive thinking, which work by reducing response to stress. Improving relevant skills, such as problem solving and time management skills, reduces uncertainty and builds confidence, which also reduces the reaction to stress-causing situations where those skills are applicable. Occupational In addition to safety risks, many jobs also present risks of disease, illness and other long-term health problems. Among the most common occupational diseases are various forms of pneumoconiosis, including silicosis and coal worker's pneumoconiosis (black lung disease). Asthma is another respiratory illness that many workers are vulnerable to. Workers may also be vulnerable to skin diseases, including eczema, dermatitis, urticaria, sunburn, and skin cancer. Other occupational diseases of concern include carpal tunnel syndrome and lead poisoning. As the number of service sector jobs has risen in developed countries, more and more jobs have become sedentary, presenting a different array of health problems than those associated with manufacturing and the primary sector. Contemporary problems, such as the growing rate of obesity and issues relating to stress and overwork in many countries, have further complicated the interaction between work and health. Many governments view occupational health as a social challenge and have formed public organizations to ensure the health and safety of workers. Examples of these include the British Health and Safety Executive and in the United States, the National Institute for Occupational Safety and Health, which conducts research on occupational health and safety, and the Occupational Safety and Health Administration, which handles regulation and policy relating to worker safety and health. See also References External links Personal life Articles containing video clips Main topic articles

Childhood trauma

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse. They may also witness abuse of a sibling or parent, or have a mentally ill parent. These events can have profound psychological, physiological, and sociological impacts leading to lasting negative effects on health and well-being. These events may include antisocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Additionally, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders. Kaiser Permanente and the Centers for Disease Control and Prevention's 1998 study on adverse childhood experiences found that traumatic experiences during childhood are a root cause of many social, emotional, and cognitive impairments. These impairments can lead to increased risk of unhealthy self-destructive behaviors, risk of violence or re-victimization, chronic health conditions, low life potential and premature mortality. As the number of adverse experiences increases, the risk of problems from childhood through adulthood also rises. Nearly 30 years of research following the initial study has confirmed these findings. Many states, health providers, and other groups now routinely screen parents and children for ACEs. Health Traumatic experiences during childhood causes stress that increases an individual's allostatic load and thus affects the immune system, nervous system, and endocrine system. Exposure to chronic stress triples or quadruples the vulnerability to adverse medical outcomes. Childhood trauma is often associated with adverse health outcomes including depression, hypertension, autoimmune diseases, lung cancer, and premature mortality. Effects of childhood trauma on brain development includes a negative impact on emotional regulation and impairment of development of social skills. Research has shown that children raised in traumatic or risky family environments tend to have excessive internalizing (e.g., social withdrawal, anxiety) or externalizing (e.g., aggressive behavior), and suicidal behavior. Recent research has found that physical and sexual abuse are associated with mood and anxiety disorders in adulthood, while personality disorders and schizophrenia are linked with emotional abuse as adults. In addition, research has proposed that mental health outcomes from childhood trauma may be better understood through a dimensional framework (internalizing and externalizing) as opposed to specific disorders. Psychological impact Childhood trauma can increase the risk of mental disorders including post-traumatic stress disorder (PTSD), attachment issues, depression, and substance abuse. Sensitive and critical stages of child development can result in altered neurological functioning, adaptive to a malevolent environment but difficult for more benign environments. In a study done by Stefania Tognin and Maria Calem comparing healthy comparisons (HC) and individuals at clinically high risk for developing psychosis (CHR), 65.6% CHR patients and 23.1% HC experienced some level of childhood trauma. The conclusion of the study shows that there is a correlation between the effects of childhood trauma and the being at high risk for psychosis. Effects on adults As an adult feelings of anxiety, worry, shame, guilt, helplessness, hopelessness, grief, sadness and anger that started with a trauma in childhood can continue. In addition, those who endure trauma as a child are more likely to encounter anxiety, depression, suicide and self harm, PTSD, drug and alcohol misuse and relationship difficulties. The effects of childhood trauma don't end with just emotional repercussions. Survivors of childhood trauma are also at higher risk of developing asthma, coronary heart disease, diabetes or having a stroke. They are also more likely to develop a "heightened stress response" which can make it difficult for them to regulate their emotions, lead to sleep difficulties, lower immune function, and increase the risk of a number of physical illnesses throughout adulthood. Epigenetics Childhood trauma can leave epigenetic marks on a child's genes, which chemically modify gene expression by silencing or activating genes, or DNA methylation. This can alter fundamental biological processes and adversely affect health outcomes throughout life. A 2013 study found that people who had experienced childhood trauma had different neuropathology than people with PTSD from trauma experienced after childhood. Another recent study in rhesus macaques showed that DNA methylation changes related to early-life adversity persisted into adulthood. This research has centered primarily around methylation associated with the NR3C1 gene, however research into the epigenetic impact of trauma has extended to other genes, including KITLG. Survivors of war trauma or childhood maltreatment are at increased risk for trauma-spectrum disorders such as PTSD. In addition, traumatic stress has been associated with alterations in the neuroendocrine and the immune system, enhancing the risk for physical diseases. In particular, epigenetic alterations in genes regulating the hypothalamus–pituitary–adrenal axis as well as the immune system have been observed in survivors of childhood and adult trauma. Traumatic experiences might even affect psychological as well as biological parameters in the next generation, i.e. traumatic stress might have transgenerational effects. Parental trauma exposure was found to be associated with greater risk for post-traumatic stress disorder (PTSD) and mood and anxiety disorders in offspring since biological alterations associated with PTSD and/or other stress-related disorders have also been observed in offspring of trauma survivors who do not themselves report trauma exposure or psychiatric disorder. Animal models have demonstrated that stress exposure can result in epigenetic alterations in the next generation, and such mechanisms have been hypothesized to underpin vulnerability to symptoms in offspring of trauma survivors. Enduring behavioral responses to stress and epigenetic alterations in adult offspring have been demonstrated to be mediated by changes in gametes in utero effects, variations in early postnatal care, and/or other early life experiences that are influenced by parental exposure. These changes could result in enduring alterations of the stress response as well as the physical health risk. Furthermore, the effects of parental trauma could be transmitted to the next generation by parental distress and the pre and postnatal environment as well as by epigenetic marks transmitted via the germline. While epigenetic research has a high potential of advancing our understanding of the consequences of trauma, the findings have to be interpreted with caution, as epigenetics only represent one piece of a complex puzzle of interacting biological and environmental factors. Transgenerational effects People can pass their epigenetic marks including de-myelinated neurons to their children. The effects of trauma can be transferred from one generation of childhood trauma survivors to subsequent generations of offspring. This is known as transgenerational trauma or intergenerational trauma, and can manifest in parenting behaviors as well as epigenetically. Exposure to childhood trauma, along with environmental stress, can also cause alterations in genes and gene expressions. A growing body of literature suggests that children's experiences of trauma and abuse within close relationships not only jeopardize their well-being in childhood, but can also have long-lasting consequences that extend well into adulthood. These long-lasting consequences can include emotion regulation issues, which can then be passed onto subsequent generations through child-parent interactions and learned behaviors. (see also behavioral epigenetics, historical trauma, and cycle of violence) Socioeconomic costs The social and economic costs of child abuse and neglect are difficult to calculate. Some costs are straightforward and directly related to maltreatment, such as hospital costs for medical treatment of injuries sustained as a result of physical abuse and foster care costs resulting from the removal of children when they cannot remain safely with their families. Other costs, less directly tied to the incidence of abuse, include lower academic achievement, adult criminality, and lifelong mental health problems. Both direct and indirect costs impact society and the economy. Resilience Exposure to maltreatment in childhood significantly predicts a variety of negative outcomes in adulthood. However, not all children who are exposed to a potentially traumatic event develop subsequent struggles with mental or physical health. Therefore, there are factors that reduce the impact of potentially traumatic events and protect an individual from developing mental health problems after exposure to a potentially traumatic event. These are called resiliency factors. Research regarding children who showed adaptive development while facing adversity began in the 1970s and continues to this day. Resilience is defined as “the process of, capacity for, or outcome of successful adaptation despite challenging or threatening circumstances." The concept of resilience stems from research that showed experiencing positive emotions had a restorative and preventive effect on the experience of negative emotions more broadly with regards to physical and psychological wellbeing in general and more specifically with reactions to trauma. This line of research has contributed to the development of interventions that focus on promoting resilience as opposed to focusing on deficits in an individual who has experienced a traumatic event. Resilience has been found to decrease risk of suicide, depression, anxiety and other mental health struggles associated with exposure to trauma in childhood. When an individual who is high in resilience experiences a potentially traumatic event, their relative level of functioning does not significantly deviate from the level of functioning they exhibited prior to exposure to a potentially traumatic event. Furthermore, that same individual may recover more quickly and successfully from a potentially traumatic experience than an individual who could be said to be less resilient. In children, level of functioning is operationalized as the child continuing to behave in a manner that is considered developmentally appropriate for a child of that age. Level of functioning is also measured by the presence of mental health disorders such as depression, anxiety, posttraumatic stress disorder, and so on. Factors that affect resilience Factors that affect resilience include cultural factors like socioeconomic status, such that having more resources at one's disposal usually equates to more resilience to trauma. Furthermore, the severity and duration of the potentially traumatic experience affect the likelihood of experiencing negative outcomes as a result of childhood trauma. One factor that does not affect resilience is gender, with both males and females being equally sensitive to risk and protective factors. Cognitive ability is also not a predictor of resilience. Attachment has been shown to be one of the most important factors to consider when it comes to evaluating the relative resilience of an individual. Children with secure attachments to an adult with effective coping strategies were most likely to endure adverse childhood experiences (ACEs) in an adaptive manner. Secure attachments throughout the lifespan (including in adolescence and adulthood) appear to be equally important in fostering and maintaining resilience. Secure attachment to one's peers throughout adolescence is a particularly strong predictor of resilience. Within the context of abuse, it is thought that these secure attachments decrease the extent to which children who are abused perceive others as being untrustworthy. In other words, while some children who are abused might begin to view other people as being unsafe and unable to be trusted, children who are able to develop and maintain healthy relationships are less likely to hold these views. Children who experience trauma but also experience healthy attachment with multiple groups of people (in essence, adults, peers, romantic partners, etc.) throughout childhood, adolescence, and adulthood are particularly resilient. Personality also affects the development (or lack of development) of adult psychopathology as a result of childhood abuse. Individuals who scored low in neuroticism exhibit fewer negative outcomes, such as psychopathology, criminal activity, and poor physical health, after exposure to a potentially traumatic event. Furthermore, individuals with higher scores on openness to experience, conscientiousness, and extraversion have been found to be more resilient to the effects of childhood trauma. Enhancing resilience One of the most common misconceptions about resilience is that individuals who show resilience are somehow special or extraordinary in some way. Successful adaptation, or resilience, is quite common among children. This is due in part to the naturally adaptive nature of childhood development. Therefore, resilience is enhanced by protecting against factors that might undermine a child's inborn resilience. Studies suggest that resiliency can be enhanced by providing children who have been exposed to trauma with environments in which they feel safe and are able to securely attach to a healthy adult. Therefore, interventions that promote strong parent-child bonds are particularly effective at buffering against the potential negative effects of trauma. Furthermore, researchers of resilience argue that successful adaptation is not merely a result, rather a developmental process that is ongoing throughout a person's lifetime. Thus, successful promotion of resilience must also be ongoing throughout a person's lifespan. Prognosis Trauma affects all children differently (see stress in early childhood). Some children who experience trauma develop significant and long-lasting problems, while others may have minimal symptoms and recover more quickly. Studies have found that despite the broad impacts of trauma, children can and do recover, and that trauma-informed care and interventions produce better outcomes than “treatment as usual”. Trauma-informed care is defined as offering services or support in a way that addresses the special needs of people who have experienced trauma. Types of trauma Emotional abuse Emotional abuse is often an understated form of trauma that can occur both overtly and covertly. Emotional abuse revolves around a pattern of emotional manipulation, abusive words, isolation, discretization, humiliation and more that tends to have an internalized effect on an individual's self-esteem, ideals, values and reality. Emotional abuse in children is a distinct issue in relation to childhood trauma and the effects it has on children when growing up in an emotionally abusive household or being in relation with emotionally abusive individuals. Bullying Bullying is any unprovoked action with the intention of harming, either physically or psychologically, someone who is considered to have less power, either physically or socially. Bullying is a form of harassment that is often repeated and habitual, and can happen in person or online. Bullying in childhood may inflict harm or distress and educational harm that can affect the later stage of adolescence. Bullying involvement, as victim, bully, bully/victim, or witness, can threaten the well-being of children. Bullying can be a risk factor for the development of an eating disorder, it can impact the functioning of the HPA axis, and it can impact functioning in adulthood. It increases the risk for physical problems such as inflammation, diabetes, and heart risk, and mental health problems such as anxiety, depression, agoraphobia, panic disorder, substance abuse, and PTSD. Community violence Unlike bullying which is direct, trauma from community violence is not always directly perpetuated on the child, but is instead the result of being exposed to violent acts and behaviors in the community, such as gang violence, school shootings, riots, or police brutality. Community violence exposure whether direct, or indirect, is associated with many negative mental health outcomes among children and adolescents including internalizing trauma-related symptoms, academic problems, substance abuse, and suicidal ideation. Evidence also indicates that violence tends to beget more violence; children who witness community violence consistently show higher levels of aggression across developmental periods including early and middle childhood, as well as adolescence. Complex trauma Complex trauma occurs from exposure to multiple and repetitive episodes of victimization or other traumatic events. Individuals who are exposed to multiple forms of trauma often display a wide range of difficulties compared to those who have only had one of few trauma exposures. For example, cognitive complications (dissociation), affective, somatic, behavioral, relational, and self-attributional problems have been seen in individuals who have experienced complex trauma. Disasters Beyond the experience of natural and man-made disasters themselves, disaster-related traumas include the loss of loved ones, disruptions caused by disaster-caused homelessness and hardship and the breakdown of community structures. Exposure to a natural disaster is a highly stressful experiences that can lead to a wide range of maladaptive outcomes, particularly in children. Exposure to natural disaster constitutes a risk factor for poor psychological health in children and adolescents. Psychological symptoms tend to decline over time after the exposure, it is not a rapid process. Intimate partner violence Similar to community violence, intimate partner violence-related trauma is not necessarily directly perpetuated on child, but can be the result of exposure to violence within the household, often of violence perpetuated against one or more caregivers or family members. It is often accompanied by direct physical and emotional abuse of the child. Witnessing violence and threats against a caregiver during early years of life is associated with severe impacts on a child's health and development. Outcomes for children include psychological distress, behavioral disorders, disturbances in self-regulation, difficulties with social interaction, and disorganized attachment. Children who were exposed to interpersonal violence were more likely to develop long term mental health problems than those with non-interpersonal traumas. The impact of seeing intimate partner violence could be more serious for younger children. Younger children are completely dependent on their caregivers than older children not only for physical care but also emotional care. This is needed for them to develop normal neurological, psychological, and social development. This dependence can contribute to their vulnerability to witnessing violence against their caregivers. Medical trauma Medical trauma, sometimes called 'paediatric medical traumatic stress' refers to a set of psychological and physiological responses of children and their families to pain, injury, serious illness, medical procedures, and invasive or frightening treatment experiences. Medical trauma may occur as a response to a single or multiple medical events. In children, they are still developing cognitive skills and because of this they process information differently. They might associate pain with punishment and could believe they did something wrong that led to them being in pain or that they somehow caused their injury. Children may experience disruptions in their attachment with their caregivers due to their traumatic medical experience. This depends on the age of the child and his understanding of his medical difficulties. For example, a young child may feel betrayed by his parents if they have forced him to participate in activities that contributed to the child's pain, such as administering medications or taking him to the doctor. At the same time, the parent-child relationship is strained due to parents feeling powerless, guilt, or inadequacy. Physical abuse Child physical abuse is physical trauma or physical injury caused by slapping, beating, hitting, or otherwise harming a child. This abuse is considered non-accidental. Injuries can range from mild bruising to broken bones, skull fractures, and even death. Short term consequences of physical abuse of children include fractures, cognitive or intellectual disabilities, social skills deficits, PTSD, other psychiatric disorders, heightened aggression, and externalizing behaviors, anxiety, risk-taking behavior, and suicidal behavior. Long-term consequences include difficulty trusting others, low self-esteem, anxiety, physical problems, anger, internalization of aggression, depression, interpersonal difficulties, and substance abuse. Refugee trauma Refugee-related childhood trauma can take place in the child's country of origin due to war, persecution, or violence, but can also be a result of the process of displacement or even the disruptions and transitions of resettlement into the destination country. Studies of refugee youth report high levels of exposure to war related trauma and have found profound averse consequences of these experiences for children's mental health. Some outcomes from experiencing trauma in refugee children are behavioral problems, mood and anxiety disorders, PTSD, and adjustment difficulty. Separation trauma Separation trauma is a disruption in an attachment relationship that disrupts neurological development and can lead to death. Chronic separation from a caregiver can be extremely traumatic to a child. Additionally, separation from a parental or attachment figure while enduring a separate childhood trauma can also produce withstanding impact on the child's attachment security. This may later be associated with the development of post-traumatic adult symptomology. Sexual abuse Traumatic grief Traumatic grief is distinguished from the traditional grieving process in that the child is unable to cope with daily life and may not even remember a loved one outside of the circumstances of his death. This can often be the case when the death is the result of a sudden illness or an act of violence. Treatment The health effects of childhood trauma can be mitigated through care and treatment. There are many treatments for childhood trauma, including psychosocial treatments and pharmacologic treatments. Psychosocial treatments can be targeted toward individuals, such as psychotherapy, or targeted towards wider populations, such as school-wide interventions. While studies (systematic reviews) of current evidence have shown that many types of treatments are effective, trauma-focused cognitive behavioral therapy may be the most effective for treating childhood trauma. In contrast, other studies have shown that pharmacologic therapies may be less effective than psychosocial therapies for treating childhood trauma. Lastly, early intervention can significantly reduce negative health effects of childhood trauma. Psychosocial treatments Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is the psychological treatment of choice for PTSD and is recommended by best-practice treatment guidelines. The goal of CBT is to help patients change their thoughts, beliefs, and attitudes to better control their emotions. Additionally, it is structured to help patients better cope with trauma and improve their problem-solving skills. Many studies provide evidence that CBT is effective for treating PTSD in terms of magnitude of symptom reduction from pre-treatment levels, and diagnostic recovery. Associated treatment barriers include stigma, cost, geography and insufficient treatment availability. Trauma-focused cognitive behavioral therapy Trauma focused cognitive behavioral therapy (TF-CBT) is a branch of cognitive behavioral therapy designed to treat PTSD cases in children and adolescents. This treatment model combines the principles of CBT with trauma-sensitive approaches. It helps introduce skills to cope with the symptoms of the trauma for both the child and the parent if available, before allowing the child to process the trauma on their own in a safe space. Studies (systematic reviews) have shown trauma-focused cognitive behavioral therapy to be one of the most effective treatments to minimize the negative psychological effects of childhood trauma, particularly PTSD. Eye movement desensitization and reprocessing therapy Eye movement desensitization and reprocessing therapy (EMDR) is a technique used by therapists to help process traumatic memories. The intervention has the patient recall traumatic memories and use bilateral stimulation such as eye movements or finger tapping to help regulate their emotions. The process is complete when the patient becomes desensitized to the memory and can recall it without having a negative response. A randomized controlled trial showed that EMDR reduced symptoms of PTSD in children who had been exposed to a single-traumatic event, and was cost-effective. Additionally, studies have shown EMDR to be an effective treatment for PTSD. Dialectical behavior therapy Dialectical behavior therapy (DBT) has been shown to be help prevent self-harm and enhance interpersonal functioning by reducing experiential avoidance and expressed anger through a combination of cognitive behavioral and mindfulness techniques. Real life heroes The real life heroes (RLH) treatment, a sequential, attachment-centered treatment intervention for children with Complex PTSD that focuses on 3 primary components: affect regulation, emotionally supportive relationships, and life story integration to build resources and skills for resilience. A study of 126 children found Real Life Heroes treatment to be effective in reducing symptoms of PTSD and in improving behavioral problems. Narrative-emotion process coding system The narrative-emotion process coding system (NEPCS) is a behavioral coding system that identifies eight client markers: Abstract Story, Empty Story, Unstoried Emotion, Inchoate Story, Same Old Story, Competing Plotlines Story, Unexpected Outcome Story, and Discovery Story. Each marker varies in the degree to which specific narrative and emotion process indicators are represented in one-minute time segments drawn from videotaped therapy sessions. As enhanced integration of narrative and emotional expression has previously been associated with recovery from complex trauma. Attachment, Self-Regulation, and Competency framework The Attachment, Self-Regulation, and Competency (ARC) Framework is an intervention for children and adolescents impacted by complex trauma. The ARC framework is a flexible, component-based intervention for treating children and adolescents who have experienced complex trauma. The framework is theoretically grounded in attachment, trauma, and developmental theories and specifically addresses three core domains impacted by exposure to chronic, interpersonal trauma: attachment, self-regulation, and developmental competencies. A study using data from the US National Child Traumatic Stress Network found that treatment with the ARC framework was effective, reducing behavioral problems and symptoms of PTSD to a similar degree that of trauma-focused cognitive behavioral therapy. School-wide approaches Many school-wide interventions that have been studied differ considerably from one another, which limits the strength of the evidence in support of school-wide interventions for treating childhood trauma; however, studies of school-wide approaches show that they tended to be moderately effective, reducing trauma symptoms, encouraging behavior change, and improving self-esteem. Pharmaceutical treatments Most studies that evaluate the effectiveness of using pharmaceuticals (medications) for treatment of childhood trauma focus specifically on treating PTSD. PTSD is only one health effect that can result from childhood trauma. Few studies evaluate the effectiveness of pharmaceutical treatment for treating other health effects of childhood trauma, besides PTSD. Selective serotonin re-uptake inhibitors (SSRI) and other anti-depressants are medications that are commonly used to treat the symptoms of PTSD. Studies (systematic reviews) have shown that medications may be less effective than psychosocial therapies for treating PTSD. However, medications have been shown to be effective when paired with another form of therapy such as CBT for PTSD. References Child and adolescent psychiatry Trauma types Adverse childhood experiences

Mental illness denial

Mental illness denial or mental disorder denial is a form of denialism in which a person denies the existence of mental disorders. Both serious analysts and pseudoscientific movements question the existence of certain disorders. A minority of professional researchers see disorders such as depression from a sociocultural perspective and argue that solutions should be sought through fixing a dysfunction in the society, not in the person's brain. Insight In psychiatry, insight is the ability of an individual to understand their mental health, and anosognosia is the lack of awareness of a mental health condition. Certain psychological analysts argue this denialism is a coping mechanism usually fueled by narcissistic injury. According to Elyn Saks, probing patient's denial may lead to better ways to help them overcome their denial and provide insight into other issues. Major reasons for denial are narcissistic injury and denialism. In denialism, a person tries to deny psychologically uncomfortable truth and tries to rationalize it. This urge for denialism is fueled further by narcissistic injury. Narcissism gets injured when a person feels vulnerable (or weak or overwhelmed) for some reason like mental illness. Scholarly criticism of psychiatric diagnosis Scholars have criticized mental health diagnoses as arbitrary. According to Thomas Szasz, mental illness is a social construct. He views psychiatry as a social control and mechanism for political oppression. Szasz wrote a book on the subject in 1961, The Myth of Mental Illness. See also Anti-intellectualism References Denialism Mental disorders

Structural functionalism

Structural functionalism, or simply functionalism, is "a framework for building theory that sees society as a complex system whose parts work together to promote solidarity and stability". This approach looks at society through a macro-level orientation, which is a broad focus on the social structures that shape society as a whole, and believes that society has evolved like organisms. This approach looks at both social structure and social functions. Functionalism addresses society as a whole in terms of the function of its constituent elements; namely norms, customs, traditions, and institutions. A common analogy called the organic or biological analogy, popularized by Herbert Spencer, presents these parts of society as human body "organs" that work toward the proper functioning of the "body" as a whole. In the most basic terms, it simply emphasizes "the effort to impute, as rigorously as possible, to each feature, custom, or practice, its effect on the functioning of a supposedly stable, cohesive system". For Talcott Parsons, "structural-functionalism" came to describe a particular stage in the methodological development of social science, rather than a specific school of thought. Theory In sociology, classical theories are defined by a tendency towards biological analogy and notions of social evolutionism: While one may regard functionalism as a logical extension of the organic analogies for societies presented by political philosophers such as Rousseau, sociology draws firmer attention to those institutions unique to industrialized capitalist society (or modernity). Auguste Comte believed that society constitutes a separate "level" of reality, distinct from both biological and inorganic matter. Explanations of social phenomena had therefore to be constructed within this level, individuals being merely transient occupants of comparatively stable social roles. In this view, Comte was followed by Émile Durkheim. A central concern for Durkheim was the question of how certain societies maintain internal stability and survive over time. He proposed that such societies tend to be segmented, with equivalent parts held together by shared values, common symbols or (as his nephew Marcel Mauss held), systems of exchanges. Durkheim used the term "mechanical solidarity" to refer to these types of "social bonds, based on common sentiments and shared moral values, that are strong among members of pre-industrial societies". In modern, complex societies, members perform very different tasks, resulting in a strong interdependence. Based on the metaphor above of an organism in which many parts function together to sustain the whole, Durkheim argued that complex societies are held together by "organic solidarity", i.e. "social bonds, based on specialization and interdependence, that are strong among members of industrial societies". The central concern of structural functionalism may be regarded as a continuation of the Durkheimian task of explaining the apparent stability and internal cohesion needed by societies to endure over time. Societies are seen as coherent, bounded and fundamentally relational constructs that function like organisms, with their various (or social institutions) working together in an unconscious, quasi-automatic fashion toward achieving an overall social equilibrium. All social and cultural phenomena are therefore seen as functional in the sense of working together, and are effectively deemed to have "lives" of their own. They are primarily analyzed in terms of this function. The individual is significant not in and of themselves, but rather in terms of their status, their position in patterns of social relations, and the behaviours associated with their status. Therefore, the social structure is the network of statuses connected by associated roles. Functionalism also has an anthropological basis in the work of theorists such as Marcel Mauss, Bronisław Malinowski and Radcliffe-Brown. The prefix 'structural' emerged in Radcliffe-Brown's specific usage. Radcliffe-Brown proposed that most stateless, "primitive" societies, lacking strong centralized institutions, are based on an association of corporate-descent groups, i.e. the respective society's recognised kinship groups. Structural functionalism also took on Malinowski's argument that the basic building block of society is the nuclear family, and that the clan is an outgrowth, not vice versa. It is simplistic to equate the perspective directly with political conservatism. The tendency to emphasize "cohesive systems", however, leads functionalist theories to be contrasted with "conflict theories" which instead emphasize social problems and inequalities. Prominent theorists Auguste Comte Auguste Comte, the "Father of Positivism", pointed out the need to keep society unified as many traditions were diminishing. He was the first person to coin the term sociology. Comte suggests that sociology is the product of a three-stage development: Theological stage: From the beginning of human history until the end of the European Middle Ages, people took a religious view that society expressed God's will. In the theological state, the human mind, seeking the essential nature of beings, the first and final causes (the origin and purpose) of all effects—in short, absolute knowledge—supposes all phenomena to be produced by the immediate action of supernatural beings. Metaphysical stage: People began seeing society as a natural system as opposed to the supernatural. This began with enlightenment and the ideas of Hobbes, Locke, and Rousseau. Perceptions of society reflected the failings of a selfish human nature rather than the perfection of God. Positive or scientific stage: Describing society through the application of the scientific approach, which draws on the work of scientists. Herbert Spencer Herbert Spencer (1820–1903) was a British philosopher famous for applying the theory of natural selection to society. He was in many ways the first true sociological functionalist. In fact, while Durkheim is widely considered the most important functionalist among positivist theorists, it is known that much of his analysis was culled from reading Spencer's work, especially his Principles of Sociology (1874–96). In describing society, Spencer alludes to the analogy of a human body. Just as the structural parts of the human body—the skeleton, muscles, and various internal organs—function independently to help the entire organism survive, social structures work together to preserve society. While reading Spencer's massive volumes can be tedious (long passages explicating the organic analogy, with reference to cells, simple organisms, animals, humans and society), there are some important insights that have quietly influenced many contemporary theorists, including Talcott Parsons, in his early work The Structure of Social Action (1937). Cultural anthropology also consistently uses functionalism. This evolutionary model, unlike most 19th century evolutionary theories, is cyclical, beginning with the differentiation and increasing complication of an organic or "super-organic" (Spencer's term for a social system) body, followed by a fluctuating state of equilibrium and disequilibrium (or a state of adjustment and adaptation), and, finally, the stage of disintegration or dissolution. Following Thomas Malthus' population principles, Spencer concluded that society is constantly facing selection pressures (internal and external) that force it to adapt its internal structure through differentiation. Every solution, however, causes a new set of selection pressures that threaten society's viability. Spencer was not a determinist in the sense that he never said that Selection pressures will be felt in time to change them; They will be felt and reacted to; or The solutions will always work. In fact, he was in many ways a political sociologist, and recognized that the degree of centralized and consolidated authority in a given polity could make or break its ability to adapt. In other words, he saw a general trend towards the centralization of power as leading to stagnation and ultimately, pressures to decentralize. More specifically, Spencer recognized three functional needs or prerequisites that produce selection pressures: they are regulatory, operative (production) and distributive. He argued that all societies need to solve problems of control and coordination, production of goods, services and ideas, and, finally, to find ways of distributing these resources. Initially, in tribal societies, these three needs are inseparable, and the kinship system is the dominant structure that satisfies them. As many scholars have noted, all institutions are subsumed under kinship organization, but, with increasing population (both in terms of sheer numbers and density), problems emerge with regard to feeding individuals, creating new forms of organization—consider the emergent division of labour—coordinating and controlling various differentiated social units, and developing systems of resource distribution. The solution, as Spencer sees it, is to differentiate structures to fulfill more specialized functions; thus, a chief or "big man" emerges, soon followed by a group of lieutenants, and later kings and administrators. The structural parts of society (e.g. families, work) function interdependently to help society function. Therefore, social structures work together to preserve society. Talcott Parsons Talcott Parsons began writing in the 1930s and contributed to sociology, political science, anthropology, and psychology. Structural functionalism and Parsons have received much criticism. Numerous critics have pointed out Parsons' underemphasis of political and monetary struggle, the basics of social change, and the by and large "manipulative" conduct unregulated by qualities and standards. Structural functionalism, and a large portion of Parsons' works, appear to be insufficient in their definitions concerning the connections amongst institutionalized and non-institutionalized conduct, and the procedures by which institutionalization happens. Parsons was heavily influenced by Durkheim and Max Weber, synthesizing much of their work into his action theory, which he based on the system-theoretical concept and the methodological principle of voluntary action. He held that "the social system is made up of the actions of individuals". His starting point, accordingly, is the interaction between two individuals faced with a variety of choices about how they might act, choices that are influenced and constrained by a number of physical and social factors. Parsons determined that each individual has expectations of the other's action and reaction to their own behavior, and that these expectations would (if successful) be "derived" from the accepted norms and values of the society they inhabit. As Parsons himself emphasized, in a general context there would never exist any perfect "fit" between behaviors and norms, so such a relation is never complete or "perfect". Social norms were always problematic for Parsons, who never claimed (as has often been alleged) that social norms were generally accepted and agreed upon, should this prevent some kind of universal law. Whether social norms were accepted or not was for Parsons simply a historical question. As behaviors are repeated in more interactions, and these expectations are entrenched or institutionalized, a role is created. Parsons defines a "role" as the normatively-regulated participation "of a person in a concrete process of social interaction with specific, concrete role-partners". Although any individual, theoretically, can fulfill any role, the individual is expected to conform to the norms governing the nature of the role they fulfill. Furthermore, one person can and does fulfill many different roles at the same time. In one sense, an individual can be seen to be a "composition" of the roles he inhabits. Certainly, today, when asked to describe themselves, most people would answer with reference to their societal roles. Parsons later developed the idea of roles into collectivities of roles that complement each other in fulfilling functions for society. Some roles are bound up in institutions and social structures (economic, educational, legal and even gender-based). These are functional in the sense that they assist society in operating and fulfilling its functional needs so that society runs smoothly. Contrary to prevailing myth, Parsons never spoke about a society where there was no conflict or some kind of "perfect" equilibrium. A society's cultural value-system was in the typical case never completely integrated, never static and most of the time, like in the case of the American society, in a complex state of transformation relative to its historical point of departure. To reach a "perfect" equilibrium was not any serious theoretical question in Parsons analysis of social systems, indeed, the most dynamic societies had generally cultural systems with important inner tensions like the US and India. These tensions were a source of their strength according to Parsons rather than the opposite. Parsons never thought about system-institutionalization and the level of strains (tensions, conflict) in the system as opposite forces per se. The key processes for Parsons for system reproduction are socialization and social control. Socialization is important because it is the mechanism for transferring the accepted norms and values of society to the individuals within the system. Parsons never spoke about "perfect socialization"in any society socialization was only partial and "incomplete" from an integral point of view. Parsons states that "this point ... is independent of the sense in which [the] individual is concretely autonomous or creative rather than 'passive' or 'conforming', for individuality and creativity, are to a considerable extent, phenomena of the institutionalization of expectations"; they are culturally constructed. Socialization is supported by the positive and negative sanctioning of role behaviours that do or do not meet these expectations. A punishment could be informal, like a snigger or gossip, or more formalized, through institutions such as prisons and mental homes. If these two processes were perfect, society would become static and unchanging, but in reality, this is unlikely to occur for long. Parsons recognizes this, stating that he treats "the structure of the system as problematic and subject to change", and that his concept of the tendency towards equilibrium "does not imply the empirical dominance of stability over change". He does, however, believe that these changes occur in a relatively smooth way. Individuals in interaction with changing situations adapt through a process of "role bargaining". Once the roles are established, they create norms that guide further action and are thus institutionalized, creating stability across social interactions. Where the adaptation process cannot adjust, due to sharp shocks or immediate radical change, structural dissolution occurs and either new structures (or therefore a new system) are formed, or society dies. This model of social change has been described as a "moving equilibrium", and emphasizes a desire for social order. Davis and Moore Kingsley Davis and Wilbert E. Moore (1945) gave an argument for social stratification based on the idea of "functional necessity" (also known as the Davis-Moore hypothesis). They argue that the most difficult jobs in any society have the highest incomes in order to motivate individuals to fill the roles needed by the division of labour. Thus, inequality serves social stability. This argument has been criticized as fallacious from a number of different angles: the argument is both that the individuals who are the most deserving are the highest rewarded, and that a system of unequal rewards is necessary, otherwise no individuals would perform as needed for the society to function. The problem is that these rewards are supposed to be based upon objective merit, rather than subjective "motivations." The argument also does not clearly establish why some positions are worth more than others, even when they benefit more people in society, e.g., teachers compared to athletes and movie stars. Critics have suggested that structural inequality (inherited wealth, family power, etc.) is itself a cause of individual success or failure, not a consequence of it. Robert Merton Robert K. Merton made important refinements to functionalist thought. He fundamentally agreed with Parsons' theory but acknowledged that Parsons' theory could be questioned, believing that it was over generalized. Merton tended to emphasize middle range theory rather than a grand theory, meaning that he was able to deal specifically with some of the limitations in Parsons' thinking. Merton believed that any social structure probably has many functions, some more obvious than others. He identified three main limitations: functional unity, universal functionalism and indispensability. He also developed the concept of deviance and made the distinction between manifest and latent functions. Manifest functions referred to the recognized and intended consequences of any social pattern. Latent functions referred to unrecognized and unintended consequences of any social pattern. Merton criticized functional unity, saying that not all parts of a modern complex society work for the functional unity of society. Consequently, there is a social dysfunction referred to as any social pattern that may disrupt the operation of society. Some institutions and structures may have other functions, and some may even be generally dysfunctional, or be functional for some while being dysfunctional for others. This is because not all structures are functional for society as a whole. Some practices are only functional for a dominant individual or a group. There are two types of functions that Merton discusses the "manifest functions" in that a social pattern can trigger a recognized and intended consequence. The manifest function of education includes preparing for a career by getting good grades, graduation and finding good job. The second type of function is "latent functions", where a social pattern results in an unrecognized or unintended consequence. The latent functions of education include meeting new people, extra-curricular activities, school trips. Another type of social function is "social dysfunction" which is any undesirable consequences that disrupts the operation of society. The social dysfunction of education includes not getting good grades, a job. Merton states that by recognizing and examining the dysfunctional aspects of society we can explain the development and persistence of alternatives. Thus, as Holmwood states, "Merton explicitly made power and conflict central issues for research within a functionalist paradigm." Merton also noted that there may be functional alternatives to the institutions and structures currently fulfilling the functions of society. This means that the institutions that currently exist are not indispensable to society. Merton states "just as the same item may have multiple functions, so may the same function be diversely fulfilled by alternative items." This notion of functional alternatives is important because it reduces the tendency of functionalism to imply approval of the status quo. Merton's theory of deviance is derived from Durkheim's idea of anomie. It is central in explaining how internal changes can occur in a system. For Merton, anomie means a discontinuity between cultural goals and the accepted methods available for reaching them. Merton believes that there are 5 situations facing an actor. Conformity occurs when an individual has the means and desire to achieve the cultural goals socialized into them. Innovation occurs when an individual strives to attain the accepted cultural goals but chooses to do so in novel or unaccepted method. Ritualism occurs when an individual continues to do things as prescribed by society but forfeits the achievement of the goals. Retreatism is the rejection of both the means and the goals of society. Rebellion is a combination of the rejection of societal goals and means and a substitution of other goals and means. Thus it can be seen that change can occur internally in society through either innovation or rebellion. It is true that society will attempt to control these individuals and negate the changes, but as the innovation or rebellion builds momentum, society will eventually adapt or face dissolution. Almond and Powell In the 1970s, political scientists Gabriel Almond and Bingham Powell introduced a structural-functionalist approach to comparing political systems. They argued that, in order to understand a political system, it is necessary to understand not only its institutions (or structures) but also their respective functions. They also insisted that these institutions, to be properly understood, must be placed in a meaningful and dynamic historical context. This idea stood in marked contrast to prevalent approaches in the field of comparative politics—the state-society theory and the dependency theory. These were the descendants of David Easton's system theory in international relations, a mechanistic view that saw all political systems as essentially the same, subject to the same laws of "stimulus and response"—or inputs and outputs—while paying little attention to unique characteristics. The structural-functional approach is based on the view that a political system is made up of several key components, including interest groups, political parties and branches of government. In addition to structures, Almond and Powell showed that a political system consists of various functions, chief among them political socialization, recruitment and communication: socialization refers to the way in which societies pass along their values and beliefs to succeeding generations, and in political terms describe the process by which a society inculcates civic virtues, or the habits of effective citizenship; recruitment denotes the process by which a political system generates interest, engagement and participation from citizens; and communication refers to the way that a system promulgates its values and information. Unilineal descent In their attempt to explain the social stability of African "primitive" stateless societies where they undertook their fieldwork, Evans-Pritchard (1940) and Meyer Fortes (1945) argued that the Tallensi and the Nuer were primarily organized around unilineal descent groups. Such groups are characterized by common purposes, such as administering property or defending against attacks; they form a permanent social structure that persists well beyond the lifespan of their members. In the case of the Tallensi and the Nuer, these corporate groups were based on kinship which in turn fitted into the larger structures of unilineal descent; consequently Evans-Pritchard's and Fortes' model is called "descent theory". Moreover, in this African context territorial divisions were aligned with lineages; descent theory therefore synthesized both blood and soil as the same. Affinal ties with the parent through whom descent is not reckoned, however, are considered to be merely complementary or secondary (Fortes created the concept of "complementary filiation"), with the reckoning of kinship through descent being considered the primary organizing force of social systems. Because of its strong emphasis on unilineal descent, this new kinship theory came to be called "descent theory". With no delay, descent theory had found its critics. Many African tribal societies seemed to fit this neat model rather well, although Africanists, such as Paul Richards, also argued that Fortes and Evans-Pritchard had deliberately downplayed internal contradictions and overemphasized the stability of the local lineage systems and their significance for the organization of society. However, in many Asian settings the problems were even more obvious. In Papua New Guinea, the local patrilineal descent groups were fragmented and contained large amounts of non-agnates. Status distinctions did not depend on descent, and genealogies were too short to account for social solidarity through identification with a common ancestor. In particular, the phenomenon of cognatic (or bilateral) kinship posed a serious problem to the proposition that descent groups are the primary element behind the social structures of "primitive" societies. Leach's (1966) critique came in the form of the classical Malinowskian argument, pointing out that "in Evans-Pritchard's studies of the Nuer and also in Fortes's studies of the Tallensi unilineal descent turns out to be largely an ideal concept to which the empirical facts are only adapted by means of fictions". People's self-interest, manoeuvring, manipulation and competition had been ignored. Moreover, descent theory neglected the significance of marriage and affinal ties, which were emphasized by Lévi-Strauss's structural anthropology, at the expense of overemphasizing the role of descent. To quote Leach: "The evident importance attached to matrilateral and affinal kinship connections is not so much explained as explained away." Biological Biological functionalism is an anthropological paradigm, asserting that all social institutions, beliefs, values and practices serve to address pragmatic concerns. In many ways, the theorem derives from the longer-established structural functionalism, yet the two theorems diverge from one another significantly. While both maintain the fundamental belief that a social structure is composed of many interdependent frames of reference, biological functionalists criticise the structural view that a social solidarity and collective conscience is required in a functioning system. By that fact, biological functionalism maintains that our individual survival and health is the driving provocation of actions, and that the importance of social rigidity is negligible. Everyday application Although the actions of humans without doubt do not always engender positive results for the individual, a biological functionalist would argue that the intention was still self-preservation, albeit unsuccessful. An example of this is the belief in luck as an entity; while a disproportionately strong belief in good luck may lead to undesirable results, such as a huge loss in money from gambling, biological functionalism maintains that the newly created ability of the gambler to condemn luck will allow them to be free of individual blame, thus serving a practical and individual purpose. In this sense, biological functionalism maintains that while bad results often occur in life, which do not serve any pragmatic concerns, an entrenched cognitive psychological motivation was attempting to create a positive result, in spite of its eventual failure. Decline Structural functionalism reached the peak of its influence in the 1940s and 1950s, and by the 1960s was in rapid decline. By the 1980s, its place was taken in Europe by more conflict-oriented approaches, and more recently by structuralism. While some of the critical approaches also gained popularity in the United States, the mainstream of the discipline has instead shifted to a myriad of empirically oriented middle-range theories with no overarching theoretical orientation. To most sociologists, functionalism is now "as dead as a dodo". As the influence of functionalism in the 1960s began to wane, the linguistic and cultural turns led to a myriad of new movements in the social sciences: "According to Giddens, the orthodox consensus terminated in the late 1960s and 1970s as the middle ground shared by otherwise competing perspectives gave way and was replaced by a baffling variety of competing perspectives. This third generation of social theory includes phenomenologically inspired approaches, critical theory, ethnomethodology, symbolic interactionism, structuralism, post-structuralism, and theories written in the tradition of hermeneutics and ordinary language philosophy." While absent from empirical sociology, functionalist themes remained detectable in sociological theory, most notably in the works of Luhmann and Giddens. There are, however, signs of an incipient revival, as functionalist claims have recently been bolstered by developments in multilevel selection theory and in empirical research on how groups solve social dilemmas. Recent developments in evolutionary theory—especially by biologist David Sloan Wilson and anthropologists Robert Boyd and Peter Richerson—have provided strong support for structural functionalism in the form of multilevel selection theory. In this theory, culture and social structure are seen as a Darwinian (biological or cultural) adaptation at the group level. Criticisms In the 1960s, functionalism was criticized for being unable to account for social change, or for structural contradictions and conflict (and thus was often called "consensus theory"). Also, it ignores inequalities including race, gender, class, which cause tension and conflict. The refutation of the second criticism of functionalism, that it is static and has no concept of change, has already been articulated above, concluding that while Parsons' theory allows for change, it is an orderly process of change [Parsons, 1961:38], a moving equilibrium. Therefore, referring to Parsons' theory of society as static is inaccurate. It is true that it does place emphasis on equilibrium and the maintenance or quick return to social order, but this is a product of the time in which Parsons was writing (post-World War II, and the start of the cold war). Society was in upheaval and fear abounded. At the time social order was crucial, and this is reflected in Parsons' tendency to promote equilibrium and social order rather than social change. Furthermore, Durkheim favoured a radical form of guild socialism along with functionalist explanations. Also, Marxism, while acknowledging social contradictions, still uses functionalist explanations. Parsons' evolutionary theory describes the differentiation and reintegration systems and subsystems and thus at least temporary conflict before reintegration (ibid). "The fact that functional analysis can be seen by some as inherently conservative and by others as inherently radical suggests that it may be inherently neither one nor the other." Stronger criticisms include the epistemological argument that functionalism is tautologous, that is, it attempts to account for the development of social institutions solely through recourse to the effects that are attributed to them, and thereby explains the two circularly. However, Parsons drew directly on many of Durkheim's concepts in creating his theory. Certainly Durkheim was one of the first theorists to explain a phenomenon with reference to the function it served for society. He said, "the determination of function is…necessary for the complete explanation of the phenomena." However Durkheim made a clear distinction between historical and functional analysis, saying, "When ... the explanation of a social phenomenon is undertaken, we must seek separately the efficient cause which produces it and the function it fulfills." If Durkheim made this distinction, then it is unlikely that Parsons did not. However Merton does explicitly state that functional analysis does not seek to explain why the action happened in the first instance, but why it continues or is reproduced. By this particular logic, it can be argued that functionalists do not necessarily explain the original cause of a phenomenon with reference to its effect. Yet the logic stated in reverse, that social phenomena are (re)produced because they serve ends, is unoriginal to functionalist thought. Thus functionalism is either undefinable or it can be defined by the teleological arguments which functionalist theorists normatively produced before Merton. Another criticism describes the ontological argument that society cannot have "needs" as a human being does, and even if society does have needs they need not be met. Anthony Giddens argues that functionalist explanations may all be rewritten as historical accounts of individual human actions and consequences (see Structuration). A further criticism directed at functionalism is that it contains no sense of agency, that individuals are seen as puppets, acting as their role requires. Yet Holmwood states that the most sophisticated forms of functionalism are based on "a highly developed concept of action," and as was explained above, Parsons took as his starting point the individual and their actions. His theory did not however articulate how these actors exercise their agency in opposition to the socialization and inculcation of accepted norms. As has been shown above, Merton addressed this limitation through his concept of deviance, and so it can be seen that functionalism allows for agency. It cannot, however, explain why individuals choose to accept or reject the accepted norms, why and in what circumstances they choose to exercise their agency, and this does remain a considerable limitation of the theory. Further criticisms have been levelled at functionalism by proponents of other social theories, particularly conflict theorists, Marxists, feminists and postmodernists. Conflict theorists criticized functionalism's concept of systems as giving far too much weight to integration and consensus, and neglecting independence and conflict. Lockwood, in line with conflict theory, suggested that Parsons' theory missed the concept of system contradiction. He did not account for those parts of the system that might have tendencies to mal-integration. According to Lockwood, it was these tendencies that come to the surface as opposition and conflict among actors. However Parsons thought that the issues of conflict and cooperation were very much intertwined and sought to account for both in his model. In this however he was limited by his analysis of an ‘ideal type' of society which was characterized by consensus. Merton, through his critique of functional unity, introduced into functionalism an explicit analysis of tension and conflict. Yet Merton's functionalist explanations of social phenomena continued to rest on the idea that society is primarily co-operative rather than conflicted, which differentiates Merton from conflict theorists. Marxism, which was revived soon after the emergence of conflict theory, criticized professional sociology (functionalism and conflict theory alike) for being partisan to advanced welfare capitalism. Gouldner thought that Parsons' theory specifically was an expression of the dominant interests of welfare capitalism, that it justified institutions with reference to the function they fulfill for society. It may be that Parsons' work implied or articulated that certain institutions were necessary to fulfill the functional prerequisites of society, but whether or not this is the case, Merton explicitly states that institutions are not indispensable and that there are functional alternatives. That he does not identify any alternatives to the current institutions does reflect a conservative bias, which as has been stated before is a product of the specific time that he was writing in. As functionalism's prominence was ending, feminism was on the rise, and it attempted a radical criticism of functionalism. It believed that functionalism neglected the suppression of women within the family structure. Holmwood shows, however, that Parsons did in fact describe the situations where tensions and conflict existed or were about to take place, even if he did not articulate those conflicts. Some feminists agree, suggesting that Parsons provided accurate descriptions of these situations. On the other hand, Parsons recognized that he had oversimplified his functional analysis of women in relation to work and the family, and focused on the positive functions of the family for society and not on its dysfunctions for women. Merton, too, although addressing situations where function and dysfunction occurred simultaneously, lacked a "feminist sensibility". Postmodernism, as a theory, is critical of claims of objectivity. Therefore, the idea of grand theory and grand narrative that can explain society in all its forms is treated with skepticism. This critique focuses on exposing the danger that grand theory can pose when not seen as a limited perspective, as one way of understanding society. Jeffrey Alexander (1985) sees functionalism as a broad school rather than a specific method or system, such as Parsons, who is capable of taking equilibrium (stability) as a reference-point rather than assumption and treats structural differentiation as a major form of social change. The name 'functionalism' implies a difference of method or interpretation that does not exist. This removes the determinism criticized above. Cohen argues that rather than needs a society has dispositional facts: features of the social environment that support the existence of particular social institutions but do not cause them. Influential theorists Kingsley Davis Michael Denton Émile Durkheim David Keen Niklas Luhmann Bronisław Malinowski Robert K. Merton Wilbert E. Moore George Murdock Talcott Parsons Alfred Reginald Radcliffe-Brown Herbert Spencer Fei Xiaotong See also Causation (sociology) Functional structuralism Historicism Neofunctionalism (sociology) New institutional economics Pure sociology Sociotechnical system Systems theory Vacancy chain Dennis Wrong (critic of structural functionalism) Notes References Barnard, A. 2000. History and Theory in Anthropology. Cambridge: CUP. Barnard, A., and Good, A. 1984. Research Practices in the Study of Kinship. London: Academic Press. Barnes, J. 1971. Three Styles in the Study of Kinship. London: Butler & Tanner. Elster, J., (1990), “Merton's Functionalism and the Unintended Consequences of Action”, in Clark, J., Modgil, C. & Modgil, S., (eds) Robert Merton: Consensus and Controversy, Falmer Press, London, pp. 129–35 Gingrich, P., (1999) “Functionalism and Parsons” in Sociology 250 Subject Notes, University of Regina, accessed, 24/5/06, uregina.ca Holy, L. 1996. Anthropological Perspectives on Kinship. London: Pluto Press. Homans, George Casper (1962). Sentiments and Activities. New York: The Free Press of Glencoe. Hoult, Thomas Ford (1969). Dictionary of Modern Sociology. Kuper, A. 1996. Anthropology and Anthropologists. London: Routledge. Layton, R. 1997. An Introduction to Theory in Anthropology. Cambridge: CUP. Leach, E. 1954. Political Systems of Highland Burma. London: Bell. Leach, E. 1966. Rethinking Anthropology. Northampton: Dickens. Lenski, Gerhard (1966). "Power and Privilege: A Theory of Social Stratification." New York: McGraw-Hill. Lenski, Gerhard (2005). "Evolutionary-Ecological Theory." Boulder, CO: Paradigm. Levi-Strauss, C. 1969. The Elementary Structures of Kinship. London: Eyre and Spottis-woode. Maryanski, Alexandra (1998). "Evolutionary Sociology." Advances in Human Ecology. 7:1–56. Maryanski, Alexandra and Jonathan Turner (1992). "The Social Cage: Human Nature and the Evolution of Society." Stanford: Stanford University Press. Marshall, Gordon (1994). The Concise Oxford Dictionary of Sociology. Parsons, T., (1961) Theories of Society: foundations of modern sociological theory, Free Press, New York Perey, Arnold (2005) "Malinowski, His Diary, and Men Today (with a note on the nature of Malinowskian functionalism) Ritzer, George and Douglas J. Goodman (2004). Sociological Theory, 6th ed. New York: McGraw-Hill. Sanderson, Stephen K. (1999). "Social Transformations: A General Theory of Historical Development." Lanham, MD: Rowman & Littlefield. Turner, Jonathan (1995). "Macrodynamics: Toward a Theory on the Organization of Human Populations." New Brunswick: Rutgers University Press. Turner, Jonathan and Jan Stets (2005). "The Sociology of Emotions." Cambridge. Cambridge University Press. Comparative politics Functionalism (social theory) History of sociology Sociological theories Anthropology Cognition

Bobath concept

The Bobath concept is an approach to neurological rehabilitation that is applied in patient assessment and treatment (such as with adults after stroke or children with cerebral palsy). The goal of applying the Bobath concept is to promote motor learning for efficient motor control in various environments, thereby improving participation and function. This is done through specific patient handling skills to guide patients through the initiation and completing of intended tasks. This approach to neurological rehabilitation is multidisciplinary, primarily involving physiotherapists, occupational therapists, and speech and language therapists. In the United States, the Bobath concept is also known as 'neuro-developmental treatment' (NDT). The concept and its international tutors / instructors have embraced neuroscience and the developments in understanding motor control, motor learning, neuroplasticity and human movement science. They believe that this approach continues to develop. The Bobath concept is named after its inventors: Berta Bobath (physiotherapist) and Karel Bobath (a psychiatrist/neurophysiologist). Their work focused mainly on patients with cerebral palsy and stroke. The main problems of these patient groups resulted in a loss of the standard postural reflex mechanism and regular movements. The Bobath concept was focused on regaining regular movements through re-education at its earliest inception. Since then, it has evolved to incorporate new information on neuroplasticity, motor learning, and motor control. Therapists that practice the Bobath concept today also embrace the goal of developing optimal movement patterns through the use of orthotics and appropriate compensations instead of aiming for ultimately "normal" movement patterns. The Bobath Centre in Watford, UK is a specialist therapy, treatment & training facility and the home of the Bobath Concept. Stroke rehabilitation In the Bobath Concept, postural control is the foundation on which patients begin to develop their skills. Patients undergoing this treatment typically learn how to control postures and movements and then progress to more difficult ones. Therapists analyze postures and movements and look for any abnormalities that may be present when asked to perform them. Examples of common abnormal movement patterns include obligatory synergy patterns. These patterns can be described as the process of trying to perform isolated movement of a particular limb but triggering the use of other typically uninvolved muscles (when compared to normal movement) in order to achieve movement. Obligatory synergy patterns can be further subdivided into flexion and extension synergy components for both the upper and lower extremities. This approach requires active participation from both the patient and the therapist. Depending on the patient, rehabilitation goals may work to improve any or all of the following: postural control, coordination of movement sequences, movement initiation, optimal body alignment, abnormal tone or muscle weakness. Treatment will therefore address both negative signs such as impaired postural control, and positive signs such as spasticity. The strategies and techniques utilized in Bobath therapy encompass therapeutic handling, facilitation, and activation of pivotal control points. Therapeutic handling is a method applied to influence movement quality, combining both facilitation and inhibition approaches. Facilitation plays a central role in Bobath therapy, fostering motor learning by utilizing sensory cues (such as tactile contact and verbal guidance) to reinforce weak movement patterns and discourage excessive ones. The precise application of facilitation during motor tasks involves considerations of timing, modality, intensity, and withdrawal, all of which impact the outcome of motor learning. Inhibition entails diminishing abnormal movement or posture elements that hinder normal functioning. Key control points often denote advantageous areas of the body for facilitating or inhibiting movement and posture. Activities assigned by a Physical Therapist or Occupational Therapist to an individual who has suffered from a stroke are selected based on functional relevance and are varied in terms of difficulty and the environment in which they are performed. The use of the individual's less involved segments, also known as compensatory training strategies, are avoided. Carryover of functional activities in the home and community setting is largely attributed to patient, family and caregiver education. History The Bobath Concepts' theoretical underpinning and practice is clearly documented in a contemporary book published by Wiley Blackman in 2009: Bobath Concept: Theory and Clinical Practice in Neurological Rehabilitation' written by the British Bobath Tutors Association (BBTA) and edited by Raine, Meadows, and Lynch-Ellerington. The chair of ACPIN (Association of Chartered Physiotherapists in Neurology) reviewed this book and concluded :- “I am not really sure that it is clear from the book what the Bobath approach actually is”, “often the prose turns into jargon” and “this book will do little to quell the critics; in fact, it will no doubt give them more fuel for the fire”. Research Paci (2003) conducted an extensive critical appraisal of studies to determine the effectiveness of the Bobath concept for adults with hemiplegia following a stroke. Selected trials showed no evidence proving the effectiveness of the Bobath Concept as the optimal type of treatment. Paci (2003) recommended that standardized guidelines for treatment be identified and described and that further investigations are necessary to develop outcome measures concerning goals of the Bobath approach such as quality of motor performance. Bobath therapy is nonstandardized as it responds, through clinical reasoning and the development of a clinical hypothesis, to the individual patient and their movement control problems. The decisions about specific treatment techniques are collaboratively made with the patient and are guided by the therapist through the use of goal setting and the development of close communication and interaction. Working to develop improved muscle tone appropriate to the task, the individual and the environment, will enable better alignment, and activation of movement, and allow for the recruitment of, for example, arm activity in functional situations within various positions. A study by Lennon et al. concluded that even under idealized conditions (patients with optimal rehabilitation potential, advanced trained therapists, unlimited therapy input, and a movement analysis laboratory) the Bobath approach had no effect on the quality of gait for patients with a stroke. Institutions The Neuro-Developmental Treatment Association (NDTA) was founded to carry on the Bobath's work; it offers certification in NDT for managing adults with stroke or brain trauma and for managing and treating children with cerebral palsy and other neuromotor disorders. People who have this certification sometimes are called "neurodevelopmentalists". Criticism The concept that Bobath can “evolve” and still be called Bobath has been challenged by the president of the American Academy of Cerebral Palsy and Developmental Medicine and the chair of the UK Association of Chartered Physiotherapists in Neurology (ACPIN). These eminent physiotherapists believe that several of the key original teachings of the founders have now been abandoned, whilst the ideas/concepts of others (non Bobath therapists & scientists) have unjustifiably been given the name of Bobath. There is a widespread use of the Bobath concept amongst therapists in stroke rehabilitation. Yet, a large review of randomized controlled trials (RCTs) of Bobath for stroke rehabilitation found only three instances of significant differences in favour of Bobath, yet 11 in favour of alternatives. The authors concluded that therapists should base their treatment methods on “evidence-based guidelines, accepted rules of motor learning, and biological mechanisms of functional recovery, rather than therapist preference for any named therapy approach”. This review pointed out that the approach is now regarded as “obsolete” in some European countries and it is therefore no longer taught. In 2018, a major review of upper limb interventions following stroke found significant positive effects for constraint and task specific-therapies and the supplementary use of biofeedback and electrical stimulation. However, they concluded that the use of Bobath therapy was not supported. Furthermore, a 2020 review of lower limb rehabilitation following stroke concluded that Bobath therapy was inferior to task specific training and that prioritising Bobath therapy over other interventions is not supported by current evidence. In the UK, an NHS review of stroke rehabilitation by Professor Tyson concluded that "the strength of evidence that task-specific functional training and strength training is effective, while Bobath is not, indicates that a paradigm shift is needed in UK stroke physiotherapy..... it is increasingly difficult to justify the continued use of the Bobath concept or its associated techniques". More recently Professor Tyson and Dr Mepsted have both written comprehensive and critical reviews of Bobath/NDT methods, theory and effectiveness. See also an interesting exchange of letters between the above authors and Bobath tutors. National evidence-based guidelines for stroke rehabilitation have been published for England, Netherlands, Canada, Australia, and New Zealand; yet in none of these is the Bobath approach recommended. Conversely, in 2016 the American Stroke Association concluded that although the effectiveness of NDT/Bobath (compared with other treatment approaches) had not been established that it still “may be considered” as a treatment option for mobility. This, however, was their lowest classification of acceptable treatment. Their two highest recommendation groups (“should be performed” and “reasonable to perform”) contained a variety of treatments for which there was much better evidence. NDT/Bobath was not listed as an option for arm/hand rehabilitation. Also, in 2016, the revised RCP guidelines for stroke made no mention of Bobath/NDT, whilst many alternatives were recommended. Importantly they stated that if a treatment was not mentioned, then it was not recommended and need not be funded. They also stated that therapists using such methods must objectively review their options in light of the evidence supporting the recommended alternatives. Furthermore, patients receiving such interventions should be informed that it was outside mainstream practice. A highly significant 2021 “position paper” by the Academy of Neurologic Physical Therapy of the American Physical Therapy Association concluded that, despite its lack of an evidence base, NDT/Bobath methods were still favoured by some therapist in the USA. To overcome this problem, they described a range of strategies that will be implemented to encourage best evidence-based practices and de-implement traditional (NDT/Bobath) methods of working at both an individual and organizational level. The Bobath (NDT) approach is also widely used on children with cerebral palsy (CP). However, when the effectiveness of interventions for the treatment of CP was reviewed by Novak et al. they concluded, “Consequently, there are no circumstances where any of the aims of NDT could not be achieved by a more effective treatment. Thus, on the grounds of wanting to do the best for children with CP, it is hard to rationalize a continued place for traditional NDT within clinical care”. They consequently recommended “ceasing provision of the ever-popular NDT”. The dichotomy between the popularity and institutional funding of this approach versus the negative findings of most RCTs has been excused on the grounds that RCTs may not be suitable for neurorehabilitation. Yet, the British Bobath Tutors Association website does quote the minority of RCTs that support their approach. See also Occupational therapy Physical therapy Speech and language pathology Brunnstrom Approach Frenkel exercises References Occupational therapy Physical therapy Rehabilitation medicine

Global mental health

Global mental health is the international perspective on different aspects of mental health. It is 'the area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide'. There is a growing body of criticism of the global mental health movement, and has been widely criticised as a neo-colonial or "missionary" project and as primarily a front for pharmaceutical companies seeking new clients for psychiatric drugs. In theory, taking into account cultural differences and country-specific conditions, it deals with the epidemiology of mental disorders in different countries, their treatment options, mental health education, political and financial aspects, the structure of mental health care systems, human resources in mental health, and human rights issues among others. The overall aim of the field of global mental health is to strengthen mental health all over the world by providing information about the mental health situation in all countries, and identifying mental health care needs in order to develop cost-effective interventions to meet those specific needs. The global burden of disease Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease (GBD). This is a global measure of so-called disability-adjusted life years (DALY's) assigned to a certain disease/disorder, which is a sum of the years lived with disability and years of life lost due to this disease within the total population. Neuropsychiatric conditions account for 14% of the global burden of disease. Among non-communicable diseases, they account for 28% of the DALY's – more than cardiovascular disease or cancer. However, it is estimated that the real contribution of mental disorders to the global burden of disease is even higher, due to the complex interactions and co-morbidity of physical and mental illness. Around the world, almost one million people die due to suicide every year, and it is the third leading cause of death among young people. The most important causes of disability due to health-related conditions worldwide include unipolar depression, alcoholism, schizophrenia, bipolar depression and dementia. In low- and middle-income countries, these conditions represent a total of 19.1% of all disability related to health conditions. According to Paul and Moser’s meta-analysis, countries with high income inequality and poor unemployment protections have worse mental health outcomes among the unemployed. Mental health by country Africa Mental illnesses and mental health disorders are widespread concerns among underdeveloped African countries, yet these issues are largely neglected, as mental health care in Africa is given statistically less attention than it is in other, westernized nations. Rising death tolls due to mental illness demonstrate the imperative need for improved mental health care policies and advances in treatment for Africans suffering from psychological disorders. Underdeveloped African countries are so visibly troubled by physical illnesses, disease, malnutrition, and contamination that the dilemma of lacking mental health care has not been prioritized, makes it challenging to have a recognized impact on the African population. In 1988 and 1990, two original resolutions were implemented by the World Health Organization's Member States in Africa. AFR/RC39/R1 and AFR/RC40/R9 attempted to improve the status of mental health care in specific African regions to combat its growing effects on the African people. However, it was found that these new policies had little impact on the status of mental health in Africa, ultimately resulting in an incline in psychological disorders instead of the desired decline, and causing this to seem like an impossible problem to manage. In Africa, many socio-cultural and biological factors have led to heightened psychological struggles, while also masking their immediate level of importance to the African eye. Increasing rates of unemployment, violence, crime, rape, and disease are often linked to substance abuse, which can cause mental illness rates to inflate. Additionally, physical disease like HIV/AIDS, the Ebola epidemic, and malaria often have lasting psychological effects on victims that go unrecognized in African communities because of their inherent cultural beliefs. Traditional African beliefs have led to the perception of mental illness as being caused by supernatural forces, preventing helpful or rational responses to abnormal behavior. For example, Ebola received loads of media attention when it became rampant in Africa and eventually spread to the US, however, researchers never really paid attention to its psychological effects on the African brain. Extreme anxiety, struggles with grief, feelings of rejection and incompetence, depression leading to suicide, PTSD, and much more are only some of the noted effects of diseases like Ebola. These epidemics come and go, but their lasting effects on mental health are remaining for years to come, and even ending lives because of the lack of action. There has been some effort to financially fund psychiatric support in countries like Liberia, due to its dramatic mental health crisis after warfare, but not much was benefited. Aside from financial reasons, it is so difficult to enforce mental health interventions and manage mental health in general in underdeveloped countries simply because the individuals living there do not necessarily believe in western psychiatry. It is also important to note that the socio-cultural model of psychology and abnormal behavior is dependent on factors surrounding cultural differences. This causes mental health abnormalities to remain more hidden due to the culture's natural behavior, compared to westernized behavior and cultural norms. This relationship between mental and physical illness is an ongoing cycle that has yet to be broken. While many organizations are attempting to solve problems about physical health in Africa, as these problems are clearly visible and recognizable, there is little action taken to confront the underlying mental effects that are left on the victims. It is recognized that many of the mentally ill in Africa search for help from spiritual or religious leaders, however this is widely because many African countries are significantly lacking in mental health professionals in comparison to the rest of the world. In Ethiopia alone, there are “only 10 psychiatrists for the population of 61 million people,” studies have shown. While numbers have definitely changed since this research was done, the lack of psychological professionals throughout African continues with a current average of 1.4 mental health workers per 100,000 people compared to the global statistic of 9.0 professionals per 100,000 people. Additionally, statistics show that the “global annual rate of visits to mental health outpatient facilities is 1,051 per 100,000 population,” while “in Africa the rate is 14 per 100,000” visits. About half of Africa's countries have some sort of mental health policy, however, these policies are highly disregarded, as Africa's government spends “less than 1% of the total health budget on mental health”. Specifically in Sierra Leone, about 98.8% of people suffering from mental disorders remain untreated, even after the building of a well below average psychiatric hospital, further demonstrating the need for intervention. Not only has there been little hands-on action taken to combat mental health issues in Africa, but there has also been little research done on the topic to spread its awareness and prevent deaths. The Lancet Global Health acknowledges that there are well over 1,000 published articles covering physical health in Africa, but there are still less than 50 discussing mental health. And this pressing dilemma of prioritizing physical health vs. mental health is only worsening as the continent's population is substantially growing with research showing that “Between 2000 and 2015 the continent's population grew by 49%, yet the number of years lost to disability as a result of mental and substance use disorders increased by 52%”. The number of deaths caused by mental instability is truly competing with those caused by physical diseases: “In 2015, 17.9 million years were lost to disability as a consequence of mental health problems. Such disorders were almost as important a cause of years lost to disability as were infectious and parasitic diseases, which accounted for 18.5 million years lost to disability,”. Mental health and physical health care, while they may seem separate, are very much connected, as these two factors determine life or death for humans. As new challenges surface and old challenges still haven't been prioritized, Africa's mental health care policies need significant improvement in order to provide its people with the appropriate health care they deserve, hopefully preventing this problem from expanding. Australia A survey conducted by Australian Bureau of Statistics in 2008 regarding adults with manageable to severe neurosis reveals almost half of the population had a mental disorder at some point of their life and one in five people had a sustained disorder in the preceding 12 months. In neurotic disorders, 14% of the population experienced anxiety and comorbidity disorders were next to common mental disorder with vulnerability to substance abuse and relapses. There were distinct gender differences in disposition to mental health illness. Women were found to have high rate of mental health disorders, and Men had higher propensity of risk for substance abuse. The SMHWB survey showed families that had low socioeconomic status and high dysfunctional patterns had a greater proportional risk for mental health disorders. A 2010 survey regarding adults with psychosis revealed 5 persons per 1000 in the population seeks professional mental health services for psychotic disorders and the most common psychotic disorder was schizophrenia. Bangladesh Mental health disorder is considered a major public health concern and it constitutes about 13% of the Global Burden of disease and severe mental health disease may reduce each individual's life expectancy by about 20%. Low and middle-income countries have a higher burden of mental health disorder as it is not considered as a health problem as other chronic diseases. Being a low-income country, in Bangladesh, mental health issues are highly stigmatized. A community-based study in the rural area of Bangladesh in 2000-2001 estimated that the burden of mental morbidity was 16.5% among rural people and most were suffering from mainly depression and anxiety and which was one-half and one-third of total cases respectively. Furthermore, the prevalence of mental disorders was higher in women in large families aged 45 years. Care for mental health in Bangladesh A study conducted in 2008 stated that only 16% of patients came directly to the Mental Health Practitioner with a mean delay of 10.5 months of the onset of mental illness, which made them more vulnerable in many ways. 22% of patients went for the religious or traditional healer and 12% consulted a rural medical practitioner with the least delay of 2-2.5 weeks. Canada According to statistics released by the Centre of Addiction and Mental Health one in five people in Canada experience a mental health or addiction problem. Young people of ages 15 to 25 are particularly found to be vulnerable. Major depression is found to affect 8% and anxiety disorder 12% of the population. Women are 1.5 times more likely to suffer from mood and anxiety disorders. WHO points out that there are distinct gender differences in patterns of mental health and illness. The lack of power and control over their socioeconomic status, gender based violence; low social position and responsibility for the care of others render women vulnerable to mental health risks. Since more women than men seek help regarding a mental health problem, this has led to not only gender stereotyping but also reinforcing social stigma. WHO has found that this stereotyping has led doctors to diagnose depression more often in women than in men even when they display identical symptoms. Often communication between health care providers and women is authoritarian leading to either the under-treatment or over-treatment of these women. Women's College Hospital has a program called the "Women's Mental Health Program" where doctors and nurses help treat and educate women regarding mental health collaboratively, individually, and online by answering questions from the public. Another Canadian organization serving mental health needs is the Centre for Addiction and Mental Health (CAMH). CAMH is one of Canada's largest and most well-known health and addiction facilities, and it has received international recognitions from the Pan American Health Organization and World Health Organization Collaborating Centre. They do research in areas of addiction and mental health in both men and women. In order to help both men and women, CAMH provides "clinical care, research, education, policy development and health promotion to help transform the lives of people affected by mental health and addiction issues." CAMH is different from Women's College Hospital due to its widely known rehab centre for women who have minor addiction issues, to severe ones. This organization provides care for mental health issues by assessments, interventions, residential programs, treatments, and doctor and family support. Middle East Israel In Israel, a Mental Health Insurance Reform took effect in July 2015, transferring responsibility for the provision of mental health services from the Ministry of Health to the four national health plans. Physical and mental health care were united under one roof; previously they had functioned separately in terms of finance, location, and provider. Under the reform, the health plans developed new services or expanded existing ones to address mental health problems. United States According to the World Health Organization in 2004, depression is the leading cause of disability in the United States for individuals ages 15 to 44. Absence from work in the U.S. due to depression is estimated to be in excess of $31 billion per year. Depression frequently co-occurs with a variety of medical illnesses such as heart disease, cancer, and chronic pain and is associated with poorer health status and prognosis. Each year, roughly 30,000 Americans take their lives, while hundreds of thousands make suicide attempts (Centers for Disease Control and Prevention). In 2004, suicide was the 11th leading cause of death in the United States (Centers for Disease Control and Prevention), third among individuals ages 15–24. Despite the increasingly availability of effectual depression treatment, the level of unmet need for treatment remains high. By way of comparison, a study conducted in Australia during 2006 to 2007 reported that one-third (34.9%) of patients diagnosed with a mental health disorder had presented to medical health services for treatment. The US has a shortage of mental healthcare workers, contributing to the unmet need for treatment. By 2025, the US will need an additional 15,400 psychiatrists and 57,490 psychologists to meet the demand for treatment. Treatment gap It is estimated that one in four people in the world will be affected by mental or neurological disorders at some point in their lives. Although many effective interventions for the treatment of mental disorders are known, and awareness of the need for treatment of people with mental disorders has risen, the proportion of those who need mental health care but who do not receive it remains very high. This so-called "treatment gap" is estimated to reach between 76–85% for low- and middle-income countries, and 35–50% for high-income countries. According to the National Alliance on Mental Illness, 33.5% of U.S. adults with a serious mental illness and 53.8% of U.S. adults with a mental illness received no treatment for it in the year 2020. Despite the acknowledged need, for the most part there have not been substantial changes in mental health care delivery during the past years. Main reasons for this problem are public health priorities, lack of a mental health policy and legislation in many countries, a lack of resources – financial and human resources – as well as inefficient resource allocation. In 2011, the World Health Organization estimated a shortage of 1.18 million mental health professionals, including 55,000 psychiatrists, 628,000 nurses in mental health settings, and 493,000 psychosocial care providers needed to treat mental disorders in 144 low- and middle-income countries. The annual wage bill to remove this health workforce shortage was estimated at about US$4.4 billion. Interventions Information and evidence about cost-effective interventions to provide better mental health care are available. Although most of the research (80%) has been carried out in high-income countries, there is also strong evidence from low- and middle-income countries that pharmacological and psychosocial interventions are effective ways to treat mental disorders, with the strongest evidence for depression, schizophrenia, bipolar disorder and hazardous alcohol use. Recommendations to strengthen mental health systems around the world have been first mentioned in the WHO's World Health Report 2001, which focused on mental health: Provide treatment in primary care Make psychotropic drugs available Give care in the community Educate the public Involve communities, families and consumers Establish national policies, programs and legislation Develop human resources Link with other sectors Monitor community mental health Support more research Based on the data of 12 countries, assessed by the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), the costs of scaling up mental health services by providing a core treatment package for schizophrenia, bipolar affective disorder, depressive episodes and hazardous alcohol use have been estimated. Structural changes in mental health systems according to the WHO recommendations have been taken into account. For most countries, this model suggests an initial period of investment of US$0.30 – 0.50 per person per year. The total expenditure on mental health would have to rise at least ten-fold in low-income countries. In those countries, additional financial resources will be needed, while in middle- and high-income countries the main challenge will be the reallocation of resources within the health system to provide better mental health service. Telemental health In low- and middle income countries there is an increasing demand for telepsychiatry which means offering mental health services through telecommunications technology (mostly videoconferencing and phone calls). This is especially pronounced due to the lack of access to quality healthcare, underfunding and low awareness of mental health issues. In a global health context telemental health may offer access to high-quality mental health services for a wider range of people. At the same time there are concerns around data security and challenges regarding proper infrastructure, capacity, access and skills. Prevention Prevention is beginning to appear in mental health strategies, including the 2004 WHO report "Prevention of Mental Disorders", the 2008 EU "Pact for Mental Health" and the 2011 US National Prevention Strategy. NIMH or the National Institute of Mental Health has over 400 grants. Should you have experienced four or more adverse childhood experiences, you're 3.2 to 4.0 times more likely to suffer from depression, as well as from various other health problems. Campaigns There are many different campaigns that are being run around the world that are trying to help all people with their mental health.  Here some examples of campaigns around the world, from high-level stakeholders: The Power of Okay is a campaign that is run by a government’s funded company in Scotland called “See Me”. This campaign is mainly focused on mental health in the workplace. It touches on two sides of the system. One being the individual struggling with mental health and not knowing how, or if they should tell anyone. Two being a staff member seeing their colleague struggling, but not knowing how to bring it up, or being worried about saying the wrong thing. This campaign was made to encourage people to reach out to their colleagues, family members, friends, neighbors, and ask the question, "are you okay?" Not Myself Today is another campaign that has started and is run in Canada, connected with the European Brain Council (EBC). This campaign is more focused on helping mental health in a workplace setting. It is trying to help companies raise awareness, reduce stigma, and build a supportive community. Not Myself Today is a program that any company can get registered for online. Once registered the company will get a comprehensive Not Myself Today toolkit and member online access. You then can engage in the provided material and evaluation surveys, which help see how the program is impacting your workplace. Better Health-Every Mind Matters is a campaign that is commissioned by Public Health England (PHE). With this campaign PHE is trying to bring to light the struggles and difficulties that have come after COVID-19. This campaign's goal is to support people to take action to look after their mental health and wellbeing, and to also help support those that are around them. The PHE encourages people to get a free NHS approved mind plan. This can be done by answering five questions through Every Mind Matters website. After answering these questions, you will get a personalized plan with tips to help you with what you are currently struggling with.     Stop The Stigma is a campaign that was started by the Canadian Mental Health association (CAMH). With this campaign CAMH came out with some ads of people talking in their workplace. These ads would have someone of a higher status, like a manager or a boss talking about their employees who had cancer. Instead of talking about it in a sincere and sympathetic way, they would talk about it in the way that most people talk about mental health. They would use phrases like, “Is it just a made-up illness to get out of work?” or “Just take something, stuck it up and get back to work.” This just shows how insincere people can be about mental health and puts in perspective that things need to change.     The world health organization (WHO) teamed up with United for Global Mental Health and the World Federation of Mental Health and are campaigning for World Mental Health Day (10 October). With this campaign WHO is looking to host a global online advocacy event on mental health. The United for Global Mental Health group also wants to have a 24-hour march for mental health that has livestreamed content from experts that talk about ways to increase awareness and break down the stigma around mental health. Stakeholders World Health Organization (WHO) Two of WHO's core programmes for mental health are WHO MIND (Mental health improvements for Nations Development) and Mental Health Gap Action Programme (mhGAP). WHO MIND focuses on 5 areas of action to ensure concrete changes in people's daily lives. These are: Action in and support to countries to improve mental health, such as the WHO Pacific Island Mental Health network (PIMHnet) Mental health policy, planning and service development Mental health human rights and legislation Mental health as a core part of human development The QualityRights Project which works to unite and empower people to improve the quality of care and promote human rights in mental health facilities and social care homes. Mental Health Gap Action Programme (mhGAP) is WHO’s action plan to scale up services for mental, neurological and substance use disorders for countries especially with low and lower middle incomes. The aim of mhGAP is to build partnerships for collective action and to reinforce the commitment of governments, international organizations and other stakeholders. The mhGAP Intervention Guide (mhGAP-IG) was launched in October 2010. It is a technical tool for the management of mental, neurological and substance use disorders in non-specialist health settings. The priority conditions included are: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioural disorders in children and adolescents, dementia, alcohol use disorders, drug use disorders, self-harm/suicide and other significant emotional or medically unexplained complaints. Criticism One of the most prominent critics of the Movement for Global Mental Health has been China Mills, author of the book Decolonizing Global Mental Health: The Psychiatrization of the Majority World. Mills writes that: Another prominent critic is Ethan Watters, author of Crazy Like Us: The Globalization of the American Psyche. A more constructive approach is offered by Vincenzo Di Nicola whose article on the Global South as an emergent epistemology creates a bridge between critiques of globalization and the initial gaps and limitations of the Global Mental Health movement. A recent review presents a simple summary outlining the key characteristics of the global mental health landscape and indicating the diversity within the field. This review demonstrates how global mental health is not confined to the local-global debate, which has historically defined it. See also Global health Mental health during the COVID-19 pandemic Mental health in China Mental health in Southeast Africa Mental health in the Middle East Parity of esteem References Further reading External links World Health Organization: Mental Health Project Atlas: Resources for Mental Health and Neurological Disorders World Health Organization. (2001) World health report 2001—mental health: new understanding, new hope. Geneva, WHO Press Global health Prevalence of mental disorders Psychiatric research Mental health

Cerebellar cognitive affective syndrome

Cerebellar cognitive affective syndrome (CCAS), also called Schmahmann's syndrome is a condition that follows from lesions (damage) to the cerebellum of the brain. It refers to a constellation of deficits in the cognitive domains of executive function, spatial cognition, language, and affect resulting from damage to the cerebellum. Impairments of executive function include problems with planning, set-shifting, abstract reasoning, verbal fluency, and working memory, and there is often perseveration, distractibility and inattention. Language problems include dysprosodia, agrammatism and mild anomia. Deficits in spatial cognition produce visual–spatial disorganization and impaired visual–spatial memory. Personality changes manifest as blunting of affect or disinhibited and inappropriate behavior. These cognitive impairments result in an overall lowering of intellectual function. CCAS challenges the traditional view of the cerebellum being responsible solely for regulation of motor functions. It is now thought that the cerebellum is responsible for monitoring both motor and nonmotor functions. The nonmotor deficits described in CCAS are believed to be caused by dysfunction in cerebellar connections to the cerebral cortex and limbic system. Signs and symptoms The CCAS has been described in both adults and children. The precise manifestations may vary on an individual basis, likely reflecting the precise location of the injury in the cerebellum. These investigators subsequently elaborated on the affective component of the CCAS, i.e., the neuropsychiatric phenomena. They reported that patients with injury isolated to the cerebellum may demonstrate distractibility, hyperactivity, impulsiveness, disinhibition, anxiety, ritualistic and stereotypical behaviors, illogical thought and lack of empathy, aggression, irritability, ruminative and obsessive behaviors, dysphoria and depression, tactile defensiveness and sensory overload, apathy, childlike behavior, and inability to comprehend social boundaries and assign ulterior motives. The CCAS can be recognized by the pattern of deficits involving executive function, visual-spatial cognition, linguistic performance and changes in emotion and personality. Underdiagnosis may reflect lack of familiarity of this syndrome in the scientific and medical community. The nature and variety of the symptoms may also prove challenging. Levels of depression, anxiety, lack of emotion, and affect deregulation can vary between patients. The symptoms of CCAS are often moderately severe following acute injury in adults and children, but tend to lessen with time. This supports the view that the cerebellum is involved with the regulation of cognitive processes. Psychiatric disorders There are a number of psychiatric disorders that are thought to be related to dysfunction of the cerebellum and that appear similar to symptoms of CCAS. It has been suggested that lesions in the cerebellum may be responsible for certain characteristics of psychiatric disorders, such as schizophrenia, depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD), developmental dyslexia, Down syndrome, and Fragile X syndrome. Schmahmann's dysmetria of thought hypothesis has been applied to these psychiatric disorders. In schizophrenia, it has been suggested that there is dysfunction of the cortical-thalamo-cerebellar circuit, which leads to problems with emotional behaviors and cognition. Supporting this idea are postmortem studies that have shown smaller anterior portions of the vermis and reduced density of the Purkinje cells in the vermis in schizophrenia. There are several pieces of evidence that support the hypothesis that symptoms of some psychiatric disorders are the result of cerebellar dysfunction. One study found that people with schizophrenia had smaller inferior vermis and less cerebellar hemispheric asymmetry than control adults. It has also been found that individuals with ADHD have smaller posterior inferior lobes than a control group. Other studies have suggested that the size of the vermis is correlated with the severity of ADHD. A study of people with dyslexia showed lower activation via positron emission tomography (PET) in the cerebellum during a motor task relative to a control group. Cause The causes of CCAS lead to variations in symptoms, but a common core of symptoms can be seen regardless of etiology. Causes of CCAS include cerebellar agenesis, dysplasia and hypoplasia, cerebellar stroke, tumor, cerebellitis, trauma, and neurodegenerative diseases (such as progressive supranuclear palsy and multiple system atrophy). CCAS can also be seen in children with prenatal, early postnatal, or developmental lesions. In these cases there are lesions of the cerebellum resulting in cognitive and affect deficits. The severity of CCAS varies depending on the site and extent of the lesion. In the original report that described this syndrome, patients with bihemispheric infarction, pancerebellar disease, or large unilateral posterior inferior cerebellar artery (PICA) infarcts had more cognitive deficits than patients with small right PICA infarcts, small right anterior interior cerebellar artery infarcts or superior cerebellar artery (SCA) territory. Overall, patients with damage to either the posterior lobe of the cerebellum or with bilateral lesions had the greatest severity of symptoms, whereas patients with lesions in the anterior lobe had less severe symptoms. In children, it was found that those with astrocytoma performed better than those with medulloblastoma on neuropsychological tests. Pathology Cerebellar pathways There are pathways that have been proposed to explain the non-motor dysfunctions seen in CCAS. A leading view of CCAS is the dysmetria of thought hypothesis, which proposes that the non-motor deficits in CCAS are caused by dysfunction in the cerebrocerebellar system linking the cerebral cortex with the cerebellum. The normal cerebellum is now thought to be responsible for regulating motor, cognitive and emotional behaviors. When there is some type of damage to the cerebellum, this regulation is affected, leading to deregulation of emotional behaviors. This effect has been compared to dysmetria of movement, which describes the motor dysfunctions seen after cerebellar lesions. These ideas build upon earlier theories and results of investigations indicating that the cerebellum is linked with the frontal orbital cortex, limbic system, and reticular structures. It was proposed that these circuits are involved with emotional regulation, such that damage to this circuit would result in behavioral dysfunctions such as hyperactivity, apathy, and stimulus-seeking behaviors. Connections lead from the cerebral cortex (including sensorimotor regions as well as cognitively relevant association areas and emotion-related limbic areas) to the cerebellum by a two-stage feed forward system. The pathway starts in the layer V neurons of the cerebral cortex that project via the cerebral peduncle to the neurons of the anterior portion of the pons (the basis pontis). The pontine axons projects via the contralateral middle cerebellar peduncle, terminating in the cerebellar cortex as mossy fibers. The feedback circuit from the cerebellum to the cerebral cortex is also a two-stage system. The cerebellar cortex projects to the deep cerebellar nuclei (the corticonuclear microcomplex). The deep nuclei then project to the thalamus, which in turn projects back to the cerebral cortex. This cerebrocerebellar circuit is key to understanding the motor as well as the non-motor roles of the cerebellum. The relevant cognitive areas of the cerebral cortex that project to the cerebellum include the posterior parietal cortex (spatial awareness), the supramodal areas of the superior temporal gyrus (language), the posterior parahippocampal areas (spatial memory), the visual association areas in the parastriate cortices (higher-order visual processing), and the prefrontal cortex (complex reasoning, judgment attention, and working memory). There are also projections from the cingulate gyrus to the pons. The organization of these anatomical pathways helps clarify the role the cerebellum plays in motor as well as non-motor functions. The cerebellum has also been shown to connect brainstem nuclei to the limbic system with implications for the function of the neurotransmitters serotonin, norepinephrine, and dopamine and the limbic system. Cerebellar anatomy It has been suggested that specific parts of the cerebellum are responsible for different functions. Mapping of the cerebellum has shown that sensorimotor, motor, and somatosensory information is processed in the anterior lobe, specifically in lobules V, VI, VIII A/B. The posterior lobe (notably cerebellar lobules VI and VII) is responsible for cognitive and emotional functions. Lobule VII includes the vermis in the midline, and the hemispheric parts of lobule VIIA (Crus I and Crus II), and lobule VIIB). This explains why CCAS occurs with damage to the posterior lobe. In the study of Levisohn et al. children with CCAS showed a positive correlation between damage to the midline vermis and impairments in affect. The authors hypothesized that deficits in affect are linked to damage of the vermis and fastigial nuclei, whereas deficits in cognition are linked to damage of the vermis and cerebellar hemispheres. These notions were consistent with the earlier suggestion (by psychiatrist Robert G. Heath), that the vermis of the cerebellum is responsible for emotional regulation. The deep nuclei of the cerebellum also have specific functions. The interpositus nucleus is involved with motor function, the dentate nucleus with cognitive functions, and the fastigial nucleus with limbic functions. It has been shown that phylogenetically the dentate nuclei developed with the association areas of the frontal cortex, supporting the view that the dentate nucleus is responsible for cognitive functions. Lateralization There have been studies that show laterality effects of cerebellar damage with relation to CCAS. Language in the cerebellum seems to be contralateral to the dominant language hemisphere in the frontal lobes, meaning if the language is dominant in the left hemisphere of the frontal lobes, the right side of the cerebellum will be responsible for language (see Tedesco et al. for a discussion of lack of lateralization). Lateralization is also observed with visuospatial functions. One study found that patients with left cerebellar lesions performed more poorly on a visuospatial task than did patients with right cerebellar lesions and healthy control adults. It has also been shown that lesions of the right cerebellum result in greater cognitive deficits than lesions of the left hemisphere. Treatments The current treatments for CCAS focus on relieving the symptoms. One treatment is a cognitive-behavioral therapy (CBT) technique that involves making the patient aware of their cognitive problems. For example, many CCAS patients struggle with multitasking. With CBT, the patient would have to be aware of this problem and focus on just one task at a time. This technique is also used to relieve some motor symptoms. In a case study with a patient who had a stroke and developed CCAS, improvements in mental function and attention were achieved through reality orientation therapy and attention process training. Reality orientation therapy consists of continually exposing the patient to stimuli of past events, such as photos. Attention process training consists of visual and auditory tasks that have been shown to improve attention. The patient struggled in applying these skills to “real-life” situations. It was the help of his family at home that significantly helped him regain his ability to perform activities of daily living. The family would motivate the patient to perform basic tasks and made a regular schedule for him to follow. Transcranial magnetic stimulation (TMS) has also been proposed to be a possible treatment of psychiatric disorders of the cerebellum. One study used TMS on the vermis of patients with schizophrenia. After stimulation, the patients showed increased happiness, alertness and energy, and decreased sadness. Neuropsychological testing post-stimulation showed improvements in working memory, attention, and visual spatial skill. Another possible method of treatment for CCAS is doing exercises that are used to relieve the motor symptoms. These physical exercises have been shown to also help with the cognitive symptoms. Medications that help relieve deficits in traumatic brain injuries in adults have been proposed as candidates to treat CCAS. Bromocriptine, a direct D2 agonist, has been shown to help with deficits in executive function and spatial learning abilities. Methylphenidate has been shown to help with deficits in attention and inhibition. Neither of these drugs has yet been tested on a CCAS population. It may also be that some of the symptoms of CCAS improve over time without any formal treatment. In the original report of CCAS, four patients with CCAS were re-examined one to nine months after their initial neuropsychological evaluation. Three of the patients showed improvement in deficits without any kind of formal treatment, though executive function was still found to be one standard deviation below average. In one patient, the deficits worsened over time. This patient had cerebellar atrophy and worsened in visual spatial abilities, concept formation, and verbal memory. Future research There is much research that needs to be conducted on CCAS. A necessity for future research is to conduct more longitudinal studies in order to determine the long-term effects of CCAS. One way this can be done is by studying cerebellar hemorrhage that occurs during infancy. This would allow CCAS to be studied over a long period to see how CCAS affects development. It may be of interest to researchers to conduct more research on children with CCAS, as the survival rate of children with tumors in the cerebellum is increasing. References Cognitive disorders Syndromes affecting the cerebellum

21st century skills

21st century skills comprise skills, abilities, and learning dispositions identified as requirements for success in 21st century society and workplaces by educators, business leaders, academics, and governmental agencies. This is part of an international movement focusing on the skills required for students to prepare for workplace success in a rapidly changing, digital society. Many of these skills are associated with deeper learning, which is based on mastering skills such as analytic reasoning, complex problem solving, and teamwork, which differ from traditional academic skills as these are not content knowledge-based. During the latter decades of the 20th century and into the 21st century, society evolved through technology advancements at an accelerated pace, impacting economy and the workplace, which impacted the educational system preparing students for the workforce. Beginning in the 1980s, government, educators, and major employers issued a series of reports identifying key skills and implementation strategies to steer students and workers towards meeting these changing societal and workplace demands. Western economies transformed from industrial-based to service-based, with trades and vocations having smaller roles. However, specific hard skills and mastery of particular skill sets, with a focus on digital literacy, are in increasingly high demand. People skills that involve interaction, collaboration, and managing others are increasingly important. Skills that enable flexibility and adaptability in different roles and fields, those that involve processing information and managing people more than manipulating equipment—in an office or a factory—are in greater demand. These are also referred to as "applied skills" or "soft skills", including personal, interpersonal, or learning-based skills, such as life skills (problem-solving behaviors), people skills, and social skills. The skills have been grouped into three main areas: Learning and innovation skills: critical thinking and problem solving, communications and collaboration, creativity and innovation Digital literacy skills: information literacy, media literacy, Information and communication technologies (ICT) literacy Career and life skills: flexibility and adaptability, initiative and self-direction, social and cross-cultural interaction, productivity and accountability Many of these skills are also identified as key qualities of progressive education, a pedagogical movement that began in the late nineteenth century and continues in various forms to the present. Background Since the early 1980s, a variety of governmental, academic, non-profit, and corporate entities have conducted considerable research to identify key personal and academic skills and competencies needed for the current and next generation. Though identification and implementation of 21st century skills into education and workplaces began in the United States, it has spread to Canada, the United Kingdom, New Zealand, and through national and international organizations such as APEC and the OECD. In 1981, the US Secretary of Education created the National Commission on Excellence in Education to examine the quality of education in the United States." The commission issued its report A Nation at Risk: The Imperative for Educational Reform in 1983. A key finding was that "educational reform should focus on the goal of creating a Learning Society." The report's recommendations included instructional content and skills: Five New Basics: English, Mathematics, Science, Social Studies, Computer Science Other Curriculum Matters: Develop proficiency, rigor, and skills in Foreign Languages, Performing Arts, Fine Arts, Vocational Studies, and the pursuit of higher-level education. Skills and abilities (consolidated): enthusiasm for learning deep understanding application of learning examination, inquiry, critical thinking and reasoning communication – write well, listen effectively, discuss intelligently, be proficient in a foreign language, cultural, social, and environmental – understanding and implications technology – understand the computer as an information, computation, and communication device, and the world of computers, electronics, and related technologies. diverse learning across a broad range – fine arts, performing arts, and vocational Until the dawn of the 21st century, education systems across the world focused on preparing students to accumulate content and knowledge. As a result, schools focused on providing literacy and numeracy skills students, as these were perceived as necessary. However, developments in technology and telecommunication have made information and knowledge easily accessible. Therefore, while skills such as literacy and numeracy remain relevant and necessary, they no longer sufficiently prepare students for 21st century workplace success. In response to technological, demographic and socio-economic changes, education systems began shifting toward curricula and instruction that integrated a range of skills involving, not only on cognition, but interdependencies of cognitive, social, and emotional characteristics. Notable efforts were conducted by the US Secretary of Labor's Commission on Achieving Necessary Skills (SCANS), a national coalition called the Partnership for 21st Century Skills (P21), the international Organisation for Economic Co-operation and Development, the American Association of college and Universities, researchers at MIT and other institutions of higher learning, and private organizations. Additional research has found that the top skills demanded by U.S. Fortune 500 companies by the year 2000 had shifted from traditional reading, writing and arithmetic to teamwork, problem solving, and interpersonal skills. A 2006 Conference Board survey of some 400 employers revealed that the most important skills for new workforce entrants included oral and written communications and critical thinking/problem solving, ahead of basic knowledge and skills, such as the reading comprehension and mathematics. While the 'three Rs' were still considered foundational to new workforce entrants' abilities, employers emphasized that applied skills like collaboration/teamwork and critical thinking were 'very important' to success at work." A 2006 report from MIT researchers countered the suggestion that students acquire critical skills and competencies independently by interacting with popular culture, noting three continuing trends that "suggest the need for policy and pedagogical interventions:" The Participation Gap – the unequal access to the opportunities, experiences, skills, and knowledge that will prepare youth for full participation in the world of tomorrow. The Transparency Problem – The challenges young people face in learning to see clearly the ways that media shape perceptions of the world. The Ethics Challenge – The breakdown of traditional forms of professional training and socialization that might prepare young people for their increasingly public roles as media makers and community participants." According to labor economists at MIT and Harvard's Graduate School of Education, the economic changes brought about over the past four decades by emerging technology and globalization, employers' demands for people with competencies like complex thinking and communications skills has increased greatly. They argue that the success of the U.S. economy will rely on the nation's ability to give students the "foundational skills in problem-solving and communications that computers don't have." In 2010, the Common Core State Standards Initiative, an effort sponsored by the National Governors Association (NGA) and the Council of Chief State School Officers (CCSSO), issued the Common Core Standards, calling for the integration of 21st century skills into K-12 curricula across the United States. Teachers and general citizens also played a critical role in its development along with the NGA and CCSSO by commenting during two public forums which helped shape the curriculum and standards. States also convened teams of teachers to assist and provide feedback looking towards the National Education Association (NEA) and many other education organizations to provide constructive feedback. As of December 2018, 45 states have entirely adopted the common core standards, one state has adopted half by only adopting the literacy section (Minnesota), and only four states remain who have not adopted into the common core standards of education (Alaska, Nebraska, Texas, and Virginia). Skills The skills and competencies considered "21st century skills" share common themes, based on the premise that effective learning, or deeper learning, requires a set of student educational outcomes that include acquisition of robust core academic content, higher-order thinking skills, and learning dispositions. This pedagogy involves creating, working with others, analyzing, and presenting and sharing both the learning experience and the learned knowledge or wisdom with peers, mentors, and teachers. Additionally, these skills foster engagement; seeking, forging, and facilitating connections to knowledge, ideas, peers, instructors, and wider audiences; creating/producing; and presenting/publishing. The classification or grouping has been undertaken to encourage and promote pedagogies that facilitate deeper learning through both traditional instruction as well as active learning, project-based learning, problem based learning, and others. A 2012 survey conducted by the American Management Association (AMA) identified three top skills necessary for their employees: critical thinking, communication and collaboration. Below are some of the more readily identifiable lists of 21st century skills. Common Core The Common Core Standards issued in 2010 intended to support the "application of knowledge through higher-order thinking skills." The initiative's stated goals promote the skills and concepts required for college and career readiness in multiple disciplines and life in the global economy. Skills identified for success in the areas of literacy and mathematics: cogent reasoning evidence collection critical-thinking, problem-solving, analytical thinking communication SCANS Following the release of A Nation at Risk, the U.S. Secretary of Labor appointed the Secretary's Commission on Achieving Necessary Skills (SCANS) to determine the skills needed for young people to succeed in the workplace fostering a high-performance economy. SCANS focused on a "learning a living" system. In 1991, an initial report was issued titled, What Work Requires of Schools. The report concluded that a high-performance workplace requires workers who have key fundamental skills: basic skills and knowledge, thinking skills to apply that knowledge, personal skills to manage and perform; and five key workplace competencies. Fundamental skills: Basic skills: reads, writes, performs arithmetic and mathematical operations, listens and speaks. Thinking skills: thinks creatively, makes decisions, solves problems, visualizes, knows how to learn, and reasons Personal qualities: displays responsibility, self-esteem, sociability, self-management, and integrity and honesty Workplace competencies: Resources: identifies, organizes, plans, and allocates resources Interpersonal: works with others (participates as member of a team, teaches others new skills, serves clients/customers, exercises leadership, negotiates, works with diversity) Information: acquires and uses information (acquires and evaluates, organizes and maintains, and interprets and communicates information; uses computers to process information) Systems: understands complex inter-relationships (understands systems, monitors and corrects performance, improves or designs systems) Technology: works with a variety of technologies (selects technology, applies technology to task, maintains and troubleshoots equipment) Partnership for 21st Century Skills (P21) In 2002, the Partnership for 21st Century Skills (then Partnership for 21st Century Learning, or P21.org, now disbanded) was founded as a non-profit organization by a coalition that included members of the national business community, education leaders, and policymakers: the National Education Association (NEA), United States Department of Education, AOL Time Warner Foundation, Apple Computer, Inc., Cable in the Classroom, Cisco Systems, Inc., Dell Computer Corporation, Microsoft Corporation, SAP, Ken Kay (President and co-founder), and Diny Golder-Dardis. To foster a national conversation on "the importance of 21st century skills for all students" and "position 21st century readiness at the center of US K-12 education", P21 identified six key areas: Core subjects 21st century content Learning and thinking skills Information and communication technologies (ICT) literacy Life skills 21st century assessments 7C Skills were identified by P21 senior fellows, Bernie Trilling and Charles Fadel: Critical thinking and problem solving Creativity and innovation Cross-cultural understanding Communications, information, and media literacy Computing and ICT literacy Career and life-skills 4 Cs Prompted by many school districts and states requesting a more manageable set of skills as a starting point, P21 conducted research that identified a commonly accepted subset they called the Four Cs of 21st century learning: Collaboration Communication Critical thinking Creativity The University of Southern California's Project New Literacies website list four different "C" skills: Create Circulate Connect Collaborate Participatory culture and new media literacies Researchers at MIT, led by Henry Jenkins, Director of the Comparative Media Studies Program, in 2006 issued a white paper ("Confronting the Challenges of a Participatory Culture: Media Education for the 21st Century"), that examined digital media and learning. To address this Digital Divide, they recommended an effort be made to develop the cultural competencies and social skills required to participate fully in modern society instead of merely advocating for installing computers in each classroom. What they term participatory culture shifts this literacy from the individual level to a broader connection and involvement, with the premise that networking and collaboration develop social skills that are vital to new literacies. These in turn build on traditional foundation skills and knowledge taught in school: traditional literacy, research, technical, and critical analysis skills. Participatory culture is defined by this study as having: low barriers to artistic expression and civic engagement, strong support for creating and sharing one's creations, informal mentorship, belief that members' own contributions matter, and social connection (caring what other people think about their creations). Forms of participatory culture include: Affiliations – memberships, formal and informal, in online communities centered around various forms of media, such as message boards, metagaming, game clans, and other social media). Expressions – producing new creative forms, such as digital sampling, skinning and modding, fan videomaking, fan fiction writing, zines, mash-ups. Collaborative Problem-solving – working together in teams, formal and informal, to complete tasks and develop new knowledge (such as through Wikipedia, alternative reality gaming, spoiling). Circulations – shaping the flow of media (such as podcasting, blogging) The skills identified were: Play Simulation Appropriation Multitasking Distributed Cognition Collective Intelligence Judgment Transmedia Navigation Networking Negotiation A 2005 study (Lenhardt & Madden) found that more than one-half of all teens have created media content, and roughly one third of teens who use the Internet shared content they produced, indicating a high degree of involvement in participatory cultures. Such digital literacies emphasize the intellectual activities of a person working with sophisticated information communications technology, not on proficiency with the tool. EnGauge 21st century skills In 2003 the North Central Regional Educational Laboratory and the Metiri Group issued a report entitled "enGauge 21st Century Skills: Literacy in the Digital Age" based on two years of research. The report called for policymakers and educators to define 21st century skills, highlight the relationship of those skills to conventional academic standards, and recognize the need for multiple assessments to measure and evaluate these skills within the context of academic standards and the current technological and global society. To provide a common understanding of, and language for discussing, the needs of students, citizens, and workers in a modern digital society, the report identified four "skill clusters": Digital-Age Inventive Thinking Effective Communication High Productivity OECD competencies In 1997, member countries of the Organisation for Economic Co-operation and Development launched the Programme for International Student Assessment (PISA) to monitor "the extent to which students near the end of compulsory schooling have acquired the knowledge and skills essential for full participation in society". In 2005 they identified three "Competency Categories to highlight delivery related, interpersonal, and strategic competencies:" Using Tools Interactively Interacting in Heterogeneous Groups Acting Autonomously American Association of Colleges and Universities (AAC&U) The AAC&U conducted several studies and surveys of their members. In 2007 they recommended that graduates of higher education attain four skills—The Essential Learning Outcomes: Knowledge of Human Cultures and the Physical and Natural World Intellectual and Practical Skills Personal and Social Responsibility Integrative Learning They found that skills most widely addressed in college and university goals are: writing critical thinking quantitative reasoning oral communication intercultural skills information literacy ethical reasoning A 2015 survey of AAC&U member institutions added the following goals: analytic reasoning research skills and projects integration of learning across disciplines application of learning beyond the classroom civic engagement and competence ISTE / NETS performance standards The ISTE Educational Technology Standards (formerly National Educational Technology Standards (NETS)) are a set of standards published by the International Society for Technology in Education (ISTE) to leverage the use of technology in K-12 education. These are sometimes intermixed with information and communication technologies (ICT) skills. In 2007 NETS issued a series of six performance indicators (only the first four are on their website as of 2016): Creativity and Innovation Communication and Collaboration Research and Information Fluency Critical Thinking, Problem Solving, and Decision Making Digital Citizenship Technology Operations and Concepts ICT Literacy Panel digital literacy standards (2007) In 2007 the Educational Testing Service (ETS) ICT Literacy Panel released its digital literacy standards: Information and Communication Technologies (ICT) proficiencies: Cognitive proficiency Technical proficiency ICT proficiency A person possessing these skills would be expected to perform these tasks for a particular set of information: access, manage, integrate, evaluate, create/publish/present. The emphasis is on proficiency with digital tools. Dede learning styles and categories In 2005, Chris Dede of the Harvard Graduate School of Education developed a framework based on new digital literacies entitled Neomillennial Learning Styles: Fluency in multiple media Active learning based on collectively seeking, sieving, and synthesizing experiences. Expression through non-linear, associational webs of representations. Co-design by teachers and students of personalized learning experiences. Dede category system With the exponential expansion of personal access to Internet resources, including social media, information and content on the Internet has evolved from being created by website providers to communities of contributors and individuals. The 21st century Internet centered on material created by a small number of people, Web 2.0 tools (e.g. Wikipedia) foster online communication, collaboration, and creation of content by large numbers of people (individually or in groups) in online communities. In 2009, Dede created a category system for Web 2.0 tools: Sharing (communal bookmarking, photo/video sharing, social networking, writers' workshops/fanfiction) Thinking (blogs, podcasts, online discussion fora) Co-Creating (wikis/collaborative file creation, mashups/collective media creation, collaborative social change communities) World Economic Forum In 2015, after consultations with Charles Fadel (of P21 and the Center for Curriculum Redesign), the World Economic Forum published a report titled "New Vision for Education: Unlocking the Potential of Technology" that focused on the pressing issue of the 21st-century skills gap and ways to address it through technology. In the report, they defined a set of 16 crucial proficiencies for education in the 21st century. Those skills include six "foundational literacies", four "competencies" and six "character qualities" listed below. Foundation literacies: Literacy and numeracy Scientific literacy ICT literacy Financial literacy Cultural literacy Civic literacy Competencies: Critical thinking/problem solving Communication Collaboration Creativity Character qualities: Initiative Persistence/grit Adaptability Curiosity Leadership Social and cultural awareness National Research Council In a paper titled "Education for Life and Work: Developing Transferable Knowledge and Skills in the 21st Century" produced by the National Research Council of National Academies, the National Research defines 21st century skills, describes how the skills relate to each other and summaries the evidence regarding these skills. As a first step toward describing "21st century skills", the National Research Council identified three domains of competence: cognitive, interpersonal, and intrapersonal while recognizing that these domains intertwine in human development and learning. More specifically, these three domains represent distinct facets of human thinking, building on previous efforts to identify and organize dimensions of human behavior. The committee produced the following cluster of 21st century skills in the above-mentioned three domains. Cognitive competencies: Cognitive processes and strategies: Critical thinking, problem solving, analysis, reasoning and argumentation, interpretation, decision-making, adaptive learning Knowledge: Information literacy, ICT literacy, oral and written communication, and active listening Creativity: Creativity and innovation Intrapersonal competencies: Intellectual openness: Flexibility, adaptability, artistic and cultural appreciation, personal and social responsibility, appreciation for diversity, adaptability, continuous learning, intellectual interest and curiosity Work ethic/conscientiousness: Initiative, self-direction, responsibility, perseverance, grit, career orientation, ethics, integrity, citizenship Positive core self-evaluation: Self monitoring, self evaluation, self reinforcement, physical and psychological health Interpersonal competencies: Teamwork and collaboration: Communication, collaboration, cooperation, teamwork, coordination, interpersonal skills Leadership: Responsibility, assertive communication, self presentation, social influence with others Center for Curriculum Redesign (“CCR”) After an extensive, 3-year review and synthesis of 111 global frameworks and 861 research papers, and using natural language processing and orthogonality analysis, CCR published in 2019 and updated in 2024 a list of ten competenciesthat concatenate the 250+ different terms used worldwide into: Skills: Creativity, Critical Thinking, Communication, Collaboration. Character: Curiosity, Courage, Resilience, Ethics. Meta-Learning: Metacognition & Metaemotion Additionally, CCR mapped the various competencies to the academic disciplines most conducive to their development. During its comprehensive research on AI’s present and future capabilities in education, CCR added an analysis of the more critical competencies in the age of AI, adding an “Emphasis” designation on specific facets of these competencies. For instance, since incremental creativity is reachable by AI, the human emphasis should be on imagination. Lastly, CCR introduced the motivational drivers of personalized learning in an age of AI: Identity (& Belonging), Agency (& Growth mindset), and Purpose (& Passion). Implementation Multiple agencies and organizations issued guides and recommendation for implementation of 21st century skills supporting and encouraging change in learning environments and learning spaces. Five separate educational areas impacted include standards, assessment, professional development, curriculum & instruction, and learning environments. The efforts to implement 21st century skills into learning environments and curricula supports the evolution of education systems from traditional practices or factory model school model into a variety of different organizational models. Examples of hands-on learning and project-based learning are observable in programs and spaces such as STEM and makerspaces. Collaborative learning environments fostered flexibility in furniture and classroom layout as well as differentiated spaces, such as small seminar rooms near classrooms. Literacy with, and access to, digital technology also impacted the design of furniture and fixed components as students and teachers use tablets, interactive whiteboards and interactive projectors. Classroom sizes changed to accommodate a variety of furniture arrangements and groupings, as opposed to traditional configurations of desks in rows. In 2016, the Brookings Institution found that more than 100 countries embraced the concept of “21st century skills” in one terminology or another. However, further research by Brookings and CCR in 2018 showed that none of the major jurisdictions provided professional development to teachers, nor assessments of these competencies. See also Applied academics Design-based learning Information literacies Learning environment Learning space Phenomenon-based learning STEM fields References External links Seven Survival Skills Chris Dede, Comparing Frameworks for "21st Century Skills", Harvard Graduate School, July 2009. How Do You Define 21st-Century Learning? Making 21st Century Schools – Creating Learner-Centered Schoolplaces/Workplaces for a New Culture of Students at Work, Bob Pearlman About eSTEM Collaboration Curricula Learning Learning methods Learning programs Pedagogy Skills United States educational programs

Cognitive distortion

A cognitive distortion is a thought that causes a person to perceive reality inaccurately due to being exaggerated or irrational. Cognitive distortions are involved in the onset or perpetuation of psychopathological states, such as depression and anxiety. According to Aaron Beck's cognitive model, a negative outlook on reality, sometimes called negative schemas (or schemata), is a factor in symptoms of emotional dysfunction and poorer subjective well-being. Specifically, negative thinking patterns reinforce negative emotions and thoughts. During difficult circumstances, these distorted thoughts can contribute to an overall negative outlook on the world and a depressive or anxious mental state. According to hopelessness theory and Beck's theory, the meaning or interpretation that people give to their experience importantly influences whether they will become depressed and whether they will experience severe, repeated, or long-duration episodes of depression. Challenging and changing cognitive distortions is a key element of cognitive behavioral therapy (CBT). Definition Cognitive comes from the Medieval Latin , equivalent to Latin , 'known'. Distortion means the act of twisting or altering something out of its true, natural, or original state. History In 1957, American psychologist Albert Ellis, though he did not know it yet, would aid cognitive therapy in correcting cognitive distortions and indirectly helping David D. Burns in writing The Feeling Good Handbook. Ellis created what he called the ABC Technique of rational beliefs. The ABC stands for the activating event, beliefs that are irrational, and the consequences that come from the beliefs. Ellis wanted to prove that the activating event is not what caused the emotional behavior or the consequences, but the beliefs and how the person irrationally perceives the events which aid the consequences. With this model, Ellis attempted to use rational emotive behavior therapy (REBT) with his patients, in order to help them "reframe" or reinterpret the experience in a more rational manner. In this model, Ellis explains it all to his clients, while Beck helps his clients figure this out on their own. Beck first started to notice these automatic distorted thought processes when practicing psychoanalysis, while his patients followed the rule of saying anything that comes to mind. He realized that his patients had irrational fears, thoughts, and perceptions that were automatic. Beck began noticing his automatic thought processes that he knew his patients had but did not report. Most of the time the thoughts were biased against themselves and very erroneous. Beck believed that the negative schemas developed and manifested themselves in the perspective and behavior. The distorted thought processes led to focusing on degrading the self, amplifying minor external setbacks, experiencing other's harmless comments as ill-intended, while simultaneously seeing self as inferior. Inevitably cognitions are reflected in their behavior with a reduced desire to care for oneself, reduced desire to seek pleasure, and finally give up. These exaggerated perceptions, due to cognition, feel real and accurate because the schemas, after being reinforced through the behavior, tend to become 'knee-jerk' automatic and do not allow time for reflection. This cycle is also known as Beck's cognitive triad, focused on the theory that the person's negative schema applied to the self, the future, and the environment. In 1972, psychiatrist, psychoanalyst, and cognitive therapy scholar Aaron T. Beck published Depression: Causes and Treatment. He was dissatisfied with the conventional Freudian treatment of depression because there was no empirical evidence for the success of Freudian psychoanalysis. Beck's book provided a comprehensive and empirically supported theoretical model for depression—its potential causes, symptoms, and treatments. In Chapter 2, titled "Symptomatology of Depression", he described "cognitive manifestations" of depression, including low self-evaluation, negative expectations, self-blame and self-criticism, indecisiveness, and distortion of the body image. Beck's student David D. Burns continued research on the topic. In his book Feeling Good: The New Mood Therapy, Burns described personal and professional anecdotes related to cognitive distortions and their elimination. When Burns published Feeling Good: The New Mood Therapy, it made Beck's approach to distorted thinking widely known and popularized. Burns sold over four million copies of the book in the United States alone. It was a book commonly "prescribed" for patients with cognitive distortions that have led to depression. Beck approved of the book, saying that it would help others alter their depressed moods by simplifying the extensive study and research that had taken place since shortly after Beck had started as a student and practitioner of psychoanalytic psychiatry. Nine years later, The Feeling Good Handbook was published, which was also built on Beck's work and includes a list of ten specific cognitive distortions that will be discussed throughout this article. Main types John C. Gibbs and Granville Bud Potter propose four categories for cognitive distortions: self-centered, blaming others, minimizing-mislabeling, and assuming the worst. The cognitive distortions listed below are categories of negative self-talk. All-or-nothing thinking The "all-or-nothing thinking distortion" is also referred to as "splitting", "black-and-white thinking", and "polarized thinking." Someone with the all-or-nothing thinking distortion looks at life in black and white categories. Either they are a success or a failure; either they are good or bad; there is no in-between. According to one article, "Because there is always someone who is willing to criticize, this tends to collapse into a tendency for polarized people to view themselves as a total failure. Polarized thinkers have difficulty with the notion of being 'good enough' or a partial success." Example (from The Feeling Good Handbook): A woman eats a spoonful of ice cream. She thinks she is a complete failure for breaking her diet. She becomes so depressed that she ends up eating the whole quart of ice cream. This example captures the polarized nature of this distortion—the person believes they are totally inadequate if they fall short of perfection. In order to combat this distortion, Burns suggests thinking of the world in terms of shades of gray. Rather than viewing herself as a complete failure for eating a spoonful of ice cream, the woman in the example could still recognize her overall effort to diet as at least a partial success. This distortion is commonly found in perfectionists. Jumping to conclusions Reaching preliminary conclusions (usually negative) with little (if any) evidence. Three specific subtypes are identified: Mind reading Inferring a person's possible or probable (usually negative) thoughts from their behaviour and nonverbal communication; taking precautions against the worst suspected case without asking the person. Example 1: A student assumes that the readers of their paper have already made up their minds concerning its topic, and, therefore, writing the paper is a pointless exercise. Example 2: Kevin assumes that because he sits alone at lunch, everyone else must think he is a loser. (This can encourage self-fulfilling prophecy; Kevin may not initiate social contact because of his fear that those around him already perceive him negatively). Fortune-telling Predicting outcomes (usually negative) of events. Example: A depressed person tells themselves they will never improve; they will continue to be depressed for their whole life. One way to combat this distortion is to ask, "If this is true, does it say more about me or them?" Labelling Labelling occurs when someone overgeneralizes the characteristics of other people. Someone might use an unfavourable term to describe a complex person or event, such as assuming that a friend is upset with them due to a late reply to a text message, even though there could be various other reasons for the delay. It is a more extreme form of jumping-to-conclusions cognitive distortion where one presumes to know the thoughts, feelings, or intentions of others without any factual basis. Emotional reasoning In the emotional reasoning distortion, it is assumed that feelings expose the true nature of things and experience reality as a reflection of emotionally linked thoughts; something is believed true solely based on a feeling. Examples: "I feel stupid, therefore I must be stupid". Feeling fear of flying in planes, and then concluding that planes must be a dangerous way to travel. Feeling overwhelmed by the prospect of cleaning one's house, therefore concluding that it's hopeless to even start cleaning. Should/shouldn't and must/mustn't statements Making "must" or "should" statements was included by Albert Ellis in his rational emotive behavior therapy (REBT), an early form of CBT; he termed it "musturbation". Michael C. Graham called it "expecting the world to be different than it is". It can be seen as demanding particular achievements or behaviors regardless of the realistic circumstances of the situation. Example: After a performance, a concert pianist believes they should not have made so many mistakes. In Feeling Good: The New Mood Therapy, David Burns clearly distinguished between pathological "should statements", moral imperatives, and social norms. A related cognitive distortion, also present in Ellis' REBT, is a tendency to "awfulize"; to say a future scenario will be awful, rather than to realistically appraise the various negative and positive characteristics of that scenario. According to Burns, "must" and "should" statements are negative because they cause the person to feel guilty and upset at themselves. Some people also direct this distortion at other people, which can cause feelings of anger and frustration when that other person does not do what they should have done. He also mentions how this type of thinking can lead to rebellious thoughts. In other words, trying to whip oneself into doing something with "shoulds" may cause one to desire just the opposite. Gratitude traps A gratitude trap is a type of cognitive distortion that typically arises from misunderstandings regarding the nature or practice of gratitude. The term can refer to one of two related but distinct thought patterns: A self-oriented thought process involving feelings of guilt, shame, or frustration related to one's expectations of how things "should" be. An "elusive ugliness in many relationships, a deceptive 'kindness,' the main purpose of which is to make others feel indebted", as defined by psychologist Ellen Kenner. Personalization and blaming Personalization is assigning personal blame disproportionate to the level of control a person realistically has in a given situation. Example 1: A foster child assumes that they have not been adopted because they are not "loveable enough". Example 2: A child has bad grades. Their mother believes it is because they are not a good enough parent. Blaming is the opposite of personalization. In the blaming distortion, the disproportionate level of blame is placed upon other people, rather than oneself. In this way, the person avoids taking personal responsibility, making way for a "victim mentality". Example: Placing blame for marital problems entirely on one's spouse. Always being right In this cognitive distortion, being wrong is unthinkable. This distortion is characterized by actively trying to prove one's actions or thoughts to be correct, and sometimes prioritizing self-interest over the feelings of another person. In this cognitive distortion, the facts that oneself has about their surroundings are always right while other people's opinions and perspectives are wrongly seen. Fallacy of change Relying on social control to obtain cooperative actions from another person. The underlying assumption of this thinking style is that one's happiness depends on the actions of others. The fallacy of change also assumes that other people should change to suit one's own interests automatically, and/or that it is fair to pressure them to change. It may be present in most abusive relationships in which partners' "visions" of each other are tied into the belief that happiness, love, trust, and perfection would just occur once they or the other person change aspects of their beings. Minimizing-mislabeling Magnification and minimization Giving proportionally greater weight to a perceived failure, weakness or threat, or lesser weight to a perceived success, strength or opportunity, so that the weight differs from that assigned by others, such as "making a mountain out of a molehill". In depressed clients, often the positive characteristics of other people are exaggerated, and their negative characteristics are understated. Catastrophizing is a form of magnification where one gives greater weight to the worst possible outcome, however unlikely, or experiences a situation as unbearable or impossible when it is just uncomfortable. Labeling and mislabeling A form of overgeneralization; attributing a person's actions to their character instead of to an attribute. Rather than assuming the behaviour to be accidental or otherwise extrinsic, one assigns a label to someone or something that is based on the inferred character of that person or thing. Assuming the worst Overgeneralizing Someone who overgeneralizes makes faulty generalizations from insufficient evidence. Such as seeing a "single negative event" as a "never-ending pattern of defeat", and as such drawing a very broad conclusion from a single incident or a single piece of evidence. Even if something bad happens only once, it is expected to happen over and over again. Example 1: A person is asked out on a first date, but not a second one. They are distraught as tells a friend, "This always happens to me! I'll never find love!" Example 2: A person is lonely and often spends most of their time at home. Friends sometimes ask them to dinner and to meet new people. They feel it is useless to even try. No one could really like them. And anyway, all people are the same: petty and selfish. One suggestion to combat this distortion is to "examine the evidence" by performing an accurate analysis of one's situation. This aids in avoiding exaggerating one's circumstances. Disqualifying the positive Disqualifying the positive refers to rejecting positive experiences by insisting they "don't count" for some reason or other. Negative belief is maintained despite contradiction by everyday experiences. Disqualifying the positive may be the most common fallacy in the cognitive distortion range; it is often analyzed with "always being right", a type of distortion where a person is in an all-or-nothing self-judgment. People in this situation show signs of depression. Examples include: "I will never be as good as Jane" "Anyone could have done as well" "They are just congratulating me to be nice" Mental filtering Filtering distortions occur when an individual dwells only on the negative details of a situation and filters out the positive aspects. Example: Andy gets mostly compliments and positive feedback about a presentation he has done at work, but he also has received a small piece of criticism. For several days following his presentation, Andy dwells on this one negative reaction, forgetting all of the positive reactions that he had also been given. The Feeling Good Handbook notes that filtering is like a "drop of ink that discolors a beaker of water". One suggestion to combat filtering is a cost–benefit analysis. A person with this distortion may find it helpful to sit down and assess whether filtering out the positive and focusing on the negative is helping or hurting them in the long run. Conceptualization In a series of publications, philosopher Paul Franceschi has proposed a unified conceptual framework for cognitive distortions designed to clarify their relationships and define new ones. This conceptual framework is based on three notions: (i) the reference class (a set of phenomena or objects, e.g. events in the patient's life); (ii) dualities (positive/negative, qualitative/quantitative, ...); (iii) the taxon system (degrees allowing to attribute properties according to a given duality to the elements of a reference class). In this model, "dichotomous reasoning", "minimization", "maximization" and "arbitrary focus" constitute general cognitive distortions (applying to any duality), whereas "disqualification of the positive" and "catastrophism" are specific cognitive distortions, applying to the positive/negative duality. This conceptual framework posits two additional cognitive distortion classifications: the "omission of the neutral" and the "requalification in the other pole". Cognitive restructuring Cognitive restructuring (CR) is a popular form of therapy used to identify and reject maladaptive cognitive distortions, and is typically used with individuals diagnosed with depression. In CR, the therapist and client first examine a stressful event or situation reported by the client. For example, a depressed male college student who experiences difficulty in dating might believe that his "worthlessness" causes women to reject him. Together, therapist and client might then create a more realistic cognition, e.g., "It is within my control to ask girls on dates. However, even though there are some things I can do to influence their decisions, whether or not they say yes is largely out of my control. Thus, I am not responsible if they decline my invitation." CR therapies are designed to eliminate "automatic thoughts" that include clients' dysfunctional or negative views. According to Beck, doing so reduces feelings of worthlessness, anxiety, and anhedonia that are symptomatic of several forms of mental illness. CR is the main component of Beck's and Burns's CBT. Narcissistic defense Those diagnosed with narcissistic personality disorder tend, unrealistically, to view themselves as superior, overemphasizing their strengths and understating their weaknesses. Narcissists use exaggeration and minimization this way to shield themselves against psychological pain. Decatastrophizing In cognitive therapy, decatastrophizing or decatastrophization is a cognitive restructuring technique that may be used to treat cognitive distortions, such as magnification and catastrophizing, commonly seen in psychological disorders like anxiety and psychosis. Major features of these disorders are the subjective report of being overwhelmed by life circumstances and the incapability of affecting them. The goal of CR is to help the client change their perceptions to render the felt experience as less significant. Criticism Common criticisms of the diagnosis of cognitive distortion relate to epistemology and the theoretical basis. If the perceptions of the patient differ from those of the therapist, it may not be because of intellectual malfunctions, but because the patient has different experiences. In some cases, depressed subjects appear to be "sadder but wiser". See also References Cognitive therapy Defence mechanisms Cognitive biases Anxiety Barriers to critical thinking Depression (mood) Error Narcissism Deception

Pain management

Pain management is an aspect of medicine and health care involving relief of pain (pain relief, analgesia, pain control) in various dimensions, from acute and simple to chronic and challenging. Most physicians and other health professionals provide some pain control in the normal course of their practice, and for the more complex instances of pain, they also call on additional help from a specific medical specialty devoted to pain, which is called pain medicine. Pain management often uses a multidisciplinary approach for easing the suffering and improving the quality of life of anyone experiencing pain, whether acute pain or chronic pain. Relief of pain in general (analgesia) is often an acute affair, whereas managing chronic pain requires additional dimensions. A typical multidisciplinary pain management team may include: medical practitioners, pharmacists, clinical psychologists, physiotherapists, occupational therapists, recreational therapists, physician assistants, nurses, and dentists. The team may also include other mental health specialists and massage therapists. Pain sometimes resolves quickly once the underlying trauma or pathology has healed, and is treated by one practitioner, with drugs such as pain relievers (analgesics) and occasionally also anxiolytics. Effective management of chronic (long-term) pain, however, frequently requires the coordinated efforts of the pain management team. Effective pain management does not always mean total eradication of all pain. Rather, it often means achieving adequate quality of life in the presence of pain, through any combination of lessening the pain and/or better understanding it and being able to live happily despite it. Medicine treats injuries and diseases to support and speed healing. It treats distressing symptoms such as pain and discomfort to reduce any suffering during treatment, healing, and dying. The task of medicine is to relieve suffering under three circumstances. The first is when a painful injury or pathology is resistant to treatment and persists. The second is when pain persists after the injury or pathology has healed. Finally, the third circumstance is when medical science cannot identify the cause of pain. Treatment approaches to chronic pain include pharmacological measures, such as analgesics (pain killer drugs), antidepressants, and anticonvulsants; interventional procedures, physical therapy, physical exercise, application of ice or heat; and psychological measures, such as biofeedback and cognitive behavioral therapy. Defining pain In the nursing profession, one common definition of pain is any problem that is "whatever the experiencing person says it is, existing whenever the experiencing person says it does". Pain management includes patient and communication about the pain problem. To define the pain problem, a health care provider will likely ask questions such as: How intense is the pain? How does the pain feel? Where is the pain? What, if anything, makes the pain lessen? What, if anything, makes the pain increase? When did the pain start? After asking such questions, the health care provider will have a description of the pain. Pain management will then be used to address that pain. Adverse effects There are many types of pain management. Each have their own benefits, drawbacks, and limits. A common challenge in pain management is communication between the health care provider and the person experiencing pain. People experiencing pain may have difficulty recognizing or describing what they feel and how intense it is. Health care providers and patients may have difficulty communicating with each other about how pain responds to treatments. There is a risk in many types of pain management for the patient to take treatment that is less effective than needed or which causes other difficulties and side effects. Some treatments for pain can be harmful if overused. A goal of pain management for the patient and their health care provider is to identify the amount of treatment needed to address the pain without going beyond that limit. Another problem with pain management is that pain is the body's natural way of communicating a problem. Pain is supposed to resolve as the body heals itself with time and pain management. Sometimes pain management covers a problem, and the patient might be less aware that they need treatment for a deeper problem. Physical approach Physical medicine and rehabilitation Physical medicine and rehabilitation uses a range of physical techniques such as heat and electrotherapy, as well as therapeutic exercises and behavioral therapy. These techniques are usually part of an interdisciplinary or multidisciplinary program that might also include pharmaceutical medicines. Spa therapy has showed positive effects in reducing pain among patients with chronic low back pain. However, there are limited studies looking at this approach. Studies have shown that kinesiotape could be used on individuals with chronic low back pain to reduce pain. The Center for Disease Control recommends that physical therapy and exercise can be prescribed as a positive alternative to opioids for decreasing one's pain in multiple injuries, illnesses, or diseases. This can include chronic low back pain, osteoarthritis of the hip and knee, or fibromyalgia. Exercise alone or with other rehabilitation disciplines (such as psychologically based approaches) can have a positive effect on reducing pain. In addition to improving pain, exercise also can improve one's well-being and general health. Manipulative and mobilization therapy are safe interventions that likely reduce pain for patients with chronic low back pain. However, manipulation produces a larger effect than mobilization. Specifically in chronic low back pain, education about the way the brain processes pain in conjunction with routine physiotherapy interventions may provide short term relief of disability and pain. Exercise interventions Physical activity interventions, such as tai chi, yoga and Pilates, promote harmony of the mind and body through total body awareness. These practices incorporate breathing techniques, meditation and a wide variety of movements, while training the body to perform functionally by increasing strength, flexibility, and range of motion. Physical activity can also benefit chronic sufferers by reducing inflammation and sensitivity, and boosting overall energy. Physical activity and exercise may improve chronic pain (pain lasting more than 12 weeks), and overall quality of life, while minimizing the need for pain medications. More specifically, walking has been effective in improving pain management in chronic low back pain. TENS Transcutaneous electrical nerve stimulation (TENS) is a self-operated portable device intended to help regulate and control chronic pain via electrical impulses. Limited research has explored the effectiveness of TENS in relation to pain management of multiple sclerosis (MS). MS is a chronic autoimmune neurological disorder, which consists of the demyelination of the nerve axons and disruption of nerve conduction velocity and efficiency. In one study, electrodes were placed over the lumbar spine and participants received treatment twice a day and at any time when they experienced a painful episode. This study found that TENS would be beneficial to MS patients who reported localized or limited symptoms to one limb. The research is mixed with whether or not TENS helps manage pain in MS patients. Transcutaneous electrical nerve stimulation has been found to be ineffective for lower back pain. However, it might help with diabetic neuropathy as well as other illnesses. tDCS Transcranial direct current stimulation (tDCS) is a non-invasive technique of brain stimulation that can modulate activity in specific brain cortex regions, and it involves the application of low-intensity (up to 2 mA) constant direct current to the scalp through electrodes in order to modulate excitability of large cortical areas. tDCS may have a role in pain assessment by contributing to efforts in distinguishing between somatic and affective aspects of pain experience. Zaghi and colleagues (2011) found that the motor cortex, when stimulated with tDCS, increases the threshold for both the perception of non-painful and painful stimuli. Although there is a greater need for research examining the mechanism of electrical stimulation in relation to pain treatment, one theory suggests that the changes in thalamic activity may be due the influence of motor cortex stimulation on the decrease in pain sensations. In relation to MS, a study found that after daily tDCS sessions resulted in an individual's subjective report of pain to decrease when compared to a sham condition. In addition, the study found a similar improvement at 1 to 3 days before and after each tDCS session. Fibromyalgia is a disorder in which an individual experiences dysfunctional brain activity, musculoskeletal pain, fatigue, and tenderness in localized areas. Research examining tDCS for pain treatment in fibromyalgia has found initial evidence for pain decreases. Specifically, the stimulation of the primary motor cortex resulted in significantly greater pain improvement in comparison to the control group (e.g., sham stimulation, stimulation of the DLPFC). However, this effect decreased after treatment ended, but remained significant for three weeks following the extinction of treatment. Acupuncture Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes. An analysis of the 13 highest quality studies of pain treatment with acupuncture, published in January 2009 in the British Medical Journal, was unable to quantify the difference in the effect on pain of real, sham and no acupuncture. A systematic review in 2019 reported that acupuncture injection therapy was an effective treatment for patients with nonspecific chronic low back pain, and is widely used in Southeast Asian countries. Light therapy Research has found evidence that light therapy such as low level laser therapy is an effective therapy for relieving low back pain. Instead of thermal therapy, where reactant energy is originated through heat, Low Level Light Therapy (LLLT) utilizes photochemical reactions requiring light to function. Photochemical reactions need light in order to function. Photons, energy created from light, from these photochemical reactions provide the reactants with energy provide the reactants with energy to embed in muscles, thus managing pain. One study conducted by Stausholm et al. showed that at certain wavelengths, LLLT reduced pain in participants with knee osteoarthritis. LLLT stimulates a variety oof cell types, which in turn can help treat tendonitis, arthritis, and pain relating to muscles. Sound therapy Audioanalgesia and music therapy are both examples of using auditory stimuli to manage pain or other distress. They are generally viewed as insufficient when used alone, but also as helpful adjuncts to other forms of therapy. Interventional procedures Interventional radiology procedures for pain control, typically used for chronic back pain, include epidural steroid injections, facet joint injections, neurolytic blocks, spinal cord stimulators and intrathecal drug delivery system implants. Pulsed radiofrequency, neuromodulation, direct introduction of medication and nerve ablation may be used to target either the tissue structures and organ/systems responsible for persistent nociception or the nociceptors from the structures implicated as the source of chronic pain. Radiofrequency treatment has been seen to improve pain in patients for facet joint low back pain. However, continuous radiofrequency is more effective in managing pain than pulsed radiofrequency. An intrathecal pump used to deliver very small quantities of medications directly to the spinal fluid. This is similar to epidural infusions used in labour and postoperatively. The major differences are that it is much more common for the drug to be delivered into the spinal fluid (intrathecal) rather than epidurally, and the pump can be fully implanted under the skin. A spinal cord stimulator is an implantable medical device that creates electric impulses and applies them near the dorsal surface of the spinal cord provides a paresthesia ("tingling") sensation that alters the perception of pain by the patient. Intra-articular ozone therapy Intra-articular ozone therapy has been seen to efficiently alleviate chronic pain in patients with knee osteoarthritis. Psychological approach Acceptance and commitment therapy Acceptance and Commitment Therapy (ACT) is a form of cognitive behavioral therapy that focuses on behavior change rather than symptom change, includes methods designed to alter the context around psychological experiences rather than to alter the makeup of the experiences, and emphasizes the use of experiential behavior change methods. The central process in ACT revolves around psychological flexibility, which in turn includes processes of acceptance, awareness, a present-oriented quality in interacting with experiences, an ability to persist or change behavior, and an ability to be guided by one's values. ACT has an increased evidence base for range of health and behavior problems, including chronic pain. ACT influences patients to adopt a tandem process to acceptance and change, which allows for a greater flexibility in the focus of treatment. Recent research has applied ACT successfully to chronic pain in older adults due to in part of its direction from individual values and being highly customizable to any stage of life. In line with the therapeutic model of ACT, significant increases in process variables, pain acceptance, and mindfulness were also observed in a study applying ACT to chronic pain in older adults. In addition, these primary results suggested that an ACT based treatment may significantly improve levels of physical disability, psychosocial disability, and depression post-treatment and at a three-month follow-up for older adults with chronic pain. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) helps patients with pain to understand the relationship between their pain, thoughts, emotions, and behaviors. A main goal in treatment is cognitive (thinking, reasoning or remembering) restructuring to encourage helpful thought patterns. This will target healthy activities such as regular exercise and pacing. Lifestyle changes are also trained to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques (e.g., relaxation, diaphragmatic breathing, and even biofeedback). Studies have demonstrated the usefulness of cognitive behavioral therapy in the management of chronic low back pain, producing significant decreases in physical and psychosocial disability. CBT is significantly more effective than standard care in treatment of people with body-wide pain, like fibromyalgia. Evidence for the usefulness of CBT in the management of adult chronic pain is generally poorly understood, due partly to the proliferation of techniques of doubtful quality, and the poor quality of reporting in clinical trials. The crucial content of individual interventions has not been isolated and the important contextual elements, such as therapist training and development of treatment manuals, have not been determined. The widely varying nature of the resulting data makes useful systematic review and meta-analysis within the field very difficult. In 2020, a systematic review of randomized controlled trials (RCTs) evaluated the clinical effectiveness of psychological therapies for the management of adult chronic pain (excluding headaches). There is no evidence that behaviour therapy (BT) is effective for reducing this type of pain, however BT may be useful for improving a person's mood immediately after treatment. This improvement appears to be small, and is short term in duration. CBT may have a small positive short-term effect on pain immediately following treatment. CBT may also have a small effect on reducing disability and potential catastrophizing that may be associated with adult chronic pain. These benefits do not appear to last very long following the therapy. CBT may contribute towards improving the mood of an adult who experiences chronic pain, which could possibility be maintained for longer periods of time. For children and adolescents, a review of RCTs evaluating the effectiveness of psychological therapy for the management of chronic and recurrent pain found that psychological treatments are effective in reducing pain when people under 18 years old have headaches. This beneficial effect may be maintained for at least three months following the therapy. Psychological treatments may also improve pain control for children or adolescents who experience pain not related to headaches. It is not known if psychological therapy improves a child or adolescents mood and the potential for disability related to their chronic pain. Hypnosis A 2007 review of 13 studies found evidence for the efficacy of hypnosis in the reduction of pain in some conditions. However the studies had some limitations like small study sizes, bringing up issues of power to detect group differences, and lacking credible controls for placebo or expectation. The authors concluded that "although the findings provide support for the general applicability of hypnosis in the treatment of chronic pain, considerably more research will be needed to fully determine the effects of hypnosis for different chronic-pain conditions." Hypnosis has reduced the pain of some harmful medical procedures in children and adolescents. In clinical trials addressing other patient groups, it has significantly reduced pain compared to no treatment or some other non-hypnotic interventions. The effects of self hypnosis on chronic pain are roughly comparable to those of progressive muscle relaxation. Hypnosis with analgesic (painkiller) has been seen to relieve chronic pain for most people and may be a safe and effective alternative to medications. However, high quality clinical data is needed to generalize to the whole chronic pain population. Mindfulness meditation A 2013 meta-analysis of studies that used techniques centered around the concept of mindfulness, concluded, "that MBIs [mindfulness-based interventions] decrease the intensity of pain for chronic pain patients." A 2019 review of studies of brief mindfulness-based interventions (BMBI) concluded that BMBI are not recommended as a first-line treatment and could not confirm their efficacy in managing chronic or acute pain. Mindfulness-based pain management Mindfulness-based pain management (MBPM) is a mindfulness-based intervention (MBI) providing specific applications for people living with chronic pain and illness. Adapting the core concepts and practices of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT), MBPM includes a distinctive emphasis on the practice of 'loving-kindness', and has been seen as sensitive to concerns about removing mindfulness teaching from its original ethical framework within Buddhism. It was developed by Vidyamala Burch and is delivered through the programs of Breathworks. It has been subject to a range of clinical studies demonstrating its effectiveness. Medications The World Health Organization (WHO) recommends a pain ladder for managing pain relief with pharmaceutical medicine. It was first described for use in cancer pain. However it can be used by medical professionals as a general principle when managing any type of pain. In the treatment of chronic pain, the three-step WHO Analgesic Ladder provides guidelines for selecting the appropriate medicine. The exact medications recommended will vary by country and the individual treatment center, but the following gives an example of the WHO approach to treating chronic pain with medications. If, at any point, treatment fails to provide adequate pain relief, then the doctor and patient move onto the next step. Mild pain Paracetamol (acetaminophen), or a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen will relieve mild pain. Mild to moderate pain Paracetamol, an NSAID or paracetamol in a combination product with a weak opioid such as tramadol, may provide greater relief than their separate use. A combination of opioid with acetaminophen can be frequently used such as Percocet, Vicodin, or Norco. Moderate to severe pain When treating moderate to severe pain, the type of the pain, acute or chronic, needs to be considered. The type of pain can result in different medications being prescribed. Certain medications may work better for acute pain, others for chronic pain, and some may work equally well on both. Acute pain medication is for rapid onset of pain such as from an inflicted trauma or to treat post-operative pain. Chronic pain medication is for alleviating long-lasting, ongoing pain. Morphine is the gold standard to which all narcotics are compared. Semi-synthetic derivatives of morphine such as hydromorphone (Dilaudid), oxymorphone (Numorphan, Opana), nicomorphine (Vilan), hydromorphinol and others vary in such ways as duration of action, side effect profile and milligramme potency. Fentanyl has the benefit of less histamine release and thus fewer side effects. It can also be administered via transdermal patch which is convenient for chronic pain management. In addition to the intrathecal patch and injectable fentanyl formulations, the FDA (Food and Drug Administration) has approved various immediate release fentanyl products for breakthrough cancer pain (Actiq/OTFC/Fentora/Onsolis/Subsys/Lazanda/Abstral). Oxycodone is used across the Americas and Europe for relief of serious chronic pain. Its main slow-release formula is known as OxyContin. Short-acting tablets, capsules, syrups and ampules which contain oxycodone are available making it suitable for acute intractable pain or breakthrough pain. Diamorphine, and methadone are used less frequently. Clinical studies have shown that transdermal buprenorphine is effective at reducing chronic pain. Pethidine, known in North America as meperidine, is not recommended for pain management due to its low potency, short duration of action, and toxicity associated with repeated use. Pentazocine, dextromoramide and dipipanone are also not recommended in new patients except for acute pain where other analgesics are not tolerated or are inappropriate, for pharmacological and misuse-related reasons. In some countries potent synthetics such as piritramide and ketobemidone are used for severe pain. Tapentadol is a newer agent introduced in the last decade. For moderate pain, tramadol, codeine, dihydrocodeine, and hydrocodone are used, with nicocodeine, ethylmorphine and propoxyphene or dextropropoxyphene (less commonly). Drugs of other types can be used to help opioids combat certain types of pain. Amitriptyline is prescribed for chronic muscular pain in the arms, legs, neck and lower back with an opiate, or sometimes without it or with an NSAID. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose. Opioids In 2009, the Food and Drug Administration stated: "According to the National Institutes of Health, studies have shown that properly managed medical use of opioid analgesic compounds (taken exactly as prescribed) is safe, can manage pain effectively, and rarely causes addiction." In 2013, the FDA stated that "abuse and misuse of these products have created a serious and growing public health problem". Opioid medications can provide short, intermediate or long acting analgesia depending upon the specific properties of the medication and whether it is formulated as an extended release drug. Opioid medications may be administered orally, by injection, via nasal mucosa or oral mucosa, rectally, transdermally, intravenously, epidurally and intrathecally. In chronic pain conditions that are opioid responsive, a combination of a long-acting (OxyContin, MS Contin, Opana ER, Exalgo and Methadone) or extended release medication is often prescribed along with a shorter-acting medication (oxycodone, morphine or hydromorphone) for breakthrough pain, or exacerbations. Most opioid treatment used by patients outside of healthcare settings is oral (tablet, capsule or liquid), but suppositories and skin patches can be prescribed. An opioid injection is rarely needed for patients with chronic pain. Although opioids are strong analgesics, they do not provide complete analgesia regardless of whether the pain is acute or chronic in origin. Opioids are effective analgesics in chronic malignant pain and modestly effective in nonmalignant pain management. However, there are associated adverse effects, especially during the commencement or change in dose. When opioids are used for prolonged periods drug tolerance will occur. Other risks can include chemical dependency, diversion and addiction. Clinical guidelines for prescribing opioids for chronic pain have been issued by the American Pain Society and the American Academy of Pain Medicine. Included in these guidelines is the importance of assessing the patient for the risk of substance abuse, misuse, or addiction. Factors correlated with an elevated risk of opioid misuse include a history of substance use disorder, younger age, major depression, and the use of psychotropic medications. Physicians who prescribe opioids should integrate this treatment with any psychotherapeutic intervention the patient may be receiving. The guidelines also recommend monitoring not only the pain but also the level of functioning and the achievement of therapeutic goals. The prescribing physician should be suspicious of abuse when a patient reports a reduction in pain but has no accompanying improvement in function or progress in achieving identified goals. The list below consists of commonly used opioid analgesics which have long-acting formulations. Common brand names for the extended release formulation are in parentheses. Oxycodone (OxyContin) Hydromorphone (Exalgo, Hydromorph Contin) Morphine (M-Eslon, MS Contin) Oxymorphone (Opana ER) Fentanyl, transdermal (Duragesic) Buprenorphine*, transdermal (Butrans) Tramadol (Ultram ER) Tapentadol (Nucynta ER) Methadone* (Metadol, Methadose) Hydrocodone bitartrate (Hysingla ER) and bicarbonate (Zohydro ER) *Methadone and buprenorphine are each used both for the treatment of opioid addiction and as analgesics Nonsteroidal anti-inflammatory drugs The other major group of analgesics are nonsteroidal anti-inflammatory drugs (NSAID). They work by inhibiting the release of prostaglandins, which cause inflammatory pain. Acetaminophen/paracetamol is not always included in this class of medications. However, acetaminophen may be administered as a single medication or in combination with other analgesics (both NSAIDs and opioids). The alternatively prescribed NSAIDs such as ketoprofen and piroxicam have limited benefit in chronic pain disorders and with long-term use are associated with significant adverse effects. The use of selective NSAIDs designated as selective COX-2 inhibitors have significant cardiovascular and cerebrovascular risks which have limited their utilization. Common NSAIDs include aspirin, ibuprofen, and naproxen. There are many NSAIDs such as parecoxib (selective COX-2 inhibitor) with proven effectiveness after different surgical procedures. Wide use of non-opioid analgesics can reduce opioid-induced side-effects. Antidepressants and antiepileptic drugs Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system, though peripheral mechanisms have been attributed as well. They are generally used to treat nerve brain that results from injury to the nervous system. Neuropathy can be due to chronic high blood sugar levels (diabetic neuropathy). These drugs also reduce pain from viruses such as shingles, phantom limb pain and post-stroke pain. These mechanisms vary and in general are more effective in neuropathic pain disorders as well as complex regional pain syndrome. A common anti-epileptic drug is gabapentin, and an example of an antidepressant would be amitriptyline. Cannabinoids Evidence of medical marijuana's effect on reducing pain is generally conclusive. Detailed in a 1999 report by the Institute of Medicine, "the available evidence from animal and human studies indicates that cannabinoids can have a substantial analgesic effect". In a 2013 review study published in Fundamental & Clinical Pharmacology, various studies were cited in demonstrating that cannabinoids exhibit comparable effectiveness to opioids in models of acute pain and even greater effectiveness in models of chronic pain. It is mainly the THC strain of medical marijuana that provide analgesic benefits, as opposed to the CBD strain. Ketamine Low-dose ketamine is sometimes used as an alternative to opioids for the treatment of acute pain in hospital emergency departments. Ketamine probably? reduces pain more than opioids and with less nausea and vomiting. Other analgesics Other drugs which can potentiate conventional analgesics or have analgesic properties in certain circumstances are called analgesic adjuvant medications. Gabapentin, an anticonvulsant, can reduce neuropathic pain itself and can also potentiate opiates. Drugs with anticholinergic activity, such as orphenadrine and cyclobenzaprine, are given in conjunction with opioids for neuropathic pain. Orphenadrine and cyclobenzaprine are also muscle relaxants, and are useful in painful musculoskeletal conditions. Clonidine, an alpha-2 receptor agonist, is another drug that has found use as an analgesic adjuvant. In 2021, researchers described a novel type of pain therapy a CRISPR-dCas9 epigenome editing method for repressing Nav1.7 gene expression which showed therapeutic potential in three mouse models of chronic pain. Self-management Self-management of chronic pain has been described as the individual's ability to manage various aspects of their chronic pain. Self-management can include building self-efficacy, monitoring one's own symptoms, goal setting and action planning. It also includes patient-physician shared decision-making, among others. The benefits of self-management vary depending on self-management techniques used. They only have marginal benefits in management of chronic musculoskeletal pain. Some research has shown that self-management of pain can use different approaches. Those approaches can range from different therapies such as yoga, acupuncture, exercise and other relaxation techniques. Patients could also take a more natural approach by taking different minerals, vitamins or herbs. However, research has shown there is a difference between rural patients and non-rural patients having more access to different self-management approaches. Physicians in these areas may be readily prescribing more pain medication in these rural cities due to being less experienced with pain management. Simply put, it is sometimes easier for rural patients to get a prescription that insurance pays for instead of natural approaches that cost more money than they can afford to spend on their pain management. Self-management may be a more expensive alternative. Society and culture The medical treatment of pain as practiced in Greece and Turkey is called algology (from the Greek άλγος, algos, "pain"). The Hellenic Society of Algology and the Turkish Algology-Pain Society are the relevant local bodies affiliated to the International Association for the Study of Pain (IASP). Undertreatment Undertreatment of pain is the absence of pain management therapy for a person in pain when treatment is indicated. Consensus in evidence-based medicine and the recommendations of medical specialty organizations establish guidelines to determine the treatment for pain which health care providers ought to offer. For various social reasons, persons in pain may not seek or may not be able to access treatment for their pain. Health care providers may not provide the treatment which authorities recommend. Some studies about gender biases have concluded that female pain recipients are often overlooked when it comes to the perception of their pain. Whether they appeared to be in high levels of pain didn't make a difference for their observers. The women participants in the studies were still perceived to be in less pain than they actually were. Men participants on the other hand were offered pain relief while their self reporting indicated that their pain levels didn't necessarily warrant treatment. Biases exist when it comes to gender. Prescribers have been seen over and under prescribing treatment to individuals based on them being male or female .There are other prevalent reasons that undertreatment of pain occurs. Gender is a factor as well as race. When it comes to prescribers treating patients racial disparities has become a real factor. Research has shown that non-white individuals pain perception has affected their pain treatment. The African-American community has been shown to suffer significantly when it comes to trusting the medical community to treat them. Oftentimes medication although available to be prescribed is dispensed in less quantities due to their pain being perceived on a smaller scale. The black community could be undermined by physicians thinking they are not in as much pain as they are reporting. Another occurrence may be physicians simply making the choice not to treat the patient accordingly in spite of the self-reported pain level. Racial disparity is definitely a real issue in the world of pain management. In children Acute pain is common in children and adolescents as a result of injury, illness, or necessary medical procedures. Chronic pain is present in approximately 15–25% of children and adolescents. It may be caused by an underlying disease, such as sickle cell anemia, cystic fibrosis, rheumatoid arthritis. Cancer or functional disorders such as migraines, fibromyalgia, and complex regional pain could also cause chronic pain in children. Pain assessment in children is often challenging due to limitations in developmental level, cognitive ability, or their previous pain experiences. Clinicians must observe physiological and behavioral cues exhibited by the child to make an assessment. Self-report, if possible, is the most accurate measure of pain. Self-report pain scales involve younger kids matching their pain intensity to photographs of other children's faces, such as the Oucher Scale, pointing to schematics of faces showing different pain levels, or pointing out the location of pain on a body outline. Questionnaires for older children and adolescents include the Varni-Thompson Pediatric Pain Questionnaire (PPQ) and the Children's Comprehensive Pain Questionnaire. They are often utilized for individuals with chronic or persistent pain. Acetaminophen, nonsteroidal anti-inflammatory agents, and opioid analgesics are commonly used to treat acute or chronic pain symptoms in children and adolescents. However a pediatrician should be consulted before administering any medication. Caregivers may provide nonpharmacological treatment for children and adolescents because it carries minimal risk and is cost effective compared to pharmacological treatment. Nonpharmacologic interventions vary by age and developmental factors. Physical interventions to ease pain in infants include swaddling, rocking, or sucrose via a pacifier. For children and adolescents physical interventions include hot or cold application, massage, or acupuncture. Cognitive behavioral therapy (CBT) aims to reduce the emotional distress and improve the daily functioning of school-aged children and adolescents with pain by changing the relationship between their thoughts and emotions. In addition this therapy teaches them adaptive coping strategies. Integrated interventions in CBT include relaxation technique, mindfulness, biofeedback, and acceptance (in the case of chronic pain). Many therapists will hold sessions for caregivers to provide them with effective management strategies. In red-haired individuals In recent studies, it has been noted that people who have red-hair through the MC1R receptor gene may react to opioids and perceive pain differently than the rest of the population. Professional certification Pain management practitioners come from all fields of medicine. In addition to medical practitioners, a pain management team may often benefit from the input of pharmacists, physiotherapists, clinical psychologists and occupational therapists, among others. Together the multidisciplinary team can help create a package of care suitable to the patient. Pain medicine in the United States Pain physicians are often fellowship-trained board-certified anesthesiologists, neurologists, physiatrists, emergency physicians, or psychiatrists. Palliative care doctors are also specialists in pain management. The American Society of Interventional Pain Physicians, the American Board of Anesthesiology, the American Osteopathic Board of Anesthesiology (recognized by the AOABOS), the American Board of Physical Medicine and Rehabilitation, the American Board of Emergency Medicine and the American Board of Psychiatry and Neurology each provide certification for a subspecialty in pain management following fellowship training. The fellowship training is recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS). As the field of pain medicine has grown rapidly, many practitioners have entered the field, some non-ACGME board-certified. See also Equianalgesic List of investigational analgesics Opioid comparison, an example of an equianalgesic chart Pain Catastrophizing Scale Pain ladder Pain management during childbirth Pain psychology References Further reading External links World Health Organization (WHO) Treatment Guidelines on Pain Acute pain Palliative care

Mores

Mores (, sometimes ; , plural form of singular , meaning "manner, custom, usage, or habit") are social norms that are widely observed within a particular society or culture. Mores determine what is considered morally acceptable or unacceptable within any given culture. A folkway is what is created through interaction and that process is what organizes interactions through routine, repetition, habit and consistency. William Graham Sumner (1840–1910), an early U.S. sociologist, introduced both the terms "mores" (1898) and "folkways" (1906) into modern sociology. Mores are strict in the sense that they determine the difference between right and wrong in a given society, and people may be punished for their immorality which is common place in many societies in the world, at times with disapproval or ostracizing. Examples of traditional customs and conventions that are mores include lying, cheating, causing harm, alcohol use, drug use, marriage beliefs, gossip, slander, jealousy, disgracing or disrespecting parents, refusal to attend a funeral, politically incorrect humor, sports cheating, vandalism, leaving trash, plagiarism, bribery, corruption, saving face, respecting your elders, religious prescriptions and fiduciary responsibility. Folkways are ways of thinking, acting and behaving in social groups which are agreed upon by the masses and are useful for the ordering of society. Folkways are spread through imitation, oral means or observation, and are meant to encompass the material, spiritual and verbal aspects of culture. Folkways meet the problems of social life, we feel security and order from their acceptance and application. Examples of folkways include: acceptable dress, manners, social etiquette, body language, posture, level of privacy, working hours and five day work week, acceptability of social drinking—abstaining or not from drinking during certain working hours, actions and behaviours in public places, school, university, business and religious institution, ceremonial situations, ritual, customary services and keeping personal space. Terminology The English word morality comes from the same Latin root "mōrēs", as does the English noun moral. However, mores do not, as is commonly supposed, necessarily carry connotations of morality. Rather, morality can be seen as a subset of mores, held to be of central importance in view of their content, and often formalized into some kind of moral code or even into customary law. Etymological derivations include More danico, More judaico, More veneto, Coitus more ferarum, and O tempora, o mores!. The Greek terms equivalent to Latin mores are ethos (ἔθος, ἦθος, 'character') or nomos (νόμος, 'law'). As with the relation of mores to morality, ethos is the basis of the term ethics, while nomos gives the suffix -onomy, as in astronomy. Anthropology The meaning of all these terms extend to all customs of proper behavior in a given society, both religious and profane, from more trivial conventional aspects of custom, etiquette or politeness—"folkways" enforced by gentle social pressure, but going beyond mere "folkways" or conventions in including moral codes and notions of justice—down to strict taboos, behavior that is unthinkable within the society in question, very commonly including incest and murder, but also the commitment of outrages specific to the individual society such as blasphemy. Such religious or sacral customs may vary. Some examples include funerary services, matrimonial services; circumcision and covering of the hair in Judaism, Christian Ten Commandments, New Commandment and the sacraments or for example baptism, and Protestant work ethic, Shahada, prayer, alms, the fast and the pilgrimage as well as modesty in Islam, and religious diet. While cultural universals are by definition part of the mores of every society (hence also called "empty universals"), the customary norms specific to a given society are a defining aspect of the cultural identity of an ethnicity or a nation. Coping with the differences between two sets of cultural conventions is a question of intercultural competence. Differences in the mores of various nations are at the root of ethnic stereotype, or in the case of reflection upon one's own mores, autostereotypes. The customary norms in a given society may include indigenous land rights, honour, filial piety, customary law and the customary international law that affects countries who may not have codified their customary norms. Land rights of indigenous peoples is under customary land tenure, its a system of arrangement in-line with customs and norms. This is the case in colonies. An example of a norm is an culture of honor exists in some societies, where the family is viewed as the main source of honor and the conduct of family members reflects upon their family honor. For instance some writers say in Rome to have an honorable stance, to be equals with someone, existed for those who are most similar to one another (family and friends) this could be due to the competing for public recognition and therefore for personal and public honor, over rhetoric, sport, war, wealth and virtue. To protrude, stand out, be recognized and demonstrate this "A Roman could win such a "competition" by pointing to past evidences of their honor" and "Or, a critic might be refuted by one's performance in a fresh showdown in which one's bona fides could be plainly demonstrated." Honor culture only can exist if the society has for males the shared code, a standard to uphold, guidelines and rules to follow, do not want to break those rules and how to interact successfully and to engage, this exists within a "closed" community of equals. Filial piety is ethics towards one's family, as Fung Yu-lan states "the ideological basis for traditional [Chinese] society" and according to Confucious repay a burden debt back to ones parents or caregiver but its also traditional in another sense so as to fulfill an obligation to ones own ancestors, also to modern scholars it suggests extends an attitude of respect to superiors also, who are deserving to have that respect. See also Culture-bound syndrome Enculturation Euthyphro dilemma, discussing the conflict of sacral and secular mores Habitus (sociology) Nihonjinron "Japanese mores" Piety Political and Moral Sociology: see Luc Boltanski and French Pragmatism Repugnancy costs Value (personal and cultural) References Conformity Consensus reality Deviance (sociology) Morality Social agreement Sociological terminology Folklore

Work (human activity)

Work or labor (or labour in British English) is the intentional activity people perform to support the needs and wants of themselves, others, or a wider community. In the context of economics, work can be viewed as the human activity that contributes (along with other factors of production) towards the goods and services within an economy. Work is fundamental to all societies but can vary widely within and between them, from gathering natural resources by hand to operating complex technologies that substitute for physical or even mental effort by many human beings. All but the simplest tasks also require specific skills, equipment or tools, and other resources, such as material for manufacturing goods. Cultures and individuals across history have expressed a wide range of attitudes towards work. Outside of any specific process or industry, humanity has developed a variety of institutions for situating work in society. As humans are diurnal, they work mainly during the day. Besides objective differences, one culture may organize or attach social status to work roles differently from another. Throughout history, work has been intimately connected with other aspects of society and politics, such as power, class, tradition, rights, and privileges. Accordingly, the division of labour is a prominent topic across the social sciences as both an abstract concept and a characteristic of individual cultures. Some people have also engaged in critique of work and expressed a wish to abolish it, e.g. Paul Lafargue in his book The Right to Be Lazy. Related terms include occupation and job; related concepts are job title and profession. Description Work can take many different forms, as varied as the environments, tools, skills, goals, and institutions around a worker. This term refers to the general activity of performing tasks, whether they are paid or unpaid, formal or informal. Work encompasses all types of productive activities, including employment, household chores, volunteering, and creative pursuits. It is a broad term that encompasses any effort or activity directed towards achieving a particular goal. Because sustained effort is a necessary part of many human activities, what qualifies as work is often a matter of context. Specialization is one common feature that distinguishes work from other activities. For example, a sport is a job for a professional athlete who earns their livelihood from it, but a hobby for someone playing for fun in their community. An element of advance planning or expectation is also common, such as when a paramedic provides medical care while on duty and fully equipped rather than performing first aid off-duty as a bystander in an emergency. Self-care and basic habits like personal grooming are also not typically considered work. While a later gift, trade, or payment may retroactively affirm an activity as productive, this can exclude work like volunteering or activities within a family setting, like parenting or housekeeping. In some cases, the distinction between work and other activities is simply a matter of common sense within a community. However, an alternative view is that labeling any activity as work is somewhat subjective, as Mark Twain expressed in the "whitewashed fence" scene of The Adventures of Tom Sawyer. History Humans have varied their work habits and attitudes over time. Hunter-gatherer societies vary their "work" intensity according to the seasonal availability of plants and the periodic migration of prey animals. The development of agriculture led to more sustained work practices, but work still changed with the seasons, with intense sustained effort during harvests (for example) alternating with less focused periods such as winters. In the early modern era, Protestantism and proto-capitalism emphasized the moral and personal advantages of hard work. The periodic re-invention of slavery encouraged more consistent work activity in the working class, and capitalist industrialization intensified demands on workers to keep up with the pace of machines. Restrictions on the hours of work and the ages of workers followed, with worker demands for time off increasing, but modern office work retains traces of expectations of sustained, concentrated work, even in affluent societies. Kinds of work There are several ways to categorize and compare different kinds of work. In economics, one popular approach is the three-sector model or variations of it. In this view, an economy can be separated into three broad categories: Primary sector, which extracts food, raw materials, and other resources from the environment Secondary sector, which manufactures physical products, refines materials, and provides utilities Tertiary sector, which provides services and helps administer the economy In complex economies with high specialization, these categories are further subdivided into industries that produce a focused subset of products or services. Some economists also propose additional sectors such as a "knowledge-based" quaternary sector, but this division is neither standardized nor universally accepted. Another common way of contrasting work roles is ranking them according to a criterion, such as the amount of skill, experience, or seniority associated with a role. The progression from apprentice through journeyman to master craftsman in the skilled trades is one example with a long history and analogs in many cultures. Societies also commonly rank different work roles by perceived status, but this is more subjective and goes beyond clear progressions within a single industry. Some industries may be seen as more prestigious than others overall, even if they include roles with similar functions. At the same time, a wide swathe of roles across all industries may be afforded more status (e.g. managerial roles) or less (like manual labor) based on characteristics such as a job being low-paid or dirty, dangerous and demeaning. Other social dynamics, like how labor is compensated, can even exclude meaningful tasks from a society's conception of work. For example, in modern market-economies where wage labor or piece work predominates, unpaid work may be omitted from economic analysis or even cultural ideas of what qualifies as work. At a political level, different roles can fall under separate institutions where workers have qualitatively different power or rights. In the extreme, the least powerful members of society may be stigmatized (as in untouchability) or even violently forced (via slavery) into performing the least desirable work. Complementary to this, elites may have exclusive access to the most prestigious work, largely symbolic sinecures, or even a "life of leisure". Unusual Occupations In the diverse world of work, there exist some truly bizarre and unusual occupations that often defy conventional expectations. These unique jobs showcase the creativity and adaptability of humans in their pursuit of livelihood. Workers Individual workers require sufficient health and resources to succeed in their tasks. Physiology As living beings, humans require a baseline of good health, nutrition, rest, and other physical needs in order to reliably exert themselves. This is particularly true of physical labor that places direct demands on the body, but even largely mental work can cause stress from problems like long hours, excessive demands, or a hostile workplace. Particularly intense forms of manual labor often lead workers to develop physical strength necessary for their job. However, this activity does not necessarily improve a worker's overall physical fitness like exercise, due to problems like overwork or a small set of repetitive motions. In these physical jobs, maintaining good posture or movements with proper technique is also a crucial skill for avoiding injury. Ironically, white-collar workers who are sedentary throughout the workday may also suffer from long-term health problems due to a lack of physical activity. Training Learning the necessary skills for work is often a complex process in its own right, requiring intentional training. In traditional societies, know-how for different tasks can be passed to each new generation through oral tradition and working under adult guidance. For work that is more specialized and technically complex, however, a more formal system of education is usually necessary. A complete curriculum ensures that a worker in training has some exposure to all major aspects of their specialty, in both theory and practice. Equipment and technology Tool use has been a central aspect of human evolution and is also an essential feature of work. Even in technologically advanced societies, many workers' toolsets still include a number of smaller hand-tools, designed to be held and operated by a single person, often without supplementary power. This is especially true when tasks can be handled by one or a few workers, do not require significant physical power, and are somewhat self-paced, like in many services or handicraft manufacturing. For other tasks needing large amounts of power, such as in the construction industry, or involving a highly-repetitive set of simple actions, like in mass manufacturing, complex machines can carry out much of the effort. The workers present will focus on more complex tasks, operating controls, or performing maintenance. Over several millennia, invention, scientific discovery, and engineering principles have allowed humans to proceed from creating simple machines that merely redirect or amplify force, through engines for harnessing supplementary power sources, to today's complex, regulated systems that automate many steps within a work process. In the 20th century, the development of electronics and new mathematical insights led to the creation and widespread adoption of fast, general-purpose computers. Just as mechanization can substitute for the physical labor of many human beings, computers allow for the partial automation of mental work previously carried out by human workers, such as calculations, document transcription, and basic customer service requests. Research and development of related technologies like machine learning and robotics continues into the 21st century. Beyond tools and machines used to actively perform tasks, workers benefit when other passive elements of their work and environment are designed properly. This includes everything from personal items like workwear and safety gear to features of the workspace itself like furniture, lighting, air quality, and even the underlying architecture. In society Organizations Even if workers are personally ready to perform their jobs, coordination is required for any effort outside of individual subsistence to succeed. At the level of a small team working on a single task, only cooperation and good communication may be necessary. As the complexity of a work process increases though, requiring more planning or more workers focused on specific tasks, a reliable organization becomes more critical. Economic organizations often reflect social thought common to their time and place, such as ideas about human nature or hierarchy. These unique organizations can also be historically significant, even forming major pillars of an economic system. In European history, for instance, the decline of guilds and rise of joint-stock companies goes hand-in-hand with other changes, like the growth of centralized states and capitalism. In industrialized economies, labor unions are another significant organization. In isolation, a worker that is easily replaceable in the labor market has little power to demand better wages or conditions. By banding together and interacting with business owners as a corporate entity, the same workers can claim a larger share of the value created by their labor. While a union does require workers to sacrifice some autonomy in relation to their coworkers, it can grant workers more control over the work process itself in addition to material benefits. Institutions The need for planning and coordination extends beyond individual organizations to society as a whole too. Every successful work project requires effective resource allocation to provide necessities, materials, and investment (such as equipment and facilities). In smaller, traditional societies, these aspects can be mostly regulated through custom, though as societies grow, more extensive methods become necessary. These complex institutions, however, still have roots in common human activities. Even the free markets of modern capitalist societies rely fundamentally on trade, while command economies, such as in many communist states during the 20th century, rely on a highly bureaucratic and hierarchical form of redistribution. Other institutions can affect workers even more directly by delimiting practical day-to-day life or basic legal rights. For example, a caste system may restrict families to a narrow range of jobs, inherited from parent to child. In serfdom, a peasant has more rights than a slave but is attached to a specific piece of land and largely under the power of the landholder, even requiring permission to physically travel outside the land-holding. How institutions play out in individual workers' lives can be complex too; in most societies where wage-labor predominates, workers possess equal rights by law and mobility in theory. Without social support or other resources, however, the necessity of earning a livelihood may force a worker to cede some rights and freedoms in fact. Values Societies and subcultures may value work in general, or specific kinds of it, very differently. When social status or virtue is strongly associated with leisure and opposed to tedium, then work itself can become indicative of low social rank and be devalued. In the opposite case, a society may hold strongly to a work ethic where work itself is seen as virtuous. For example, German sociologist Max Weber hypothesized that European capitalism originated in a Protestant work ethic, which emerged with the Reformation. Many Christian theologians appeal to the Old Testament's Book of Genesis in regards to work. According to Genesis 1, human beings were created in the image of God, and according to Genesis 2, Adam was placed in the Garden of Eden to "work it and keep it". Dorothy L. Sayers has argued that "work is the natural exercise and function of man – the creature who is made in the image of his Creator." Likewise, John Paul II said in that by his work, man shares in the image of his creator. Christian theologians see the fall of man as profoundly affecting human work. In Genesis 3:17, God said to Adam, "cursed is the ground because of you; in pain you shall eat of it all the days of your life". Leland Ryken said out that, because of the fall, "many of the tasks we perform in a fallen world are inherently distasteful and wearisome." Christian theologians interpret that through the fall, work has become toil, but John Paul II says that work is a good thing for man in spite of this toil, and that "perhaps, in a sense, because of it", because work is something that corresponds to man's dignity and through it, he achieves fulfilment as a human being. The fall also means that a work ethic is needed. As a result of the fall, work has become subject to the abuses of idleness on the one hand, and overwork on the other. Drawing on Aristotle, Ryken suggests that the moral ideal is the golden mean between the two extremes of being lazy and being a workaholic. Some Christian theologians also draw on the doctrine of redemption to discuss the concept of work. Oliver O'Donovan said that although work is a gift of creation, it is "ennobled into mutual service in the fellowship of Christ." Pope Francis is critical of the hope that technological progress might eliminate or diminish the need for work: "the goal should not be that technological progress increasingly replace human work, for this would be detrimental to humanity", and McKinsey consultants suggest that work will change, but not end, as a result of automation and the increasing adoption of artificial intelligence. For some, work may hold a spiritual value in addition to any secular notions. Especially in some monastic or mystical strands of several religions, simple manual labor may be held in high regard as a way to maintain the body, cultivate self-discipline and humility, and focus the mind. Current issues The contemporary world economy has brought many changes, overturning some previously widespread labor issues. At the same time, some longstanding issues remain relevant, and other new ones have emerged. One issue that continues despite many improvements is slave labor and human trafficking. Though ideas about universal rights and the economic benefits of free labor have significantly diminished the prevalence of outright slavery, it continues in lawless areas, or in attenuated forms on the margins of many economies. Another difficulty, which has emerged in most societies as a result of urbanization and industrialization, is unemployment. While the shift from a subsistence economy usually increases the overall productivity of society and lifts many out of poverty, it removes a baseline of material security from those who cannot find employment or other support. Governments have tried a range of strategies to mitigate the problem, such as improving the efficiency of job matching, conditionally providing welfare benefits or unemployment insurance, or even directly overriding the labor market through work-relief programs or a job guarantee. Since a job forms a major part of many workers' self-identity, unemployment can have severe psychological and social consequences beyond the financial insecurity it causes. One more issue, which may not directly interfere with the functioning of an economy but can have significant indirect effects, is when governments fail to account for work occurring out-of-view from the public sphere. This may be important, uncompensated work occurring everyday in private life; or it may be criminal activity that involves clear but furtive economic exchanges. By ignoring or failing to understand these activities, economic policies can have counter-intuitive effects and cause strains on the community and society. Child labour Due to various reasons such as the cheap labour, the poor economic situation of the deprived classes, the weakness of laws and legal supervision, the migration existence of child labour is very much observed in different parts of the world. According to the World Bank Globally rate of child labour have decreased from 25% to 10% between 60s to the early years of the 21st century. Nevertheless, giving the population of the world also increased the total number of child labourers remains high, with UNICEF and ILO acknowledging an estimated 168 million children aged 5–17 worldwide were involved in some sort of child labour in 2013. Some scholars like Jean-Marie Baland and James A. Robinson suggests any labour by children aged 18 years or less is wrong since this encourages illiteracy, inhumane work and lower investment in human capital. In other words, there are moral and economic reasons that justify a blanket ban on labour from children aged 18 years or less, everywhere in the world. On the other hand, some scholars like Christiaan Grootaert and Kameel Ahmady believe that child labour is the symptom of poverty. If laws ban most lawful work that enables the poor to survive, informal economy, illicit operations and underground businesses will thrive. Workplace See also In modern market-economies: Career Employment Job guarantee Labour economics Profession Trade union Volunteering Wage slavery Workaholic Labor issues: Annual leave Informal economy Job strain Karoshi Labor rights Leave of absence Minimum wage Occupational safety and health Paid time off Sick leave Unemployment Unfree labor Unpaid work Working poor Workplace safety standards Related concepts: Critique of work Effects of overtime Ergonomics Flow (psychology) Helping behavior Occupational burnout Occupational stress Post-work society Problem solving Refusal of work References Employment Labour economics Sociological terminology

Recreational therapy

Recreational therapy or therapeutic recreation (TR) is a systematic process that utilizes recreation (leisure) and other activities as interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being. Recreational therapy may also be simply referred to as recreation therapy, but in short, it is the utilization and enhancement of leisure. The work of recreational therapists differs from other professionals on the basis of using leisure activities alone to meet well-being goals, they work with clients to enhance motor, social and cognitive functioning, build confidence, develop coping skills, and integrate skills learned in treatment settings into community settings. Intervention areas vary widely and are based upon enjoyable and rewarding interests of the client. Examples of intervention modalities include creative arts (e.g., crafts, music, dance, drama, among others), games, sports like adventure programming, exercises like dance/movement, and skill enhancement activities (Motor, locomotion, sensory, cognition, communication, and behavior). "Today, the United States Department of Labor projects that there are over 19,000 recreational therapists in the United States. As of January 2023, there are 19,278 professionals who hold active, inactive, or eligible for re-entry status on the NCTRC registry. The CTRS credential is the most professionally advanced credential for the field of therapeutic recreation." There are four approaches in therapeutic recreation: Recreation services: Providing recreation services to people with disabilities for experiencing leisure and its benefits, often this takes a rehabilitation tone in approach for helping clients to reach an optimal level of health and well-being. Therapeutic approach: The purpose of this approach is curative in nature. It attempts to lessen and ameliorate the effects of illness' and disabilities, it also can be prescriptive for improving certain functional capacities. Umbrella or combined approach: Use of recreation as a subjective continuation of enjoyable activities as well as a recreation service for bringing purposeful change. Leisure ability approach: An approach that operates leisure activities therapeutically and engages the clients fully for participation with good dissemination on the benefits of structured leisure/ leisure awareness education (Gun & Peterson, 1978). Eight domains of leisure are: leisure awareness, leisure attitudes, leisure skills, community integration skills, community participation, cultural and social behaviors, interpersonal skills. Educational programs A bachelor's degree in recreational therapy is required for most entry-level positions. These programs typically cover areas such as treatment and program planning, human body, physiology, kinesiology, and professional ethics. Some programs offer the opportunity to specialize in occupational therapy, and in the intervention of those that are mentally or physically challenged. Most employers prefer to hire candidates who are Certified Therapeutic Recreation Specialists (CTRS). Therapists become certified through the National Council for Therapeutic Recreation Certification (NCTRC) or through a provincial regulatory body such as, Therapeutic Recreation Ontario (TRO). To qualify for certification under the Academic Path, applicants must have a bachelor's degree in TR, complete an internship under the supervision of a CTRS, and pass a written exam. There is also an Equivalency Path A and B for certification. The requirements are slightly different and include a bachelor's degree outside of TR, paid work experience, and successful completion of the written exam. Pre-Internship Requirements An individual must be enrolled in a regionally accredited baccalaureate degree program (or higher). Degrees include; "(a) therapeutic recreation (recreation therapy); (b) recreation or leisure with an option in therapeutic recreation; (c) therapeutic recreation, recreation, or leisure in combination with other fields of study (e.g., Therapeutic Recreation and Health Studies; Recreation and Sport Management; Leisure and Tourism); and (d) a major in another field of study with a concentration/emphasis/sub-plan/option/minor/certificate in recreation therapy/therapeutic recreation". A a minimum of 90 credit hours towards attaining the degree must be completed. A minimum of 18 semester or 24 quarter credit hours of Recreational Therapy/Therapeutic Recreation (RT/TR) specific courses have to be completed: A minimum of 6 courses in RT/TR are required (two of the required must be taught by applicant as an educator). Each individual must take 3 semester hours or 4 quarter hours coursework in each of the areas; anatomy and physiology, abnormal psychology, human growth and development across the lifespan, and the remaining semester hours or quarter hours should be fulfilled in the areas of social sciences and humanities. Internship Requirements The duration of the Internship is a minimum of 560 hours over the course of 14 consecutive weeks (or more). If you go under 20 hours in a week (Sun-Sat), the internship must restart. Supervision by internship supervisor must have active CTRS (Certified Therapeutic Recreation Specialist) and have been certified for at least one year prior to supervising interns. Internship completion must appear on official academic transcript. The CTRS credential, is evidence that the individual completed and met the qualifications for the NCTRC's CTRS Certification Standards. This is a limited license that requires individuals to continue education and trainings. Continuing Education Recreation Therapists with the Certified Therapeutic Recreation Specialist (CTRS) credential are required to complete 50 clock hours (5.0 CEUs) of continuing education within a 5 year span as part of the overall requirements to renew national certification through NCTRC. NCTRC has outlined several ways a CTRS can earn continuing education Continuing Education. These include: a.) Academic Courses b.) Teleconferences/Audio Seminars like ATRA's webinar series. c.) Internet Course Programs: Some online programs identified are on the Therapeutic Recreation Directory website: Therapeutic Recreation Directory: CEU Opportunities. The largest online providers for RT continuing education are: 1) ATRA- American Therapeutic Recreation Association Webinars 2) Rec Therapy Today 3) SMART CEUs Hub- Success Makers Are Rec Therapists- Unlimited NCTRC Pre-Approved CEUs d.) Conferences: American Therapeutic Recreation Association (ATRA) and state branches of ATRA. Recreation therapists can attend conferences provided by related professional organizations and earn CEUs (pending the session meets Therapeutic Recreation (TR) knowledge areas required by NCTRC. e.) Internships & Externships: Supervised guidance to practice. Professional Organizations The American Therapeutic Recreation Association (ATRA) and the Canadian Therapeutic Recreation Association (CTRA) are the largest national membership organizations representing the interests and needs of recreational therapists in the U. S. and Canada. ATRA is the only organization that represents the therapeutic recreation profession in the United States."ATRA, was incorporated in the District of Columbia in 1984 as a non-profit, grassroots organization in response to a growing concern about the dramatic changes in the healthcare industry. As a result of this response, ATRA has grown from a membership of 60 individuals in June 1984 to 2,200 in 2014." Credentialing Certification: The National Council for Therapeutic Recreation Certification, a charter member of the National Organization for Competency Assurance (NOCA), also provides a certification that expires after 5 years. "NCTRC was founded to protect the consumer of recreational therapy services and the public at large, resulting in many benefits to the public, the profession, the individual practitioner, and the organization." Those who are certified must apply for re-certification at the end of the expiration period. Specialty certification is now available in five areas. Health and human service professionals who acquire a higher level of knowledge and more advanced skills provide the consumer with a greater depth of service compared to individuals who practice at less advanced levels. Specialization is well recognized within professional practice and has become the norm within the health and human service delivery system today. The median salary for recreational therapists in the United States was estimated $51,330 a year in 2022. This number may vary slightly based on specific geographic region, years of experience, and type of employing agency. Licensure: There are currently five states that require a Recreational Therapy licensure (Utah, North Carolina, New Hampshire, New Jersey and Oklahoma). To practice Recreational Therapy in these states, professionals must possess a current, valid state license. In addition to the five currently licensed states, numerous other states are currently moving toward developing licensure. Through the Joint Task Force on Recreational Therapy Licensure sponsored by the American Therapeutic Recreation Association and the National Council for Therapeutic Recreation Certification, significant progress is being made in the licensure arena. Licensure is being pursued by the profession as a further means of protecting the public from potential harm. References Further reading Robertson, T. & Long, T. (Eds.) (2007). Foundations of Therapeutic Recreation. Champaign, IL: Human Kinetics. Stumbo, N. J.& Peterson, C. A.(2009). Therapeutic recreation program design: Principles and procedures. Toronto, ON: Pearson Benjamin Cummings. Dattilo, J. & McKenney, A. (2011). Facilitation Techniques in Therapeutic Recreation (2nd ed). State College, PA: Venture Publishing. Carter, M., Van Andel, G., & Robb, G. (2003). Therapeutic Recreation A Practical Approach. Prospect Heights, IL: Waveland Press, Inc. Austin, D. R., Crawford, M.E., McCormick, B.P. & Van Puymbroeck, M. (2015). Recreational Therapy: An Introduction (4thed). Urbana, IL: Sagamore Publishing. Kunstler, R., & Stavola Daly, F. (2010). Therapeutic recreation leadership and programming. Champaign, IL: Human Kinetics. External links American Therapeutic Recreation Association (ATRA) National Therapeutic Recreation Society U.S. Bureau of Labor: Recreational Therapist Allied health professions Rehabilitation team Leisure

Mental state

A mental state, or a mental property, is a state of mind of a person. Mental states comprise a diverse class, including perception, pain/pleasure experience, belief, desire, intention, emotion, and memory. There is controversy concerning the exact definition of the term. According to epistemic approaches, the essential mark of mental states is that their subject has privileged epistemic access while others can only infer their existence from outward signs. Consciousness-based approaches hold that all mental states are either conscious themselves or stand in the right relation to conscious states. Intentionality-based approaches, on the other hand, see the power of minds to refer to objects and represent the world as the mark of the mental. According to functionalist approaches, mental states are defined in terms of their role in the causal network independent of their intrinsic properties. Some philosophers deny all the aforementioned approaches by holding that the term "mental" refers to a cluster of loosely related ideas without an underlying unifying feature shared by all. Various overlapping classifications of mental states have been proposed. Important distinctions group mental phenomena together according to whether they are sensory, propositional, intentional, conscious or occurrent. Sensory states involve sense impressions like visual perceptions or bodily pains. Propositional attitudes, like beliefs and desires, are relations a subject has to a proposition. The characteristic of intentional states is that they refer to or are about objects or states of affairs. Conscious states are part of the phenomenal experience while occurrent states are causally efficacious within the owner's mind, with or without consciousness. An influential classification of mental states is due to Franz Brentano, who argues that there are only three basic kinds: presentations, judgments, and phenomena of love and hate. Mental states are usually contrasted with physical or material aspects. For (non-eliminative) physicalists, they are a kind of high-level property that can be understood in terms of fine-grained neural activity. Property dualists, on the other hand, claim that no such reductive explanation is possible. Eliminativists may reject the existence of mental properties, or at least of those corresponding to folk psychological categories such as thought and memory. Mental states play an important role in various fields, including philosophy of mind, epistemology and cognitive science. In psychology, the term is used not just to refer to the individual mental states listed above but also to a more global assessment of a person's mental health. Definition Various competing theories have been proposed about what the essential features of all mental states are, sometimes referred to as the search for the "mark of the mental". These theories can roughly be divided into epistemic approaches, consciousness-based approaches, intentionality-based approaches and functionalism. These approaches disagree not just on how mentality is to be defined but also on which states count as mental. Mental states encompass a diverse group of aspects of an entity, like this entity's beliefs, desires, intentions, or pain experiences. The different approaches often result in a satisfactory characterization of only some of them. This has prompted some philosophers to doubt that there is a unifying mark of the mental and instead see the term "mental" as referring to a cluster of loosely related ideas. Mental states are usually contrasted with physical or material aspects. This contrast is commonly based on the idea that certain features of mental phenomena are not present in the material universe as described by the natural sciences and may even be incompatible with it. Epistemic and consciousness-based approaches Epistemic approaches emphasize that the subject has privileged access to all or at least some of their mental states. It is sometimes claimed that this access is direct, private and infallible. Direct access refers to non-inferential knowledge. When someone is in pain, for example, they know directly that they are in pain, they do not need to infer it from other indicators like a body part being swollen or their tendency to scream when it is touched. But we arguably also have non-inferential knowledge of external objects, like trees or cats, through perception, which is why this criterion by itself is not sufficient. Another epistemic privilege often mentioned is that mental states are private in contrast to public external facts. For example, the fallen tree lying on a person's leg is directly open to perception by the bystanders while the victim's pain is private: only they know it directly while the bystanders have to infer it from their screams. It was traditionally often claimed that we have infallible knowledge of our own mental states, i.e. that we cannot be wrong about them when we have them. So when someone has an itching sensation, for example, they cannot be wrong about having this sensation. They can only be wrong about the non-mental causes, e.g. whether it is the consequence of bug bites or of a fungal infection. But various counterexamples have been presented to claims of infallibility, which is why this criterion is usually not accepted in contemporary philosophy. One problem for all epistemic approaches to the mark of the mental is that they focus mainly on conscious states but exclude unconscious states. A repressed desire, for example, is a mental state to which the subject lacks the forms of privileged epistemic access mentioned. One way to respond to this worry is to ascribe a privileged status to conscious mental states. On such a consciousness-based approach, conscious mental states are non-derivative constituents of the mind while unconscious states somehow depend on their conscious counterparts for their existence. An influential example of this position is due to John Searle, who holds that unconscious mental states have to be accessible to consciousness to count as "mental" at all. They can be understood as dispositions to bring about conscious states. This position denies that the so-called "deep unconscious", i.e. mental contents inaccessible to consciousness, exists. Another problem for consciousness-based approaches, besides the issue of accounting for the unconscious mind, is to elucidate the nature of consciousness itself. Consciousness-based approaches are usually interested in phenomenal consciousness, i.e. in qualitative experience, rather than access consciousness, which refers to information being available for reasoning and guiding behavior. Conscious mental states are normally characterized as qualitative and subjective, i.e. that there is something it is like for a subject to be in these states. Opponents of consciousness-based approaches often point out that despite these attempts, it is still very unclear what the term "phenomenal consciousness" is supposed to mean. This is important because not much would be gained theoretically by defining one ill-understood term in terms of another. Another objection to this type of approach is to deny that the conscious mind has a privileged status in relation to the unconscious mind, for example, by insisting that the deep unconscious exists. Intentionality-based approaches Intentionality-based approaches see intentionality as the mark of the mental. The originator of this approach is Franz Brentano, who defined intentionality as the characteristic of mental states to refer to or be about objects. One central idea for this approach is that minds represent the world around them, which is not the case for regular physical objects. So a person who believes that there is ice cream in the fridge represents the world as being a certain way. The ice cream can be represented but it does not itself represent the world. This is why a mind is ascribed to the person but not to the ice cream, according to the intentional approach. One advantage of it in comparison to the epistemic approach is that it has no problems to account for unconscious mental states: they can be intentional just like conscious mental states and thereby qualify as constituents of the mind. But a problem for this approach is that there are also some non-mental entities that have intentionality, like maps or linguistic expressions. One response to this problem is to hold that the intentionality of non-mental entities is somehow derivative in relation to the intentionality of mental entities. For example, a map of Addis Ababa may be said to represent Addis Ababa not intrinsically but only extrinsically because people interpret it as a representation. Another difficulty is that not all mental states seem to be intentional. So while beliefs and desires are forms of representation, this seems not to be the case for pains and itches, which may indicate a problem without representing it. But some theorists have argued that even these apparent counterexamples should be considered intentional when properly understood. Behaviorism and functionalism Behaviorist definitions characterize mental states as dispositions to engage in certain publicly observable behavior as a reaction to particular external stimuli. On this view, to ascribe a belief to someone is to describe the tendency of this person to behave in certain ways. Such an ascription does not involve any claims about the internal states of this person, it only talks about behavioral tendencies. A strong motivation for such a position comes from empiricist considerations stressing the importance of observation and the lack thereof in the case of private internal mental states. This is sometimes combined with the thesis that we could not even learn how to use mental terms without reference to the behavior associated with them. One problem for behaviorism is that the same entity often behaves differently despite being in the same situation as before. This suggests that explanation needs to make reference to the internal states of the entity that mediate the link between stimulus and response. This problem is avoided by functionalist approaches, which define mental states through their causal roles but allow both external and internal events in their causal network. On this view, the definition of pain-state may include aspects such as being in a state that "tends to be caused by bodily injury, to produce the belief that something is wrong with the body and ... to cause wincing or moaning". One important aspect of both behaviorist and functionalist approaches is that, according to them, the mind is multiply realizable. This means that it does not depend on the exact constitution of an entity for whether it has a mind or not. Instead, only its behavioral dispositions or its role in the causal network matter. The entity in question may be a human, an animal, a silicon-based alien or a robot. Functionalists sometimes draw an analogy to the software-hardware distinction where the mind is likened to a certain type of software that can be installed on different forms of hardware. Closely linked to this analogy is the thesis of computationalism, which defines the mind as an information processing system that is physically implemented by the neural activity of the brain. One problem for all of these views is that they seem to be unable to account for the phenomenal consciousness of the mind emphasized by consciousness-based approaches. It may be true that pains are caused by bodily injuries and themselves produce certain beliefs and moaning behavior. But the causal profile of pain remains silent on the intrinsic unpleasantness of the painful experience itself. Some states that are not painful to the subject at all may even fit these characterizations. Externalism Theories under the umbrella of externalism emphasize the mind's dependency on the environment. According to this view, mental states and their contents are at least partially determined by external circumstances. For example, some forms of content externalism hold that it can depend on external circumstances whether a belief refers to one object or another. The extended mind thesis states that external circumstances not only affect the mind but are part of it. The closely related view of enactivism holds that mental processes involve an interaction between organism and environment. Classifications of mental states There is a great variety of types of mental states, which can be classified according to various distinctions. These types include perception, belief, desire, intention, emotion and memory. Many of the proposed distinctions for these types have significant overlaps and some may even be identical. Sensory states involve sense impressions, which are absent in non-sensory states. Propositional attitudes are mental states that have propositional contents, in contrast to non-propositional states. Intentional states refer to or are about objects or states of affairs, a feature which non-intentional states lack. A mental state is conscious if it belongs to a phenomenal experience. Unconscious mental states are also part of the mind but they lack this phenomenal dimension. Occurrent mental states are active or causally efficacious within the owner's mind while non-occurrent or standing states exist somewhere in the back of one's mind but do not currently play an active role in any mental processes. Certain mental states are rationally evaluable: they are either rational or irrational depending on whether they obey the norms of rationality. But other states are arational: they are outside the domain of rationality. A well-known classification is due to Franz Brentano, who distinguishes three basic categories of mental states: presentations, judgments, and phenomena of love and hate. Types of mental states There is a great variety of types of mental states including perception, bodily awareness, thought, belief, desire, motivation, intention, deliberation, decision, pleasure, emotion, mood, imagination and memory. Some of these types are precisely contrasted with each other while other types may overlap. Perception involves the use of senses, like sight, touch, hearing, smell and taste, to acquire information about material objects and events in the external world. It contrasts with bodily awareness in this sense, which is about the internal ongoings in our body and which does not present its contents as independent objects. The objects given in perception, on the other hand, are directly (i.e. non-inferentially) presented as existing out there independently of the perceiver. Perception is usually considered to be reliable but our perceptual experiences may present false information at times and can thereby mislead us. The information received in perception is often further considered in thought, in which information is mentally represented and processed. Both perceptions and thoughts often result in the formation of new or the change of existing beliefs. Beliefs may amount to knowledge if they are justified and true. They are non-sensory cognitive propositional attitudes that have a mind-to-world direction of fit: they represent the world as being a certain way and aim at truth. They contrast with desires, which are conative propositional attitudes that have a world-to-mind direction of fit and aim to change the world by representing how it should be. Desires are closely related to agency: they motivate the agent and are thus involved in the formation of intentions. Intentions are plans to which the agent is committed and which may guide actions. Intention-formation is sometimes preceded by deliberation and decision, in which the advantages and disadvantages of different courses of action are considered before committing oneself to one course. It is commonly held that pleasure plays a central role in these considerations. "Pleasure" refers to experience that feels good, that involves the enjoyment of something. The topic of emotions is closely intertwined with that of agency and pleasure. Emotions are evaluative responses to external or internal stimuli that are associated with a feeling of pleasure or displeasure and motivate various behavioral reactions. Emotions are quite similar to moods, some differences being that moods tend to arise for longer durations at a time and that moods are usually not clearly triggered by or directed at a specific event or object. Imagination is even further removed from the actual world in that it represents things without aiming to show how they actually are. All the aforementioned states can leave traces in memory that make it possible to relive them at a later time in the form of episodic memory. Sensation, propositional attitudes and intentionality An important distinction among mental states is between sensory and non-sensory states. Sensory states involve some form of sense impressions like visual perceptions, auditory impressions or bodily pains. Non-sensory states, like thought, rational intuition or the feeling of familiarity, lack sensory contents. Sensory states are sometimes equated with qualitative states and contrasted with propositional attitude states. Qualitative states involve qualia, which constitute the subjective feeling of having the state in question or what it is like to be in it. Propositional attitudes, on the other hand, are relations a subject has to a proposition. They are usually expressed by verbs like believe, desire, fear or hope together with a that-clause. So believing that it will rain today, for example, is a propositional attitude. It has been argued that the contrast between qualitative states and propositional attitudes is misleading since there is some form of subjective feel to certain propositional states like understanding a sentence or suddenly thinking of something. This would suggest that there are also non-sensory qualitative states and some propositional attitudes may be among them. Another problem with this contrast is that some states are both sensory and propositional. This is the case for perception, for example, which involves sensory impressions that represent what the world is like. This representational aspect is usually understood as involving a propositional attitude. Closely related to these distinctions is the concept of intentionality. Intentionality is usually defined as the characteristic of mental states to refer to or be about objects or states of affairs. The belief that the moon has a circumference of 10921 km, for example, is a mental state that is intentional in virtue of being about the moon and its circumference. It is sometimes held that all mental states are intentional, i.e. that intentionality is the "mark of the mental". This thesis is known as intentionalism. But this view has various opponents, who distinguish between intentional and non-intentional states. Putative examples of non-intentional states include various bodily experiences like pains and itches. Because of this association, it is sometimes held that all sensory states lack intentionality. But such a view ignores that certain sensory states, like perceptions, can be intentional at the same time. It is usually accepted that all propositional attitudes are intentional. But while the paradigmatic cases of intentionality are all propositional as well, there may be some intentional attitudes that are non-propositional. This could be the case when an intentional attitude is directed only at an object. In this view, Elsie's fear of snakes is a non-propositional intentional attitude while Joseph's fear that he will be bitten by snakes is a propositional intentional attitude. Conscious and unconscious A mental state is conscious if it belongs to phenomenal experience. The subject is aware of the conscious mental states it is in: there is some subjective feeling to having them. Unconscious mental states are also part of the mind but they lack this phenomenal dimension. So it is possible for a subject to be in an unconscious mental state, like a repressed desire, without knowing about it. It is usually held that some types of mental states, like sensations or pains, can only occur as conscious mental states. But there are also other types, like beliefs and desires, that can be both conscious and unconscious. For example, many people share the belief that the moon is closer to the earth than to the sun. When considered, this belief becomes conscious, but it is unconscious most of the time otherwise. The relation between conscious and unconscious states is a controversial topic. It is often held that conscious states are in some sense more basic with unconscious mental states depending on them. One such approach states that unconscious states have to be accessible to consciousness, that they are dispositions of the subject to enter their corresponding conscious counterparts. On this position there can be no "deep unconscious", i.e. unconscious mental states that can not become conscious. The term "consciousness" is sometimes used not in the sense of phenomenal consciousness, as above, but in the sense of access consciousness. A mental state is conscious in this sense if the information it carries is available for reasoning and guiding behavior, even if it is not associated with any subjective feel characterizing the concurrent phenomenal experience. Being an access-conscious state is similar but not identical to being an occurrent mental state, the topic of the next section. Occurrent and standing A mental state is occurrent if it is active or causally efficacious within the owner's mind. Non-occurrent states are called standing or dispositional states. They exist somewhere in the back of one's mind but currently play no active role in any mental processes. This distinction is sometimes identified with the distinction between phenomenally conscious and unconscious mental states. It seems to be the case that the two distinctions overlap but do not fully match despite the fact that all conscious states are occurrent. This is the case because unconscious states may become causally active while remaining unconscious. A repressed desire may affect the agent's behavior while remaining unconscious, which would be an example of an unconscious occurring mental state. The distinction between occurrent and standing is especially relevant for beliefs and desires. At any moment, there seems to be a great number of things we believe or things we want that are not relevant to our current situation. These states remain inactive in the back of one's head even though one has them. For example, while Ann is engaged in her favorite computer game, she still believes that dogs have four legs and desires to get a pet dog on her next birthday. But these two states play no active role in her current state of mind. Another example comes from dreamless sleep when most or all of our mental states are standing states. Rational, irrational and arational Certain mental states, like beliefs and intentions, are rationally evaluable: they are either rational or irrational depending on whether they obey the norms of rationality. But other states, like urges, experiences of dizziness or hunger, are arational: they are outside the domain of rationality and can be neither rational nor irrational. An important distinction within rationality concerns the difference between theoretical and practical rationality. Theoretical rationality covers beliefs and their degrees while practical rationality focuses on desires, intentions and actions. Some theorists aim to provide a comprehensive account of all forms of rationality but it is more common to find separate treatments of specific forms of rationality that leave the relation to other forms of rationality open. There are various competing definitions of what constitutes rationality but no universally accepted answer. Some accounts focus on the relation between mental states for determining whether a given state is rational. In one view, a state is rational if it is well-grounded in another state that acts as its source of justification. For example, Scarlet's belief that it is raining in Manchester is rational because it is grounded in her perceptual experience of the rain while the same belief would be irrational for Frank since he lacks such a perceptual ground. A different version of such an approach holds that rationality is given in virtue of the coherence among the different mental states of a subject. This involves an holistic outlook that is less concerned with the rationality of individual mental states and more with the rationality of the person as a whole. Other accounts focus not on the relation between two or several mental states but on responding correctly to external reasons. Reasons are usually understood as facts that count in favor or against something. On this account, Scarlet's aforementioned belief is rational because it responds correctly to the external fact that it is raining, which constitutes a reason for holding this belief. Classification according to Brentano An influential classification of mental states is due to Franz Brentano. He argues that there are three basic kinds: presentations, judgments, and phenomena of love and hate. All mental states either belong to one of these kinds or are constituted by combinations of them. These different types differ not in content or what is presented but in mode or how it is presented. The most basic kind is presentation, which is involved in every mental state. Pure presentations, as in imagination, just show their object without any additional information about the veridical or evaluative aspects of their object. A judgment, on the other hand, is an attitude directed at a presentation that asserts that its presentation is either true or false, as is the case in regular perception. Phenomena of love and hate involve an evaluative attitude towards their presentation: they show how things ought to be, and the presented object is seen as either good or bad. This happens, for example, in desires. More complex types can be built up through combinations of these basic types. To be disappointed about an event, for example, can be construed as a judgment that this event happened together with a negative evaluation of it. Brentano's distinction between judgments, phenomena of love and hate, and presentations is closely related to the more recent idea of direction of fit between mental state and world, i.e. mind-to-world direction of fit for judgments, the world-to-mind direction of fit for phenomena of love and hate and null direction of fit for mere presentations. Brentano's tripartite system of classification has been modified in various ways by Brentano's students. Alexius Meinong, for example, divides the category of phenomena of love and hate into two distinct categories: feelings and desires. Uriah Kriegel is a contemporary defender of Brentano's approach to the classification of mental phenomena. Academia Discussions about mental states can be found in many areas of study. In cognitive psychology and the philosophy of mind, a mental state is a kind of hypothetical state that corresponds to thinking and feeling, and consists of a conglomeration of mental representations and propositional attitudes. Several theories in philosophy and psychology try to determine the relationship between the agent's mental state and a proposition. Instead of looking into what a mental state is, in itself, clinical psychology and psychiatry determine a person's mental health through a mental status examination. Epistemology Mental states also include attitudes towards propositions, of which there are at least two—factive and non-factive, both of which entail the mental state of acquaintance. To be acquainted with a proposition is to understand its meaning and be able to entertain it. The proposition can be true or false, and acquaintance requires no specific attitude towards that truth or falsity. Factive attitudes include those mental states that are attached to the truth of the proposition—i.e. the proposition entails truth. Some factive mental states include "perceiving that", "remembering that", "regretting that", and (more controversially) "knowing that". Non-factive attitudes do not entail the truth of the propositions to which they are attached. That is, one can be in one of these mental states and the proposition can be false. An example of a non-factive attitude is believing—people can believe a false proposition and people can believe a true proposition. Since there is the possibility of both, such mental states do not entail truth, and therefore, are not factive. However, belief does entail an attitude of assent toward the presumed truth of the proposition (whether or not it is so), making it and other non-factive attitudes different from a mere acquaintance. See also Altered state of consciousness, a mental state that is different from the normal state of consciousness Flow (psychology), the mental state of operation in which a person in an activity is fully immersed in a feeling of energized focus Mental factors (Buddhism), aspects of the mind that apprehend the quality of an object, and that have the ability to color the mind Mental representation, a hypothetical internal cognitive symbol Mood (psychology), an emotional state Propositional attitude, a relational mental state connecting a person to a proposition Benj Hellie's Vertiginous question References Sources Mental content

Enmeshment

Enmeshment is a concept in psychology and psychotherapy introduced by Salvador Minuchin to describe families where personal boundaries are diffused, sub-systems undifferentiated, and over-concern for others leads to a loss of autonomous development. According to this hypothesis, by being enmeshed in parental needs, trapped in a discrepant role function, a child may lose their capacity for self-direction; their own distinctiveness, under the weight of "psychic incest"; and, if family pressures increase, may end up becoming the identified patient or family scapegoat. Enmeshment was also used by John Bradshaw to describe a state of cross-generational bonding within a family, whereby a child (normally of the opposite sex) becomes a surrogate spouse for their mother or father. The term is sometimes applied to engulfing codependent relationships, where an unhealthy symbiosis is in existence. Others suggest that for the toxically enmeshed child, the adult's carried feelings may be the only ones they know, outweighing and eclipsing their own. Critiques There are important cultural differences in how "enmeshment" would be experienced or conceptualized, however. One study found that "enmeshed" adults in the United Kingdom experienced more depression than those in Italy, because of cultural expectations in more individualistic versus more collectivist cultures. Further, feminist family therapy critics have argued that the very concept of enmeshment may "reflect prototypically male standards of self and relationships, which contribute to the common practice of labeling women's preferred interactional styles as pathological or dysfunctional". Empirical research in this critical feminist tradition has found that young women with the strongest sense of family cohesion have the highest social self-esteem, despite exhibiting what could be pathologized as "enmeshment". See also References Further reading Robin Skynner, One Flesh, Separate Persons (London 1976) External links Enmeshment: Symptoms and Causes Psychological concepts Family therapy Interpersonal communication

Impact of prostitution on mental health

The Impact of prostitution on mental health refers to the psychological, cognitive, and emotional consequences experienced by individuals involved in prostitution. These consequences include a wide range of mental health issues and difficulties in emotional management and interpersonal relationships. Prostitution is closely linked to various psychological pathologies and affects not only those directly involved but also society at large. Studies have shown that both street and indoor sex workers have experienced high levels of abuse in childhood and adulthood, with differences in trauma rates between the two groups. Women in prostitution experience a profound impact on their identity, encompassing cognitive, physical, and emotional dimensions, manifesting in health problems and difficulties in emotional management and interpersonal relationships. Prostitution, being strongly linked to psychopathology and social health, should be addressed as a medical situation that affects not only the individuals involved but also society at large, with psychological aspects. Sex work involves the provision of one or more sexual services in exchange for money or goods. However, sex workers are not a homogeneous group. Street sex workers are often illegal, finding clients on the street and providing services in alleys or clients' cars. On the other hand, indoor sex workers operate in brothels, massage parlors, or as private escorts. Previous research has shown that both street and indoor sex workers have experienced high levels of abuse in childhood and adulthood, though indoor sex workers report lower rates of abuse and trauma compared to street workers. There is a high prevalence of victimization in childhood and adulthood among sex workers, with secondary trauma disorders. Recurrent victimization, known as "Type II trauma," can cause pathological psychological changes that are difficult to classify. Proposed diagnoses include developmental trauma disorder for childhood and complex post-traumatic stress disorder (cPTSD) for adulthood, though these are not included in official diagnostic manuals. There is a connection between prostitution and trafficking, organized crimes that reflect sexism, patriarchy, capitalism, and economic inequality. The physical consequences of sexual exploitation include sexually transmitted diseases, cervical cancer, chronic pain, liver problems, unintended pregnancies, eating disorders, concentration and memory difficulties, visual and hearing problems, fractures, and, in extreme cases, death. Psychologically, women suffer from low self-esteem, stress, pathological ties with control networks, social isolation, loneliness, extreme fear, hopelessness, and a lack of assertiveness in seeking support, resulting in trauma that alters their beliefs and perceptions, causing irreparable damage to their personal identity. These conditions are exacerbated by language barriers and other vulnerability factors, such as having suffered sexual abuse in childhood or being the main economic support for their family, which is exploited by pimps. The effects on mental health are severe, with high rates of depression, anxiety, and post-traumatic stress disorder (PTSD) among those who sell sex, exacerbated by social stigma, discrimination, physical violence, and mistreatment by authorities. Studies in the United States and Canada reveal depression symptoms in 68% of these individuals and PTSD symptoms in nearly a third, showing higher rates than in combat veterans. Substance abuse is common, generally as a response to sex work rather than a cause, with most increasing drug use to cope with their reality. The sex industry is a global business worth $57 billion annually, with the United States hosting the largest number of adult clubs in the world, employing over 500,000 people. Between 66% and 90% of women in this industry were sexually abused during their childhood. These women have higher rates of substance abuse, sexually transmitted infections, domestic violence, depression, violent aggression, rape, and PTSD compared to the general population. The emotional effects of prostitution are devastating. Dissociation, a response to uncontrollable traumatic events, is common among prostituted individuals, similar to the response of prisoners of war. Research has shown that both indoor and outdoor sex work increase the risk of being assaulted. In outdoor sex work 82% of women reported being physically assaulted, and 68% reported being raped. In indoor settings, more sexual violence and threats with weapons were reported. Women in the sex industry frequently face multiple psychosocial stressors, limited resources, and a high rate of untreated health and legal problems. Other studies that assessed the presence of psychological alterations in prostitutes, compared to non-prostitutes, also documented concentration and memory difficulties, as well as sleep problems (with an incidence of 79%), irritability (64%), anxiety (60%), phobias (26%), panic attacks (24%), compulsions (37%), obsessions (53%), fatigue (82%), and concerns about physical health (35%), and 30% of the sample reported a suicide attempt. Context The consequences of being repeatedly bought and sold for sex with strangers result in a variety of medical issues, including malnutrition, pregnancy-related problems, old and new injuries from sexual assaults and physical attacks such as burns, broken bones, stab wounds, dental trauma, traumatic brain injuries, anogenital injuries (rectal prolapse/vaginal injuries), internal injuries, sexually transmitted infections, and untreated chronic medical conditions. Individuals in prostitution are subjected to multiple forms of violence, such as rape, sexual assault, emotional abuse, economic and physical abuse, food deprivation and sleep deprivation, and acts of torture by pimps, traffickers, brothel owners, and sex buyers. This results in cumulative psychological and physical trauma with lifelong impacts. Individuals in prostitution often experience stress and multiple traumas, such as physical or sexual abuse in childhood, the sexual exploitation itself, and homelessness, and may have difficulty remembering details of their lives due to traumatic brain injuries, cognitive impairment, repressed memories, or dissociation, largely caused by pimps, traffickers, and sex buyers. Reported psychiatric disorders include depression, anxiety, schizophrenia, eating disorders, sexual dysfunction, substance abuse, suicidal ideation or suicide attempts, self-harm, post-traumatic stress disorder (PTSD), and dissociative disorders. Dissociation, a severe symptom related to trauma, is common and develops as a coping strategy in response to extremely painful, frightening, or potentially life-threatening events. Additionally, pimps and traffickers often control victims' access to medical care, allowing them to seek help only when injuries or illnesses are particularly severe or if their ability to earn money is affected, but often prohibiting preventive or follow-up care. The traumatic scars from this physical and psychological damage are permanent. Children trafficked for sex are the most vulnerable to medical and psychological harm. Entry into prostitution typically occurs during childhood and adolescence, with most initially lured by a "boyfriend" and/or "protector." While not all enter the sex trade through a pimp or trafficker, each encounter with a sex buyer puts the individual at risk of harm. Studies suggest that up to 50% of human trafficking victims seek medical care while in trafficking situations. The harmful effects of prostitution are reflected in the high rates of PTSD among survivors, with symptoms such as anxiety, depression, insomnia, irritability, recurrent memories, emotional numbness, and hypervigilance. Of 475 individuals in prostitution interviewed in five countries, 67% met the diagnostic criteria for PTSD, indicating that the traumatic consequences of prostitution are similar across cultures. Individuals in prostitution suffer extremely high levels of violence: 62% of women report being raped and 73% report being physically assaulted in the sex trade. Transgender youth in prostitution are over four times more likely to have HIV than those without such a history. The mortality rates for women in prostitution are 40 to 50 times the national average. Among known victims of fatal violence against transgender individuals in the U.S. from 2013 to 2018, 32% were in the sex trade, including many who died while in prostitution. In "Prostitution and the Invisibility of Harm," Melissa Farley examines how the harms associated with prostitution are invisible in society, law, public health, and psychology. Farley argues that the invisibility of these harms originates from the use of terms that conceal the inherent violence of prostitution, as well as from public health perspectives and psychological theories that ignore the harm inflicted by men on women in prostitution. The author summarizes literature documenting the overwhelming physical and psychological harms suffered by individuals in prostitution and discusses the interconnection of prostitution with racism, colonialism, and child sexual abuse. Farley describes prostitution as a form of sexual violence that generates economic benefits for perpetrators and argues that, like slavery, it is a lucrative form of oppression. She highlights how institutions protect the commercial sex industry due to its enormous profits, and how these institutions, deeply rooted in cultures, become invisible. The author criticizes the normalization of prostitution by researchers, public health agencies, and the law, pointing out the contradiction in opposing human trafficking while promoting "consensual sex work." Farley argues that assuming consent in prostitution erases its harm and mentions that the line between coercion and consent in prostitution is deliberately blurred. The author proposes using terms that maintain the dignity of women in prostitution and criticizes the use of terms that disguise the inherent violence of this practice. Furthermore, the article documents the prevalence of physical and sexual violence in prostitution, citing studies showing high percentages of rape and physical assault among women in this situation. Farley also highlights the similarity between domestic violence and violence in prostitution, suggesting that treatment approaches for battered women are also applicable to prostituted women. Finally, Farley addresses the intersection of racism and colonialism in prostitution, pointing out how women are exploited based on their appearance and ethnic stereotypes, and discusses how child sexual abuse sets the stage for prostitution in adolescence and adulthood. Research on the psychological impact associated with sex work, especially when exposed to violent situations, has shown that this activity is linked to the development of psychological stress and many other negative consequences in the short, medium, and long term. These consequences include depressive disorders, anxiety disorders, post-traumatic stress disorder, sexual trauma symptoms, and addiction disorders related to substance use. The study by El-Bassel et al. (1997) showed that sex workers, compared to a control sample, had higher scores on the subscales of obsessive–compulsive symptomatology, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. To assess whether there was a direct relationship, the authors isolated other variables that could contribute to these higher values (differences in age, ethnicity, pregnancy, perceived risk of contracting HIV, rape, and substance use) and found a significant correlation between sex work and psychological stress. In recent decades, the perception of mental health has changed significantly, especially among young people, who openly discuss depression, anxiety, and therapy. Mental health has become a recurring topic in popular culture, frequently featured in TV shows, movies, and songs, and has been the focus of numerous recently proposed and passed laws. This change is crucial to addressing the mental health of high-risk groups, such as people who sell sex. These individuals, often forced into this activity by survival, coercion, or deception, usually lack support networks and face economic precariousness, prior violence, and social marginalization, with a particular risk for LGBTQ+ and Black girls. Most who have sold sex started as minors, wanted to leave the sex trade, and suffered significant harm, as recounted by Esperanza Fonseca, a survivor who describes feelings of loneliness and deep sadness. Prostitution can have profound and lasting psychological effects on those who engage in it. These effects can manifest in various disorders and symptoms that impact mental health and emotional well-being. Below is a detailed table exploring different psychological disorders associated with prostitution, describing their symptoms, reasons for occurrence, possible consequences, available treatments, severity, and prevalence among affected women. Motivations for entering prostitution The study titled "Prostituição: um estudo sobre as dimensões de sofrimento psíquico entre as profissionais e seu trabalho" investigates the psychological difficulties that sex workers face due to moral judgments and adverse working conditions. It is based on the psychodynamic approach to work, which defines normality as a precarious balance between work constraints and the psychological defenses workers develop to maintain their mental health. Prostitutes can preserve a psychological balance despite the constraints and moral judgments they face in contemporary society. One of the research questions was why women choose prostitution as a profession. The answers indicated that economic necessity is the most important factor. The workers mentioned the need to support their children and families as the main motivations for entering prostitution. Additionally, some compared their earnings in prostitution with previous jobs where they earned much less for longer and more difficult working hours. Sex workers develop mechanisms to manage their clients' desires and tastes, demonstrating their capacity for conception within their profession. However, they set clear boundaries on what they are willing to do, regardless of payment, to preserve their integrity and mental health. Most research points to financial and social problems as the main causes of prostitution. Factors such as lack of job opportunities, family conflicts, and urgent economic needs drive many women into this profession. However, while the patriarchal system and gender violence are realities, there are also women who choose this profession by their own desires and will. Prostitution is not homogeneous and encompasses a plurality of desires and expressions of sexuality. Many women enter sex work through false promises of marriage or well-paid employment in another city. Once in sex work, perceived stigma and sexual abuse by law enforcement officers, who often are also clients, convince them that no external help is available. These extreme circumstances force women to focus on survival rather than escape, which is essentially the core of Stockholm syndrome: a psychological attempt to survive physically in captivity. This behavior pattern is not limited to prostitution in brothels, as similar relationships are present in street, home-based, and caste-based prostitution. This has been a point of difficulty for rehabilitation programs against trafficking worldwide. The role of motherhood affects the decisions and behaviors of women trapped in these situations. Motherhood becomes not only a natural and biological role but also a source of vulnerability and emotional strength. From a psychological perspective, the fear of losing their children or being unable to care for them adequately due to their sexual exploitation is one of the most influential factors in these women's psyches. This fear can generate intense anxiety and chronic stress, which in turn perpetuates the cycle of exploitation. The constant threat of separation from their children can trigger submissive and compliant responses, as women may feel trapped and without options. Anxiety and fear of abandonment not only affect their emotional well-being but also limit their ability to make rational and strategic decisions to escape their situation. The need to protect and support their children can conflict with their desire to escape and seek a better life. This cognitive dissonance can be debilitating, as women may feel constantly torn between two equally painful options. The maternal instinct to protect their children can also motivate some women to seek escape from exploitation. But this protective drive may be hindered by the lack of resources, support, and viable options. Uncertainty about the future and fear of violent reprisals can paralyze their ability to act. From a psychological perspective, this can generate a state of learned helplessness, where women believe they have no control over their situation and that any attempt to change it will be futile or dangerous. Risk factors Prostitution is primarily associated with poverty and, in most cases, is not a professional choice or vocation, but a way of monetizing the body due to lack of opportunities. It is directly related to social inequality and gender issues in the country. The main beneficiaries of this trade are pimps and those involved in managing trafficking and sex tourism. Prostitution is often understood in the context of the traditional consumer risk model, where the consumed product is perceived as the agent carrying risks. However, in prostitution, the prostituted person is the "product" consumed, and it is they who are at greater risk, even though prostitution is sometimes erroneously described as "sex between consenting adults." Prostitution occurs because the prostituted person would not consent to sex with the buyer if they were not paid, which redefines the notion of consent and risk in this context. The traditional consumer risk model does not adequately apply to prostitution, where the prostituted person assumes significantly greater risks than the sex buyer or the pimp. A sex buyer interviewed explained that "being with a prostitute is like having a cup of coffee, when you finish, you throw it away." This perspective shows the dehumanization and objectification of prostituted individuals. Prostitution is often the result of a combination of individual, social, and economic factors. Individuals who engage in prostitution do so due to a series of adverse circumstances that limit their options and increase their vulnerability to exploitation. Below is a list of risk factors that can contribute to a person falling into prostitution: Poverty: The lack of economic resources is one of the main factors driving people to prostitution. The urgent need for money to cover basic necessities like food, housing, and medical care can lead to desperate decisions. Lack of education: Limited educational opportunities restrict employment options, which in turn can push individuals toward prostitution as a way to earn money quickly. Unemployment: The lack of employment or job instability can lead people to seek alternative means of income, including prostitution, especially in contexts where there are few formal job opportunities. History of childhood sexual abuse: Sexual abuse during childhood is a common precursor to prostitution. Traumatic experiences can lead to vulnerability and the normalization of sexual exploitation in adulthood. Domestic violence: Individuals who have been victims of domestic violence may turn to prostitution as a way to escape an abusive situation or to gain financial independence. Lack of family and social support: The absence of a strong support network can leave individuals without emotional or financial resources, increasing their vulnerability to sexual exploitation. Mental disorders: Mental health issues such as depression, anxiety, and post-traumatic stress disorder can make individuals more susceptible to exploitation in prostitution. Previous experiences of exploitation: Individuals who have been trafficked or exploited for labor may be more vulnerable to falling into prostitution due to the continuation of the exploitation cycle. Gender inequality: Discrimination and gender inequality can limit opportunities and increase women's vulnerability to sexual exploitation. Displacement and migration: Displaced or migrant individuals, especially those without documentation, are particularly vulnerable to sexual exploitation due to their precarious situation and lack of legal protection. Cultural and social factors: In some cultures and societies, social norms and expectations can contribute to sexual exploitation, either by stigmatizing victims or accepting prostitution as an economic solution. Coercion and deception: Many individuals are forced or deceived into prostitution, either through human trafficking, false promises of employment, or direct coercion by pimps. The risks associated with prostitution are numerous and well-documented. They include sexual harassment, rape and unprotected rape, domestic violence, physical assault, and psychological aftermaths such as post-traumatic stress disorder (PTSD), dissociative disorders, depression, eating disorders, suicide attempts, and substance abuse. The frequency of rape in prostitution results in extremely high rates of sexually transmitted infections, including HIV, with studies reporting an HIV prevalence of 93% in some prostituted populations. Family abuse and neglect often precede entry into prostitution. Physical, sexual, and emotional abuse during childhood is a common precursor, considered by many experts to be a necessary risk factor for prostitution. In one study, 70% of adult women in prostitution reported that childhood sexual abuse was responsible for their entry into prostitution. This abuse creates a cycle of victimization that impacts their futures and prepares them for exploitation in prostitution. The fantasies of sex buyers drive the realities of prostituted individuals. Buyers seek to fulfill their fantasies through prostituted individuals, who must act according to the buyer's expectations. Failure to meet these expectations often leads to brutal violence. Objectification and dehumanization are intrinsic to prostitution, where prostituted individuals are seen as objects or products with economic value, facilitating their exploitation and abuse. Physical violence is a constant in prostitution. An occupational study noted that 99% of women in prostitution were victims of violence, with more frequent injuries than in occupations considered dangerous such as mining or firefighting. Poverty and duration in prostitution are associated with greater violence. In Vancouver, 75% of women in prostitution suffered physical injuries from violence, including fractures and head injuries. The emotional effects of prostitution are devastating. Dissociation, a response to uncontrollable traumatic events, is common among prostituted individuals, similar to the response of tortured prisoners of war or sexually abused children. Dissociation is a necessary skill for surviving rape in prostitution, reflecting the dissociation needed to endure family sexual abuse. Dissociative disorders, depression, and other mood disorders are common among prostituted individuals in various settings. Prostitution and slavery share characteristics of dehumanization and objectification, resulting in a "social death." The prostituted individual is reduced to body parts and acts out the roles desired by buyers, suffering a systematic assault on their humanity. This objectification becomes internalized, causing profound changes in their self-perception and their relationships with others. Sex buyers often understand the risks and consequences of prostitution but rationalize their behavior. Many acknowledge exploitation and economic coercion but continue to buy sex. Risk denial strategies, such as minimizing abuse or justifying payment, perpetuate exploitation. Prostitution not only involves risks for prostituted individuals but also for buyers, who face legal risks, social stigma, and health risks. However, public attention often focuses more on the buyer's health than on the prostituted individual's, perpetuating the myth that prostituted individuals are vectors of disease. Public denial of prostitution risks is fueled by narratives from buyers and pimps that conceal violence and exploitation. This denial is similar to strategies used by the tobacco industry or climate change deniers, where harms are minimized, and exploitation is justified. Government complicity sustains prostitution. The legalization and decriminalization of prostitution integrate this exploitation into the state economy, relieving governments of the responsibility to find employment for women. However, legalization does not eliminate the inherent risks of prostitution, as demonstrated by the recommendation for hostage negotiation training for those in legalized prostitution in Australia. Harm reduction approaches in prostitution, such as distributing condoms, do not address the root causes of the problem. Eliminating risk requires real survival options outside prostitution and a change in power structures that perpetuate exploitation. Survivor voices who have exited prostitution point toward obvious legal solutions. Sex buyers and pimps must be held accountable, and survival alternatives must be offered to prostituted individuals without criminalizing them. Several countries have adopted abolitionist approaches, penalizing sex buyers and providing exit services and job training for prostituted individuals. Types of prostitutes From a psychological perspective, prostitution presents a series of significant impacts that vary according to the type of sex work and the conditions under which it is carried out. Independent prostitutes, such as escorts and call girls, may experience lower levels of exploitation and have greater control over their working conditions, potentially mitigating some negative effects on their psychological well-being. However, those working under conditions of high exploitation and violence, such as street prostitutes or those held in debt bondage, face severe psychological consequences. These include post-traumatic stress disorder, depression, anxiety, and other mental health problems due to physical, sexual, and emotional violence they suffer. Debt bondage, in particular, is an extreme form of exploitation where women are kept in conditions of slavery due to unpayable debts, prevalent in underdeveloped countries. This situation subjects them to severe trauma and a constant threat of violence, exacerbating their psychological problems and making it difficult to escape this cycle of abuse and exploitation. Street sex work, in particular, is associated with higher levels of stress and risk due to exposure to violence, third-party exploitation, and poor working conditions. Many street workers report experiences of physical and emotional abuse by both clients and pimps. This environment can lead to a higher incidence of mental health disorders, such as anxiety, depression, and post-traumatic stress disorder. On the other hand, sex workers operating in more controlled environments, such as escort agencies or brothels, report higher levels of job satisfaction and self-esteem. These workers have more control over their working conditions, can select their clients, and generally experience less violence. This greater autonomy and control can translate into better mental health and a greater sense of empowerment. High-end prostitutes In 1958, the study of the psychology of high-end prostitutes revealed a series of common patterns and traumas that shaped their behavior and life choices. Many of these women came from difficult childhoods, marked by broken homes and dysfunctional family relationships, contributing to their sense of insecurity and low self-esteem. From an early age, they learned to see sex as a currency, a means to obtain the emotional contact and tangible rewards they craved. These women, despite their superior intelligence and artistic abilities, felt emotionally adrift and lacked a clear concept of their feminine role. Their adult lives were marked by a constant search for validation and security, though paradoxically, they were trapped in a profession that perpetuated their feelings of worthlessness and anxiety. Most struggled with addiction problems and unstable relationships, unable to maintain solid friendships and resorting to psychological defenses such as projection and denial to cope with their reality. Financial success and outward luxury failed to mask their deep emotional distress. Often, they feigned joy and affection toward their clients, but in their private lives, many were unable to experience sexual satisfaction and suffer from anxiety and depression. The high rates of suicide attempts among these women underscore the severity of their psychological suffering. Psychotherapeutic treatment can offer relief and a way out of prostitution, helping these women confront and overcome their past traumas. Through therapy, some manage to establish healthier relationships and embark on new legitimate careers, finally finding a measure of stability and emotional peace. Coping mechanisms Female sex workers suffer intense physical, sexual, and mental abuse, widely documented in medical and public health literature. However, the mental coping mechanisms employed by these women to survive have been less studied. In the debate on prostitution, women are often divided into two groups: those who were forced into prostitution and those who 'chose' this activity. The definition of 'force' or 'coercion' can vary, but the underlying logic remains: some women are compelled to prostitute themselves through violence or economic coercion and thus deserve compassion. On the other hand, there are those who seemingly choose it freely, even though they may have other options available, such as access to social services and unemployment benefits. The reality, however, is more complex. Women from all social classes may find themselves in prostitution due to experiences of sexual, physical, or emotional abuse and may be reenacting these traumas within the realm of prostitution. Rachel Moran argues that prostitution is not only a consequence of women's lack of economic power but exists primarily due to male demand. Prostitution is also seen as a reenactment of previous traumas. Andrea Dworkin mentioned that incest is the training ground for prostitution, indicating that experiences of childhood abuse can predispose women to prostitution. Huschke Mau adds that traumatic situations can become addictive due to the release of adrenaline, a familiar experience for those who have faced violence from a young age. The sociologist Pierre Bourdieu suggests that the body serves as a means of memory for any social order, unconsciously internalizing the structures of social inequality or sexual hierarchies. This means that experiences of violence and degradation become integrated into one's self-perception, profoundly affecting self-esteem and self-worth. Prostituted women often internalize violence and develop dissociative mechanisms to cope with the reality of their situation. Forcing themselves to feel enjoyment during sexual acts is a common strategy to protect themselves psychologically and to meet the expectations of clients, who often need to believe that the women enjoy the sexual interaction to soothe any guilt about their actions. Prostitution also plays a role in maintaining the second-class status of all women within the gender hierarchy. Michael Meuser describes how spaces reserved exclusively for men allow them to reinforce their dominance and normalize social dynamics that perpetuate male supremacy. Therefore, the existence of prostitution has adverse effects not only on prostituted women but on all women in society. Leaving prostitution is a long and complex process that involves not only finding a new source of income but also readjusting to daily life outside the sex trade. Women who manage to exit prostitution often face significant challenges in rebuilding their self-esteem and social integration. Depersonalization Dissociation is a psychological process in which a person disconnects from their thoughts, feelings, memories, or identity. This phenomenon is especially prevalent in individuals who have experienced severe traumas, such as childhood sexual abuse. Dissociation can manifest in various ways, from amnesia to the creation of multiple identities, known as multiple personality disorder (MPD). Dissociative identity disorder (DID), formerly known as Multiple Personality Disorder, is a condition often misunderstood and sensationalized in the media. However, various studies have revealed that between 1 and 3% of the general population meet the diagnostic criteria for DID. Various studies have investigated the relationship between child sexual abuse and dissociative disorders. The disorder most commonly associated with childhood sexual abuse is multiple personality disorder. In a study by Colin A. Ross and colleagues, 236 people with MPD were examined, and a high prevalence of childhood sexual abuse and dissociation was found. This study also highlighted that, in addition to MPD, prostitution and work in the adult entertainment industry (exotic dancers) showed a significant incidence of dissociative experiences. To assess the prevalence of dissociation and childhood sexual abuse, tools such as the Dissociative Disorders Interview Schedule (DDIS) and the Dissociative Experiences Scale (DES) were used. These instruments help identify and measure the frequency and severity of dissociative symptoms. In the mentioned study, 60 subjects were included, divided into three groups: 20 patients diagnosed with MPD, 20 sex workers (prostitutes), and 20 exotic dancers. The results showed that most subjects with MPD met the DSM-III-R criteria for the diagnosis of this disorder, and dissociation was common in all three categories of subjects studied. Causes One of the most common causes of DID is childhood sexual abuse. When a child experiences a stressful event such as sexual abuse, the fight or flight response is activated. Dissociation is a form of psychological escape when the child cannot physically escape. The child may imagine that the abuse is happening to another person or another "part" of themselves. If the abuse is severe and prolonged, this "part" can develop its own identity, separate from the child's conscious memory. Survivors of trauma may exhibit symptoms instead of memories. Many people with DID report memories of childhood traumas and evident symptoms such as "waking up" in unfamiliar places or meeting people who call them by another name. However, it is common for some individuals not to remember their childhood traumas, but to exhibit more subtle and difficult-to-recognize symptoms of PTSD and DID. These symptoms include inexplicable feelings of guilt, shame, and worthlessness, emotional numbness, concentration problems, thought insertion, Depersonalization and Derealization. Without known traumatic memories to attribute these symptoms to, the person is often misdiagnosed and only superficial problems are treated, masking their true needs. Many trafficking victims have histories of child sexual abuse, a primary cause of PTSD and DID. Additionally, studies have shown that women in prostitution experience PTSD levels comparable to those of combat veterans. It has also been found that 35% of prostituted individuals and 80% of exotic dancers experience dissociative disorders, and between 5% and 18% of prostituted individuals and 35% of exotic dancers meet the diagnostic criteria for DID. Religion Women in prostitution often turn to different religious traditions to address their situation, though with very different approaches. For some, religion presents an escape route, offering spiritual redemption and a fresh start. Some Pentecostal churches in Brazil have provided emotional and community support, encouraging women to leave prostitution through conversion, abandoning sinful behaviors, and integrating into a community that values their new moral identity. In contrast, Afro-Brazilian religions such as Umbanda and Candomblé provide tools to improve their economic success within prostitution. Through rituals and offerings to entities like Pombagira, these women seek to attract more clients and increase their income. These practices reflect a pragmatic and materialistic relationship with the divine, based on the belief that spiritual entities can grant favors and material success in exchange for specific offerings. Umbanda Erika Bourguignon explored dissociative phenomena in different cultural contexts. In her research, Bourguignon compared dissociative cases, such as a woman in New York and a man in São Paulo, showing how dissociation manifests in culturally specific ways. In the context of Umbanda, an Afro-Brazilian religion, dissociative states are interpreted as spiritual possession, where the individual acts as a medium for ancestral spirits. These experiences are not seen as pathologies but as mediumistic abilities that require development and acceptance within the religious community. For prostitutes, dissociation can be a necessary strategy to manage the dissonance between their personal identity and the demands of their work. This mental separation allows them to perform sexual acts without involving their true selves, creating a psychological barrier that protects their mental health. These dissociative experiences enable the individual to face stressful situations without being completely overwhelmed by them. Bernstein and Putnam propose a continuum for dissociation in the psychopathological dimension, suggesting that not all dissociative experiences are inherently pathological. This perspective is useful for understanding how prostitutes use dissociation as a tool to survive emotionally and psychologically in a hostile environment. In practice, prostitutes may experience a variety of dissociative states, from feeling like external observers of their own bodies to adopting alternative identities that handle interactions with clients. These identities can act as a form of self-protection, allowing women to fulfill their work without feeling the direct emotional impact. Pombagira In Brazil, many women in prostitution turn to spiritual and mystical practices to increase their income. These women frequent spiritist houses and candomblé or umbanda terreiros, where they are advised to buy herbs for baths and products for offerings to spiritual entities like the Lady of the Night or Pombagira. The belief is that these rituals will attract more clients and, therefore, generate higher income. For each entity, the offerings vary and include drinks, perfumes, and red objects. Although some women express skepticism towards these beliefs, many attribute financial success to their participation in these rituals. It is noted that older women often have more economic success than their younger counterparts, attributed to their involvement in these spiritual practices. The cost of these rituals can be significant. Some women report spending large sums of money on products for offerings, with the promise of obtaining greater profits. However, there is a mixed perception of the effectiveness of these rituals, as although they may attract more clients, the associated cost of offerings may not be compensatory. Pombagira is a central figure in these spiritual practices, seen as a powerful entity capable of performing "miracles" and attracting success in love, relationships, and material progress. This entity is associated with manipulating sensuality and sexuality and is believed to remove obstacles and enemies to ensure the success of her devotees. The beliefs surrounding Pombagira are not limited to prostitution. In the Brazilian social imagination, Pombagira represents the archetype of the ritual prostitute and is commonly requested to perform works on romantic relationships. Although not all Pombagiras are considered prostitutes, the connection with prostitution is due to her representation as a free and powerful woman. Women in prostitution who participate in these spiritual practices do so under the principle of reciprocity. They offer objects and perform rituals in exchange for economic favors and success in their profession. This system of exchange reflects similar practices in popular Catholicism, where people make promises to saints in exchange for divine favors. However, in prostitution, these offerings are primarily aimed at improving sexual attraction and financial success. The article "A Pomba-Gira in the Imagination of Prostitutes," published in the journal "Man, Time, and Space," examines the relationship between prostitutes and Pomba-Gira, an entity from the Umbanda pantheon known for her free manifestation of female genital power. This study, conducted by Francisco Gleidson Vieira dos Santos and Simone Simões Ferreira Soares, delves into the symbolic and psychological importance of Pomba-Gira in the lives of prostitutes. Pomba-Gira represents a powerful archetype in Umbanda, characterized by attributes associated with sexuality, disobedience, and the transgression of social norms. From a deep psychological perspective, this entity can be interpreted as a projection of the collective unconscious of prostitutes, who find in her a figure of empowerment and resistance. Identifying with Pomba-Gira allows prostitutes to negotiate their self-esteem and sense of agency in a social context that stigmatizes and marginalizes them. In psychological terms, the figure of Pomba-Gira could be seen as a manifestation of a dissociative personality in prostitutes, emerging as a defense mechanism against the adversity of their environment. Dissociation is a psychological process by which a person can divide their identity into different states or personalities to face difficult or traumatic situations. In this case, Pomba-Gira would serve as an alternative personality, allowing prostitutes to perform their work more bearably and with less emotional pain. Pomba-Gira, with her defiant character and celebration of free sexuality, offers an alternative narrative to the guilt and shame commonly associated with prostitution. This identification with a powerful and transgressive entity can help prostitutes reconnect with repressed aspects of their identity and find a sense of dignity and worth in a sacred context. By incorporating Pomba-Gira during rituals, prostitutes can experience a form of catharsis, temporarily freeing themselves from the emotional burdens of their daily reality. Monique Augras, cited in the study, suggests that Pomba-Gira is a Brazilian creation that emerged from the destitution of the sexual characteristics of Iemanjá, another Umbanda figure syncretized with the Immaculate Conception. This new entity channels the most scandalous aspects of female sexuality, directly confronting patriarchal values. From a Jungian point of view, Pomba-Gira could be seen as a manifestation of the anima, representing the erotic and autonomous dimension of the female unconscious that challenges the restrictions imposed by patriarchal society. Interviews with "fathers-of-saint" and other Umbanda practitioners reveal that Pombas-Giras are considered complex and powerful figures, revered for their ability to influence matters of love and desire. This reverence is reflected in ritual practices, where Pombas-Giras, when incorporated by mediums, act as agents of transformation and empowerment. This allows prostitutes to assert their value and dignity in a sacred context. Positive identity One of the fundamental principles of social identity theory is that individuals seek to enhance their self-esteem through their social identities, and an important component of self-definition is occupational identity. Individuals employed as prostitutes constantly engage in various ideological techniques to neutralize the negative connotations associated with the work they do. Ashforth and Kreiner identified three of these techniques: restructuring, recalibration, and refocusing, which are used at the group level to transform the meaning of stigmatized work. Restructuring allows prostitutes to transform stigma into a symbol of honor by asserting that they provide an educational and therapeutic service rather than selling their bodies. These protective techniques enhance the self-definition of prostitutes and can be considered coping mechanisms. However, engaging in these techniques requires mental and emotional energy, which can become a stressor. Additionally, the requirement for a strong group culture to support these ideological techniques is not always present for prostitutes. Even with efforts to adopt these techniques, most members of occupations considered "dirty work" maintain some ambivalence about their jobs, as they remain part of a broader society that stigmatizes their labor as "dirty" and have continuous contact with people outside their occupation. Prostitutes also have to construct their self-identity in circumstances that put pressure on the relationship between their professional and personal lives. The bodies of prostitutes, and potentially their psyches, are consumed by the client in the act of commercial sex, creating additional pressure to maintain a division between the professional and the personal. Many of the techniques that prostitutes use to maintain this division are considered coping mechanisms. Emotional labor in prostitution Emotional labor is defined as the "act of displaying organizationally desired emotions during service transactions." Emotional labor is believed to be more prevalent in service occupations, as people working in services are generally subject to stricter norms about the appropriate expression of emotions in certain situations. In particular, what is disturbing for people is the imbalance or dissonance between what the worker feels and the emotions they must display. This discrepancy between felt and expressed emotions has a negative effect on physical health. Prostitutes face very different demands compared to the general population regarding the emotional labor required. Their work consists of acts that are intensely personal and intimate. They must fake affection and emotion to develop a regular clientele. One way that prostitutes cope with the emotional demands imposed on them is by "categorizing different types of sexual encounters [as] relational, professional, or recreational." This way, they can maintain distance from the encounter with the client and preserve their self-identity. The literature also suggests that prostitutes maintain emotional distance by using condoms at work or during professional sex and by refusing to kiss clients. Kissing "is rejected because it is too similar to the kind of behavior one would engage in with a non-commercial partner; it implies too much genuine desire and love for the other person." Use of stimulation and pleasure Pleasure and pain are more related than they seem. Under certain circumstances, pain can intensify sensations of pleasure due to the release of endorphins and other chemicals in the brain. This mechanism is similar to the "runner's high" that athletes experience after an intense exercise session. The relationship between pleasure and pain in the human brain is intricate. They share similar neuronal pathways, allowing the brain to modulate pleasurable experiences to counteract pain. This neurochemical capability can explain how some sex workers find pleasure in their interactions, using it as a way to dissociate from the physical and emotional pain that often accompanies their work. The release of neurotransmitters such as endorphins during these moments can provide temporary relief and a sense of well-being. Prostitution involves practices aimed at minimizing physical issues, although these same practices can generate psychological complications. Sex workers use stimulation and pleasure to reduce physical pain, which, paradoxically, can lead to significant emotional disconnection. Some clients seek not only to receive pleasure but also to provide pleasure to the worker. For example, a client may pay to give a massage and provide sexual pleasure, which can result in a gratifying experience for both. This type of interaction can go beyond the negative stereotypes associated with sex work, showing that it does not always involve exploitation or abuse. A study by Elizabeth Megan Smith of La Trobe University, published in the journal Sexualities, investigated how sex workers integrate pleasure into their work. This study, titled "'It gets very intimate for me': Discursive boundaries of pleasure and performance in sex work," involved nine women from the sex industry in Victoria, Australia. Through narratives and photographs, the participants explored their relationship with intimacy, performance, and pleasure. The study shows that sex workers often experience pleasure during their work to achieve better vaginal lubrication, reducing the risk of tears and other physical injuries. However, this pursuit of pleasure is not inherently positive. Some sex workers emphasize the importance of focusing on their own pleasure to maintain a sexual experience and avoid resentment towards clients and the work itself. The ability to reach orgasm can be a strategy to preserve personal integrity. For many, forcing oneself to feel pleasure in unwanted situations can be a survival strategy to avoid physical pain but comes at a high psychological cost. Sex workers may experience a diminished ability to form genuine emotional connections outside of work, leading to feelings of isolation and difficulties in their personal relationships. Stockholm syndrome Stockholm syndrome, a phenomenon where victims develop bonds with their captors as a survival strategy, has been mentioned in the media in relation to this vulnerable population, but it has not been formally investigated. The four main criteria of Stockholm syndrome (perceived threat to survival, displays of kindness by the captor, isolation from other perspectives, perception of inability to escape) have been identified in the narrative accounts of these women. The threat can be explicit, like physical violence, or more subtle, like emotional abuse or the threat of harm. Victims may believe they cannot survive without the abuser's protection and support and may feel responsible for the safety of others, such as their families. The perception of kindness, even in the smallest form, can be disproportionate due to the victim's low self-esteem. These victims may interpret any cessation of violence or minimal gesture as an act of kindness and may downplay their situation with thoughts like "at least he didn't..." or "it could have been worse". The first criterion of Stockholm syndrome is the perception of a threat to survival and the belief that the captor would carry out that threat. Many trafficked women experience physical violence and torture, perpetrated by brothel workers (pimps, traffickers, madams) as well as clients. The second condition is the captor's display of love or kindness. Many women maintain relationships with their traffickers or develop bonds with clients, often hoping to start a family with them. This "act of kindness" can be any action that helps the woman survive, as her survival is essential for the functioning of the sex market. The third condition is isolation from the outside world. Many women described their first months in the brothel as completely isolated, contributing to Depersonalization and demoralization. The fourth condition is the perception of inability to escape. Sex workers who attempted to escape were publicly beaten to deter others from trying. Rescued sex workers refuse to testify against their traffickers, a behavior observed in countries like the United States, England, and India. The closest psychiatric diagnoses to the traumas suffered by these women are complex post-traumatic stress disorder (CPTSD) and disorders of extreme stress not otherwise specified (DESNOS), but these are not included in the DSM IV due to debates about their distinction from post-traumatic stress disorder (PTSD). Stockholm syndrome could be an additional explanation for this behavior, as the conditions described for this syndrome are present in the accounts of sex workers. Addictions The relationship between prostitution and addiction is a complex phenomenon involving multiple psychological, social, and economic factors. Many individuals involved in prostitution may have experienced significant traumas in their lives, such as physical, emotional, or sexual abuse during childhood. These traumas often contribute to mental health issues like post-traumatic stress disorder (PTSD), depression, and anxiety, which can predispose a person to develop addictions as a coping mechanism. Individuals involved in prostitution and struggling with addictions often experience a range of negative psychological effects. Shame, guilt, and low self-esteem are common, exacerbated by social stigma and negative self-perception. Addiction, in turn, can lead to further social alienation and isolation, reinforcing these negative feelings and contributing to the persistence of addictive behavior. Emotional and sexual addiction Involvement in prostitution is not always driven solely by economic reasons. Psychological and emotional factors play a significant role. Some individuals in sex work may experience addictions related to seeking validation, the need to control trauma, or as a way to cope with stress and anxiety. Childhood trauma and prolonged stress can alter brain responses, increasing susceptibility to addictive behaviors, not necessarily related to substances but to activities that generate a sense of reward, such as commercial sex. Some women in prostitution find this activity a way to exert power and control, especially if they have suffered traumas or seek to regain a sense of agency in their lives. This control can be a way to manage their self-esteem and feel validated through men's attention and desire. Additionally, some seek prostitution as a form of emotional independence and autonomy from adverse personal situations. Some studies highlight that not all individuals in sex work are there due to extreme economic need; some choose this profession for the exploration of their sexuality and the financial independence it offers. For some, prostitution offers a temporary escape from personal problems and a sense of empowerment, despite significant risks to their physical and emotional well-being. This addiction is not always driven solely by the desire for money but also by the need for validation and power over their clients. Compulsive sexual behavior can cause changes in brain circuits, leading individuals to seek more intense sexual encounters to achieve the same satisfaction, similar to other addictions such as drugs or alcohol. Additionally, prostitutes can be influenced and develop addictive behaviors due to constant interaction with clients who have sexual addictions. Repeated exposure to these compulsive behaviors can contribute to sex workers developing similar addictions, either seeking emotional validation or feeling a compulsive need to engage in sexual activities to gain a sense of control and power. Besides sex and the need for validation, prostitutes can also develop addictions to behaviors such as gambling, compulsive shopping, excessive exercise, and social media use. These behavioral addictions are similar to substance addictions in how they affect the brain and can lead to financial, health, and personal relationship problems. However, prostitution is rarely a completely free choice when options are limited, and socio-economic conditions are adverse. Addiction to cosmetic surgeries Sex workers often resort to cosmetic procedures to enhance their appearance, hoping to increase their attractiveness and, consequently, their income. This trend is especially notable in countries like Colombia, where the cosmetic surgery industry is booming. Prostitutes may undergo multiple surgeries to achieve an ideal of beauty influenced by cultural norms and client demands. This pursuit of physical perfection can become an addiction similar to other behavioral addictions, where individuals continuously seek surgical procedures despite potential negative risks. This addictive behavior is often related to psychological disorders such as body dysmorphic disorder (BDD), a mental condition where individuals are excessively concerned about perceived defects in their appearance. Substance abuse People engaged in prostitution are predominantly women, although men are also involved. There are various types of prostitution, from high-end escort services to street-level services. In the United States, prostitution is illegal except in some counties in Nevada. Women in street prostitution often face greater social and legal consequences, including high rates of arrest, incarceration, violence, and victimization, as well as health, mental health, and substance abuse issues. Substance abuse is common among women in prostitution, including the use of heroin, cocaine, marijuana, and alcohol. Some women start prostituting to fund their drug use, while others develop substance abuse problems after becoming involved in prostitution. Substance use can provide women with a coping mechanism for the difficulties of prostitution. Most women in prostitution have experienced violent events throughout their lives, often from childhood. There is a high prevalence of childhood sexual abuse among women in prostitution, and many also face violence in their intimate relationships and within the context of prostitution. These experiences of violence and trauma throughout life place women at risk of developing disorders such as post-traumatic stress disorder (PTSD), anxiety, depression, and other related issues. The high levels of substance abuse and trauma among women in prostitution suggest the need for programs that address both issues comprehensively. This study aims to inform the implementation of the SPD and highlight the importance of developing and implementing effective interventions for this population. Recidivism For some, dissatisfaction and increasing emotional distress prompted periods of disengagement from sex work, ranging from days to years, or the beginning of what they described as their exit from sex work. However, for most, these breaks were short-lived, and emotional and financial difficulties led them back. Emotional and financial difficulties were frequently interconnected, as drug addiction as a means of emotional management created economic problems. Participants struggled with limited monetary benefits and faced significant barriers to accessing alternative employment and educational opportunities. Women reported few options for earning quick money, making them return to sex work as an immediate solution to urgent financial needs. Despite not necessarily wanting to return, sex work was seen as an easy way out in situations of extreme economic need. Even those who tried to leave sex work found it difficult to refuse face-to-face propositions or calls from regular clients. Once experienced in sex work, alternative options seemed scarce, and sex work offered a level of familiarity and flexibility. Additionally, for some, it was important to avoid the time restrictions and obligations associated with formal employment, preferring to avoid the legal implications of criminal activities such as theft. Substance use often drove the need to earn quick money with few obligations, although some women described how sex work met basic needs and then became accustomed to the extra money. In addition to financial appeal, some participants were drawn back to sex work seeking companionship, purpose, and relief from loneliness and boredom. Returning to sex work offered a sense of belonging, especially for those with limited family contacts or loss of custody of their children due to drug problems. Although some women accessed activities in support services, they reported a limited range of self-directed leisure activities, sometimes leading them back to sex work due to boredom. Psychological consequences Post-traumatic stress disorder One of the strongest psychological effects of prostitution on sex workers is post-traumatic stress disorder (PTSD). PTSD is described as episodes of anxiety, depression, insomnia, irritability, recurrent memories, emotional numbness, and hypervigilance. PTSD symptoms are more severe and long-lasting when the stressor is a person. According to Melissa Farley, "PTSD is normative among prostituted women." In San Francisco, Farley conducted a study with 130 prostitutes, 55% of whom reported being sexually assaulted in childhood and 49% reported being physically assaulted in childhood. As adults in prostitution: 82% had been physically assaulted, 83% had been threatened with a weapon, 68% had been raped while working as prostitutes, and 84% reported being homeless at some point. According to the 130 people interviewed, 68% met the DSM III-R criteria for a PTSD diagnosis. Farley notes that 73% of the 473 people interviewed in five different countries (South Africa, Thailand, Turkey, US, and Zambia) reported being assaulted in prostitution and 62% had been raped in prostitution. Any prostitute who experiences trauma can develop PTSD. Research found that of the 500 prostitutes interviewed worldwide, 67% suffer from PTSD. The study titled "Prostitution in Five Countries: Violence and Post-Traumatic Stress Disorder" conducted by Melissa Farley, Isin Baral, Merab Kiremire, and Ufuk Sezgin and published in Feminism & Psychology in 1998 investigates the prevalence of violence and post-traumatic stress disorder (PTSD) among prostituted individuals in South Africa, Thailand, Turkey, the United States, and Zambia. The research, based on interviews with 475 individuals in prostitution, shows that 73% of respondents reported being physically assaulted, 62% reported being raped, and 67% met the diagnostic criteria for PTSD. The study also examines differences in experiences of violence by location of prostitution (street or brothel) and race, although it found no significant variations in the severity of PTSD among different groups. The data indicate that prostitution inherently carries a high risk of violence and psychological trauma, regardless of the cultural or legal context. Additionally, an average of 92% of respondents expressed a desire to leave prostitution, needing support such as job training, healthcare, and physical protection. The research demonstrates that prostitution is a form of violence against women and raises serious implications for public policies and support programs aimed at individuals in prostitution. The table provides a detailed comparison between sex workers with current PTSD and those without current PTSD, focusing on several key dimensions: demographics, drug use, risky sexual behaviors, and mental health and trauma experiences. In terms of demographics, the mean age of women with current PTSD is 34 years, similar to women without current PTSD, who have a mean age of 33 years. Both cohorts have a median of 9 years of schooling. However, a notable difference is the rate of homelessness in the past 12 months, which is 50% among women with current PTSD, compared to 42% in women without current PTSD. Additionally, A&TSI (Aboriginal and Torres Strait Islander) status is more prevalent among women with current PTSD (27% vs. 20%). Regarding recreational drug use, the median age at first use of injectable drugs is slightly lower in women with current PTSD (17 years) compared to those without current PTSD (18 years). The rates of heroin dependence are high in both cohorts, though slightly lower in women with current PTSD (73% vs. 86%). Dependence on cocaine and cannabis is also relevant, with similar percentages between both groups. However, a significant finding is that 20% of women with current PTSD shared injection equipment in the last month, compared to 40% of those without current PTSD, suggesting possible differences in risk behaviors related to drug use. In terms of risky sexual behaviors, the median age at starting sex work is slightly higher in women with current PTSD (20 years) compared to those without current PTSD (18 years). The prevalence of condom use is high in both groups, both during sex with clients (91% for current PTSD and 83% for no current PTSD) and during oral sex with clients (62% for current PTSD and 60% for no current PTSD). This indicates a high level of awareness about protection in both groups. The most pronounced differences are observed in variables related to mental health and trauma. Women with current PTSD report a significantly higher median number of traumas (7 traumas) compared to those without current PTSD (5 traumas). Severe depressive symptoms are more common in women with current PTSD (73% vs. 48%), as are suicide attempts (50% vs. 40%). Both groups have similar rates of physical assault while working (77% in both cases) and childhood sexual abuse (82% in current PTSD vs. 72% in no current PTSD). However, childhood neglect is significantly more reported by women with current PTSD (59% vs. 28%), and adult sexual assault is also notably higher in this group (82% vs. 53%). The median age at first sexual assault is slightly lower in the group with current PTSD (13 years) compared to the group without current PTSD (14 years). Analysis This analysis suggests that sex workers with current PTSD not only face a higher burden of trauma and adverse conditions throughout their lives but also exhibit more severe patterns of risky behavior and mental health consequences. The high prevalence of multiple traumas, severe depression, and experiences of violence in both childhood and adulthood demonstrates the need for targeted interventions and trauma-focused treatments for this vulnerable group. The lower rate of sharing injection equipment among the group with current PTSD could indicate greater caution in certain health risk aspects, but this does not mitigate the need for comprehensive support due to the severity of mental health issues and traumatic experiences they face. Symptoms The study conducted by Young-Eun Jung and colleagues compared mental symptoms, especially PTSD symptoms, in women who escaped prostitution, activists helping in shelters, and a control group. The research evaluated 113 ex-prostitutes living in shelters, 81 activists, and 65 control subjects using self-report questionnaires on demographic data, trauma-related symptoms and PTSD, stress reactions, and other mental health factors. The results showed that ex-prostitutes exhibited more frequent and severe responses to stress, somatization, depression, fatigue, frustration, sleep problems, smoking, and alcoholism, as well as more frequent and severe PTSD symptoms compared to the other two groups. Activists also showed higher tension, sleep problems, smoking, and more frequent and severe PTSD symptoms than the control group. These findings suggest that involvement in prostitution may increase the risks of exposure to violence, psychologically traumatizing not only the prostitutes themselves but also those who help them. Moreover, the effects of trauma can persist for a long time. Future research is needed to develop methods to assess specific factors contributing to vicarious trauma in prostitution and to protect field workers from this trauma. Borderline personality disorder Borderline personality disorder (BPD) is a mental disorder characterized by significant impulsivity, seduction, and excessive sexuality. Sexual promiscuity, sexual obsessions, and hypersexuality or sexual addiction are common in both men and women with BPD. Research indicates that more than 90% of sex addicts exhibit personality disorder traits and often suffer from other psychological issues. BPD is one of the most prevalent personality disorders among those with hypersexuality. A person with BPD may engage in impulsive and self-destructive behaviors, including sexual activity as a form of self-harm. In this context, many individuals with BPD and hypersexual behaviors may be drawn to prostitution as a way to meet their emotional and psychological needs. Prostitution may be seen as an outlet for impulsivity and the need for emotional validation, offering a sense of control and worth that individuals with BPD may desperately seek. Additionally, the financial instability often associated with BPD may drive these individuals to prostitution as a means of economic support. Participation in prostitution can, in turn, exacerbate BPD symptoms due to exposure to abuse, violence, and social stigma, creating a harmful cycle that further hinders treatment and recovery. Jane Eloy, a sex worker, provides a raw perspective on how the search for validation and instant gratification can be driven by emotional deficiencies and a need for recognition. From a psychological standpoint, the behavior of participants shows power dynamics and cognitive dissonance, where unmet expectations generate tension that is resolved by conforming to group rules. This allows for the exploration of repressed sexual identities and power roles, using transgression and control as means to fulfill subconscious desires and resolve deep-seated insecurities. The prevalence of survival sex and mental illnesses are overrepresented in homeless populations. A recent study evaluated the relationship between borderline personality disorder (BPD) symptoms and participation in survival sex among homeless women. Researchers surveyed 158 homeless women about self-reported BPD symptomatology and sexual history. Bivariate and multivariate analyses in this study revealed that certain BPD symptoms are strongly correlated with survival sex among adult homeless women. The results indicate that impulsivity is a significant factor associated with participation in survival sex, even after controlling for other demographic and homelessness experience variables. These findings suggest the need for service agencies and others working with at-risk female populations to consider impulsivity as a critical factor when developing interventions to prevent survival sex. The study sample included women from Omaha, Nebraska; Pittsburgh, Pennsylvania; and Portland, Oregon, and interviews were conducted in shelters, community meal programs, and outdoor locations. Participants received $20 for completing the interviews. The results showed that 23.8% of the women surveyed had engaged in survival sex, and BPD dimensions such as impulsivity and fear of abandonment were significantly related to this practice. Age was also identified as a risk factor, with a higher likelihood of engaging in survival sex as women aged. The results highlight the need for training for service providers working with homeless populations, particularly to identify and support older women with high levels of impulsivity. This study underscores the importance of continuing to investigate the relationship between BPD and survival sex to develop more effective interventions. Self-destructive behaviors Self-destructive behavior in female sex workers refers to actions that endanger their own safety and physical health, considered a form of self-destruction. This phenomenon manifests through high levels of suicidal ideation and suicide attempts, primarily motivated by emotions such as shame, anger, and resentment. Among sex workers, it is common to find underdeveloped psychological protection mechanisms, contributing to maintaining risky sexual behaviors. These mechanisms include primitive forms of psychological defense, such as denial and projection. Additionally, there is a significant propensity toward active victim behaviors, characterized by a tendency to take risks and adopt a passive or provocative attitude in dangerous situations. The analysis of the psychological and behavioral patterns of these women has identified three main variants: the emotional-anxious-dysthymic, the exalted affective-hyperthymic-cyclothymic, and the demonstrative-excitative-stubborn. The first is characterized by high emotional lability, a pessimistic perception of reality, and low self-esteem. The second variant shows turbulent behavior with unstable emotional responses and a constant search for entertainment and pleasure. The third variant is distinguished by egocentrism, irritability, and a tendency towards conflict due to a lack of acceptance of other opinions. In terms of general and sexual education, it has been found that many sex workers lack adequate training, contributing to a disharmonious personality and a lack of adaptability. This educational deficit includes both the absence of sex education in the family environment and exposure to immoral or repressive types of education. Women who engage in prostitution on the street face numerous problems that can increase their risk of having suicidal thoughts. Factors such as violence, substance abuse, mental health issues, and lack of social support are common in their lives and significantly contribute to this risk. Street prostitutes often live in difficult and dangerous conditions. Many have been victims of physical, emotional, or sexual violence. A study conducted in several European cities revealed that approximately 60% of street prostitutes have experienced some form of violence in the past year, and 42% report having had suicidal thoughts during the same period. Additionally, it was found that 35% of these women suffer from clinical depression, and 25% have attempted suicide at least once in their lives. A study conducted by Alexandre Teixeira from the Faculty of Psychology at the University of Porto concluded that 44% of women who engage in street prostitution have had at least one suicidal episode, identifying precariousness, lack of legislation, and exposure to violence as the main risk factors. The research, which included 52 street prostitutes aged 18 to 60, revealed that the lack of income is the primary reason why these women turn to prostitution, although they recognize that this activity is insufficient for their sustenance. Teixeira noted that 23 of the women studied had attempted suicide one or more times, attributing this high rate of suicide attempts to causes such as victimization and exposure to verbal, physical, and sexual violence from clients and peers. He also highlighted that legal regulation of prostitution, with rights to social protection and the possibility of making contributions to social security, could positively influence these women's emotional health. According to the researcher, approximately 70% of the participants have been in prostitution for five or more years, which allows it to be considered a career rather than a temporary activity, although the women themselves do not usually perceive it this way, referring to prostitution as a temporary solution to immediate problems. Self-harm and suicide The diathesis-stress theory of suicide suggests that a biological predisposition (diathesis) combined with negative life circumstances (stress) precipitates suicidal behaviors. Women engaged in sex work and who use drugs face multiple risk factors for suicidal ideation and attempts, including childhood adversities, high levels of physical and sexual violence, and social stigmatization. Violence and substance use can have an interdependent relationship, where intimate partner violence can increase alcohol and drug consumption, and vice versa. Stigma and discrimination, especially related to sex work and drug use, increase the risk of suicide by generating social isolation and feelings of internal shame. The study "Increased burden of suicidality among young street-involved sex workers who use drugs in Vancouver, Canada" investigated the risk of suicide attempts among young people living on the street and engaged in sex work in Vancouver, Canada. Data were obtained from the At-Risk Youth Study, a prospective cohort of street youth who use drugs. Multivariable generalized estimating equation analyses were used to determine if these youth had an elevated risk of attempting suicide, controlling for possible confounding factors. Between September 2005 and May 2015, 1210 youth were recruited, of whom 173 (14.3%) reported having recently attempted suicide. In the multivariable analysis, youth engaged in sex work were more likely to report recent suicide attempts. Systematic discrimination and unaddressed trauma were found to contribute to the increased risk of suicide in this population. Anna's suicide and prostitution in London In 2009, a Chinese woman named Anna committed suicide near Heathrow Airport in London. Friends later discovered that she worked as a prostitute in an illegal massage parlor. Jenny Lu, an art student from Taiwan and Anna's friend, investigated her friend's secret life, resulting in her first feature film, "The Receptionist." The film, which premiered in Taiwan in 2017, has yet to have a release date in Brazil. Anna, originally from a small town in China, moved to London in search of a better life but ended up leading a double life unknown to those close to her. Lu contacted women who worked with Anna at the massage parlor, discovering that many were immigrants from China, Malaysia, the Philippines, and Thailand, some with false passports or through arranged marriages. Anna, married to an unemployed Briton, worked to pay off the debt from her fake marriage and help her brother in China. Lu's film portrays the mistreatment and abuse these women face, including extortion and violence from criminals offering "protection." Despite the fictional nature of the scenes, they are based on the real experiences of Anna and her colleagues. Lu arranged meetings between the actors and the women to ensure the script's authenticity. Many of these women continue in prostitution due to language barriers and the difficulty of finding well-paying jobs. The film highlights how these women live in isolation, fearing discovery by their neighbors and working with the curtains always closed. Anna, 35, had been in the sex industry for only a year when she committed suicide. Family pressure and the shame of her secret work contributed to her decision. Lu's film, partially funded by Taiwanese agencies and crowdfunding, was selected for the Edinburgh film festival and received nominations in Italy and Taiwan. Depression A study conducted by researchers at the Pontifical Catholic University of Rio Grande do Sul (PUC-RS) revealed that 67% of prostitutes in Porto Alegre exhibit symptoms of depression. Published in the Revista de Psiquiatria do Rio Grande do Sul, the study evaluated 97 women aged 18 to 60 who engage in prostitution in various settings, such as bars, nightclubs, and streets. The research analyzed variables such as age, educational level, religious practice, skin color, reasons for continuing the activity, average monthly income, intention to leave prostitution, condom use, sexually transmitted diseases, and illicit drug use. To assess depressive symptoms, a 21-question questionnaire about the previous week was used. Despite the participants' average monthly income of approximately one thousand reais, a relatively high figure compared to the average Brazilian salary, more than 90% continued in prostitution for economic reasons, and 86.6% expressed a desire to leave the profession. Additionally, the study found that 48.5% of the participants had had at least one abortion, nearly 30% had contracted sexually transmitted diseases, and more than 50% had a steady partner. A positive finding was that 93% of the prostitutes used condoms in their sexual relations. Condom use was associated with a lower prevalence of sexually transmitted diseases, which stood at 28.9%. The research also highlighted that 70% of women with depressive symptoms consumed alcohol and that 32.2% practiced a religion, which acted as a protective factor against depression. The study titled "Transtorno Mental Comum em Acompanhantes de Pacientes em Internação Hospitalar de Curto e Médio Período: Um Estudo Transversal," published in the Revista Multidebates in June 2020, aimed to evaluate the prevalence of common mental disorder (CMD) in companions of patients hospitalized for short or medium periods. This cross-sectional study was conducted in a general hospital in Greater São Paulo in 2019, with a sample of 272 individuals, using the Self-Reporting Questionnaire (SRQ-20), globally validated. The results showed that 41.2% of the companions had CMD. The highest prevalence was observed in those who were the patient's children (49.1%), women (44.8%), aged 40 to 59 years (45.1%), who had another professional occupation (42%), suffered from a chronic disease (51.1%), and did not engage in physical activity (46.6%). The three sectors evaluated showed that the green sector, the first admission area, had the highest prevalence of CMD (49.5%). In a cross-sectional study conducted in Shenyang and Guangzhou, China, in 2017, it was found that 25.25% of transgender sex workers exhibited high levels of depression. The study, which included 198 participants, used a structured questionnaire to assess background characteristics, self-esteem, feelings of defeat and entrapment, and depression. The results showed a negative correlation between self-esteem and depression, as well as between self-esteem and feelings of defeat and entrapment. Additionally, it was found that feelings of entrapment and defeat fully mediated the relationship between self-esteem and depression. Anxiety Anxiety is one of the most common mental disorders among sex workers due to constant exposure to high-risk situations such as violence, sexual coercion, and stigmatization. Studies have shown that sex workers exhibit significantly higher rates of anxiety symptoms compared to the general population. The prevalence of anxiety in this group can be related to multiple factors, including childhood abuse, workplace violence, and lack of social support. Additionally, sex workers often face health issues such as sexually transmitted infections and HIV, which can exacerbate their anxiety. Treating anxiety in sex workers requires a comprehensive approach that addresses both their physical and mental health through cognitive-behavioral therapy, psychological support, and, in some cases, medication. The environment in which these women work, often characterized by a lack of security and instability, contributes to a constant sense of danger and alertness. Anxiety can manifest in a variety of symptoms, including panic attacks, irrational fear, excessive worry, hypervigilance, and difficulty sleeping. Repeated exposure to traumatic events, such as physical and sexual assaults, can also lead to the development of post-traumatic stress disorder (PTSD), which often coexists with anxiety. Specific research, such as the study conducted in KwaZulu-Natal, South Africa, found that 78.4% of sex workers exhibited anxiety symptoms according to the Self Reporting Questionnaire (SRQ 20). This study also revealed that 72% of sex workers had experienced violence and 69% had suffered childhood abuse. These traumatic factors significantly contribute to the development of anxiety disorders and other mental health problems. Difficulty in forming emotional bonds Women involved in prostitution tend to be characterized by insecure attachment and cognitions marked by emotional deprivation, distrust, fear of abandonment, feelings of unworthiness of love, and submission to others' control. These factors can result in social isolation and difficulties in relational commitment, particularly in the context of romantic relationships. However, interviews with these women revealed that almost three-quarters of them reported maintaining a relationship with a person who represented a significant source of support, well-being, and could act as a catalyst for change. Nonetheless, their support network seems to depend on a specific person or, at least, a very limited number of people. Another significant finding of the study is that when women reveal their involvement in prostitution to their loved ones, the latter tend to position themselves as positive actors in the change process rather than being a source of rejection and stigmatization. Direct interventions with loved ones should inform them that the support they can provide to these women is necessary. Most women (78%) reported that sex work negatively affected their personal romantic relationships, mainly due to issues of lying, trust, guilt, and jealousy. A small number of women reported positive impacts of sex work, such as better sexual self-esteem and confidence. About half of the women were in a relationship at the time of the study, and of these, 51% reported that their partner knew the nature of their work. 77% of single women chose to remain single due to the nature of their work. Many women used mental separation as a coping mechanism to manage the tensions between sex work and their personal relationships. The main ways in which sex work negatively affected women in relationships included dishonesty, distrust, jealousy, stigma, and pragmatic issues. Women in relationships often lied to their partners about the nature of their work, causing guilt and trust issues. Partners who knew about the women's work often experienced jealousy and misunderstandings due to the stigma associated with the sex industry. More than half of the women in the study were single, primarily by choice, due to the nature of their work. Some women chose to remain single because they were not comfortable with the idea of having a relationship while working in the sex industry, or because they felt their partners would not be comfortable with their work. About half of the women mentioned the need to maintain a distinction between their work and personal lives, using separation as a coping mechanism. More than half of the women found it difficult to mentally separate their work lives from their personal lives. Some strategies included not socializing with other sex workers outside of work and using condoms with clients but not with romantic partners. The findings of this study coincide with and expand on previous studies that also found that women working in the sex industry commonly report negative impacts on their relationships due to issues of dishonesty, trust, and guilt. The stigma associated with the sex industry was a significant barrier in the personal relationships of sex workers, leading to issues of support and understanding from their partners. Social isolation The mental health of sex workers is affected by a variety of factors, including social isolation, loneliness, and the social stigma associated with their occupation. These factors not only influence their emotional well-being but also interact with structural aspects such as criminalization and violence. The mode of work, whether solitary or with colleagues, also plays an important role in their daily experience and mental health. The lack of information and the infantilizing treatment they often receive contribute to a negative self-image and the perception of being unable to make decisions about their own lives, further exacerbating mental health issues in this group. Social isolation and loneliness have a strong impact on the mental health of sex workers. A study conducted by the "European Sex Workers' Rights Alliance" showed that more than 70% of respondents considered that isolation greatly affects mental health. The mode of sex work can also influence their ability to work with colleagues or individually. Focus group participants indicated that the inherent loneliness of escorting was difficult to manage, while a participant who worked on the streets with colleagues mentioned enjoying having people around. A sex worker in Finland expressed that upon entering this industry, the lack of information is so great and the loneliness is so intense that it deeply affects them. Another impact of social stigma on mental health is the underlying assumption that sex workers are victims. A sex worker in Finland commented that they are not asked for their opinion or listened to, and that others make decisions for them, assuming they are incapable of choosing for themselves, which contributes to infantilization that can generate negative self-images and negatively affect mental health. Stigma acts as an umbrella factor that intertwines with many other structural factors influencing the mental health of sex workers, such as criminalization or violence. Low self-esteem Low self-esteem is a significant factor in the mental health of many people, and among sex workers, this issue can be especially pronounced. Self-esteem, defined as the value a person places on themselves, influences how they perceive and relate to the world. In the context of sex workers, low self-esteem is often related to experiences of rejection, social stigmatization, and traumatic situations. These women may face a cycle of self-criticism and personal worthlessness, exacerbated by discrimination and marginalization in their daily lives. People with low self-esteem are more susceptible to manipulation and exploitation by pimps and other exploiters. There is a connection between low self-esteem and prostitution. In some cases, pimps use underage sex workers to recruit other residents of group homes. Sexual abuse can have a significant impact on self-esteem. Adopted individuals and those who have suffered sexual abuse tend to experience low self-esteem and difficulties in relationships. Numerous studies have shown that low self-esteem is closely linked to a range of mental health problems, such as depression and anxiety. Sex workers with low self-esteem may feel trapped in their circumstances, unable to see a viable way out, reinforcing feelings of defeat and hopelessness. This cycle of negativity can be difficult to break without adequate support and intervention strategies that address both emotional aspects and social contexts that perpetuate low self-esteem. The study "Sex work and three dimensions of self-esteem: self-worth, authenticity and self-efficacy" analyzes the relationship between sex work and self-esteem. The study uses a heterogeneous sample of 218 Canadian sex workers providing services in various locations, utilizing a three-dimensional framework of self-esteem: self-worth, authenticity (being oneself), and self-efficacy (competence). Sex work is assumed to have a negative effect on self-esteem, expressed almost exclusively as low self-esteem due to its social unacceptability, despite the diversity of people, positions, and roles within the sex industry. In this study, a heterogeneous sample of 218 Canadian sex workers delivering services in various locations was asked how their work affected their sense of self. Using a thematic analysis based on a three-dimensional conception of self-esteem, we shed light on the relationship between engagement in sex work and self-esteem. The findings demonstrate that the relationship between sex work and self-esteem is complex: most participants discussed multiple dimensions of self-esteem and often spoke about how sex work had both positive and negative effects on their sense of self. Social background factors, the location of work, and life events and experiences also had an effect on self-esteem. Future research should adopt a more complex approach to understanding these issues by considering elements beyond self-esteem, such as authenticity and self-efficacy, and examining how the backgrounds and individual motivations of sex workers intersect with these three dimensions. In a study titled "Evaluation of Self-Esteem of Female Sex Workers," focusing on analyzing the self-esteem of sex workers in Campina Grande-PB, the results showed that these women's self-esteem is low, influenced by the social stigma associated with prostitution and personal factors such as motherhood, family context, and age. Additionally, the study noted that younger workers charged more for their services than older ones, showing an economic impact of age on their profession. Cultural differences In the article "Self-esteem and cognitive distortion among women involved in prostitution in Malaysia," published in Procedia Social and Behavioral Sciences (2010), authors Rohany Nasir et al. examine how self-esteem and cognitive distortions vary among Muslim and non-Muslim women in Malaysia. Using the Rosenberg Self-Esteem Scale and Briere's Cognitive distortion Scale, the study reveals that Muslim prostitutes have significantly lower self-esteem and higher cognitive distortions compared to their non-Muslim counterparts. Additionally, a negative correlation was found between self-esteem and cognitive distortion, suggesting that higher self-esteem is associated with lower cognitive distortions. Cognitive impairment Research titled "Screening for Traumatic Brain Injury in Prostituted Women" highlights that violence is a predominant aspect of prostitution and a significant cause of TBI. 95% of participants had suffered head injuries, frequently as a result of being hit with objects or having their heads slammed against surfaces. Notably, 61% of the head injuries occurred while engaged in prostitution. The study documents both acute and chronic symptoms associated with these injuries, including dizziness, depression, headaches, sleep problems, concentration and memory difficulties, trouble following instructions, low frustration tolerance, fatigue, and changes in appetite and weight. The study highlights the importance of screening for Traumatic brain injury (TBI) to ensure effective care for prostituted women. The authors note that TBIs, often caused by blows to the head or violent shaking, are common in interpersonal assaults, more than in accidents or falls. Additionally, head injuries are frequent in intimate partner violence (IPV), and women in prostitution often experience high rates of this type of violence. Treatment Psychotherapy for these women must be tailored to their specific needs, considering the use of crisis interventions and the building of coping skills during severe stress episodes. During periods of milder symptoms, a psychodynamic approach focused on self-reflection and deep exploration can be employed. The therapeutic relationship is necessary to establish trust and safety, allowing patients to explore their experiences and develop healthier coping mechanisms. Understanding transference and countertransference is essential for effective treatment, and clear professional boundaries must be maintained to avoid breaches that could harm the therapeutic relationship. Long-term psychological effects Transitioning from life in prostitution to life outside this activity involves profound psychological issues. The experience of having worked in the sex industry carries a series of long-term repercussions that affect mental and emotional health. In the text "Life After Prostitution" by Bethany St. James, the psychological impact of her experience in the adult entertainment industry is described. Although superficially the industry seemed benevolent, it was actually extremely damaging and unhealthy. Upon leaving the industry, St. James faced an identity crisis, having spent 20 years in an environment that, though incomprehensible to outsiders, made sense to her. Leaving this life meant losing her identity and feeling disoriented in the real world. This lack of identity outside of work left her emotionally unstable, unable to relate to people outside the business. Removing the facade she had built as Bethany St. James left her feeling vulnerable and exposed. Everyday tasks began to trigger panic attacks, leading her to believe she was experiencing a mental breakdown. Seeking a new identity through her Christian faith and church participation did not provide the expected comfort, as her past experiences significantly differentiated her from her new peers, causing isolation and judgment from the religious community. These emotional and social problems culminated in the appearance of severe PTSD symptoms. Comparing herself to her husband, a veteran with war-related PTSD, revealed that her form of PTSD was opposite to his: while he couldn't turn off his emergency response system, she didn't know how to react to normal situations after living in a constant state of alert. Cognitive therapy revealed that St. James had developed coping mechanisms that allowed her to neutralize normal emotional responses, making stressful situations seem routine. This emotional imbalance prevented her from recognizing the damage she had inflicted on herself over the years. The diagnosis of severe PTSD made her understand that her inability to perceive her experiences as traumatic was part of the problem. Not feeling that she had lived through traumatic events contrasted with others' perceptions, who saw her experiences as clearly traumatic. Therapy helped her process and heal, allowing her to understand and accept the complexity of her past and present life. The study "Symptoms of Posttraumatic Stress Disorder and Mental Health in Women Who Escaped Prostitution and Helping Activists in Shelters," published in 2008, analyzes women who escaped prostitution, activists helping them in shelters, and a control group. The researchers found that former prostitutes exhibited significantly higher levels of PTSD symptoms, stress, somatization, depression, fatigue, sleep problems, smoking, and alcoholism compared to the other two groups. Activists also showed higher levels of tension, sleep problems, and smoking, and more frequent and severe PTSD symptoms than the control group. The research concludes that participation in prostitution increases the risk of exposure to violence, which can cause psychological trauma in both the women involved and those who help them. These effects can be long-lasting, and the need to develop methods to assess and mitigate vicarious trauma in workers assisting prostitution victims is suggested. Additionally, the importance of early diagnosis and treatment is highlighted to reduce the social and economic burden of PTSD. Case studies Prostitutes of Minas Gerais A cross-sectional study conducted in Minas Gerais evaluated the prevalence of common mental disorders (CMD) and associated factors in a group of prostitutes. The Self-Reporting Questionnaire (SRQ-20) was used to interview 216 women registered with the Prostitutes' Association of Minas Gerais (Aprosmig) between November 2012 and May 2013. The study analyzed sociodemographic characteristics and aspects of sex work, using the chi-squared test to examine the association between categorical variables and the presence of CMD, and employing a logistic regression model to identify factors associated with CMD. The overall prevalence of CMD was 57.9%, being more frequent in women with low education, history of physical violence, and early entry into prostitution. Women with less than eight years of schooling had twice the likelihood of developing CMD (OR = 2.05), and those with a history of physical violence also showed a significantly higher likelihood (OR = 2.18). The study concludes the need to improve healthcare for this group, given the high rates of CMD compared to the general population. Women trafficked for sexual exploitation The study titled "A Study on the Psychological Effects on Women Who Were Trafficked for Sexual Exploitation" addresses the psychological consequences experienced by women victims of trafficking for sexual exploitation. The research is based on various documentaries available on YouTube, including "Trafficking of Women for Sexual Exploitation" and "Amazonas Has a Human Trafficking Route Without Oversight." Human trafficking is a serious crime that infringes on women's rights, making them vulnerable in various psychological aspects. According to the UN, human trafficking generates $32 billion annually, with 85% coming from sexual exploitation and 98% of victims being women. The Palermo Protocol defines human trafficking as the recruitment, transportation, and exploitation of people through coercion, fraud, or abuse of vulnerability. This crime can involve luring and prolonged exploitation, causing severe psychological harm to the victims. Trafficked women generally come from regions with high poverty rates and low education, making them easy targets for traffickers who promise better living conditions abroad. The study's methodology is exploratory and qualitative, using documentary data and victim testimonies. The analyzed documentaries recount real stories of suffering and exploitation, highlighting psychological effects categories such as objectification, desire for death, fear, fear of death, pain/suffering, and sadness. The results show that victims suffer deep psychological traumas, including depression, anxiety, suicide attempts, and post-traumatic stress disorder. Psychology plays a crucial role in the recovery of these women, helping them overcome traumas and rebuild their lives. The study concludes that trafficking of women for sexual exploitation is a continuous violence crime causing long-lasting psychological harm. Risk factors study The systematic review "Invisible and Stigmatized: A Systematic Review of Mental Health and Risk Factors Among Sex Workers," published in Acta Psychiatrica Scandinavica, examines the mental health and associated risk factors in sex workers (SW). The research, conducted by Laura Martín-Romo, Francisco J. Sanmartín, and Judith Velasco, analyzes studies published between 2010 and 2022 in various databases. Of 527 studies identified, 30 met the inclusion criteria. The review highlights the prevalence of mental health issues among SWs, with depression being the most common problem, followed by anxiety, substance abuse, and suicidal ideation. SWs are exposed to multiple occupational risks, including violence and high-risk sexual behaviors, and face significant barriers to accessing health services due to stigma. SWs have higher probabilities of being diagnosed with mood disorders, with depression rates ranging between 50% and 88%. Anxiety affects between 13.6% and 51% of SWs, while post-traumatic stress disorder (PTSD) has a prevalence between 10% and 39.6%. Substance abuse is common, with problematic alcohol use reported between 36.7% and 45.4% of SWs. Women are the majority in sex work, and lack of social support is associated with poorer psychological adaptation. Violence is a significant risk factor, with studies indicating that SWs experience high levels of violence, contributing to mental health problems. The review suggests that unfavorable working conditions, lack of access to health services, and stigma play a crucial role in the poor mental health of SWs. The review notes the need for longitudinal studies and a better understanding of the clinical backgrounds of SWs to determine the impact of sex work on mental health. AESHA study in Vancouver In a study conducted in Vancouver, Canada, titled An Evaluation of Sex Workers Health Access (AESHA), it was found that 48.8% of the sex workers surveyed reported having ever been diagnosed with a mental health issue, with the most common diagnoses being depression (35.1%) and anxiety (19.9%). This study used interviewer-administered questionnaires and bivariate and multivariable logistic regression analyses to evaluate the burden of mental health diagnoses and their correlations. The study's findings highlighted that sex workers with mental health diagnoses were more likely to identify as sexual/gender minorities (LGBTQ), use non-injection drugs, have experienced physical/sexual trauma in childhood, and work in informal or public spaces. These findings show the need for evidence-based interventions addressing the intersections between trauma and mental health, along with policies promoting access to safer workspaces and adequate health services. Sex workers often operate in environments characterized by insecurity and instability, contributing to a constant sense of danger and alertness. Anxiety can manifest in various symptoms, including panic attacks, irrational fears, excessive worry, hypervigilance, and sleep difficulties. Repeated exposure to traumatic events can lead to the development of post-traumatic stress disorder (PTSD), which often coexists with anxiety. The Vancouver study also revealed that sex workers with mental health diagnoses were more likely to have used non-injection drugs and experienced physical or sexual violence, both in childhood and adulthood. These traumatic factors significantly contribute to the development of anxiety disorders and other mental health issues. Additionally, identifying as a sexual/gender minority was strongly associated with mental health diagnoses, due to the structural discrimination and stigma faced by these individuals. See also Prostitution Post-traumatic stress disorder Sexual abuse Body dysmorphic disorder Violence against women Sexual exploitation References Bibliography External links Study on Prostitution and Its Psychological Impacts Psychological Consequences of Prostitution Dissociative Identity Disorder Impact of Prostitution on Women's Identity Mental Health Impacts of the Sex Trade Psychotherapy for Victims of Prostitution Violence and Prostitution: An Analysis The Invisibility of Harm in Prostitution Post-traumatic Stress in Prostitution Victims Types of Sex Workers and Their Environments Prostitution Mental health Psychological effects Sexual health Social issues Women's health Human trafficking Public health Violence against women Sexual abuse Post-traumatic stress disorder Depression (mood) Anxiety disorders Addiction Sex industry Mental disorders

Cognitive remediation therapy

Cognitive remediation is designed to improve neurocognitive abilities such as attention, working memory, cognitive flexibility and planning, and executive functioning which leads to improved psychosocial functioning. Empirical support Empirical support for cognitive remediation in traumatic brain injury and schizophrenia is documented by published randomized controlled trials and meta-analyses. Effects on cognitive skill performance in schizophrenia are durable for months after the therapies are withdrawn, particularly in terms of executive functioning, working memory, and verbal memory. Importantly, neurocognitive gains have been linked to improvements in obtaining and working in competitive jobs. In practice Narrowly defined, CR is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning. However, from the vantage point of the rehabilitation field, CR engages the participant in a learning activity to enhance the neurocognitive skills relevant to overall recovery goals. CR programs vary in the extent to which they reflect these narrow or broader perspectives, and there is ongoing research to identify the active ingredients that result in a positive response to treatment. Data suggests that when cognitive remediation is provided to people with schizophrenia, it is most effective when given in the broader context of psychosocial rehabilitation. Recent attention has turned to incorporating motivational enhancements into the treatment of cognitive dysfunction for psychological disorders. Meta-analyses on cognitive remediation usually also consider interventions targeting social cognition and metacognition, such as social cognition and intervention training and metacognitive training. For anorexia nervosa For individuals with anorexia nervosa (AN), CRT is an interactive treatment which combines practical exercises with discussions about their relevance to the patient’s everyday life. Cognitive remediation therapy was adapted for anorexia nervosa by Professor Kate Tchanturia and colleagues at the Institute of Psychiatry, Psychology and Neuroscience to address the process rather than the content of thinking, thus helping patients to develop a metacognitive awareness of their own thinking style. The treatment is hypothesized to work by strengthening and refining neural circuits, and by learning and transferring new cognitive strategies to appropriate situations. The aim is to identify and target the cognitive impairments specific to each patient, and to motivate the patient to engage in meta-cognitive processes i.e. to consider their cognitive/thinking styles and to explore alternative strategies, which in turn might lead to behavioral changes. By becoming aware of problematic cognitive styles, the patient can reflect on how these affect everyday life and learn to develop new strategies. The intervention was originally developed for adults with chronic AN but it has been explored for younger patients as well. See also Alice Medalia Rehabilitation psychology References External links Handbook of Cognitive Dysfunction Management Cognitive Remediation to Improve Functional Outcome Neuropsychology

Basic symptoms of schizophrenia

Basic symptoms of schizophrenia are subjective symptoms, described as experienced from a person's perspective, which show evidence of underlying psychopathology. Basic symptoms have generally been applied to the assessment of people who may be at risk to develop psychosis. Though basic symptoms are often disturbing for the person, problems generally do not become evident to others until the person is no longer able to cope with their basic symptoms. Basic symptoms are more specific to identifying people who exhibit signs of prodromal psychosis (prodrome) and are more likely to develop schizophrenia over other disorders related to psychosis. Schizophrenia is a psychotic disorder, but is not synonymous with psychosis. In the prodrome to psychosis, uncharacteristic basic symptoms develop first, followed by more characteristic basic symptoms and brief and self-limited psychotic-like symptoms, and finally the onset of psychosis. People who were assessed to be high risk according to the basic symptoms criteria have a 48.5% likelihood of progressing to psychosis. In 2015, the European Psychiatric Association issued guidance recommending the use of a subscale of basic symptoms, called the Cognitive Disturbances scale (COGDIS), in the assessment of psychosis risk in help-seeking psychiatric patients; in a meta-analysis, COGDIS was shown to be as predictive of transition to psychosis as the Ultra High Risk (UHR) criteria up to 2 years after assessment, and significantly more predictive thereafter. The basic symptoms measured by COGDIS, as well as those measured by another subscale, the Cognitive-Perceptive basic symptoms scale (COPER), are predictive of transition to schizophrenia. Course There are several factors that interact prior to the development of basic symptoms, including predisposed vulnerability, environmental stressors, and support systems. Recent work in the field of neural oscillation has demonstrated that defective excitatory and inhibitory signalling in the brain during development plays an important role in the formation of basic symptoms. These signalling disturbances can lead to cognitive deficits that result in the future appearance of more complicated symptoms of the disorder. The interaction of these factors increases the risk for development of basic symptoms of schizophrenia. It is important to identify when a person is exposed to these factors to prevent, modify or delay the onset of basic symptoms through early intervention. The recognition of these basic symptoms in the prodromal phase can lead to early intervention in psychosis that aids in the delay or prevention of schizophrenia. Such early interventions include cognitive behavioural therapy (CBT) or the use of antipsychotic drugs. Basic symptoms are subjective and can be subtle. It may be difficult for the person to realize that something is wrong and tell someone else, especially without being asked directly. Often, the person will try to adapt and cope with the symptoms. Functioning becomes impaired when people reach their adaptive capacity. In the period leading up to the first episode of schizophrenia, uncharacteristic basic symptoms first appear and are followed by the onset of more characteristic basic symptoms and, finally, psychosis. Basic symptoms often appear several years before the onset of psychosis, but are often preceded by the onset of self-disorders. They may sometimes appear and then disappear before appearing again much later, where they occur as part of an outpost syndrome. At one point, uncharacteristic basic symptoms will appear, which comprise various disturbances of mood, emotions, drive, thought, and attention that can occur in many other disorders, followed by the characteristic basic symptoms, which comprise disturbances of thought, perception, and attention, along with minor reality distortion, that are associated with schizophrenia in particular. Afterward, attenuated symptoms of psychosis or brief periods of psychosis will appear, before culminating in the emergence of full-blown psychosis. At any stage before psychosis, the person will attempt to cope with the basic symptoms, which might conceal the problems from others; once the person reaches the limit of their ability to compensate, however, the problems will become evident to others and cause impairment. Poorer long-term outcomes such as increases in relapses, increases in hospitalizations, and poorer social/occupational functioning are associated with the age of onset of these symptoms, suggesting the importance of early intervention. After the resolution of psychosis, basic symptoms may follow one of 3 courses: Psychosis and the basic symptoms may resolve completely allowing the restoration of normal functioning; they may remit but remain at an uncharacteristic level, with relapses of psychosis; or the characteristic basic symptoms may remain creating a deficit syndrome dominated by negative symptoms. Evaluation Basic symptoms are generally evaluated using the Schizophrenia Proneness Instrument (SPI), of which there are both a child and youth version (SPI-CY) and an adult version (SPI-A); this instrument assesses basic symptoms, both those that are uncharacteristic and those characteristic of psychosis. Out of the items evaluated on the SPI-CY and the SPI-A, there can be derived 2 scales to evaluate specifically the characteristic basic symptoms: the Cognitive Disturbances scale (COGDIS) and the Cognitive-Perceptual Basic Symptoms scale (COPER). COGDIS criteria are met when at least 2 of the symptoms on the scale (see table below) are present with at least weekly occurrence in the last 3 months, and which were not present during the pre-morbid phase of the illness and do not result from drug use. The European Psychiatric Association (EPA) recommends the use of this scale, along with attenuated psychotic symptoms and brief transient psychosis, to detect at-risk mental states in help-seeking people. COPER criteria are met when at least 1 of the symptoms on the scale (see table below) is present with at least weekly occurrence in the last 3 months, and the first occurrence of symptoms was more than 12 months prior to evaluation. Below are the basic symptoms associated with psychosis, along with whether they appear on COGDIS, COPER, or both: The Examination of Anomalous Self-Experience (EASE) is another scale used to evaluate subjective symptoms of schizophrenia. This is a semi-structured interview scheme that was designed to specifically assess anomalous self-experience. See also Early intervention in psychosis References External links International Working Group on Basic Symptoms Psychosis Schizophrenia Symptoms and signs of mental disorders Early psychosis

Psychological trauma

Psychological trauma (also known as mental trauma, psychiatric trauma, emotional damage, or psychotrauma) is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones generally with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples of distressing events include violence, rape, or a terrorist attack. Short-term reactions such as psychological shock and psychological denial are typically followed. Long-term reactions and effects include bipolar disorder, uncontrollable flashbacks, panic attacks, insomnia, nightmare disorder, difficulties with interpersonal relationships, and post-traumatic stress disorder (PTSD). Physical symptoms including migraines, hyperventilation, hyperhidrosis, and nausea are often developed. As subjective experiences differ between individuals, people react to similar events differently. Most people who experience a potentially traumatic event do not become psychologically traumatized, though they may be distressed and experience suffering. Some will develop PTSD after exposure to a traumatic event, or series of events. This discrepancy in risk rate can be attributed to protective factors some individuals have, that enable them to cope with difficult events, including temperamental and environmental factors, such as resilience and willingness to seek help. Psychotraumatology is the study of psychological trauma. Signs and symptoms People who experience trauma often have problems and difficulties afterwards. The severity of these symptoms depends on the person, the types of trauma involved, and the support and treatment they receive from others. The range of reactions to trauma can be wide and varied, and differ in severity from person to person. After a traumatic experience, a person may re-experience the trauma mentally and physically. For example, the sound of a motorcycle engine may cause intrusive thoughts or a sense of re-experiencing a traumatic experience that involved a similar sound e.g. gunfire. Sometimes a benign stimulus (e.g. noise from a motorcycle) may get connected in the mind with the traumatic experience. This process is called traumatic coupling. In this process, the benign stimulus becomes a trauma reminder, also called a trauma trigger. These can produce uncomfortable and even painful feelings. Re-experiencing can damage people's sense of safety, self, self-efficacy, as well as their ability to regulate emotions and navigate relationships. They may turn to psychoactive drugs, including alcohol, to try to escape or dampen the feelings. These triggers cause flashbacks, which are dissociative experiences where the person feels as though the events are recurring. Flashbacks can range from distraction to complete dissociation or loss of awareness of the current context. Re-experiencing of symptoms is a sign that the body and mind are actively struggling to cope with the traumatic experience. Triggers and cues act as reminders of the trauma and can cause anxiety and other associated emotions. Often the person can be completely unaware of what these triggers are. In many cases, this may lead a person with a traumatic disorder to engage in disruptive behaviors or self-destructive coping mechanisms, often without being fully aware of the nature or causes of their own actions. Panic attacks are an example of a psychosomatic response to such emotional triggers. Consequently, intense feelings of anger may frequently surface, sometimes in inappropriate or unexpected situations, as danger may always seem to be present due to re-experiencing past events. Upsetting memories such as images, thoughts, or flashbacks may haunt the person, and nightmares may be frequent. Insomnia may occur as lurking fears and insecurity keep the person vigilant and on the lookout for danger, both day and night. A messy personal financial scene, as well as debt, are common features in trauma-affected people. Trauma does not only cause changes in one's daily functions, but could also lead to morphological changes. Such epigenetic changes can be passed on to the next generation, thus making genetics one of the components of psychological trauma. However, some people are born with or later develop protective factors such as genetics that help lower their risk of psychological trauma. The person may not remember what actually happened, while emotions experienced during the trauma may be re-experienced without the person understanding why (see Repressed memory). This can lead to the traumatic events being constantly experienced as if they were happening in the present, preventing the subject from gaining perspective on the experience. This can produce a pattern of prolonged periods of acute arousal punctuated by periods of physical and mental exhaustion. This can lead to mental health disorders like acute stress and anxiety disorder, prolonged grief disorder, somatic symptom disorder, conversion disorders, brief psychotic disorder, borderline personality disorder, adjustment disorder, etc. Obsessive- compulsive disorder is another mental health disorder with symptoms similar to that of psychological trauma, such as hyper-vigilance and intrusive thoughts. Research has indicated that individuals who have experienced a traumatic event have been known to use symptoms of obsessive- compulsive disorder, such as compulsive checking of safety, as a way to mitigate the symptoms associated with trauma. In time, emotional exhaustion may set in, leading to distraction, and clear thinking may be difficult or impossible. Emotional detachment, as well as dissociation or "numbing out" can frequently occur. Dissociating from the painful emotion includes numbing all emotion, and the person may seem emotionally flat, preoccupied, distant, or cold. Dissociation includes depersonalisation disorder, dissociative amnesia, dissociative fugue, dissociative identity disorder, etc. Exposure to and re-experiencing trauma can cause neurophysiological changes like slowed myelination, abnormalities in synaptic pruning, shrinking of the hippocampus, cognitive and affective impairment. This is significant in brain scan studies done regarding higher-order function assessment with children and youth who were in vulnerable environments. Some traumatized people may feel permanently damaged when trauma symptoms do not go away and they do not believe their situation will improve. This can lead to feelings of despair, transient paranoid ideation, loss of self-esteem, profound emptiness, suicidality, and frequently, depression. If important aspects of the person's self and world understanding have been violated, the person may call their own identity into question. Often despite their best efforts, traumatized parents may have difficulty assisting their child with emotion regulation, attribution of meaning, and containment of post-traumatic fear in the wake of the child's traumatization, leading to adverse consequences for the child. In such instances, seeking counselling in appropriate mental health services is in the best interests of both the child and the parent(s). Trauma is hard to speak of by those that experience it. The event in question might recur to them in a dream or another medium, but it is rare for them to speak of it. Causes Situational trauma Trauma can be caused by human-made, technological and natural disasters, including war, abuse, violence, vehicle collisions, or medical emergencies. An individual's response to psychological trauma can be varied based on the type of trauma, as well as socio-demographic and background factors. There are several behavioral responses commonly used towards stressors including the proactive, reactive, and passive responses. Proactive responses include attempts to address and correct a stressor before it has a noticeable effect on lifestyle. Reactive responses occur after the stress and possible trauma has occurred and is aimed more at correcting or minimizing the damage of a stressful event. A passive response is often characterized by an emotional numbness or ignorance of a stressor. There is also a distinction between trauma induced by recent situations and long-term trauma which may have been buried in the unconscious from past situations such as child abuse. Trauma is sometimes overcome through healing; in some cases this can be achieved by recreating or revisiting the origin of the trauma under more psychologically safe circumstances, such as with a therapist. More recently, awareness of the consequences of climate change is seen as a source of trauma as individuals contemplate future events as well as experience climate change related disasters. Emotional experiences within these contexts are increasing, and collective processing and engagement with these emotions can lead to increased resilience and post-traumatic growth, as well as a greater sense of belongingness. These outcomes are protective against the devastating impacts of psychological trauma. Stress disorders All psychological traumas originate from stress, a physiological response to an unpleasant stimulus. Long-term stress increases the risk of poor mental health and mental disorders, which can be attributed to secretion of glucocorticoids for a long period of time. Such prolonged exposure causes many physiological dysfunctions such as the suppression of the immune system and increase in blood pressure. Not only does it affect the body physiologically, but a morphological change in the hippocampus also takes place. Studies showed that extreme stress early in life can disrupt normal development of hippocampus and impact its functions in adulthood. Studies surely show a correlation between the size of hippocampus and one's susceptibility to stress disorders. In times of war, psychological trauma has been known as shell shock or combat stress reaction. Psychological trauma may cause an acute stress reaction which may lead to post-traumatic stress disorder (PTSD). PTSD emerged as the label for this condition after the Vietnam War in which many veterans returned to their respective countries demoralized, and sometimes, addicted to psychoactive substances. The symptoms of PTSD must persist for at least one month for diagnosis to be made. The main symptoms of PTSD consist of four main categories: trauma (i.e. intense fear), reliving (i.e. flashbacks), avoidance behavior (i.e. emotional numbing), and hypervigilance (i.e. continuous scanning of the environment for danger). Research shows that about 60% of the US population reported as having experienced at least one traumatic symptom in their lives, but only a small proportion actually develops PTSD. There is a correlation between the risk of PTSD and whether or not the act was inflicted deliberately by the offender. Psychological trauma is treated with therapy and, if indicated, psychotropic medications. The term continuous posttraumatic stress disorder (CTSD) was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire, and emergency services. As one of the processes of treatment, confrontation with their sources of trauma plays a crucial role. While debriefing people immediately after a critical incident has not been shown to reduce incidence of PTSD, coming alongside people experiencing trauma in a supportive way has become standard practice. The impact of PTSD on children is to a degree unknown, but education on coping mechanisms have shown to improve the lives of children who have undergone a traumatic event. Moral injury Moral injury is distress such as guilt or shame following a moral transgression. There are many other definitions some based on different models of causality. Moral injury is associated with post-traumatic stress disorder but is distinguished from it. Moral injury is associated with guilt and shame while PTSD is correlated with fear and anxiety. Vicarious trauma Normally, hearing about or seeing a recording of an event, even if distressing, does not cause trauma; however, an exception is made to the diagnostic criteria for work-related exposures. Vicarious trauma affects workers who witness their clients' trauma. It is more likely to occur in situations where trauma-related work is the norm rather than the exception. Listening with empathy to the clients generates feeling, and seeing oneself in clients' trauma may compound the risk for developing trauma symptoms. Trauma may also result if workers witness situations that happen in the course of their work (e.g. violence in the workplace, reviewing violent video tapes.) Risk increases with exposure and with the absence of help-seeking protective factors and pre-preparation of preventive strategies. Individuals who have a personal history of trauma are also at increased risk for developing vicarious trauma. Vicarious trauma can lead workers to develop more negative views of themselves, others, and the world as a whole, which can compromise their quality of life and ability to work effectively. Theoretical models Shattered assumptions theory Janoff-Bulman, theorises that people generally hold three fundamental assumptions about the world that are built and confirmed over years of experience: the world is benevolent, the world is meaningful, and I am worthy. According to the shattered assumption theory, there are some extreme events that "shatter" an individual's worldviews by severely challenging and breaking assumptions about the world and ourself. Once one has experienced such trauma, it is necessary for an individual to create new assumptions or modify their old ones to recover from the traumatic experience. Therefore, the negative effects of the trauma are simply related to our worldviews, and if we repair these views, we will recover from the trauma. In psychodynamics Psychodynamic viewpoints are controversial, but have been shown to have utility therapeutically. French neurologist Jean-Martin Charcot argued in the 1890s that psychological trauma was the origin of all instances of the mental illness known as hysteria. Charcot's "traumatic hysteria" often manifested as paralysis that followed a physical trauma, typically years later after what Charcot described as a period of "incubation". Sigmund Freud, Charcot's student and the father of psychoanalysis, examined the concept of psychological trauma throughout his career. Jean Laplanche has given a general description of Freud's understanding of trauma, which varied significantly over the course of Freud's career: "An event in the subject's life, defined by its intensity, by the subject's incapacity to respond adequately to it and by the upheaval and long-lasting effects that it brings about in the psychical organization". The French psychoanalyst Jacques Lacan claimed that what he called "The Real" had a traumatic quality external to symbolization. As an object of anxiety, Lacan maintained that The Real is "the essential object which isn't an object any longer, but this something faced with which all words cease and all categories fail, the object of anxiety par excellence". Fred Alford, citing the work of object relations theorist Donald Winnicott, uses the concept of inner other, and internal representation of the social world, with which one converses internally and which is generated through interactions with others. He posits that the inner other is damaged by trauma but can be repaired by conversations with others such as therapists. He relates the concept of the inner other to the work of Albert Camus viewing the inner other as that which removes the absurd. Alford notes how trauma damages trust in social relations due to fear of exploitation and argues that culture and social relations can help people recover from trauma. Diana Fosha, a pioneer of modern psychodynamic perspective, also argues that social relations can help people recover from trauma, but specifically refers to attachment theory and the attachment dynamic of the therapeutic relationship. Fosha argues that the sense of emotional safety and co-regulation that occurs in a psychodynamically oriented therapeutic relationship acts as the secure attachment that is necessary to allow a client to experience and process through their trauma safely and effectively. Diagnosis As "trauma" adopted a more widely defined scope, traumatology as a field developed a more interdisciplinary approach. This is in part due to the field's diverse professional representation including: psychologists, medical professionals, and lawyers. As a result, findings in this field are adapted for various applications, from individual psychiatric treatments to sociological large-scale trauma management. While the field has adopted a number of diverse methodological approaches, many pose their own limitations in practical application. The experience and outcomes of psychological trauma can be assessed in a number of ways. Within the context of a clinical interview, the risk of imminent danger to the self or others is important to address but is not the focus of assessment. In most cases, it will not be necessary to involve contacting emergency services (e.g., medical, psychiatric, law enforcement) to ensure the individuals safety; members of the individual's social support network are much more critical. Understanding and accepting the psychological state of an individual is paramount. There are many misconceptions of what it means for a traumatized individual to be in psychological crisis. These are times when an individual is in inordinate amounts of pain and incapable of self-comfort. If treated humanely and respectfully, the individual is less likely to resort to self harm. In these situations it is best to provide a supportive, caring environment and to communicate to the individual that no matter the circumstance, the individual will be taken seriously rather than being treated as delusional. It is vital for the assessor to understand that what is going on in the traumatized person's head is valid and real. If deemed appropriate, the assessing clinician may proceed by inquiring about both the traumatic event and the outcomes experienced (e.g., post-traumatic symptoms, dissociation, substance abuse, somatic symptoms, psychotic reactions). Such inquiry occurs within the context of established rapport and is completed in an empathic, sensitive, and supportive manner. The clinician may also inquire about possible relational disturbance, such as alertness to interpersonal danger, abandonment issues, and the need for self-protection via interpersonal control. Through discussion of interpersonal relationships, the clinician is better able to assess the individual's ability to enter and sustain a clinical relationship. During assessment, individuals may exhibit activation responses in which reminders of the traumatic event trigger sudden feelings (e.g., distress, anxiety, anger), memories, or thoughts relating to the event. Because individuals may not yet be capable of managing this distress, it is necessary to determine how the event can be discussed in such a way that will not "retraumatize" the individual. It is also important to take note of such responses, as these responses may aid the clinician in determining the intensity and severity of possible post traumatic stress as well as the ease with which responses are triggered. Further, it is important to note the presence of possible avoidance responses. Avoidance responses may involve the absence of expected activation or emotional reactivity as well as the use of avoidance mechanisms (e.g., substance use, effortful avoidance of cues associated with the event, dissociation). In addition to monitoring activation and avoidance responses, clinicians carefully observe the individual's strengths or difficulties with affect regulation (i.e., affect tolerance and affect modulation). Such difficulties may be evidenced by mood swings, brief yet intense depressive episodes, or self-mutilation. The information gathered through observation of affect regulation will guide the clinician's decisions regarding the individual's readiness to partake in various therapeutic activities. Though assessment of psychological trauma may be conducted in an unstructured manner, assessment may also involve the use of a structured interview. Such interviews might include the Clinician-Administered PTSD Scale, Acute Stress Disorder Interview, Structured Interview for Disorders of Extreme Stress, Structured Clinical Interview for DSM-IV Dissociative Disorders - Revised, and Brief Interview for post-traumatic Disorders. Lastly, assessment of psychological trauma might include the use of self-administered psychological tests. Individual scores on such tests are compared to normative data in order to determine how the individual's level of functioning compares to others in a sample representative of the general population. Psychological testing might include the use of generic tests (e.g., MMPI-2, MCMI-III, SCL-90-R) to assess non-trauma-specific symptoms as well as difficulties related to personality. In addition, psychological testing might include the use of trauma-specific tests to assess post-traumatic outcomes. Such tests might include the post-traumatic Stress Diagnostic Scale, Davidson Trauma Scale, Detailed Assessment of post-traumatic Stress, Trauma Symptom Inventory, Trauma Symptom Checklist for Children, Traumatic Life Events Questionnaire, and Trauma-related Guilt Inventory. Children are assessed through activities and therapeutic relationship, some of the activities are play genogram, sand worlds, coloring feelings, self and kinetic family drawing, symbol work, dramatic-puppet play, story telling, Briere's TSCC, etc. Definition The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines trauma as the symptoms that occur following exposure to an event (i.e., traumatic event) that involves actual or threatened death, serious injury, or sexual violence. This exposure could come in the form of experiencing the event or witnessing the event, or learning that an extreme violent or accidental event was experienced by a loved one. Trauma symptoms may come in the form of intrusive memories, dreams, or flashbacks; avoidance of reminders of the traumatic event; negative thoughts and feelings; or increased alertness or reactivity. Memories associated with trauma are typically explicit, coherent, and difficult to forget. Due to the complexity of the interaction between traumatic event occurrence and trauma symptomatology, a person's distress response to aversive details of a traumatic event may involve intense fear or helplessness, but ranges according to the context. In children, trauma symptoms can be manifested in the form of disorganized or agitative behaviors. Trauma can be caused by a wide variety of events, but there are a few common aspects. There is frequently a violation of the person's core assumptions about the world and their human rights, putting the person in a state of extreme confusion and insecurity. This is seen when institutions depended upon for survival violate, humiliate, betray, or cause major losses or separations instead of evoking aspects like positive self worth, safe boundaries and personal freedom. Psychologically traumatic experiences often involve physical trauma that threatens one's survival and sense of security. Typical causes and dangers of psychological trauma include harassment; embarrassment; abandonment; abusive relationships; rejection; co-dependence; physical assault; sexual abuse; partner battery; employment discrimination; police brutality; judicial corruption and misconduct; bullying; paternalism; domestic violence; indoctrination; being the victim of an alcoholic parent; the threat or the witnessing of violence (particularly in childhood); life-threatening medical conditions; and medication-induced trauma. Catastrophic natural disasters such as earthquakes and volcanic eruptions; large scale transportation accidents; house or domestic fire; motor collision; mass interpersonal violence like war; terrorist attacks or other mass victimization like sex trafficking; being taken as a hostage or being kidnapped can also cause psychological trauma. Long-term exposure to situations such as extreme poverty or other forms of abuse, such as verbal abuse, exist independently of physical trauma but still generate psychological trauma. Some theories suggest childhood trauma can increase one's risk for mental disorders including post-traumatic stress disorder (PTSD), depression, and substance abuse. Childhood adversity is associated with neuroticism during adulthood. Parts of the brain in a growing child are developing in a sequential and hierarchical order, from least complex to most complex. The brain's neurons change in response to the constant external signals and stimulation, receiving and storing new information. This allows the brain to continually respond to its surroundings and promote survival. The five traditional signals (sight, hearing, taste, smell, and touch) contribute to the developing brain structure and its function. Infants and children begin to create internal representations of their external environment, and in particular, key attachment relationships, shortly after birth. Violent and victimizing attachment figures impact infants' and young children's internal representations. The more frequently a specific pattern of brain neurons is activated, the more permanent the internal representation associated with the pattern becomes. This causes sensitization in the brain towards the specific neural network. Because of this sensitization, the neural pattern can be activated by decreasingly less external stimuli. Child abuse tends to have the most complications, with long-term effects out of all forms of trauma, because it occurs during the most sensitive and critical stages of psychological development. It could lead to violent behavior, possibly as extreme as serial murder. For example, Hickey's Trauma-Control Model suggests that "childhood trauma for serial murderers may serve as a triggering mechanism resulting in an individual's inability to cope with the stress of certain events." Often, psychological aspects of trauma are overlooked even by health professionals: "If clinicians fail to look through a trauma lens and to conceptualize client problems as related possibly to current or past trauma, they may fail to see that trauma victims, young and old, organize much of their lives around repetitive patterns of reliving and warding off traumatic memories, reminders, and affects." Biopsychosocial models offer a broader view of health problems than biomedical models. Effects Evidence suggests that a minority of people who experience severe trauma in adulthood will experience enduring personality change. Personality changes include guilt, distrust, impulsiveness, aggression, avoidance, obsessive behaviour, emotional numbness, loss of interest, hopelessness and altered self-perception. Treatment A number of psychotherapy approaches have been designed with the treatment of trauma in mind—EMDR, progressive counting, somatic experiencing, biofeedback, Internal Family Systems Therapy, and sensorimotor psychotherapy, and Emotional Freedom Technique (EFT) etc. Trauma informed care provides a framework for any person in any discipline or context to promote healing, or at least not re-traumatizing. A 2018 systematic review provided moderate evidence that Eye Movement Desensitization and Reprocessing (EMDR) is effective in reducing PTSD and depression symptoms, and it increases the likelihood of patients no longer meeting the criteria for PTSD. There is a large body of empirical support for the use of cognitive behavioral therapy for the treatment of trauma-related symptoms, including post-traumatic stress disorder. Institute of Medicine guidelines identify cognitive behavioral therapies as the most effective treatments for PTSD. Two of these cognitive behavioral therapies, prolonged exposure and cognitive processing therapy, are being disseminated nationally by the Department of Veterans Affairs for the treatment of PTSD. A 2010 Cochrane review found that trauma-focused cognitive behavioral therapy was effective for individuals with acute traumatic stress symptoms when compared to waiting list and supportive counseling. Seeking Safety is another type of cognitive behavioral therapy that focuses on learning safe coping skills for co-occurring PTSD and substance use problems. While some sources highlight Seeking Safety as effective with strong research support, others have suggested that it did not lead to improvements beyond usual treatment. A review from 2014 showed that a combination of treatments involving dialectical behavior therapy (DBT), often used for borderline personality disorder, and exposure therapy is highly effective in treating psychological trauma. If, however, psychological trauma has caused dissociative disorders or complex PTSD, the trauma model approach (also known as phase-oriented treatment of structural dissociation) has been proven to work better than the simple cognitive approach. Studies funded by pharmaceuticals have also shown that medications such as the new anti-depressants are effective when used in combination with other psychological approaches. At present, the selective serotonin reuptake inhibitor (SSRI) antidepressants sertraline (Zoloft) and paroxetine (Paxil) are the only medications that have been approved by the Food and Drug Administration (FDA) in the United States to treat PTSD. Other options for pharmacotherapy include serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants and anti-psychotic medications, though none have been FDA approved. Trauma therapy allows processing trauma-related memories and allows growth towards more adaptive psychological functioning. It helps to develop positive coping instead of negative coping and allows the individual to integrate upsetting-distressing material (thoughts, feelings and memories) and to resolve these internally. It also aids in the growth of personal skills like resilience, ego regulation, empathy, etc. Processes involved in trauma therapy are: Psychoeducation: Information dissemination and educating in vulnerabilities and adoptable coping mechanisms. Emotional regulation: Identifying, countering discriminating, grounding thoughts and emotions from internal construction to an external representation. Cognitive processing: Transforming negative perceptions and beliefs about self, others and environment to positive ones through cognitive reconsideration or re-framing. Trauma processing: Systematic desensitization, response activation and counter-conditioning, titrated extinction of emotional response, deconstructing disparity (emotional vs. reality state), resolution of traumatic material (in theory, to a state in which triggers no longer produce harmful distress and the individual is able to express relief.) Emotional processing: Reconstructing perceptions, beliefs and erroneous expectations, habituating new life contexts for auto-activated trauma-related fears, and providing crisis cards with coded emotions and appropriate cognition. (This stage is only initiated in pre-termination phase from clinical assessment and judgement of the mental health professional.) Experiential processing: Visualization of achieved relief state and relaxation methods. A number of complementary approaches to trauma treatment have been implicated as well, including yoga and meditation. There has been recent interest in developing trauma-sensitive yoga practices, but the actual efficacy of yoga in reducing the effects of trauma needs more exploration. In health and social care settings, a trauma informed approach means that care is underpinned by understandings of trauma and its far-reaching implications. Trauma is widespread. For example, 26% of participants in the Adverse Childhood Experiences (ACEs) study were survivors of one ACE and 12.5% were survivors of four or more ACEs. A trauma-informed approach acknowledges the high rates of trauma and means that care providers treat every person as if they might be a survivor of trauma. Measurement of the effectiveness of a universal trauma informed approach is in early stages and is largely based in theory and epidemiology. Trauma informed teaching practice is an educative approach for migrant children from war-torn countries, who have typically experienced complex trauma, and the number of such children entering Canadian schools has led some school jurisdictions to consider new classroom approaches to assist these pupils. Along with complex trauma, these students often have experienced interrupted schooling due to the migration process, and as a consequence may have limited literacy skills in their first language. One study of a Canadian secondary school classroom, as told through journal entries of a student teacher, showed how Blaustein and Kinniburgh's ARC (attachment, regulation and competency) framework was used to support newly arrived refugee students from war zones. Tweedie et al. (2017) describe how key components of the ARC framework, such as establishing consistency in classroom routines; assisting students to identify and self-regulate emotional responses; and enabling student personal goal achievement, are practically applied in one classroom where students have experienced complex trauma. The authors encourage teachers and schools to avoid a deficit lens to view such pupils, and suggest ways schools can structure teaching and learning environments which take into account the extreme stresses these students have encountered. Society and culture Some people, and many self-help books, use the word trauma broadly, to refer to any unpleasant experience, even if the affected person has a psychologically healthy response to the experience. This imprecise language may promote the medicalization of normal human behaviors (e.g., grief after a death) and make discussions of psychological trauma more complex, but it might also encourage people to respond with compassion to the distress and suffering of others. See also References Further reading External links The International Society for Traumatic Stress Studies (ISTSS) Trauma-Focused Cognitive Behavioral Therapy – Medical University of South Carolina National Child Traumatic Stress Network (NCTSN) Trauma Information Pages Psychological stress Abuse Harassment and bullying Counseling Anxiety disorders Post-traumatic stress disorder Victimology Trauma types Adverse childhood experiences

Unlicensed assistive personnel

Unlicensed assistive personnel (UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). UAPs also provide bedside care—including basic nursing procedures—all under the supervision of a registered nurse, licensed practical nurse or other health care professional. UAPs must demonstrate their ability and competence before gaining any expanded responsibilities in a clinical setting. While providing this care, UAPs offer compassion and patience and are part of the patient's healthcare support system. Communication between UAPs and registered nurses (RNs) is key as they are working together in their patients' best interests. The scope of care UAPs are responsible for is delegated by RNs or other clinical licensed professionals. UAPs care for patients in hospitals, residents of nursing facilities, clients in private homes, and others in need of their services due to old age or disability. By definition, UAPs do not hold a license or other mandatory professional requirements for practice, though many hold various certifications. They are collectively categorized under the group "personal care workers in health services" in the International Standard Classification of Occupations, 2008 revision. Scope of care The responsibilities and duties of a UAP include: Observing, documenting and reporting clinical and treatment information, including patients' behavioral changes Assisting with motion exercises and other rehabilitative measures Taking and recording blood pressure, temperature, pulse, respiration, and body weight Assisting with ambulation and mobilization of patients Collecting specimens for required medical tests, Providing emotional and support services to patients, their families and other caregivers Assisting with personal hygiene: bathing, oral hygiene, nail care, and grooming Assisting with dressing, repositioning, feeding, and toileting Some states allow UAPs to administer medications after completing a course or showing they are competent in doing so Most UAPs, including nursing assistants, are not certified to change sterile dressings, distribute medications, insert or remove any tubing, or conduct tube feedings. Such tasks should be therefore left to the overseeing nurse or clinical licensed professional. UAPs must be delegated responsibilities. The nurses are ultimately accountable for all the care patients receive as a result of their delegating. Due to the nursing shortage and to reduce the heavy workload placed on nurses, delegating tasks to UAPs is crucial. Types and training Nursing assistant, nursing auxiliary, auxiliary nurse, patient care technician, home health aide/assistant, geriatric aide/assistant, psychiatric aide, nurse aide, and nurse tech are all common titles for UAPs. There are some differences in scope of care across UAPs based on title and description. Unlicensed assistive personnel are important members of the health care team who often hold a high level of experience and ability. While they do not require extensive health care training to practice their profession, manual dexterity and good interpersonal communication skills are usually necessary. They often undergo some formal education, apprenticeship or on-the-job training in areas such as body mechanics, nutrition, anatomy and physiology, cognitive impairments and mental health issues, infection control, personal care skills, and record-keeping. Training for UAPs is available from various outlets such as home health care agencies, community colleges, vocational schools, eldercare programs, and on-the-job training. Certified nursing assistant (CNA) The National Association of Health Care Assistants defines the role of CNAs as: "In the United States, certified nursing assistants typically work in a nursing home or hospital and perform everyday living tasks for the elderly, chronically sick, or rehabilitation patients who cannot care for themselves." Many community colleges offer CNA training in one semester. Other educational programs offer accelerated programs. In some cases, Skilled Nursing Facilities pay for a CNA course for their employees. CNA certification requirements vary by state. The requirements generally include taking an accredited CNA course, passing the state's CNA written and practical exams, registering as a CNA within the state, and acquiring a minimum number of hours of supervised on-duty experience. Moving to a different state requires recertification in the new state unless both states use the National Nurse Aide Assessment Program (NNAAP) standard. In that case, the new state accepts previous NNAAP test scores and allows registration. These certification exams are distributed by the state. Classes to study for these exams are provided by the American Red Cross as well as other providers. The Red Cross courses encompass everything in the state exams, from communication to health terms to sensitivity. In the United States, CNAs must work a minimum number of hours every two years as specified by the state and have no records of abuse or neglect to keep their certification. Each state also has its own mandatory continuing education hours that CNAs must fulfill. Similar titles in the United Kingdom and elsewhere include healthcare assistant, healthcare support worker, or clinical support worker. These providers usually work in hospitals or community settings under the guidance of a qualified healthcare professional. In the United Kingdom, the Care Certificate was introduced in April 2015, following the Cavendish Review of April 2013 into standards of care among health care assistants and support workers in the NHS and social care settings. The purpose of the Care Certificate is to "address inconsistencies in training and competencies in the workforce so that all staff have the same introductory skills, knowledge and behaviours to provide safe, high quality and compassionate care of the highest standards". The Care Certificate was jointly developed by Skills for Health, Health Education England and Skills for Care. Home health aide (HHA) A home health aide (HHA) provides in-home care for patients who need assistance with daily living beyond what family or friends can provide. Patients include those who have a physical or mental disability, are recovering from an injury or surgery, have a chronic illness, or are advanced in age. Training requirements to become an HHA are generally minimal and vary by state. Personal support worker (PSW) Personal support worker (PSW) is the title for a similar type of health worker in Canada. Personal support work is unique among health care professions in that the scope of a PSW's duties does not extend beyond what the client could do him/herself if the client were physically and cognitively able. No other profession's scope is similarly described. In Newfoundland and Labrador, a PSW is called a Personal Care Attendant (PCA). In May 2011, Ontario's Ministry of Health and Long-Term Care (MOHLTC) announced the creation of a Registry of Personal Support Workers to acknowledge the care it provides daily to some of Ontario's most vulnerable populations, including seniors and people with chronic illnesses and disabilities. The Ontario PSW Registry was launched on June 1, 2012, and now has over 23,000 registered PSWs. Surgical technologist Surgical technologists are considered UAPs in the US, where they are also sometimes called "scrub tech". The title can mean different things in other countries. In Mozambique, for example, surgical technologists are medical professionals trained and registered to perform advanced clinical procedures including emergency surgery. Birth Assistant Birth attendants, such as doulas, childbirth educators and other persons providing emotional support and general care and advice to women and families during pregnancy and childbirth, are also typically considered UAPs. They are distinguished from midwives, physicians, nurses, and other professionals who are trained and licensed to provide basic and emergency pregnancy and childbirth-related health care services and manage complications. Practice In the context of aging populations and health care reform, there is growing demand for UAPs in many countries. But without formal qualifications, UAPs are often unable to perform some tasks due to issues of liability and legality. Some places have made attempts to regulate, control, and verify education. This allows an employer to verify experience and knowledge as well as assist in preventing individuals who have been "struck" (had registration/certification invalidated) from continuing to work in healthcare roles. In the UK, for example, the credibility of the Healthcare Assistant and other social care workers is intended to be strengthened by their compulsory registration from 2009 with the General Social Care Council in England or its Scottish or Welsh equivalents. In the United States, families and employers can verify a UAP's certification by checking the state's nursing registry. Each state is required to maintain an updated nursing registry under the Omnibus Budget Reconciliation Act (OBRA). The registry details valid certifications and reports of abuse or neglect. The background information these registries provide is important in protecting patients. Turnover and job stability Typically, the turnover rate among an organization's UAPs is very high, which can be detrimental to patients' quality of care and cause stress and dissatisfaction among the personnel. Studies exploring the reasons for turnover show that it is not just a matter of pay, but can have many causes, such as the degree of respect the unlicensed personnel receive, the stress level, physical demands, scheduling flexibility, and their commitment to the profession. UAPs need coping strategies, outlets, and a support system to deal with problems on the job such as difficult patients and grueling tasks. See also Activities of daily living assistance Health care provider Health human resources Nursing Orderly References Caregiving Health care occupations Nursing in the United States Assistance

Identity crisis

In psychology, identity crisis is a stage theory of identity development which involves the resolution of a conflict over eight stages of life. The term was coined by German psychologist Erik Erikson. The stage of psychosocial development in which identity crisis may occur is called identity cohesion vs. role confusion. During this stage, adolescents are faced with physical growth, sexual maturity, and integrating ideas of themselves and about what others think of them. They therefore form their self-image and endure the task of resolving the crisis of their ego identity. Successful resolution of the crisis depends on one's progress through previous developmental stages, centering on issues such as trust, autonomy, and initiative. Erikson's interest in identity began in childhood. Born Ashkenazi Jewish, he felt that he was an outsider. His later studies of cultural life among the Yurok of northern California and the Sioux of South Dakota helped formalize his ideas about identity development and identity crisis. Erikson described those going through an identity crisis as exhibiting confusion. Concept Adolescents may withdraw from normal life, not taking action or acting as they usually would at work, in their marriage or at school, or be unable to make defining choices about the future. They may even turn to negative activities, such as crime or drugs since from their point of view having a negative identity could be more acceptable than none at all. On the other side of the spectrum, those who emerge from the adolescent stage of personality development with a strong sense of identity are well equipped to face adulthood with confidence and certainty. Erikson studied eight stages that made up his theory. To him, ego identity is a key concept to understanding what identity is, and it plays a large role in the conscious mind that includes fantasies, feelings, memories, perceptions, self-awareness, sensations, and thoughts; Each contributing a sense to self that is developed through social interaction. He felt that peers have a strong impact on the development of ego identity during adolescence. He believed that association with negative groups such as cults or fanatics can actually "redistrict" the developing ego during this fragile time. The basic strength that Erikson argued should be developed during adolescence is fidelity, which only emerges from a cohesive ego identity. Fidelity encompasses sincerity, genuineness and a sense of duty in relationships with other people. Erikson defined the crisis as an argument between identity and confusion. Confusion lies between the younger generation, teenagers, and during adolescence he states that they "need to develop a sense of self and personal identity". If they do not develop this sense, they will be insecure and lose themselves, lacking confidence and certainty in adult life. He described identity as "a subjective sense as well as an observable quality of personal sameness and continuity, paired with some belief in the sameness and continuity of some shared world image. As a quality of unself-conscious living, this can be gloriously obvious in a young person who has found himself as he has found his commonality. In him we see emerge a unique unification of what is irreversibly given—that is, body type and temperament, giftedness and vulnerability, infantile models and acquired ideals—with the open choices provided in available roles, occupational possibilities, values offered, mentors met, friendships made, and first sexual encounters." Marcian theory James Marcia's research on identity statuses of adolescents also applies to Erikson's framework of identity crises in adolescents. Identity foreclosure is an identity status which Marcia claimed is an identity developed by an individual without much choice. "The foreclosure status is when a commitment is made without exploring alternatives. Often these commitments are based on parental ideas and beliefs that are accepted without question". Identity foreclosure can contribute to identity crises in adolescents when the "security blanket" of their assumed identity is removed. These "foreclosed individuals often go into crisis, not knowing what to do without being able to rely on the norms, rules, and situations to which they have been accustomed". An example of this would be a son of a farmer who learns that his father is selling the farm, and whose identity as an heir to a farm and the lifestyle and identity of a farmer has been disrupted by that news. Identity diffusion is a Marcian identity status that can lead to identity crises in adolescents. Identity diffusion can be described as "the apathetic state that represents the relative lack of both exploration and commitment". Identity diffusion can overlap with diagnoses such as schizophrenia and depression, and can best be described as a lack of identity structure. An example of an identity crisis emerging from this status is an adolescent who becomes reclusive after his identity as a star athlete is destroyed by a serious injury. Identity moratorium is the status that Marcia theorizes lasts the longest in individuals, is the most volatile, and can be best described as "the active exploration of alternatives". Individuals experiencing identity moratorium can be very open-minded and thoughtful but also in crisis over their identity. An example of this would be a college student who lacks conviction in their future after changing majors multiple times but still cannot seem to find their passion. Identity achievement is the resolution to many identity crises. Identity achievement occurs when the adolescent has explored and committed to important aspects of their identity. See also Erikson's stages of psychosocial development Existential crisis References Bibliography Further reading Examining Our Sense of Identity and Who We Are Teenagers, Identity Crises and Procrastination Psychological adjustment Psychological concepts

Global Assessment of Functioning

The Global Assessment of Functioning (GAF) is a numeric scale used by mental health clinicians and physicians to rate subjectively the social, occupational, and psychological functioning of an individual, i.e., how well one is meeting various problems in living. Scores range from 100 (extremely high functioning) to 1 (severely impaired). The scale was included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) version 4 (DSM-IV), but replaced in DSM-5 with the World Health Organization Disability Assessment Schedule (WHODAS), a survey or interview with detailed items. The WHODAS is considered more detailed and objective than a single global impression. The main advantage of the GAF is its brevity. Development and exclusion from DSM-5 Interest in a quantifiable global rating of functioning dates back to as early as 1962 with the publication of the Health-Sickness Rating Scale (which was rated 0 to 100) by Luborsky et al. in the paper "Clinicians' Judgements of Mental Health". This was subsequently revised in 1976 as the Global Assessment Scale (GAS) in the paper "The Global Assessment Scale:Procedure for Measuring Overall Severity of Psychiatric Disturbance" by Endicott et al. The rating scale was further modified and published as the Global Assessment of Functioning Scale in the DSM-III-R and DSM-IV. Some versions of the scale stopped at 90 as the maximum score, and others extended to 100. Because the scale was most often used with people seeking health services, it would be rare to have scores over 90, as they would indicate not just a lack of symptoms, but also "superior functioning." The related Social and Occupational Functioning Assessment Scale (SOFAS) was initially described in a paper by Goldman et al. in 1992 in the paper "Revising Axis V for DSM-IV: A review of measures of social functioning." The DSM-IV included the SOFAS within the section "Criteria Sets and Axes Provided for Further Study." The SOFAS scale is similar to the GAF, but it only looks at social and occupational functioning rather than also considering symptom severity. DSM-5 removed the multiaxial system, including Axis V disability and functioning; and the DSM-5 Task Force recommended the GAF be replaced by the WHO Disability Assessment Schedule (WHODAS 2.0) in an effort to increase the reliability of scores. Scale 91 – 100 No symptoms. Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. [Note that this range is not included in some versions of the GAF] 81 – 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns. 71 – 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 61 – 70 Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. 51 – 60 Moderate symptoms (e.g., flat affect and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 41 – 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job, cannot work). 31 – 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed adult avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 21 – 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends) 11 – 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). 1 – 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death. 0 Inadequate information Use in litigation Montalvo attempts to substitute "social, occupational, or school functioning" for "overall level of functioning and carrying out activities of daily living". It is possible to see the recourse of some degree of overlap because "social functioning" is arguably a subset of overall functioning and activities of daily living. However, it is arguable whether equivalence is clearly stated in DSM-IV-TR. GAF scores were commonly used by the Veterans Benefits Administration (VBA) to help determine disability ratings for service-connected psychiatric disorders. The probative value given to GAF scores diminished since the 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which eliminated GAF scores from the Manual's nosology because GAF scores do not demonstrate good reliability or construct validity. On February 23, 2018, the United States Court of Appeals for Veterans Claims (CAVC), issued an opinion in Golden v. Shulkin. ruling that, except for some older cases on appeal, the Board of Veterans Appeals (BVA) "... should not use [GAF scores] at all when assigning a psychiatric rating in cases where the DSM-5 applies." In disability cases before the Social Security Administration, the agency determines if the GAF is consistent with the narrative report and it is addressed as one technique for capturing the "complexity of clinical situations." The agency noted the GAF is just one tool used by clinicians to develop the clinical picture. It cannot be used in isolation from the rest of the evidence to make a disability decision. The Commissioner of Social Security has acknowledged that the GAF system has some problems (anchor points, lack of standardization, not designed to predict an outcome, and requiring more supportive detail), but found that, if provided by an "acceptable medical source, a GAF is a medical opinion as defined in" the Regulations, and must be considered with all of the relevant evidence, but can be given "controlling weight" if well supported and not inconsistent with the other evidence. See also Diagnostic classification and rating scales used in psychiatry DSM-IV Codes Children's Global Assessment Scale High-functioning alcoholism Autism High-functioning autism Low-functioning autism References External links Modified Global Assessment of Functioning – Revised (mGAF-R) - adapted in 2004 by the Florida DCF Functional Assessment Workgroup from the original M-GAF reported by S. Caldecott-Hazard & R.C.W. Hall, 1995 Diagnostic and Statistical Manual of Mental Disorders Global screening and assessment tools in psychiatry

Nursing theory

Nursing theory is defined as "a creative and conscientious structuring of ideas that project a tentative, purposeful, and systematic view of phenomena". Through systematic inquiry, whether in nursing research or practice, nurses are able to develop knowledge relevant to improving the care of patients. Theory refers to "a coherent group of general propositions used as principles of explanation". Nursing theory Importance In the early part of nursing's history, there was little formal nursing knowledge. As nursing education developed, the need to categorize knowledge led to development of nursing theory to help nurses evaluate increasingly complex client care situations. Nursing theories give a plan for reflection in which to examine a certain direction in where the plan needs to head. As new situations are encountered, this framework provides an arrangement for management, investigation and decision-making. Nursing theories also administer a structure for communicating with other nurses and with other representatives and members of the health care team. Nursing theories assist the development of nursing in formulating beliefs, values and goals. They help to define the different particular contribution of nursing with the care of clients. Nursing theory guides research and practice. Borrowed and shared theories Not all theories in nursing are unique nursing theories; many are borrowed or shared with other disciplines. Theories developed by Neuman, Watson, Parse, Orlando and Peplau are considered unique nursing theories. Theories and concepts that originated in related sciences have been borrowed by nurses to explain and explore phenomena specific to nursing. Types Grand nursing theories Grand nursing theories have the broadest scope and present general concepts and propositions. Theories at this level may both reflect and provide insights useful for practice but are not designed for empirical testing. This limits the use of grand nursing theories for directing, explaining, and predicting nursing in particular situations. However, these theories may contain concepts that can lend themselves to empirical testing. Theories at this level are intended to be pertinent to all instances of nursing. Grand theories consist of conceptual frameworks defining broad perspectives for practice and ways of looking at nursing phenomena based on the perspectives. Mid-range nursing theories Middle-range nursing theories are narrower in scope than grand nursing theories and offer an effective bridge between grand nursing theories and nursing practice. They present concepts and a lower level of abstraction and guide theory-based research and nursing practice strategies. One of the hallmarks of mid-range theory compared to grand theories is that mid-range theories are more tangible and verifiable through testing. The functions of middle-range theories includes to describe, explain, or predict phenomenon. Middle-range theories are simple, straightforward, general, and consider a limited number of variables and limited aspect of reality. Nursing practice theories Nursing practice theories have the most limited scope and level of abstraction and are developed for use within a specific range of nursing situations. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. The capacity of these theories is limited, and analyzes a narrow aspect of a phenomenon. Nursing practice theories are usually defined to an exact community or discipline. Nursing models Nursing models are usually described as a representation of reality or a more simple way of organising a complex phenomenon. The nursing model is a consolidation of both concepts and the assumption that combine them into a meaningful arrangement. A model is a way of presenting a situation in such a way that it shows the logical terms in order to showcase the structure of the original idea. The term nursing model cannot be used interchangeably with nursing theory. Components of nursing modeling There are three main key components to a nursing model: Statement of goal that the nurse is trying to achieve Set of beliefs and values Awareness, skills and knowledge the nurse needs to practice. The first important step in development of ideas about nursing is to establish the body approach essential to nursing, then to analyse the beliefs and values around those. Common concepts of nursing modeling: a metaparadigm A metaparadigm contains philosophical worldviews and concepts that are unique to a discipline and defines boundaries that separate it from other disciplines. A metaparadigm is intended to help guide others to conduct research and utilize the concepts for academia within that discipline. The nursing metaparadigm consist of four main concepts: person, health, environment, and nursing. The person (Patient) The environment Health Nursing (Goals, Roles Functions) Each theory is regularly defined and described by a nursing theorist. The main focal point of nursing out of the four various common concepts is the person (patient). Notable nursing theorists and theories Anne Casey: Casey's model of nursing Betty Neuman: Neuman systems model Callista Roy: Adaptation model of nursing Carl O. Helvie: Helvie energy theory of nursing and health Dorothea Orem: Self-care deficit nursing theory Faye Abdellah: Patient-centered approach to Nursing Helen Erickson Hildegard Peplau: Theory of interpersonal relations Imogene King Isabel Hampton Robb Kari Martinsen Adequate care must involve both objective observation and perceptive response. Katharine Kolcaba: Theory of Comfort Madeleine Leininger Katie Love: Empowered Holistic Nursing Education Marie Manthey: Primary Nursing Martha E. Rogers: Science of unitary human beings Ramona T Mercer: Maternal role attainment theory Virginia Henderson: Henderson's need theory Jean Watson Nancy Roper, Winifred W. Logan, and Alison J. Tierney: Roper-Logan-Tierney model of nursing Phil Barker: Tidal Model Fundamentals of Care (FoC) Purposely omitted from this list is Florence Nightingale. Nightingale never actually formulated a theory of nursing science but was posthumously accredited with formulating some by others who categorized her personal journaling and communications into a theoretical framework. Also not included are the many nurses who improved on these theorists' ideas without developing their own theoretical vision. See also Nursing Nursing assessment Nursing process Nursing research References Nursing theory - history and modernity. Prominent theories of nursing. Nursing Theories - a companion to nursing theories and models Nursing Theory and Theorists External links Nursing Theory Page Nursing Theories and Sub-Theories Nurses.info Nightingale's Notes on Nursing at project Gutenberg Administrative theory

Job demands-resources model

The job demands-resources model (JD-R model) is an occupational stress model that suggests strain is a response to imbalance between demands on the individual and the resources he or she has to deal with those demands. The JD-R was introduced as an alternative to other models of employee well-being, such as the demand-control model and the effort-reward imbalance model. The authors of the JD-R model argue that these models "have been restricted to a given and limited set of predictor variables that may not be relevant for all job positions" (p.309). Therefore, the JD-R incorporates a wide range of working conditions into the analyses of organizations and employees. Furthermore, instead of focusing solely on negative outcome variables (e.g., burnout, ill health, and repetitive strain) the JD-R model includes both negative and positive indicators and outcomes of employee well-being. Basic assumptions The JD-R model can be summarized with a short list of assumptions/premises: Whereas every occupation may have its own specific risk factors associated with job stress, these factors can be classified in two general categories: job demands and job resources. Job demands: physical, psychological, social, or organizational aspects of the job, that require sustained physical and/or psychological effort or skills. Therefore, they are associated with certain physiological and/or psychological costs. Examples are work pressure and emotional demands. Job resources: physical, psychological, social, or organizational aspects of the job that are either: functional in achieving work goals; reduce job demands and the associated physiological and psychological cost; stimulate personal growth, learning, and development. Examples are career opportunities, supervisor coaching, role-clarity, and autonomy. Workplace resources vs. personal resources: The authors of the JD-R make a distinction between workplace resources and personal resources. Two different underlying psychological processes play a role in the development of job strain and motivation. The first are physical and social resources available in the workplace setting. The latter, personal resources, are those the employee brings with them. These consist of specific personality traits: self-efficacy and optimism. Both types of resources are powerful mediators of employee well-being (e.g. engagement). Outcomes of continued job strain Health impairment process: through this process, poorly designed jobs or chronic job demands exhaust employees' mental and physical resources. In turn, this might lead to the depletion of energy and to health problems. Outcomes of abundant job and personal resources Motivational process: through this process, job resources exert their motivating potential and lead to high work engagement, low cynicism, and excellent performance. Job resources may play either an intrinsic or an extrinsic motivational role. The interaction between job demands and job resources is important for the development of job strain and motivation as well. According to the JD-R model, job resources may buffer the effect of job demands on job strain, including burnout. Which specific job resources buffer the effect of different job demands, depends on the particular work environment. Thus, different types of job demands and job resources may interact in predicting job strain. Good examples of job resources that have the potential of buffering job demands are performance feedback and social support (e.g.,). Job resources particularly influence motivation or work engagement when job demands are high. This assumption is based on the premises of the conservation of resources (COR) theory. According to this theory, people are motivated to obtain, retain and protect their resources, because they are valuable. Hobfoll argues that resource gain acquires its saliency in the context of resource loss. This implies that job resources gain their motivational potential particularly when employees are confronted with high job demands. For example, when employees are faced with high emotional demands, the social support of colleagues might become more visible and more instrumental. Evidence Evidence for the dual process: a number of studies have supported the dual pathways to employee well being proposed by the JD-R model. It has been shown that the model can predict important organizational outcomes (e.g. Taken together, research findings support the JD-R model's claim that job demands and job resources initiate two different psychological processes, which eventually affect important organizational outcomes (see also,). When both job demands and resources are high, high strain and motivation is to be expected. When both are low, absence of strain and motivation is to be expected. Consequently, the high demands-low resources condition should result in high strain and low motivation while the low demands-high resources condition should have as a consequence low strain and high motivation. Evidence for the buffer effect of job resources: some support has been obtained for the proposed interaction between job demands and job resources in their relationship with employee well being (see,). However, most published studies on the model did either not examine or not report such interactions, whereas the practical relevance of this interaction – if present – is usually small. In a large-scale study, it was found that this interaction accounted for on average only 0.5% of the differences among workers in task enjoyment and work commitment. Evidence for the salience of job resources in the context of high job demands: one previous study outside the framework of the JD-R model has supported the hypothesis that resources gain their salience in the context of high demands (see.) Studies using the JD-R model have shown that job resources particularly affect work engagement when job demands are high (see ); and ). Practical implications The JD-R model assumes that whereas every occupation may have its own specific working characteristics, these characteristics can be classified in two general categories (i.e. job demands and job resources), thus constituting an overarching model that may be applied to various occupational settings, irrespective of the particular demands and resources involved. The central assumption of the JD-R model is that job strain develops – irrespective of the type of job or occupation – when (certain) job demands are high and when (certain) job resources are limited. In contrast, work engagement is most likely when job resources are high (also in the face of high job demands). This implies that the JD-R model can be used as a tool for human resource management. Continuing research The most recent article written by the authors of the original JD-R paper proposes that the interactions of demands and resources are nuanced and not clearly understood. Here Bakker and Demerouti suggest that demands may sometimes actually have a positive influence on the employee, by providing a challenge to be overcome rather than an insurmountable obstacle. In this same article, the authors describe a cumulative effect of demands and resources in their suggestion of gain and loss spirals. They conclude that these issues and that of workplace aggression may all be part of the JD-R framework. See also European Academy of Occupational Health Psychology Occupational health psychology Occupational stress Society for Occupational Health Psychology Stress management References Occupational health psychology Economics models Human resource management

Positive behavior support

Positive behavior support (PBS) uses tools from applied behaviour analysis and values of normalisation and social role valorisation theory to improve quality of life, usually in schools. PBS uses functional analysis to understand what maintains an individual's challenging behavior and how to support the individual to get these needs met in more appropriate way, instead of using 'challenging behaviours'. People's inappropriate behaviors are difficult to change because they are functional; they serve a purpose for them. These behaviors may be supported by reinforcement in the environment. People may inadvertently reinforce undesired behaviors by providing objects and/or attention because of the behavior. The positive behavior support process involves identifying goals, then undertaking functional behavior assessment (FBA). FBAs clearly describe behaviors, identify the contexts (events, times, and situation) that predict when behavior will and will not occur, and consequences that maintain the behavior. The FBA includes a hypothesis about the behavior and data for a baseline. This informs the support plan design, implementation and monitoring of the plan. Positive behavior support is increasingly being recognized as a strategy that is feasible, desirable, and effective. For example, teachers and parents need strategies they are able and willing to use and that affect the child's ability to participate in community and school activities. By changing stimulus and reinforcement in the environment and teaching the person to strengthen deficit skill areas, their behavior changes. In schools, this can allow students to be included in the general education setting. Three areas of deficit skills addressed by PBS are communication skills, social skills, and self-management skills. Re-directive therapy as positive behavior support is especially effective in the parent–child relationship. Where other treatment plans have failed, re-directive therapy allows for a positive interaction between parents and children. Positive behavior support is successful in the school setting because it is primarily a teaching method. In U.S. schools Schools are required to conduct functional behavioral assessment (FBA) and use positive behavior support with students who are identified as disabled and are at risk for expulsion, alternative school placement, or more than 10 days of suspension. Even though FBA is required under limited circumstances it is good professional practice to use a problem-solving approach to managing problem behaviors in the school setting. The use of positive behavior interventions and supports (PBIS) in schools is widespread in part because it is a professional skill in early special education programs (as opposed to Rogerian counseling). The program offers a primary, secondary, and tertiary level of intervention. A basic tenet of the PBIS approach includes identifying students in one of three categories – primary, secondary, or tertiary Interventions are specifically developed for each of these levels with the goal of reducing the risk for academic or social failure. The interventions become more focused and complex at each level. Primary prevention strategies focus on interventions used on a school-wide basis for all students. PBS use for other than a designated population group has neither been approved by the professions or the public-at-large. This level of prevention is considered "primary" because all students are exposed in the same way, and at the same level, to the intervention. Approximately 80–85% of students who are not at risk for behavior problems respond in a positive manner to this prevention level. Primary prevention strategies include, but are not limited to, using effective teaching practices and curricula, explicitly teaching behavior that is acceptable within the school environment, focusing on ecological arrangement and systems within the school, consistent use of precorrection procedures, using active supervision of common areas, and creating reinforcement systems that are used on a school-wide basis. Secondary prevention strategies involve around 10–15% of the school population who do not respond to the primary prevention strategies and are at risk for academic failure or behavior problems but are not in need of individual support. Interventions at the secondary level often are delivered in small groups to maximize time and effort and should be developed with the unique needs of the students within the group. Examples of these interventions include social support such as social skills training (e.g., explicit instruction in skill-deficit areas, friendship clubs, check in/check out, role playing) or academic support. Additionally, secondary programs could include behavioral support approaches (e.g., simple Functional Behavioral Assessments [FBA], precorrection, self-management training). Even with the heightened support within secondary level interventions, some students (1–7%) will need the additional assistance at the tertiary level.Tertiary prevention programs focus on students who display persistent patterns of disciplinary problems. Tertiary-level programs are also called intensive or individualized interventions and are the most comprehensive and complex. The interventions within this level are strength-based in that the complexity and intensity of the intervention plans directly reflect the complexity and intensity of the behaviors. Students within the tertiary level continue involvement in primary and secondary intervention programs and receive additional support as well. These supports could include use of full FBA, de-escalation training for the student, heightened use of natural supports (e.g., family members, friends of the student), and development of a Behavior Intervention Plan (BIP). Although comprehensive services are important for all students, a critical aspect of the three-tiered model is the identification of students at one of the three levels. One method of identifying students in need of interventions is to analyze office disciplinary referrals (ODR) taken at the school. ODRs may be a means of both identifying students' risk level for antisocial behavior and school failure. Researchers have advocated analyzing this naturally occurring data source as a relatively cheap, effective, and ongoing measurement device for PBS programs. ODRs have also been shown to be effective in determining where students fall within a three-leveled model, developing professional development as well as helping coordinate school efforts with other community agencies, predicting school failure in older grades as well as delinquency, indicating types of behavior resulting in referrals, and determination of the effectiveness of precorrection techniques. Analyzing discipline referral data can also help school personnel identify where to improve ecological arrangements within a school and to recognize how to increase active supervision in common areas. A limitation of only using ODRs to measure behavior problems is that they have been found to be ineffective at measuring internalizing behavior problems such as anxiety, depression, and withdrawal. Functional behavior assessment Functional Behavior Assessment (FBA) emerged from applied behavior analysis, and just like its parent, targets "getting 'stuck' in repetitive movements" (i.e., healthy stimming) as a "problem behavior". It is the cornerstone of a Positive Behavior Support plan. The assessment seeks to describe the behavior and environmental factors and setting events that predict the behavior in order to guide the development of effective support plans. Assessment lays the foundation of PBS. The assessment includes: a description of the problem behavior and its general setting of occurrence identification of events, times and situations that predict problem behavior identification of consequences that maintain behavior identification of the motivating function of behavior collection of direct observational data identification of alternative behavior that could replace the person's problem behavior (i.e., what a typical child or adult does). Often this is measured through direct observation or standardized behavioral assessment instruments. The results of the assessment help in developing the individualized behavior support plan. This outlines procedures for teaching alternatives to the behavior problems, and redesign of the environment to make the problem behavior irrelevant, inefficient, and ineffective. Behavior chain analysis is another avenue of functional behavior assessment, which is growing in popularity. In behavior chain analysis, one looks at the progressive changes of behavior as they lead to problem behavior and then attempts to disrupt this sequence. Whereas FBA is concerned mostly with setting-antecedent-behavior-consequence relations, the behavior chain analysis looks at the progression of behavior. For example, a child may fidget at first, then begin to tease others, then start to throw things, and finally hit another student. Behavioral strategies available There are many different behavioral strategies that PBS can use to encourage individuals to change their behavior. Some of these strategies are delivered through the consultation process to teachers. The strong part of functional behavior assessment is that it allows interventions to directly address the function (purpose) of a problem behavior. For example, a child who acts out for attention could receive attention for alternative behavior (contingency management) or the teacher could make an effort to increase the amount of attention throughout the day (satiation). Changes in setting events or antecedents are often preferred by PBS because contingency management often takes more effort. Another tactic especially when dealing with disruptive behavior is to use information from a behavior chain analysis to disrupt the behavioral problem early in the sequence to prevent disruption. Some of the most commonly used approaches are: Modifying the environment or routine, using the three term contingency, particularly antecedents (such as curriculum), behavior, and/or consequences Providing an alternative to the undesired behavior (not the same as a reward; it should be an alternative that is readily available to the person. The thought behind this is that the person may, over time, learn to more independently seek out appropriate options rather than the undesired behavior(s)). Tactical ignoring of the behavior (also called extinction) Distracting the child Positive reinforcement for an appropriate behavior Changing expectations and demands placed upon the child Teaching the child new skills and behaviors Graded extinction and cognitive behavioral therapies (CBTs) such as desensitization Provide sensory based breaks to promote an optimal level of arousal and calming for increased use the replacement/alternative behavior Changing how people around the child react Time-out (child) Medication Behavior management program The main keys to developing a behavior management program include: Identifying the specific behaviors to address Establishing the goal for change and the steps required to achieve it Procedures for recognizing and monitoring changed behavior Choosing the appropriate behavioral strategies that will be most effective. Through the use of effective behavior management at a school-wide level, PBS programs offer an effective method to reduce school crime and violence. To prevent the most severe forms of problem behaviors, normal social behavior in these programs should be actively taught. Consequential management/contingency management Consequential management is a positive response to challenging behavior. It serves to give the person informed choice and an opportunity to learn. Consequences must be clearly related to the challenging behavior. For example, if a glass of water was thrown and the glass smashed, the consequence (restitution) would be for the person to clean up the mess and replace the glass. These sorts of consequences are consistent with normal social reinforcement contingencies. Providing choices is very important and staff can set limits by giving alternatives that are related to a behavior they are seeking. It is important that the alternative is stated in a positive way and that words are used which convey that the person has a choice. For example: Coercive approach – "If you don't cut that out you'll have to leave the room." Positive approach – "You can watch TV quietly or leave the room." Implementation on a school-wide level School-Wide Positive Behavior Support (SW-PBS) consists of a broad range of systematic and individualized strategies for achieving important social and learning outcomes while preventing problem behavior with all students. A measurable goal for a school may be to reduce the level of violence, but a main goal might be to create a healthy, respectful, and safe learning, and teaching, environment. PBS on a school-wide level is a system that can be used to create the "perfect" school, or at the very least a better school, particularly because before implementation it is necessary to develop a vision for what the school environment should look like in the future. According to Horner et al. (2004), once a school decides to implement PBS, the following characteristics require addressing: define 3 to 5 school-wide expectations for appropriate behavior; actively teach the school-wide behavioral expectations to all students; monitor and acknowledge students for engaging in behavioral expectations; correct problem behaviors using a consistently administered continuum of behavioral consequences gather and use information about student behavior to evaluate and guide decision making; obtain leadership of school-wide practices from an administrator committed to providing adequate support and resources; and procure district-level support. Proponents state that such a program is able to create a positive atmosphere and culture in almost any school, but the support, resources, and consistency in using the program over time must be present. See also Applied behavior analysis Behavior management Behavior modification Behavioral engineering Child time-out Contingency management Positive education Professional practice of behavior analysis Reinforcement Systematic desensitization Tootling Alternatives to special education approaches (special populations): Family support Group home Inclusion (education) Normalization Social role valorization Supported housing Supported living References External links Virtuoso Education Consulting LLC – Professional Development Training on PBS Association for Positive Behavior Support The US Dept. of Education Technical Assistance Center on Positive Behavior Support Florida's Positive Behavior Support Project The PBIS Compendium The Irish Association for Behavioural Support The Callan Institute '"Training & Consultancy Services in PBS, Dublin, Ireland "' Training and consultancy services, The Behavior Analyst Online Utah's Academic, Behavior, and Coaching Initiative Learning Together Ltd. Positive Behaviour Support Social Role Valorization consulting group National PBS Behavior modification Industrial and organizational psychology Life coaching Personal development Behaviorism

Psychiatric history

A psychiatric history is the result of a medical process where a clinician working in the field of mental health (usually a psychiatrist) systematically records the content of an interview with a patient. This is then combined with the mental status examination to produce a "psychiatric formulation" of the person being examined. Psychologists take a similar history, often referred to as a psychological history. This article mainly covers the initial assessment history taking of a patient presenting for the first time with a new complaint. Background In the field of medicine a patient history is an account of the significant events in the patient's life that have a relevance to the issue being addressed. The clinician taking the history guides the process in an attempt to achieve a succinct summary of these relevant details. Much of the history is obtained by asking questions. Some of these questions are quite specific, such as, "How old are you?" and others are more open, such as, "How have you been feeling lately?" Although the structure of the interview may appear disjointed, the result is usually under a set of headings which have a worldwide similarity. Patient identification The basic details of who the patient is are collected. This includes their age, sex, educational status, religion, occupation, relationship status, address and contact details. This serves several purposes. Firstly, it is necessary information for administrative purposes and for this reason some of this is often taken by clerks. Secondly, the questions are largely non threatening and provide a gentle introduction into the meeting of patient and clinician. Thirdly, it provides a format for individual introduction suitable to the culture. Thus the clinician may start by introducing themselves and then move on to these questions. This initial structure can provide a sense of familiarity for the patient who is stressed about what is happening. It also helps the clinician understand the patient's social situation. Source and method of presentation The next step is to determine why the patient is there. How did they get to be in the interview? Were they referred by someone (such as another clinician, a relative or friend, or by the police or the courts) or did they come looking for help? If they were referred by someone then what was that person's reason for the referral. Often such information is provided in a referral letter or by an earlier phone call. The main (chief) complaints The clinician next tries to clarify what are the main problems that have brought the patient to be there. Some of this may have already been achieved in the previous section. The patient may have more than one problem and these may be related, such as posttraumatic stress disorder and alcohol abuse or seemingly unrelated, such as panic disorder and premature ejaculation. The patient is unlikely to present a diagnosis and is more likely to describe the nature of their problems in common language. History of the presenting complaints (present illness) The clinician then attempts to obtain a clear description of these problems. When did they start? How did they start, suddenly, slowly or in fits and starts? Have they fluctuated over time? What does the patient describe as the essential features of the complaints? Having developed a hypothesis of what may be the diagnosis, the clinician next looks at symptoms that might confirm this hypothesis or lead them to consider another possibility. Much of the mental process for the clinician is involved in this process of hypothesis testing to arrive at a diagnostic formulation that will form the basis of a management plan. The severity of each complaint is assessed and this may include probing questions on sensitive issues such as suicidal thoughts or sexual difficulties. History This is divided into the psychiatric history, which looks at any previous episodes of the presenting complaint as well as any other past or ongoing psychiatric problems. The substance (drug) history includes data about patterns of use (mode of administration, age of onset, frequency, amount, last use, medical or psychological complications, history of attempting to quit) for alcohol, tobacco, and illicit drugs. The medical history documents significant illnesses, both past and current, and significant medical events such as head injury, seizures, major surgeries, and major illnesses. A separate sexual history gathers data about sexual orientation and sexual activity. Finally a history of abuse, including physical, emotional, and sexual abuse is obtained from the patient and collateral sources (family members or close family friends) as trauma might not be directly remembered by the patient. Family history Many psychiatric disorders have a genetic component and the biological family history is thus relevant. Clinical experience also suggests that a response to treatment may have a genetic component as well. Thus a patient who presents with clinical depression whose mother also suffered from the same disorder and responded well to fluoxetine would indicate that this drug would be more likely to help in the patient's disorder. Apart from the genetic factors, research has shown that illnesses in the parents such as depression and alcohol abuse are associated with a higher rate of some conditions in the children growing up in that environment. Similar effects are seen with the death of a parent from a protracted illness. Developmental history This documents the significant events in the patient's life. Ideally it starts with pre-natal factors such as maternal illnesses or complications with the pregnancy, then documents delivery and early childhood illnesses or problems. It then looks at significant events in the patient's life such as parental separation, abuse, education, psychosexual development, peer relationships, behavioural aspects and any legal complications. It flows then into adulthood with relationship and occupational histories. The aim is to get an overview of who the patient is and what they have experienced in life, both good and bad. Major stresses and transitions such as marriage, parenthood, retirement, death or loss of a partner, and financial success and failure are all important, as is how the patient has dealt with them. Sexual adjustment and problems can be relevant and are often questioned. Social history If the information has not already been obtained, the clinician then documents the social circumstances of the patient looking at factors such as finances, housing, relationships, drug and alcohol use, and problems with the law or other authorities. This is also a time to document racial or cultural issues that are relevant to the presenting complaint. Review of Systems A psychiatric review of systems may include screening questions directed at identifying or exploring co-morbid psychiatric illnesses or issues (e.g., SIGECAPS mnemonic or PHQ-9 for depression, Generalized Anxiety Disorder 7 for anxiety, DIGFAST mnemonic for mania, or specific questioning around psychoses or other psychiatric complaints. A full review of systems should attempt to identify and list all of the relevant STRESSORS that may be impacting a patient's function and overall health. Summary Having collected this information the clinician usually then considers any other factors that might be relevant to the particular patient and enquires about them. Although the gathering of the information may follow the flow of the patient's thoughts rather than those of the clinician, it is not uncommon for the clinician to record the psychiatric history under headings, such as those above, to make it easier for others who will later read it. Subsequent history taking on reviews concentrates on changes in the levels of symptoms and responses to treatment, including possible side-effects. See also Medical history Mental status examination References External links PsychSkills.co.uk - The Psychiatric Patient History : Psychiatric assessment Medical mnemonics

Allied health professions

Allied health professions (AHPs) are a category of health professionals that provide a range of diagnostic, preventive, therapeutic, and rehabilitative services in connection with health care. While there is no international standard for defining the diversity of allied health professions, they are typically considered those which are distinct from the fields of medicine, nursing and dentistry. In providing care to patients with certain illnesses, AHPs may work in the public or private sector, in hospitals or in other types of facilities, and often in clinical collaboration with other providers having complementary scopes of practice. Allied health professions are usually of smaller size proportional to physicians and nurses. It has been estimated that approximately 30% of the total health workforce worldwide are AHPs. In most jurisdictions, AHPs are subject to health professional requisites including minimum standards for education, regulation and licensing. They must work based on scientific principles and within an evidence based practice model. They may sometimes be considered to perform the role of mid-level practitioners, when having an advanced education and training to diagnose and treat patients, but not the certification of a physician. Allied health professionals are different from alternative medicine practitioners, also sometimes called natural healers, who work outside the conventions of modern biomedicine. Definition The organization of International Chief Health Professions Officers (ICHPO) developed a widely-used definition of the allied health professions: Professions The allied health professions represent a large cluster of health and care service providers, which usually require specific training and/or certification, but which are distinct from the medicine, nursing and dentistry professions. There is a large demand for allied health professionals, especially in rural and medically underserved areas. AHPs are generally considered distinct from other healthcare service providers on the basis of several factors. These factors may include AHPs offering services in ways which support treatments provided by other healthcare professionals (working either in independent autonomous practice or under direct supervision), or by offering services which other healthcare professionals require but do not provide themselves (for example in the use of medical technologies). The precise titles, roles and requisites of AHPs vary considerably from country to country. For the United States, a generic definition is in the Public Health Service Act, including those with "training, in a science relating to health care, [and] who shares in the responsibility for the delivery of health care services or related services" (other than a registered nurse or physician assistant). In South Africa, AHPs are identified and regulated through the Health Professions Council of South Africa (e.g., clinical technologists, dental therapists) or through the Allied Health Professions Council (e.g., massage therapists, chiropractors). Depending on the country and local health care system, the professions that are considered AHPs vary. For example, in some contexts optometrists are not considered AHPs, as the profession has a longer history of primary care practice independent of modern medicine, whereas in others optometrists are identified as falling under the AHP umbrella. Similarly, in some health care jurisdictions physiotherapists are not considered AHPs, as they tend to have more autonomy in private practice without the need for medical referral, whereas in other jurisdictions physiotherapists are identified and regulated as AHPs. A limited subset of the following professional areas may be represented, and may be regulated: Training and education Some allied health professions are more specialized, and so must adhere to national training and education standards and their professional scope of practice. Often they must prove their skills through degrees, diplomas, certified credentials, and continuing education. Other allied health professions require no special training or credentials and are trained for their work by their employer through on-the-job training (which would then exclude them from consideration as an allied health profession in a country like Australia). Many allied health jobs are considered career ladder jobs because of the opportunities for advancement within specific fields. Allied health professions can include the use of many skills. Depending on the profession, these may include basic life support; medical terminology, acronyms and spelling; basics of medical law and ethics; understanding of human relations; interpersonal communication skills; counseling skills; computer literacy; ability to document healthcare information; interviewing skills; and proficiency in word processing; database management and electronic dictation. History and growth The explosion of scientific knowledge that followed World War II brought increasingly sophisticated and complex medical diagnostic and treatment procedures. Increasing public demand for medical services combined with higher health care costs provoked a trend toward expansion of service delivery from treating patients in hospitals to widespread provision of care in physician's private and group practices, ambulatory medical and emergency clinics, and mobile clinics and community-based care. Changes in the health industry and emphasis on cost-efficient solutions to health care delivery will continue to encourage expansion of the allied health workforce. The World Health Organization estimates there is currently a worldwide shortage of about 2 million allied health professionals (considering all health workers aside from medical and nursing personnel) needed in order to meet global health goals. In recognition of the growth of the number and diversity of allied health professionals in recent years, the 2008 version of the International Standard Classification of Occupations increased the number of groups dedicated to allied health professions. Depending on the presumed skill level, they may either be identified as "health professionals" or "health associate professionals". For example, new categories have been created for delineating "paramedical practitioners"—grouping professions such as clinical officers, clinical associates, physician assistants, Feldshers, and assistant medical officers—as well as for community health workers; dietitians and nutritionists; audiologists and speech therapists; and others. In developing countries, many national human resources for health strategic plans and international development initiatives are focusing on scaling up training of allied health professions, such as HIV/AIDS counsellors, clinical officers and community health workers, in providing essential preventive and treatment services in ambulatory and community-based care settings. With growing demand for ambulatory health care, researchers expect to witness a heavier demand for professions that are employed outside of hospital settings — including allied health. Modern times India In India, the National Commission for Allied and Healthcare Professions identifies and sets quality standards for 56 professions in diagnostics, therapeutics, community health, and biomedical technology (e.g., physiotherapists, radiologists). United Kingdom In the United Kingdom there are 12 distinct professions who are considered allied health professionals; in combination they account for about 6% of the NHS workforce. In 2013 the annual expenditure on services provided by allied health professionals amounted to around £2 billion, although there is a lack of evidence around the extent to which these services improve the quality of care. United States In the United States, the Association of Schools of Allied Health Professionals uses wording from the Public Health Service Act to list those who are considered to be allied health professionals. Professionals who are excluded under the Act from the list of AHPs, although they may possess degrees or diplomas in health sciences, include the following: Employment projections Projections in the United States and many other countries have shown an expected long-term shortage of qualified workers to fill many allied health positions. This is primarily due to expansion of the health industry due to demographic changes (a growing and aging population), large numbers of health workers nearing retirement, the industry's need to be cost efficient, and a lack of sufficient investment in training programs to keep pace with these trends. Studies have also pointed to the need for increased diversity in the allied health workforce to realize a culturally competent health system. Workforce and health care experts anticipate that health services will increasingly be delivered via ambulatory and nursing care settings rather than in hospitals. According to the North American Industry Classification System (NAICS), the health care industry consists of four main sub-sectors, divided by the types of services provided at each facility: Hospitals: primarily provides inpatient health services and may provide some outpatient services as a secondary activity. Ambulatory health care settings: primarily provides outpatient services at facilities such as doctors' offices, outpatient clinics and clinical laboratories. Nursing and residential care facilities: provides residential care, such as community care for the elderly or mental health and substance abuse facilities. Social Assistance: provides services for the elderly and/or disabled, services for the homeless and poor, vocational rehabilitation, or child day care services. In the US, a larger proportion of the allied health care workforce is already employed in ambulatory settings. In California, nearly half (49.4 percent) of the allied health workforce is employed in ambulatory health care settings, compared with 28.7 percent and 21.9 percent employed in hospital and nursing care, respectively. One source reported allied health professionals making up 60 percent of the total US health workforce. Advancements in medical technology also allow for more services that formerly required expensive hospital stays to be delivered via ambulatory care. For example, in California, research has predicted the total consumption of hospital days per person will decline from 4 days in 2010 to 3.2 days in 2020 to 2.5 days in 2030. In contrast, the number of ambulatory visits per person will increase from 3.2 visits per person in 2010 to 3.6 visits per person in 2020 to 4.2 visits in 2030. See also Health care providers Human resources for health Paramedicine Unlicensed assistive personnel References External links Allied Health Professionals on NHS Careers (UK) AMA Allied health professionals Association of Schools Advancing Health Professions (ASAHP) National Commission for Allied and Healthcare Professions (India)

Anatomy of an Epidemic

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is a book by Robert Whitaker published in 2010 by Crown. Whitaker asks why the number of Americans who receive government disability for mental illness approximately doubled since 1987. In the book, Whitaker tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S. Synopsis Magic bullets Whitaker begins by reviewing the discovery of antipsychotics, benzodiazepines and antidepressants. These were discovered as side effects during research for antihistamines (specifically promethazine), gram negative antibiotics (specifically mephenesin) and the anti-tuberculosis agents isoniazid and iproniazid respectively. The psychiatric mechanisms of action of these drugs were not known at the time and these were initially called major tranquilizers (now typical antipsychotics) due to their induction of "euphoric quietude"; minor tranquilizers (now benzodiazepines) and psychic energizers (now antidepressants) due to patients "dancing in the wards." These compounds were developed during a period of growth for the pharmaceutical industry bolstered by the 1951 Durham-Humphrey Amendment, giving physicians monopolistic prescribing rights thus aligning the interests of physicians and pharmaceutical companies. This also followed the industry's development of "magic bullets" that treat people with, for example, diabetes, which according to Whitaker provided an analogy to sell the idea of these drugs to the public. It was not until many years later, after the mechanisms of these drugs were determined, that the serotonergic hypothesis of depression and dopaminergic hypothesis of schizophrenia were developed to fall in line with the drug's mechanisms. According to Whitaker's analysis of the primary literature, lower levels of serotonin and higher levels of dopamine "have proved to be true in patients WITH prior exposure to antidepressants or antipsychotics (ie as homeostatic mechanisms) but NOT in patients without prior exposure." Whitaker further criticizes the magic bullet theory by attacking the historical notion that the "invention of the antipsychotic Thorazine" emptied the asylums. His case begins by showing that during the late 1940s and 1950s ~75% of cases admitted for first episode schizophrenia recovered to the community by approximately 3 years (Thorazine was not released until 1955). He then notes that the arrival of Thorazine did not improve discharge rates in the 1950s for people newly diagnosed with schizophrenia. In fact, based on the only large scale first episode schizophrenia study of this era, 88% of those who were not treated were discharged within eighteen months compared to 74% of neuroleptic treated. This is additionally evidenced by the fact that when Thorazine was introduced in 1955 there were 267 thousand schizophrenia patients in state and county mental hospitals, and eight years later, there were 253 thousand, thus indicating that the advent of neuroleptics barely budged the number of hospitalized patients. What he argues actually cleared the asylums was the beginning of Medicare and Medicaid in 1965. These programs provided federal subsidies for nursing home care but no such subsidy for care in state mental hospitals, and so the states, seeking to save money, began sending their chronic patients to nursing homes. Psychiatric drugs Whitaker acknowledges that psychiatric medications do sometimes work but believes that they must be used in a "selective, cautious manner. It should be understood that they’re not fixing any chemical imbalances. And honestly, they should be used on a short-term basis." Whitaker traces the effects of what looks like an iatrogenic epidemic: the drugs that patients receive can perturb their normal brain function. Whitaker suggests that the "wonder drug" glow around the second generation psychotropics has long since disappeared. He views the "hyping" of the top-selling atypical antipsychotics as "one of the more embarrassing episodes in psychiatry's history, as one government study after another failed to find that they were any better than the first-generation anti-psychotics." Whitaker speaks warmly of Open Dialogue, an organisation of care documented by professor psychologist Jaakko Seikkula at Keropudas Hospital in Tornio in Lapland where drugs are given to patients only on a limited basis. According to Whitaker, the district has the lowest per capita spending on mental health of all health districts in Finland. Children Whitaker sees that children are vulnerable to being prescribed a lifetime of drugs. As the author says, a psychiatrist and parents may give a child a "cocktail" to force him or her to behave. Then when this child reaches the age of eighteen, Whitaker says the child often becomes a disabled adult. Review of data and statistics Whitaker spent a year and a half researching for this book, and maintains a website listing some relevant studies. Reception and media coverage Whitaker did interviews with Salon and The Boston Globe during the release of this book. He also did a book tour, and he spoke for an hour and a half on C-SPAN where there is an archived video. A review by sleep researcher Dennis Rosen for The Boston Globe concludes that "although extensively researched and drawing upon hundreds of sources, the gaps in his theory remain too large for him to succeed in making a convincing argument", and compares Whitaker to Thabo Mbeki and AIDS denialism. The book received positive reviews from New Scientist, The Record, Time magazine, and Salon. Over a year after the book was published, Marcia Angell, former editor of The New England Journal of Medicine, published a two-part review of Whitaker's and other books in The New York Review of Books Whitaker presented his views at a psychiatric Grand Rounds at Massachusetts General Hospital on January 13, 2011, where his data and approach were critiqued by psychiatrist Andrew Nierenberg. Additional criticism has come from psychiatrist and author Daniel Carlat. Whitaker has responded to critics on his website. Awards In April 2011, Investigative Reporters and Editors (IRE) announced that the book had won its award as the best investigative journalism book of 2010 stating, "this book provides an in-depth exploration of medical studies and science and intersperses compelling anecdotal examples. In the end, Whitaker rejects the conventional wisdom of treatment of mental illness with drugs." See also Mad in America (2002) by Robert Whitaker Side Effects (2008) by Alison Bass Rethinking Madness book by Paris Williams Evidence-based medicine References Bibliography External links Book home page at author's site, Mad in America Author keynote at Alternatives 2010 (funded by the Substance Abuse & Mental Health Services Administration of the U.S. Department of Health and Human Services) Part One Part Two Part Three Part Four 2010 non-fiction books American history books Books about the politics of science Books about mental health History books about medicine History of psychiatry Books about the history of science Popular science books

Psychology

Psychology is the scientific study of mind and behavior. Its subject matter includes the behavior of humans and nonhumans, both conscious and unconscious phenomena, and mental processes such as thoughts, feelings, and motives. Psychology is an academic discipline of immense scope, crossing the boundaries between the natural and social sciences. Biological psychologists seek an understanding of the emergent properties of brains, linking the discipline to neuroscience. As social scientists, psychologists aim to understand the behavior of individuals and groups. A professional practitioner or researcher involved in the discipline is called a psychologist. Some psychologists can also be classified as behavioral or cognitive scientists. Some psychologists attempt to understand the role of mental functions in individual and social behavior. Others explore the physiological and neurobiological processes that underlie cognitive functions and behaviors. Psychologists are involved in research on perception, cognition, attention, emotion, intelligence, subjective experiences, motivation, brain functioning, and personality. Psychologists' interests extend to interpersonal relationships, psychological resilience, family resilience, and other areas within social psychology. They also consider the unconscious mind. Research psychologists employ empirical methods to infer causal and correlational relationships between psychosocial variables. Some, but not all, clinical and counseling psychologists rely on symbolic interpretation. While psychological knowledge is often applied to the assessment and treatment of mental health problems, it is also directed towards understanding and solving problems in several spheres of human activity. By many accounts, psychology ultimately aims to benefit society. Many psychologists are involved in some kind of therapeutic role, practicing psychotherapy in clinical, counseling, or school settings. Other psychologists conduct scientific research on a wide range of topics related to mental processes and behavior. Typically the latter group of psychologists work in academic settings (e.g., universities, medical schools, or hospitals). Another group of psychologists is employed in industrial and organizational settings. Yet others are involved in work on human development, aging, sports, health, forensic science, education, and the media. Etymology and definitions The word psychology derives from the Greek word psyche, for spirit or soul. The latter part of the word psychology derives from -λογία -logia, which means "study" or "research". The word psychology was first used in the Renaissance. In its Latin form psychiologia, it was first employed by the Croatian humanist and Latinist Marko Marulić in his book Psichiologia de ratione animae humanae (Psychology, on the Nature of the Human Soul) in the decade 1510-1520 The earliest known reference to the word psychology in English was by Steven Blankaart in 1694 in The Physical Dictionary. The dictionary refers to "Anatomy, which treats the Body, and Psychology, which treats of the Soul." Ψ (psi), the first letter of the Greek word psyche from which the term psychology is derived, is commonly associated with the field of psychology. In 1890, William James defined psychology as "the science of mental life, both of its phenomena and their conditions." This definition enjoyed widespread currency for decades. However, this meaning was contested, notably by radical behaviorists such as John B. Watson, who in 1913 asserted that the discipline is a natural science, the theoretical goal of which "is the prediction and control of behavior." Since James defined "psychology", the term more strongly implicates scientific experimentation. Folk psychology is the understanding of the mental states and behaviors of people held by ordinary people, as contrasted with psychology professionals' understanding. History The ancient civilizations of Egypt, Greece, China, India, and Persia all engaged in the philosophical study of psychology. In Ancient Egypt the Ebers Papyrus mentioned depression and thought disorders. Historians note that Greek philosophers, including Thales, Plato, and Aristotle (especially in his treatise), addressed the workings of the mind. As early as the 4th century BC, the Greek physician Hippocrates theorized that mental disorders had physical rather than supernatural causes. In 387 BCE, Plato suggested that the brain is where mental processes take place, and in 335 BCE Aristotle suggested that it was the heart. In China, psychological understanding grew from the philosophical works of Laozi and Confucius, and later from the doctrines of Buddhism. This body of knowledge involves insights drawn from introspection and observation, as well as techniques for focused thinking and acting. It frames the universe in term of a division of physical reality and mental reality as well as the interaction between the physical and the mental. Chinese philosophy also emphasized purifying the mind in order to increase virtue and power. An ancient text known as The Yellow Emperor's Classic of Internal Medicine identifies the brain as the nexus of wisdom and sensation, includes theories of personality based on yin–yang balance, and analyzes mental disorder in terms of physiological and social disequilibria. Chinese scholarship that focused on the brain advanced during the Qing dynasty with the work of Western-educated Fang Yizhi (1611–1671), Liu Zhi (1660–1730), and Wang Qingren (1768–1831). Wang Qingren emphasized the importance of the brain as the center of the nervous system, linked mental disorder with brain diseases, investigated the causes of dreams and insomnia, and advanced a theory of hemispheric lateralization in brain function. Influenced by Hinduism, Indian philosophy explored distinctions in types of awareness. A central idea of the Upanishads and other Vedic texts that formed the foundations of Hinduism was the distinction between a person's transient mundane self and their eternal, unchanging soul. Divergent Hindu doctrines and Buddhism have challenged this hierarchy of selves, but have all emphasized the importance of reaching higher awareness. Yoga encompasses a range of techniques used in pursuit of this goal. Theosophy, a religion established by Russian-American philosopher Helena Blavatsky, drew inspiration from these doctrines during her time in British India. Psychology was of interest to Enlightenment thinkers in Europe. In Germany, Gottfried Wilhelm Leibniz (1646–1716) applied his principles of calculus to the mind, arguing that mental activity took place on an indivisible continuum. He suggested that the difference between conscious and unconscious awareness is only a matter of degree. Christian Wolff identified psychology as its own science, writing Psychologia Empirica in 1732 and Psychologia Rationalis in 1734. Immanuel Kant advanced the idea of anthropology as a discipline, with psychology an important subdivision. Kant, however, explicitly rejected the idea of an experimental psychology, writing that "the empirical doctrine of the soul can also never approach chemistry even as a systematic art of analysis or experimental doctrine, for in it the manifold of inner observation can be separated only by mere division in thought, and cannot then be held separate and recombined at will (but still less does another thinking subject suffer himself to be experimented upon to suit our purpose), and even observation by itself already changes and displaces the state of the observed object." In 1783, Ferdinand Ueberwasser (1752–1812) designated himself Professor of Empirical Psychology and Logic and gave lectures on scientific psychology, though these developments were soon overshadowed by the Napoleonic Wars. At the end of the Napoleonic era, Prussian authorities discontinued the Old University of Münster. Having consulted philosophers Hegel and Herbart, however, in 1825 the Prussian state established psychology as a mandatory discipline in its rapidly expanding and highly influential educational system. However, this discipline did not yet embrace experimentation. In England, early psychology involved phrenology and the response to social problems including alcoholism, violence, and the country's crowded "lunatic" asylums. Beginning of experimental psychology Philosopher John Stuart Mill believed that the human mind was open to scientific investigation, even if the science is in some ways inexact. Mill proposed a "mental chemistry" in which elementary thoughts could combine into ideas of greater complexity. Gustav Fechner began conducting psychophysics research in Leipzig in the 1830s. He articulated the principle that human perception of a stimulus varies logarithmically according to its intensity. The principle became known as the Weber–Fechner law. Fechner's 1860 Elements of Psychophysics challenged Kant's negative view with regard to conducting quantitative research on the mind. Fechner's achievement was to show that "mental processes could not only be given numerical magnitudes, but also that these could be measured by experimental methods." In Heidelberg, Hermann von Helmholtz conducted parallel research on sensory perception, and trained physiologist Wilhelm Wundt. Wundt, in turn, came to Leipzig University, where he established the psychological laboratory that brought experimental psychology to the world. Wundt focused on breaking down mental processes into the most basic components, motivated in part by an analogy to recent advances in chemistry, and its successful investigation of the elements and structure of materials. Paul Flechsig and Emil Kraepelin soon created another influential laboratory at Leipzig, a psychology-related lab, that focused more on experimental psychiatry. James McKeen Cattell, a professor of psychology at the University of Pennsylvania and Columbia University and the co-founder of Psychological Review, was the first professor of psychology in the United States. The German psychologist Hermann Ebbinghaus, a researcher at the University of Berlin, was a 19th-century contributor to the field. He pioneered the experimental study of memory and developed quantitative models of learning and forgetting. In the early 20th century, Wolfgang Kohler, Max Wertheimer, and Kurt Koffka co-founded the school of Gestalt psychology of Fritz Perls. The approach of Gestalt psychology is based upon the idea that individuals experience things as unified wholes. Rather than reducing thoughts and behavior into smaller component elements, as in structuralism, the Gestaltists maintained that whole of experience is important, and differs from the sum of its parts. Psychologists in Germany, Denmark, Austria, England, and the United States soon followed Wundt in setting up laboratories. G. Stanley Hall, an American who studied with Wundt, founded a psychology lab that became internationally influential. The lab was located at Johns Hopkins University. Hall, in turn, trained Yujiro Motora, who brought experimental psychology, emphasizing psychophysics, to the Imperial University of Tokyo. Wundt's assistant, Hugo Münsterberg, taught psychology at Harvard to students such as Narendra Nath Sen Gupta—who, in 1905, founded a psychology department and laboratory at the University of Calcutta. Wundt's students Walter Dill Scott, Lightner Witmer, and James McKeen Cattell worked on developing tests of mental ability. Cattell, who also studied with eugenicist Francis Galton, went on to found the Psychological Corporation. Witmer focused on the mental testing of children; Scott, on employee selection. Another student of Wundt, the Englishman Edward Titchener, created the psychology program at Cornell University and advanced "structuralist" psychology. The idea behind structuralism was to analyze and classify different aspects of the mind, primarily through the method of introspection. William James, John Dewey, and Harvey Carr advanced the idea of functionalism, an expansive approach to psychology that underlined the Darwinian idea of a behavior's usefulness to the individual. In 1890, James wrote an influential book, The Principles of Psychology, which expanded on the structuralism. He memorably described "stream of consciousness." James's ideas interested many American students in the emerging discipline. Dewey integrated psychology with societal concerns, most notably by promoting progressive education, inculcating moral values in children, and assimilating immigrants. A different strain of experimentalism, with a greater connection to physiology, emerged in South America, under the leadership of Horacio G. Piñero at the University of Buenos Aires. In Russia, too, researchers placed greater emphasis on the biological basis for psychology, beginning with Ivan Sechenov's 1873 essay, "Who Is to Develop Psychology and How?" Sechenov advanced the idea of brain reflexes and aggressively promoted a deterministic view of human behavior. The Russian-Soviet physiologist Ivan Pavlov discovered in dogs a learning process that was later termed "classical conditioning" and applied the process to human beings. Consolidation and funding One of the earliest psychology societies was La Société de Psychologie Physiologique in France, which lasted from 1885 to 1893. The first meeting of the International Congress of Psychology sponsored by the International Union of Psychological Science took place in Paris, in August 1889, amidst the World's Fair celebrating the centennial of the French Revolution. William James was one of three Americans among the 400 attendees. The American Psychological Association (APA) was founded soon after, in 1892. The International Congress continued to be held at different locations in Europe and with wide international participation. The Sixth Congress, held in Geneva in 1909, included presentations in Russian, Chinese, and Japanese, as well as Esperanto. After a hiatus for World War I, the Seventh Congress met in Oxford, with substantially greater participation from the war-victorious Anglo-Americans. In 1929, the Congress took place at Yale University in New Haven, Connecticut, attended by hundreds of members of the APA. Tokyo Imperial University led the way in bringing new psychology to the East. New ideas about psychology diffused from Japan into China. American psychology gained status upon the U.S.'s entry into World War I. A standing committee headed by Robert Yerkes administered mental tests ("Army Alpha" and "Army Beta") to almost 1.8 million soldiers. Subsequently, the Rockefeller family, via the Social Science Research Council, began to provide funding for behavioral research. Rockefeller charities funded the National Committee on Mental Hygiene, which disseminated the concept of mental illness and lobbied for applying ideas from psychology to child rearing. Through the Bureau of Social Hygiene and later funding of Alfred Kinsey, Rockefeller foundations helped establish research on sexuality in the U.S. Under the influence of the Carnegie-funded Eugenics Record Office, the Draper-funded Pioneer Fund, and other institutions, the eugenics movement also influenced American psychology. In the 1910s and 1920s, eugenics became a standard topic in psychology classes. In contrast to the US, in the UK psychology was met with antagonism by the scientific and medical establishments, and up until 1939, there were only six psychology chairs in universities in England. During World War II and the Cold War, the U.S. military and intelligence agencies established themselves as leading funders of psychology by way of the armed forces and in the new Office of Strategic Services intelligence agency. University of Michigan psychologist Dorwin Cartwright reported that university researchers began large-scale propaganda research in 1939–1941. He observed that "the last few months of the war saw a social psychologist become chiefly responsible for determining the week-by-week-propaganda policy for the United States Government." Cartwright also wrote that psychologists had significant roles in managing the domestic economy. The Army rolled out its new General Classification Test to assess the ability of millions of soldiers. The Army also engaged in large-scale psychological research of troop morale and mental health. In the 1950s, the Rockefeller Foundation and Ford Foundation collaborated with the Central Intelligence Agency (CIA) to fund research on psychological warfare. In 1965, public controversy called attention to the Army's Project Camelot, the "Manhattan Project" of social science, an effort which enlisted psychologists and anthropologists to analyze the plans and policies of foreign countries for strategic purposes. In Germany after World War I, psychology held institutional power through the military, which was subsequently expanded along with the rest of the military during Nazi Germany. Under the direction of Hermann Göring's cousin Matthias Göring, the Berlin Psychoanalytic Institute was renamed the Göring Institute. Freudian psychoanalysts were expelled and persecuted under the anti-Jewish policies of the Nazi Party, and all psychologists had to distance themselves from Freud and Adler, founders of psychoanalysis who were also Jewish. The Göring Institute was well-financed throughout the war with a mandate to create a "New German Psychotherapy." This psychotherapy aimed to align suitable Germans with the overall goals of the Reich. As described by one physician, "Despite the importance of analysis, spiritual guidance and the active cooperation of the patient represent the best way to overcome individual mental problems and to subordinate them to the requirements of the Volk and the Gemeinschaft." Psychologists were to provide Seelenführung [lit., soul guidance], the leadership of the mind, to integrate people into the new vision of a German community. Harald Schultz-Hencke melded psychology with the Nazi theory of biology and racial origins, criticizing psychoanalysis as a study of the weak and deformed. Johannes Heinrich Schultz, a German psychologist recognized for developing the technique of autogenic training, prominently advocated sterilization and euthanasia of men considered genetically undesirable, and devised techniques for facilitating this process. After the war, new institutions were created although some psychologists, because of their Nazi affiliation, were discredited. Alexander Mitscherlich founded a prominent applied psychoanalysis journal called Psyche. With funding from the Rockefeller Foundation, Mitscherlich established the first clinical psychosomatic medicine division at Heidelberg University. In 1970, psychology was integrated into the required studies of medical students. After the Russian Revolution, the Bolsheviks promoted psychology as a way to engineer the "New Man" of socialism. Consequently, university psychology departments trained large numbers of students in psychology. At the completion of training, positions were made available for those students at schools, workplaces, cultural institutions, and in the military. The Russian state emphasized pedology and the study of child development. Lev Vygotsky became prominent in the field of child development. The Bolsheviks also promoted free love and embraced the doctrine of psychoanalysis as an antidote to sexual repression. Although pedology and intelligence testing fell out of favor in 1936, psychology maintained its privileged position as an instrument of the Soviet Union. Stalinist purges took a heavy toll and instilled a climate of fear in the profession, as elsewhere in Soviet society. Following World War II, Jewish psychologists past and present, including Lev Vygotsky, A.R. Luria, and Aron Zalkind, were denounced; Ivan Pavlov (posthumously) and Stalin himself were celebrated as heroes of Soviet psychology. Soviet academics experienced a degree of liberalization during the Khrushchev Thaw. The topics of cybernetics, linguistics, and genetics became acceptable again. The new field of engineering psychology emerged. The field involved the study of the mental aspects of complex jobs (such as pilot and cosmonaut). Interdisciplinary studies became popular and scholars such as Georgy Shchedrovitsky developed systems theory approaches to human behavior. Twentieth-century Chinese psychology originally modeled itself on U.S. psychology, with translations from American authors like William James, the establishment of university psychology departments and journals, and the establishment of groups including the Chinese Association of Psychological Testing (1930) and the Chinese Psychological Society (1937). Chinese psychologists were encouraged to focus on education and language learning. Chinese psychologists were drawn to the idea that education would enable modernization. John Dewey, who lectured to Chinese audiences between 1919 and 1921, had a significant influence on psychology in China. Chancellor T'sai Yuan-p'ei introduced him at Peking University as a greater thinker than Confucius. Kuo Zing-yang who received a PhD at the University of California, Berkeley, became President of Zhejiang University and popularized behaviorism. After the Chinese Communist Party gained control of the country, the Stalinist Soviet Union became the major influence, with Marxism–Leninism the leading social doctrine and Pavlovian conditioning the approved means of behavior change. Chinese psychologists elaborated on Lenin's model of a "reflective" consciousness, envisioning an "active consciousness" able to transcend material conditions through hard work and ideological struggle. They developed a concept of "recognition" which referred to the interface between individual perceptions and the socially accepted worldview; failure to correspond with party doctrine was "incorrect recognition." Psychology education was centralized under the Chinese Academy of Sciences, supervised by the State Council. In 1951, the academy created a Psychology Research Office, which in 1956 became the Institute of Psychology. Because most leading psychologists were educated in the United States, the first concern of the academy was the re-education of these psychologists in the Soviet doctrines. Child psychology and pedagogy for the purpose of a nationally cohesive education remained a central goal of the discipline. Women in psychology 1900 - 1949 Women in the early 1900s started to make key findings within the world of psychology. In 1923, Anna Freud, the daughter of Sigmund Freud, built on her father's work using different defense mechanisms (denial, repression, and suppression) to psychoanalyze children. She believed that once a child reached the latency period, child analysis could be used as a mode of therapy. She stated it is important focus on the child's environment, support their development, and prevent neurosis. She believed a child should be recognized as their own person with their own right and have each session catered to the child's specific needs. She encouraged drawing, moving freely, and expressing themselves in any way. This helped build a strong therapeutic alliance with child patients, which allows psychologists to observe their normal behavior. She continued her research on the impact of children after family separation, children with socio-economically disadvantaged backgrounds, and all stages of child development from infancy to adolescence. Functional periodicity, the belief women are mentally and physically impaired during menstruation, impacted women's rights because employers were less likely to hire them due to the belief they would be incapable of working for 1 week a month. Leta Stetter Hollingworth wanted to prove this hypothesis and Edward L. Thorndike's theory, that women have lesser psychological and physical traits than men and were simply mediocre, incorrect. Hollingworth worked to prove differences were not from male genetic superiority, but from culture. She also included the concept of women's impairment during menstruation in her research. She recorded both women and men performances on tasks (cognitive, perceptual, and motor) for three months. No evidence was found of decreased performance due to a woman's menstrual cycle. She also challenged the belief intelligence is inherited and women here are intellectually inferior to men. She stated that women do not reach positions of power due to the societal norms and roles they are assigned. As she states in her article, "Variability as related to sex differences in achievement: A Critique", the largest problem women have is the social order that was built due to the assumption women have less interests and abilities than men. To further prove her point, she completed another experiment with infants who have not been influenced by the environment of social norms, like the adult male getting more opportunities than women. She found no difference between infants besides size. After this research proved the original hypothesis wrong, Hollingworth was able to show there is no difference between the physiological and psychological traits of men and women, and women are not impaired during menstruation. The first half of the 1900s was filled with new theories and it was a turning point for women's recognition within the field of psychology. In addition to the contributions made by Leta Stetter Hollingworth and Anna Freud, Mary Whiton Calkins invented the paired associates technique of studying memory and developed self-psychology. Karen Horney developed the concept of "womb envy" and neurotic needs. Psychoanalyst Melanie Klein impacted developmental psychology with her research of play therapy. These great discoveries and contributions were made during struggles of sexism, discrimination, and little recognition for their work. 1950 - 1999 Women in the second half of the 20th century continued to do research that had large-scale impacts on the field of psychology. Mary Ainsworth's work centered around attachment theory. Building off fellow psychologist John Bowlby, Ainsworth spent years doing fieldwork to understand the development of mother-infant relationships. In doing this field research, Ainsworth developed the Strange Situation Procedure, a laboratory procedure meant to study attachment style by separating and uniting a child with their mother several different times under different circumstances. These field studies are also where she developed her attachment theory and the order of attachment styles, which was a landmark for developmental psychology. Because of her work, Ainsworth became one of the most cited psychologists of all time. Mamie Phipps Clark was another woman in psychology that changed the field with her research. She was one of the first African-Americans to receive a doctoral degree in psychology from Columbia University, along with her husband, Kenneth Clark. Her master's thesis, "The Development of Consciousness in Negro Pre-School Children," argued that black children's self-esteem was negatively impacted by racial discrimination. She and her husband conduced research building off her thesis throughout the 1940s. These tests, called the doll tests, asked young children to choose between identical dolls whose only difference was race, and they found that the majority of the children preferred the white dolls and attributed positive traits to them. Repeated over and over again, these tests helped to determine the negative effects of racial discrimination and segregation on black children's self-image and development. In 1954, this research would help decide the landmark Brown v. Board of Education decision, leading to the end of legal segregation across the nation. Clark went on to be an influential figure in psychology, her work continuing to focus on minority youth. As the field of psychology developed throughout the latter half of the 20th century, women in the field advocated for their voices to be heard and their perspectives to be valued. Second-wave feminism did not miss psychology. An outspoken feminist in psychology was Naomi Weisstein, who was an accomplished researcher in psychology and neuroscience, and is perhaps best known for her paper, "Kirche, Kuche, Kinder as Scientific Law: Psychology Constructs the Female." Psychology Constructs the Female criticized the field of psychology for centering men and using biology too much to explain gender differences without taking into account social factors. Her work set the stage for further research to be done in social psychology, especially in gender construction. Other women in the field also continued advocating for women in psychology, creating the Association for Women in Psychology to criticize how the field treated women. E. Kitsch Child, Phyllis Chesler, and Dorothy Riddle were some of the founding members of the organization in 1969. The latter half of the 20th century further diversified the field of psychology, with women of color reaching new milestones. In 1962, Martha Bernal became the first Latina woman to get a Ph.D. in psychology. In 1969, Marigold Linton, the first Native American woman to get a Ph.D. in psychology, founded the National Indian Education Association. She was also a founding member of the Society for Advancement of Chicanos and Native Americans in Science. In 1971, The Network of Indian Psychologists was established by Carolyn Attneave. Harriet McAdoo was appointed to the White House Conference on Families in 1979. 2000 - Current Dr. Kay Redfield Jamison, named one of Time Magazine's "Best Doctors in the United States" is a lecturer, psychologist, and writer. She is known for her vast modern contributions to bipolar disorder and her books An Unquiet Mind (Published 1995) and Nothing Was the Same (Published in 2009). Having Bipolar Disorder herself, she has written several memoirs about her experience with suicidal thoughts, manic behaviors, depression, and other issues that arise from being Bipolar. Dr. Angela Neal-Barnett views psychology through a Black lens and dedicated her career to focusing on the anxiety of African American women. She founded the organization Rise Sally Rise which helps Black women cope with anxiety. She published her work Soothe Your Nerves: The Black Woman's Guide to Understanding and Overcoming Anxiety, Panic and Fear in 2003. In 2002 Dr. Teresa LaFromboise, former president of the Society of Indian Psychologists, received the APA's Distinguished Career Contribution to Research Award from the Society for the Psychological Study of Culture Ethnicity, and Race for her research on suicide prevention. She was the first person to lead an intervention for Native American children and adolescents that utilized evidence-based suicide prevention. She has spent her career dedicated to aiding racial and ethnic minority youth cope with cultural adjustment and pressures. Dr. Shari Miles-Cohen, a psychologist and political activist has applied a black, feminist, and class lens to all her psychological studies. Aiding progressive and women's issues, she has been the executive director for many NGOs. In 2007 she became the Senior Director of the Women's Programs Office of the American Psychological Association. Therefore, she was one of the creators of the APA's "Women in Psychology Timeline" which features the accomplishments of women of color in psychology. She is well known for co-editing Eliminating Inequities for Women with Disabilities: An Agenda for Health and Wellness (published in 2016), her article published in the Women's Reproductive Health Journal about women of color's struggle with pregnancy and postpartum (Published in 2018), and co-authoring the "APA Handbook of the Psychology of Women" (published in 2019). Disciplinary organizations Institutions In 1920, Édouard Claparède and Pierre Bovet created a new applied psychology organization called the International Congress of Psychotechnics Applied to Vocational Guidance, later called the International Congress of Psychotechnics and then the International Association of Applied Psychology. The IAAP is considered the oldest international psychology association. Today, at least 65 international groups deal with specialized aspects of psychology. In response to male predominance in the field, female psychologists in the U.S. formed the National Council of Women Psychologists in 1941. This organization became the International Council of Women Psychologists after World War II and the International Council of Psychologists in 1959. Several associations including the Association of Black Psychologists and the Asian American Psychological Association have arisen to promote the inclusion of non-European racial groups in the profession. The International Union of Psychological Science (IUPsyS) is the world federation of national psychological societies. The IUPsyS was founded in 1951 under the auspices of the United Nations Educational, Cultural and Scientific Organization (UNESCO). Psychology departments have since proliferated around the world, based primarily on the Euro-American model. Since 1966, the Union has published the International Journal of Psychology. IAAP and IUPsyS agreed in 1976 each to hold a congress every four years, on a staggered basis. IUPsyS recognizes 66 national psychology associations and at least 15 others exist. The American Psychological Association is the oldest and largest. Its membership has increased from 5,000 in 1945 to 100,000 in the present day. The APA includes 54 divisions, which since 1960 have steadily proliferated to include more specialties. Some of these divisions, such as the Society for the Psychological Study of Social Issues and the American Psychology–Law Society, began as autonomous groups. The Interamerican Psychological Society, founded in 1951, aspires to promote psychology across the Western Hemisphere. It holds the Interamerican Congress of Psychology and had 1,000 members in year 2000. The European Federation of Professional Psychology Associations, founded in 1981, represents 30 national associations with a total of 100,000 individual members. At least 30 other international organizations represent psychologists in different regions. In some places, governments legally regulate who can provide psychological services or represent themselves as a "psychologist." The APA defines a psychologist as someone with a doctoral degree in psychology. Boundaries Early practitioners of experimental psychology distinguished themselves from parapsychology, which in the late nineteenth century enjoyed popularity (including the interest of scholars such as William James). Some people considered parapsychology to be part of "psychology." Parapsychology, hypnotism, and psychism were major topics at the early International Congresses. But students of these fields were eventually ostracized, and more or less banished from the Congress in 1900–1905. Parapsychology persisted for a time at Imperial University in Japan, with publications such as Clairvoyance and Thoughtography by Tomokichi Fukurai, but it was mostly shunned by 1913. As a discipline, psychology has long sought to fend off accusations that it is a "soft" science. Philosopher of science Thomas Kuhn's 1962 critique implied psychology overall was in a pre-paradigm state, lacking agreement on the type of overarching theory found in mature hard sciences such as chemistry and physics. Because some areas of psychology rely on research methods such as self-reports in surveys and questionnaires, critics asserted that psychology is not an objective science. Skeptics have suggested that personality, thinking, and emotion cannot be directly measured and are often inferred from subjective self-reports, which may be problematic. Experimental psychologists have devised a variety of ways to indirectly measure these elusive phenomenological entities. Divisions still exist within the field, with some psychologists more oriented towards the unique experiences of individual humans, which cannot be understood only as data points within a larger population. Critics inside and outside the field have argued that mainstream psychology has become increasingly dominated by a "cult of empiricism", which limits the scope of research because investigators restrict themselves to methods derived from the physical sciences. Feminist critiques have argued that claims to scientific objectivity obscure the values and agenda of (historically) mostly male researchers. Jean Grimshaw, for example, argues that mainstream psychological research has advanced a patriarchal agenda through its efforts to control behavior. Major schools of thought Biological Psychologists generally consider biology the substrate of thought and feeling, and therefore an important area of study. Behaviorial neuroscience, also known as biological psychology, involves the application of biological principles to the study of physiological and genetic mechanisms underlying behavior in humans and other animals. The allied field of comparative psychology is the scientific study of the behavior and mental processes of non-human animals. A leading question in behavioral neuroscience has been whether and how mental functions are localized in the brain. From Phineas Gage to H.M. and Clive Wearing, individual people with mental deficits traceable to physical brain damage have inspired new discoveries in this area. Modern behavioral neuroscience could be said to originate in the 1870s, when in France Paul Broca traced production of speech to the left frontal gyrus, thereby also demonstrating hemispheric lateralization of brain function. Soon after, Carl Wernicke identified a related area necessary for the understanding of speech. The contemporary field of behavioral neuroscience focuses on the physical basis of behavior. Behaviorial neuroscientists use animal models, often relying on rats, to study the neural, genetic, and cellular mechanisms that underlie behaviors involved in learning, memory, and fear responses. Cognitive neuroscientists, by using neural imaging tools, investigate the neural correlates of psychological processes in humans. Neuropsychologists conduct psychological assessments to determine how an individual's behavior and cognition are related to the brain. The biopsychosocial model is a cross-disciplinary, holistic model that concerns the ways in which interrelationships of biological, psychological, and socio-environmental factors affect health and behavior. Evolutionary psychology approaches thought and behavior from a modern evolutionary perspective. This perspective suggests that psychological adaptations evolved to solve recurrent problems in human ancestral environments. Evolutionary psychologists attempt to find out how human psychological traits are evolved adaptations, the results of natural selection or sexual selection over the course of human evolution. The history of the biological foundations of psychology includes evidence of racism. The idea of white supremacy and indeed the modern concept of race itself arose during the process of world conquest by Europeans. Carl von Linnaeus's four-fold classification of humans classifies Europeans as intelligent and severe, Americans as contented and free, Asians as ritualistic, and Africans as lazy and capricious. Race was also used to justify the construction of socially specific mental disorders such as drapetomania and dysaesthesia aethiopica—the behavior of uncooperative African slaves. After the creation of experimental psychology, "ethnical psychology" emerged as a subdiscipline, based on the assumption that studying primitive races would provide an important link between animal behavior and the psychology of more evolved humans. Behaviorist A tenet of behavioral research is that a large part of both human and lower-animal behavior is learned. A principle associated with behavioral research is that the mechanisms involved in learning apply to humans and non-human animals. Behavioral researchers have developed a treatment known as behavior modification, which is used to help individuals replace undesirable behaviors with desirable ones. Early behavioral researchers studied stimulus–response pairings, now known as classical conditioning. They demonstrated that when a biologically potent stimulus (e.g., food that elicits salivation) is paired with a previously neutral stimulus (e.g., a bell) over several learning trials, the neutral stimulus by itself can come to elicit the response the biologically potent stimulus elicits. Ivan Pavlov—known best for inducing dogs to salivate in the presence of a stimulus previously linked with food—became a leading figure in the Soviet Union and inspired followers to use his methods on humans. In the United States, Edward Lee Thorndike initiated "connectionist" studies by trapping animals in "puzzle boxes" and rewarding them for escaping. Thorndike wrote in 1911, "There can be no moral warrant for studying man's nature unless the study will enable us to control his acts." From 1910 to 1913 the American Psychological Association went through a sea change of opinion, away from mentalism and towards "behavioralism." In 1913, John B. Watson coined the term behaviorism for this school of thought. Watson's famous Little Albert experiment in 1920 was at first thought to demonstrate that repeated use of upsetting loud noises could instill phobias (aversions to other stimuli) in an infant human, although such a conclusion was likely an exaggeration. Karl Lashley, a close collaborator with Watson, examined biological manifestations of learning in the brain. Clark L. Hull, Edwin Guthrie, and others did much to help behaviorism become a widely used paradigm. A new method of "instrumental" or "operant" conditioning added the concepts of reinforcement and punishment to the model of behavior change. Radical behaviorists avoided discussing the inner workings of the mind, especially the unconscious mind, which they considered impossible to assess scientifically. Operant conditioning was first described by Miller and Kanorski and popularized in the U.S. by B.F. Skinner, who emerged as a leading intellectual of the behaviorist movement. Noam Chomsky published an influential critique of radical behaviorism on the grounds that behaviorist principles could not adequately explain the complex mental process of language acquisition and language use. The review, which was scathing, did much to reduce the status of behaviorism within psychology. Martin Seligman and his colleagues discovered that they could condition in dogs a state of "learned helplessness", which was not predicted by the behaviorist approach to psychology. Edward C. Tolman advanced a hybrid "cognitive behavioral" model, most notably with his 1948 publication discussing the cognitive maps used by rats to guess at the location of food at the end of a maze. Skinner's behaviorism did not die, in part because it generated successful practical applications. The Association for Behavior Analysis International was founded in 1974 and by 2003 had members from 42 countries. The field has gained a foothold in Latin America and Japan. Applied behavior analysis is the term used for the application of the principles of operant conditioning to change socially significant behavior (it supersedes the term, "behavior modification"). Cognitive Green Red BluePurple Blue Purple Blue Purple RedGreen Purple Green The Stroop effect is the fact that naming the color of the first set of words is easier and quicker than the second. Cognitive psychology involves the study of mental processes, including perception, attention, language comprehension and production, memory, and problem solving. Researchers in the field of cognitive psychology are sometimes called cognitivists. They rely on an information processing model of mental functioning. Cognitivist research is informed by functionalism and experimental psychology. Starting in the 1950s, the experimental techniques developed by Wundt, James, Ebbinghaus, and others re-emerged as experimental psychology became increasingly cognitivist and, eventually, constituted a part of the wider, interdisciplinary cognitive science. Some called this development the cognitive revolution because it rejected the anti-mentalist dogma of behaviorism as well as the strictures of psychoanalysis. Albert Bandura helped along the transition in psychology from behaviorism to cognitive psychology. Bandura and other social learning theorists advanced the idea of vicarious learning. In other words, they advanced the view that a child can learn by observing the immediate social environment and not necessarily from having been reinforced for enacting a behavior, although they did not rule out the influence of reinforcement on learning a behavior. Technological advances also renewed interest in mental states and mental representations. English neuroscientist Charles Sherrington and Canadian psychologist Donald O. Hebb used experimental methods to link psychological phenomena to the structure and function of the brain. The rise of computer science, cybernetics, and artificial intelligence underlined the value of comparing information processing in humans and machines. A popular and representative topic in this area is cognitive bias, or irrational thought. Psychologists (and economists) have classified and described a sizeable catalog of biases which recur frequently in human thought. The availability heuristic, for example, is the tendency to overestimate the importance of something which happens to come readily to mind. Elements of behaviorism and cognitive psychology were synthesized to form cognitive behavioral therapy, a form of psychotherapy modified from techniques developed by American psychologist Albert Ellis and American psychiatrist Aaron T. Beck. On a broader level, cognitive science is an interdisciplinary enterprise involving cognitive psychologists, cognitive neuroscientists, linguists, and researchers in artificial intelligence, human–computer interaction, and computational neuroscience. The discipline of cognitive science covers cognitive psychology as well as philosophy of mind, computer science, and neuroscience. Computer simulations are sometimes used to model phenomena of interest. Social Social psychology is concerned with how behaviors, thoughts, feelings, and the social environment influence human interactions. Social psychologists study such topics as the influence of others on an individual's behavior (e.g. conformity, persuasion) and the formation of beliefs, attitudes, and stereotypes about other people. Social cognition fuses elements of social and cognitive psychology for the purpose of understanding how people process, remember, or distort social information. The study of group dynamics involves research on the nature of leadership, organizational communication, and related phenomena. In recent years, social psychologists have become interested in implicit measures, mediational models, and the interaction of person and social factors in accounting for behavior. Some concepts that sociologists have applied to the study of psychiatric disorders, concepts such as the social role, sick role, social class, life events, culture, migration, and total institution, have influenced social psychologists. Psychoanalytic Psychoanalysis is a collection of theories and therapeutic techniques intended to analyze the unconscious mind and its impact on everyday life. These theories and techniques inform treatments for mental disorders. Psychoanalysis originated in the 1890s, most prominently with the work of Sigmund Freud. Freud's psychoanalytic theory was largely based on interpretive methods, introspection, and clinical observation. It became very well known, largely because it tackled subjects such as sexuality, repression, and the unconscious. Freud pioneered the methods of free association and dream interpretation. Psychoanalytic theory is not monolithic. Other well-known psychoanalytic thinkers who diverged from Freud include Alfred Adler, Carl Jung, Erik Erikson, Melanie Klein, D.W. Winnicott, Karen Horney, Erich Fromm, John Bowlby, Freud's daughter Anna Freud, and Harry Stack Sullivan. These individuals ensured that psychoanalysis would evolve into diverse schools of thought. Among these schools are ego psychology, object relations, and interpersonal, Lacanian, and relational psychoanalysis. Psychologists such as Hans Eysenck and philosophers including Karl Popper sharply criticized psychoanalysis. Popper argued that psychoanalysis was not falsifiable (no claim it made could be proven wrong) and therefore inherently not a scientific discipline, whereas Eysenck advanced the view that psychoanalytic tenets had been contradicted by experimental data. By the end of the 20th century, psychology departments in American universities mostly had marginalized Freudian theory, dismissing it as a "desiccated and dead" historical artifact. Researchers such as António Damásio, Oliver Sacks, and Joseph LeDoux; and individuals in the emerging field of neuro-psychoanalysis have defended some of Freud's ideas on scientific grounds. Existential-humanistic Humanistic psychology, which has been influenced by existentialism and phenomenology, stresses free will and self-actualization. It emerged in the 1950s as a movement within academic psychology, in reaction to both behaviorism and psychoanalysis. The humanistic approach seeks to view the whole person, not just fragmented parts of the personality or isolated cognitions. Humanistic psychology also focuses on personal growth, self-identity, death, aloneness, and freedom. It emphasizes subjective meaning, the rejection of determinism, and concern for positive growth rather than pathology. Some founders of the humanistic school of thought were American psychologists Abraham Maslow, who formulated a hierarchy of human needs, and Carl Rogers, who created and developed client-centered therapy. Later, positive psychology opened up humanistic themes to scientific study. Positive psychology is the study of factors which contribute to human happiness and well-being, focusing more on people who are currently healthy. In 2010, Clinical Psychological Review published a special issue devoted to positive psychological interventions, such as gratitude journaling and the physical expression of gratitude. It is, however, far from clear that positive psychology is effective in making people happier. Positive psychological interventions have been limited in scope, but their effects are thought to be somewhat better than placebo effects. The American Association for Humanistic Psychology, formed in 1963, declared: Existential psychology emphasizes the need to understand a client's total orientation towards the world. Existential psychology is opposed to reductionism, behaviorism, and other methods that objectify the individual. In the 1950s and 1960s, influenced by philosophers Søren Kierkegaard and Martin Heidegger, psychoanalytically trained American psychologist Rollo May helped to develop existential psychology. Existential psychotherapy, which follows from existential psychology, is a therapeutic approach that is based on the idea that a person's inner conflict arises from that individual's confrontation with the givens of existence. Swiss psychoanalyst Ludwig Binswanger and American psychologist George Kelly may also be said to belong to the existential school. Existential psychologists tend to differ from more "humanistic" psychologists in the former's relatively neutral view of human nature and relatively positive assessment of anxiety. Existential psychologists emphasized the humanistic themes of death, free will, and meaning, suggesting that meaning can be shaped by myths and narratives; meaning can be deepened by the acceptance of free will, which is requisite to living an authentic life, albeit often with anxiety with regard to death. Austrian existential psychiatrist and Holocaust survivor Viktor Frankl drew evidence of meaning's therapeutic power from reflections upon his own internment. He created a variation of existential psychotherapy called logotherapy, a type of existentialist analysis that focuses on a will to meaning (in one's life), as opposed to Adler's Nietzschean doctrine of will to power or Freud's will to pleasure. Themes Personality Personality psychology is concerned with enduring patterns of behavior, thought, and emotion. Theories of personality vary across different psychological schools of thought. Each theory carries different assumptions about such features as the role of the unconscious and the importance of childhood experience. According to Freud, personality is based on the dynamic interactions of the id, ego, and super-ego. By contrast, trait theorists have developed taxonomies of personality constructs in describing personality in terms of key traits. Trait theorists have often employed statistical data-reduction methods, such as factor analysis. Although the number of proposed traits has varied widely, Hans Eysenck's early biologically based model suggests at least three major trait constructs are necessary to describe human personality, extraversion–introversion, neuroticism-stability, and psychoticism-normality. Raymond Cattell empirically derived a theory of 16 personality factors at the primary-factor level and up to eight broader second-stratum factors. Since the 1980s, the Big Five (openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism) emerged as an important trait theory of personality. Dimensional models of personality are receiving increasing support, and a version of dimensional assessment has been included in the DSM-V. However, despite a plethora of research into the various versions of the "Big Five" personality dimensions, it appears necessary to move on from static conceptualizations of personality structure to a more dynamic orientation, acknowledging that personality constructs are subject to learning and change over the lifespan. An early example of personality assessment was the Woodworth Personal Data Sheet, constructed during World War I. The popular, although psychometrically inadequate, Myers–Briggs Type Indicator was developed to assess individuals' "personality types" according to the personality theories of Carl Jung. The Minnesota Multiphasic Personality Inventory (MMPI), despite its name, is more a dimensional measure of psychopathology than a personality measure. California Psychological Inventory contains 20 personality scales (e.g., independence, tolerance). The International Personality Item Pool, which is in the public domain, has become a source of scales that can be used personality assessment. Unconscious mind Study of the unconscious mind, a part of the psyche outside the individual's awareness but that is believed to influence conscious thought and behavior, was a hallmark of early psychology. In one of the first psychology experiments conducted in the United States, C.S. Peirce and Joseph Jastrow found in 1884 that research subjects could choose the minutely heavier of two weights even if consciously uncertain of the difference. Freud popularized the concept of the unconscious mind, particularly when he referred to an uncensored intrusion of unconscious thought into one's speech (a Freudian slip) or to his efforts to interpret dreams. His 1901 book The Psychopathology of Everyday Life catalogs hundreds of everyday events that Freud explains in terms of unconscious influence. Pierre Janet advanced the idea of a subconscious mind, which could contain autonomous mental elements unavailable to the direct scrutiny of the subject. The concept of unconscious processes has remained important in psychology. Cognitive psychologists have used a "filter" model of attention. According to the model, much information processing takes place below the threshold of consciousness, and only certain stimuli, limited by their nature and number, make their way through the filter. Much research has shown that subconscious priming of certain ideas can covertly influence thoughts and behavior. Because of the unreliability of self-reporting, a major hurdle in this type of research involves demonstrating that a subject's conscious mind has not perceived a target stimulus. For this reason, some psychologists prefer to distinguish between implicit and explicit memory. In another approach, one can also describe a subliminal stimulus as meeting an objective but not a subjective threshold. The automaticity model of John Bargh and others involves the ideas of automaticity and unconscious processing in our understanding of social behavior, although there has been dispute with regard to replication. Some experimental data suggest that the brain begins to consider taking actions before the mind becomes aware of them. The influence of unconscious forces on people's choices bears on the philosophical question of free will. John Bargh, Daniel Wegner, and Ellen Langer describe free will as an illusion. Motivation Some psychologists study motivation or the subject of why people or lower animals initiate a behavior at a particular time. It also involves the study of why humans and lower animals continue or terminate a behavior. Psychologists such as William James initially used the term motivation to refer to intention, in a sense similar to the concept of will in European philosophy. With the steady rise of Darwinian and Freudian thinking, instinct also came to be seen as a primary source of motivation. According to drive theory, the forces of instinct combine into a single source of energy which exerts a constant influence. Psychoanalysis, like biology, regarded these forces as demands originating in the nervous system. Psychoanalysts believed that these forces, especially the sexual instincts, could become entangled and transmuted within the psyche. Classical psychoanalysis conceives of a struggle between the pleasure principle and the reality principle, roughly corresponding to id and ego. Later, in Beyond the Pleasure Principle, Freud introduced the concept of the death drive, a compulsion towards aggression, destruction, and psychic repetition of traumatic events. Meanwhile, behaviorist researchers used simple dichotomous models (pleasure/pain, reward/punishment) and well-established principles such as the idea that a thirsty creature will take pleasure in drinking. Clark Hull formalized the latter idea with his drive reduction model. Hunger, thirst, fear, sexual desire, and thermoregulation constitute fundamental motivations in animals. Humans seem to exhibit a more complex set of motivations—though theoretically these could be explained as resulting from desires for belonging, positive self-image, self-consistency, truth, love, and control. Motivation can be modulated or manipulated in many different ways. Researchers have found that eating, for example, depends not only on the organism's fundamental need for homeostasis—an important factor causing the experience of hunger—but also on circadian rhythms, food availability, food palatability, and cost. Abstract motivations are also malleable, as evidenced by such phenomena as goal contagion: the adoption of goals, sometimes unconsciously, based on inferences about the goals of others. Vohs and Baumeister suggest that contrary to the need-desire-fulfillment cycle of animal instincts, human motivations sometimes obey a "getting begets wanting" rule: the more you get a reward such as self-esteem, love, drugs, or money, the more you want it. They suggest that this principle can even apply to food, drink, sex, and sleep. Development psychology Developmental psychology is the scientific study of how and why the thought processes, emotions, and behaviors of humans change over the course of their lives. Some credit Charles Darwin with conducting the first systematic study within the rubric of developmental psychology, having published in 1877 a short paper detailing the development of innate forms of communication based on his observations of his infant son. The main origins of the discipline, however, are found in the work of Jean Piaget. Like Piaget, developmental psychologists originally focused primarily on the development of cognition from infancy to adolescence. Later, developmental psychology extended itself to the study cognition over the life span. In addition to studying cognition, developmental psychologists have also come to focus on affective, behavioral, moral, social, and neural development. Developmental psychologists who study children use a number of research methods. For example, they make observations of children in natural settings such as preschools and engage them in experimental tasks. Such tasks often resemble specially designed games and activities that are both enjoyable for the child and scientifically useful. Developmental researchers have even devised clever methods to study the mental processes of infants. In addition to studying children, developmental psychologists also study aging and processes throughout the life span, including old age. These psychologists draw on the full range of psychological theories to inform their research. Genes and environment All researched psychological traits are influenced by both genes and environment, to varying degrees. These two sources of influence are often confounded in observational research of individuals and families. An example of this confounding can be shown in the transmission of depression from a depressed mother to her offspring. A theory based on environmental transmission would hold that an offspring, by virtue of their having a problematic rearing environment managed by a depressed mother, is at risk for developing depression. On the other hand, a hereditarian theory would hold that depression risk in an offspring is influenced to some extent by genes passed to the child from the mother. Genes and environment in these simple transmission models are completely confounded. A depressed mother may both carry genes that contribute to depression in her offspring and also create a rearing environment that increases the risk of depression in her child. Behavioral genetics researchers have employed methodologies that help to disentangle this confound and understand the nature and origins of individual differences in behavior. Traditionally the research has involved twin studies and adoption studies, two designs where genetic and environmental influences can be partially un-confounded. More recently, gene-focused research has contributed to understanding genetic contributions to the development of psychological traits. The availability of microarray molecular genetic or genome sequencing technologies allows researchers to measure participant DNA variation directly, and test whether individual genetic variants within genes are associated with psychological traits and psychopathology through methods including genome-wide association studies. One goal of such research is similar to that in positional cloning and its success in Huntington's: once a causal gene is discovered biological research can be conducted to understand how that gene influences the phenotype. One major result of genetic association studies is the general finding that psychological traits and psychopathology, as well as complex medical diseases, are highly polygenic, where a large number (on the order of hundreds to thousands) of genetic variants, each of small effect, contribute to individual differences in the behavioral trait or propensity to the disorder. Active research continues to work toward understanding the genetic and environmental bases of behavior and their interaction. Applications Psychology encompasses many subfields and includes different approaches to the study of mental processes and behavior. Psychological testing Psychological testing has ancient origins, dating as far back as 2200 BC, in the examinations for the Chinese civil service. Written exams began during the Han dynasty (202 BC – AD 200). By 1370, the Chinese system required a stratified series of tests, involving essay writing and knowledge of diverse topics. The system was ended in 1906. In Europe, mental assessment took a different approach, with theories of physiognomy—judgment of character based on the face—described by Aristotle in 4th century BC Greece. Physiognomy remained current through the Enlightenment, and added the doctrine of phrenology: a study of mind and intelligence based on simple assessment of neuroanatomy. When experimental psychology came to Britain, Francis Galton was a leading practitioner. By virtue of his procedures for measuring reaction time and sensation, he is considered an inventor of modern mental testing (also known as psychometrics). James McKeen Cattell, a student of Wundt and Galton, brought the idea of psychological testing to the United States, and in fact coined the term "mental test". In 1901, Cattell's student Clark Wissler published discouraging results, suggesting that mental testing of Columbia and Barnard students failed to predict academic performance. In response to 1904 orders from the Minister of Public Instruction, One example of an observational study was run by Arthur Bandura. This observational study focused on children who were exposed to an adult exhibiting aggressive behaviors and their reaction to toys versus other children who were not exposed to these stimuli. The result shows that children who had seen the adult acting aggressively towards a toy, in turn, were aggressive towards their own toy when put in a situation that frustrated them. psychologists Alfred Binet and Théodore Simon developed and elaborated a new test of intelligence in 1905–1911. They used a range of questions diverse in their nature and difficulty. Binet and Simon introduced the concept of mental age and referred to the lowest scorers on their test as idiots. Henry H. Goddard put the Binet-Simon scale to work and introduced classifications of mental level such as imbecile and feebleminded. In 1916, (after Binet's death), Stanford professor Lewis M. Terman modified the Binet-Simon scale (renamed the Stanford–Binet scale) and introduced the intelligence quotient as a score report. Based on his test findings, and reflecting the racism common to that era, Terman concluded that intellectual disability "represents the level of intelligence which is very, very common among Spanish-Indians and Mexican families of the Southwest and also among negroes. Their dullness seems to be racial." Following the Army Alpha and Army Beta tests, which was developed by psychologist Robert Yerkes in 1917 and then used in World War 1 by industrial and organizational psychologists for large-scale employee testing and selection of military personnel. Mental testing also became popular in the U.S., where it was applied to schoolchildren. The federally created National Intelligence Test was administered to 7 million children in the 1920s. In 1926, the College Entrance Examination Board created the Scholastic Aptitude Test to standardize college admissions. The results of intelligence tests were used to argue for segregated schools and economic functions, including the preferential training of Black Americans for manual labor. These practices were criticized by Black intellectuals such a Horace Mann Bond and Allison Davis. Eugenicists used mental testing to justify and organize compulsory sterilization of individuals classified as mentally retarded (now referred to as intellectual disability). In the United States, tens of thousands of men and women were sterilized. Setting a precedent that has never been overturned, the U.S. Supreme Court affirmed the constitutionality of this practice in the 1927 case Buck v. Bell. Today mental testing is a routine phenomenon for people of all ages in Western societies. Modern testing aspires to criteria including standardization of procedure, consistency of results, output of an interpretable score, statistical norms describing population outcomes, and, ideally, effective prediction of behavior and life outcomes outside of testing situations. Psychological testing is regularly used in forensic contexts to aid legal judgments and decisions. Developments in psychometrics include work on test and scale reliability and validity. Developments in item-response theory, structural equation modeling, and bifactor analysis have helped in strengthening test and scale construction. Mental health care The provision of psychological health services is generally called clinical psychology in the U.S. Sometimes, however, members of the school psychology and counseling psychology professions engage in practices that resemble that of clinical psychologists. Clinical psychologists typically include people who have graduated from doctoral programs in clinical psychology. In Canada, some of the members of the abovementioned groups usually fall within the larger category of professional psychology. In Canada and the U.S., practitioners get bachelor's degrees and doctorates; doctoral students in clinical psychology usually spend one year in a predoctoral internship and one year in postdoctoral internship. In Mexico and most other Latin American and European countries, psychologists do not get bachelor's and doctoral degrees; instead, they take a three-year professional course following high school. Clinical psychology is at present the largest specialization within psychology. It includes the study and application of psychology for the purpose of understanding, preventing, and relieving psychological distress, dysfunction, and/or mental illness. Clinical psychologists also try to promote subjective well-being and personal growth. Central to the practice of clinical psychology are psychological assessment and psychotherapy although clinical psychologists may also engage in research, teaching, consultation, forensic testimony, and program development and administration. Credit for the first psychology clinic in the United States typically goes to Lightner Witmer, who established his practice in Philadelphia in 1896. Another modern psychotherapist was Morton Prince, an early advocate for the establishment of psychology as a clinical and academic discipline. In the first part of the twentieth century, most mental health care in the United States was performed by psychiatrists, who are medical doctors. Psychology entered the field with its refinements of mental testing, which promised to improve the diagnosis of mental problems. For their part, some psychiatrists became interested in using psychoanalysis and other forms of psychodynamic psychotherapy to understand and treat the mentally ill. Psychotherapy as conducted by psychiatrists blurred the distinction between psychiatry and psychology, and this trend continued with the rise of community mental health facilities. Some in the clinical psychology community adopted behavioral therapy, a thoroughly non-psychodynamic model that used behaviorist learning theory to change the actions of patients. A key aspect of behavior therapy is empirical evaluation of the treatment's effectiveness. In the 1970s, cognitive-behavior therapy emerged with the work of Albert Ellis and Aaron Beck. Although there are similarities between behavior therapy and cognitive-behavior therapy, cognitive-behavior therapy required the application of cognitive constructs. Since the 1970s, the popularity of cognitive-behavior therapy among clinical psychologists increased. A key practice in behavioral and cognitive-behavioral therapy is exposing patients to things they fear, based on the premise that their responses (fear, panic, anxiety) can be deconditioned. Mental health care today involves psychologists and social workers in increasing numbers. In 1977, National Institute of Mental Health director Bertram Brown described this shift as a source of "intense competition and role confusion." Graduate programs issuing doctorates in clinical psychology emerged in the 1950s and underwent rapid increase through the 1980s. The PhD degree is intended to train practitioners who could also conduct scientific research. The PsyD degree is more exclusively designed to train practitioners. Some clinical psychologists focus on the clinical management of patients with brain injury. This subspecialty is known as clinical neuropsychology. In many countries, clinical psychology is a regulated mental health profession. The emerging field of disaster psychology (see crisis intervention) involves professionals who respond to large-scale traumatic events. The work performed by clinical psychologists tends to be influenced by various therapeutic approaches, all of which involve a formal relationship between professional and client (usually an individual, couple, family, or small group). Typically, these approaches encourage new ways of thinking, feeling, or behaving. Four major theoretical perspectives are psychodynamic, cognitive behavioral, existential–humanistic, and systems or family therapy. There has been a growing movement to integrate the various therapeutic approaches, especially with an increased understanding of issues regarding culture, gender, spirituality, and sexual orientation. With the advent of more robust research findings regarding psychotherapy, there is evidence that most of the major therapies have equal effectiveness, with the key common element being a strong therapeutic alliance. Because of this, more training programs and psychologists are now adopting an eclectic therapeutic orientation. Diagnosis in clinical psychology usually follows the Diagnostic and Statistical Manual of Mental Disorders (DSM). The study of mental illnesses is called abnormal psychology. Education Educational psychology is the study of how humans learn in educational settings, the effectiveness of educational interventions, the psychology of teaching, and the social psychology of schools as organizations. Educational psychologists can be found in preschools, schools of all levels including post secondary institutions, community organizations and learning centers, Government or private research firms, and independent or private consultant. The work of developmental psychologists such as Lev Vygotsky, Jean Piaget, and Jerome Bruner has been influential in creating teaching methods and educational practices. Educational psychology is often included in teacher education programs in places such as North America, Australia, and New Zealand. School psychology combines principles from educational psychology and clinical psychology to understand and treat students with learning disabilities; to foster the intellectual growth of gifted students; to facilitate prosocial behaviors in adolescents; and otherwise to promote safe, supportive, and effective learning environments. School psychologists are trained in educational and behavioral assessment, intervention, prevention, and consultation, and many have extensive training in research. Work Industrial and organizational (I/O) psychology involves research and practices that apply psychological theories and principles to organizations and individuals' work-lives. In the field's beginnings, industrialists brought the nascent field of psychology to bear on the study of scientific management techniques for improving workplace efficiency. The field was at first called economic psychology or business psychology; later, industrial psychology, employment psychology, or psychotechnology. An influential early study examined workers at Western Electric's Hawthorne plant in Cicero, Illinois from 1924 to 1932. Western Electric experimented on factory workers to assess their responses to changes in illumination, breaks, food, and wages. The researchers came to focus on workers' responses to observation itself, and the term Hawthorne effect is now used to describe the fact that people's behavior can change when they think they are being observed. Although the Hawthorne research can be found in psychology textbooks, the research and its findings were weak at best. The name industrial and organizational psychology emerged in the 1960s. In 1973, it became enshrined in the name of the Society for Industrial and Organizational Psychology, Division 14 of the American Psychological Association. One goal of the discipline is to optimize human potential in the workplace. Personnel psychology is a subfield of I/O psychology. Personnel psychologists apply the methods and principles of psychology in selecting and evaluating workers. Another subfield, organizational psychology, examines the effects of work environments and management styles on worker motivation, job satisfaction, and productivity. Most I/O psychologists work outside of academia, for private and public organizations and as consultants. A psychology consultant working in business today might expect to provide executives with information and ideas about their industry, their target markets, and the organization of their company. Organizational behavior (OB) is an allied field involved in the study of human behavior within organizations. One way to differentiate I/O psychology from OB is that I/O psychologists train in university psychology departments and OB specialists, in business schools. Military and intelligence One role for psychologists in the military has been to evaluate and counsel soldiers and other personnel. In the U.S., this function began during World War I, when Robert Yerkes established the School of Military Psychology at Fort Oglethorpe in Georgia. The school provided psychological training for military staff. Today, U.S. Army psychologists perform psychological screening, clinical psychotherapy, suicide prevention, and treatment for post-traumatic stress, as well as provide prevention-related services, for example, smoking cessation. The United States Army's Mental Health Advisory Teams implement psychological interventions to help combat troops experiencing mental problems. Psychologists may also work on a diverse set of campaigns known broadly as psychological warfare. Psychological warfare chiefly involves the use of propaganda to influence enemy soldiers and civilians. This so-called black propaganda is designed to seem as if it originates from a source other than the Army. The CIA's MKULTRA program involved more individualized efforts at mind control, involving techniques such as hypnosis, torture, and covert involuntary administration of LSD. The U.S. military used the name Psychological Operations (PSYOP) until 2010, when these activities were reclassified as Military Information Support Operations (MISO), part of Information Operations (IO). Psychologists have sometimes been involved in assisting the interrogation and torture of suspects, staining the records of the psychologists involved. Health, well-being, and social change Social change An example of the contribution of psychologists to social change involves the research of Kenneth and Mamie Phipps Clark. These two African American psychologists studied segregation's adverse psychological impact on Black children. Their research findings played a role in the desegregation case Brown v. Board of Education (1954). The impact of psychology on social change includes the discipline's broad influence on teaching and learning. Research has shown that compared to the "whole word" or "whole language" approach, the phonics approach to reading instruction is more efficacious. Medical applications Medical facilities increasingly employ psychologists to perform various roles. One aspect of health psychology is the psychoeducation of patients: instructing them in how to follow a medical regimen. Health psychologists can also educate doctors and conduct research on patient compliance. Psychologists in the field of public health use a wide variety of interventions to influence human behavior. These range from public relations campaigns and outreach to governmental laws and policies. Psychologists study the composite influence of all these different tools in an effort to influence whole populations of people. Worker health, safety and wellbeing Psychologists work with organizations to apply findings from psychological research to improve the health and well-being of employees. Some work as external consultants hired by organizations to solve specific problems, whereas others are full-time employees of the organization. Applications include conducting surveys to identify issues and designing interventions to make work healthier. Some of the specific health areas include: Accidents and injuries: A major contribution is the concept of safety climate, which is employee shared perceptions of the behaviors that are encouraged (e.g., wearing safety gear) and discouraged (not following safety rules) at work. Organizations with strong safety climates have fewer work accidents and injuries. Cardiovascular disease: Cardiovascular disease has been related to lack of job control. Mental health: Exposure to occupational stress is associated with mental health disorder. Musculoskeletal disorder: These are injuries in bones, nerves and tendons due to overexertion and repetitive strain. They have been linked to job satisfaction and workplace stress. Physical health symptoms: Occupational stress has been linked to physical symptoms such as digestive distress and headache. Workplace violence: Violence prevention climate is related to being physically assaulted and psychologically mistreated at work. Interventions that improve climates are a way to address accidents and violence. Interventions that reduce stress at work or provide employees with tools to better manage it can help in areas where stress is an important component. Industrial psychology became interested in worker fatigue during World War I, when government ministers in Britain were concerned about the impact of fatigue on workers in munitions factories but not other types of factories. In the U. K. some interest in worker well-being emerged with the efforts of Charles Samuel Myers and his National Institute of Industrial Psychology (NIIP) during the inter-War years. In the U. S. during the mid-twentieth century industrial psychologist Arthur Kornhauser pioneered the study of occupational mental health, linking industrial working conditions to mental health as well as the spillover of an unsatisfying job into a worker's personal life. Zickar accumulated evidence to show that "no other industrial psychologist of his era was as devoted to advocating management and labor practices that would improve the lives of working people." Occupational health psychology As interest in the worker health expanded toward the end of the twentieth century, the field of occupational health psychology (OHP) emerged. OHP is a branch of psychology that is interdisciplinary. OHP is concerned with the health and safety of workers. OHP addresses topic areas such as the impact of occupational stressors on physical and mental health, mistreatment of workers (e.g., bullying and violence), work-family balance, the impact of involuntary unemployment on physical and mental health, the influence of psychosocial factors on safety and accidents, and interventions designed to improve/protect worker health. OHP grew out of health psychology, industrial and organizational psychology, and occupational medicine. OHP has also been informed by disciplines outside psychology, including industrial engineering, sociology, and economics. Research methods Quantitative psychological research lends itself to the statistical testing of hypotheses. Although the field makes abundant use of randomized and controlled experiments in laboratory settings, such research can only assess a limited range of short-term phenomena. Some psychologists rely on less rigorously controlled, but more ecologically valid, field experiments as well. Other research psychologists rely on statistical methods to glean knowledge from population data. The statistical methods research psychologists employ include the Pearson product–moment correlation coefficient, the analysis of variance, multiple linear regression, logistic regression, structural equation modeling, and hierarchical linear modeling. The measurement and operationalization of important constructs is an essential part of these research designs. Although this type of psychological research is much less abundant than quantitative research, some psychologists conduct qualitative research. This type of research can involve interviews, questionnaires, and first-hand observation. While hypothesis testing is rare, virtually impossible, in qualitative research, qualitative studies can be helpful in theory and hypothesis generation, interpreting seemingly contradictory quantitative findings, and understanding why some interventions fail and others succeed. Controlled experiments A true experiment with random assignment of research participants (sometimes called subjects) to rival conditions allows researchers to make strong inferences about causal relationships. When there are large numbers of research participants, the random assignment (also called random allocation) of those participants to rival conditions ensures that the individuals in those conditions will, on average, be similar on most characteristics, including characteristics that went unmeasured. In an experiment, the researcher alters one or more variables of influence, called independent variables, and measures resulting changes in the factors of interest, called dependent variables. Prototypical experimental research is conducted in a laboratory with a carefully controlled environment. A quasi-experiment is a situation in which different conditions are being studied, but random assignment to the different conditions is not possible. Investigators must work with preexisting groups of people. Researchers can use common sense to consider how much the nonrandom assignment threatens the study's validity. For example, in research on the best way to affect reading achievement in the first three grades of school, school administrators may not permit educational psychologists to randomly assign children to phonics and whole language classrooms, in which case the psychologists must work with preexisting classroom assignments. Psychologists will compare the achievement of children attending phonics and whole language classes and, perhaps, statistically adjust for any initial differences in reading level. Experimental researchers typically use a statistical hypothesis testing model which involves making predictions before conducting the experiment, then assessing how well the data collected are consistent with the predictions. These predictions are likely to originate from one or more abstract scientific hypotheses about how the phenomenon under study actually works. Other types of studies Surveys are used in psychology for the purpose of measuring attitudes and traits, monitoring changes in mood, and checking the validity of experimental manipulations (checking research participants' perception of the condition they were assigned to). Psychologists have commonly used paper-and-pencil surveys. However, surveys are also conducted over the phone or through e-mail. Web-based surveys are increasingly used to conveniently reach many subjects. Observational studies are commonly conducted in psychology. In cross-sectional observational studies, psychologists collect data at a single point in time. The goal of many cross-sectional studies is the assess the extent factors are correlated with each other. By contrast, in longitudinal studies psychologists collect data on the same sample at two or more points in time. Sometimes the purpose of longitudinal research is to study trends across time such as the stability of traits or age-related changes in behavior. Because some studies involve endpoints that psychologists cannot ethically study from an experimental standpoint, such as identifying the causes of depression, they conduct longitudinal studies a large group of depression-free people, periodically assessing what is happening in the individuals' lives. In this way psychologists have an opportunity to test causal hypotheses regarding conditions that commonly arise in people's lives that put them at risk for depression. Problems that affect longitudinal studies include selective attrition, the type of problem in which bias is introduced when a certain type of research participant disproportionately leaves a study. One example of an observational study was run by Arthur Bandura. This observational study focused on children who were exposed to an adult exhibiting aggressive behaviors and their reaction to toys versus other children who were not exposed to these stimuli. The result shows that children who had seen the adult acting aggressively towards a toy, in turn, were aggressive towards their own toy when put in a situation that frustrated them. Exploratory data analysis includes a variety of practices that researchers use to reduce a great many variables to a small number overarching factors. In Peirce's three modes of inference, exploratory data analysis corresponds to abduction. Meta-analysis is the technique research psychologists use to integrate results from many studies of the same variables and arriving at a grand average of the findings. Direct brain observation/manipulation A classic and popular tool used to relate mental and neural activity is the electroencephalogram (EEG), a technique using amplified electrodes on a person's scalp to measure voltage changes in different parts of the brain. Hans Berger, the first researcher to use EEG on an unopened skull, quickly found that brains exhibit signature "brain waves": electric oscillations which correspond to different states of consciousness. Researchers subsequently refined statistical methods for synthesizing the electrode data, and identified unique brain wave patterns such as the delta wave observed during non-REM sleep. Newer functional neuroimaging techniques include functional magnetic resonance imaging and positron emission tomography, both of which track the flow of blood through the brain. These technologies provide more localized information about activity in the brain and create representations of the brain with widespread appeal. They also provide insight which avoids the classic problems of subjective self-reporting. It remains challenging to draw hard conclusions about where in the brain specific thoughts originate—or even how usefully such localization corresponds with reality. However, neuroimaging has delivered unmistakable results showing the existence of correlations between mind and brain. Some of these draw on a systemic neural network model rather than a localized function model. Interventions such as transcranial magnetic stimulation and drugs also provide information about brain–mind interactions. Psychopharmacology is the study of drug-induced mental effects. Computer simulation Computational modeling is a tool used in mathematical psychology and cognitive psychology to simulate behavior. This method has several advantages. Since modern computers process information quickly, simulations can be run in a short time, allowing for high statistical power. Modeling also allows psychologists to visualize hypotheses about the functional organization of mental events that could not be directly observed in a human. Computational neuroscience uses mathematical models to simulate the brain. Another method is symbolic modeling, which represents many mental objects using variables and rules. Other types of modeling include dynamic systems and stochastic modeling. Animal studies Animal experiments aid in investigating many aspects of human psychology, including perception, emotion, learning, memory, and thought, to name a few. In the 1890s, Russian physiologist Ivan Pavlov famously used dogs to demonstrate classical conditioning. Non-human primates, cats, dogs, pigeons, and rats and other rodents are often used in psychological experiments. Ideally, controlled experiments introduce only one independent variable at a time, in order to ascertain its unique effects upon dependent variables. These conditions are approximated best in laboratory settings. In contrast, human environments and genetic backgrounds vary so widely, and depend upon so many factors, that it is difficult to control important variables for human subjects. There are pitfalls, however, in generalizing findings from animal studies to humans through animal models. Comparative psychology is the scientific study of the behavior and mental processes of non-human animals, especially as these relate to the phylogenetic history, adaptive significance, and development of behavior. Research in this area explores the behavior of many species, from insects to primates. It is closely related to other disciplines that study animal behavior such as ethology. Research in comparative psychology sometimes appears to shed light on human behavior, but some attempts to connect the two have been quite controversial, for example the Sociobiology of E.O. Wilson. Animal models are often used to study neural processes related to human behavior, e.g. in cognitive neuroscience. Qualitative research Qualitative research is often designed to answer questions about the thoughts, feelings, and behaviors of individuals. Qualitative research involving first-hand observation can help describe events as they occur, with the goal of capturing the richness of everyday behavior and with the hope of discovering and understanding phenomena that might have been missed if only more cursory examinations are made. Qualitative psychological research methods include interviews, first-hand observation, and participant observation. Creswell (2003) identified five main possibilities for qualitative research, including narrative, phenomenology, ethnography, case study, and grounded theory. Qualitative researchers sometimes aim to enrich our understanding of symbols, subjective experiences, or social structures. Sometimes hermeneutic and critical aims can give rise to quantitative research, as in Erich Fromm's application of psychological and sociological theories, in his book Escape from Freedom, to understanding why many ordinary Germans supported Hitler. Just as Jane Goodall studied chimpanzee social and family life by careful observation of chimpanzee behavior in the field, psychologists conduct naturalistic observation of ongoing human social, professional, and family life. Sometimes the participants are aware they are being observed, and other times the participants do not know they are being observed. Strict ethical guidelines must be followed when covert observation is being carried out. Program evaluation Program evaluation involves the systematic collection, analysis, and application of information to answer questions about projects, policies and programs, particularly about their effectiveness. In both the public and private sectors, stakeholders often want to know the extent which the programs they are funding, implementing, voting for, receiving, or objecting to are producing the intended effects. While program evaluation first focuses on effectiveness, important considerations often include how much the program costs per participant, how the program could be improved, whether the program is worthwhile, whether there are better alternatives, if there are unintended outcomes, and whether the program goals are appropriate and useful. Contemporary issues Metascience Metascience involves the application of scientific methodology to study science itself. The field of metascience has revealed problems in psychological research. Some psychological research has suffered from bias, problematic reproducibility, and misuse of statistics. These findings have led to calls for reform from within and from outside the scientific community. Confirmation bias In 1959, statistician Theodore Sterling examined the results of psychological studies and discovered that 97% of them supported their initial hypotheses, implying possible publication bias. Similarly, Fanelli (2010) found that 91.5% of psychiatry/psychology studies confirmed the effects they were looking for, and concluded that the odds of this happening (a positive result) was around five times higher than in fields such as space science or geosciences. Fanelli argued that this is because researchers in "softer" sciences have fewer constraints to their conscious and unconscious biases. Replication A replication crisis in psychology has emerged. Many notable findings in the field have not been replicated. Some researchers were even accused of publishing fraudulent results. Systematic efforts, including efforts by the Reproducibility Project of the Center for Open Science, to assess the extent of the problem found that as many as two-thirds of highly publicized findings in psychology failed to be replicated. Reproducibility has generally been stronger in cognitive psychology (in studies and journals) than social psychology and subfields of differential psychology. Other subfields of psychology have also been implicated in the replication crisis, including clinical psychology, developmental psychology, and a field closely related to psychology, educational research. Focus on the replication crisis has led to other renewed efforts in the discipline to re-test important findings. In response to concerns about publication bias and data dredging (conducting a large number of statistical tests on a great many variables but restricting reporting to the results that were statistically significant), 295 psychology and medical journals have adopted result-blind peer review where studies are accepted not on the basis of their findings and after the studies are completed, but before the studies are conducted and upon the basis of the methodological rigor of their experimental designs and the theoretical justifications for their proposed statistical analysis before data collection or analysis is conducted. In addition, large-scale collaborations among researchers working in multiple labs in different countries have taken place. The collaborators regularly make their data openly available for different researchers to assess. Allen and Mehler estimated that 61 per cent of result-blind studies have yielded null results, in contrast to an estimated 5 to 20 per cent in traditional research. Misuse of statistics Some critics view statistical hypothesis testing as misplaced. Psychologist and statistician Jacob Cohen wrote in 1994 that psychologists routinely confuse statistical significance with practical importance, enthusiastically reporting great certainty in unimportant facts. Some psychologists have responded with an increased use of effect size statistics, rather than sole reliance on p-values. WEIRD bias In 2008, Arnett pointed out that most articles in American Psychological Association journals were about U.S. populations when U.S. citizens are only 5% of the world's population. He complained that psychologists had no basis for assuming psychological processes to be universal and generalizing research findings to the rest of the global population. In 2010, Henrich, Heine, and Norenzayan reported a bias in conducting psychology studies with participants from "WEIRD" ("Western, Educated, Industrialized, Rich, and Democratic") societies. Henrich et al. found that "96% of psychological samples come from countries with only 12% of the world's population" (p. 63). The article gave examples of results that differ significantly between people from WEIRD and tribal cultures, including the Müller-Lyer illusion. Arnett (2008), Altmaier and Hall (2008) and Morgan-Consoli et al. (2018) view the Western bias in research and theory as a serious problem considering psychologists are increasingly applying psychological principles developed in WEIRD regions in their research, clinical work, and consultation with populations around the world. In 2018, Rad, Martingano, and Ginges showed that nearly a decade after Henrich et al.'s paper, over 80% of the samples used in studies published in the journal Psychological Science employed WEIRD samples. Moreover, their analysis showed that several studies did not fully disclose the origin of their samples; the authors offered a set of recommendations to editors and reviewers to reduce WEIRD bias. STRANGE bias Similar to the WEIRD bias, starting in 2020, researchers of non-human behavior have started to emphasize the need to document the possibility of the STRANGE (Social background, Trappability and self-selection, Rearing history, Acclimation and habituation, Natural changes in responsiveness, Genetic makeup, and Experience) bias in study conclusions. Unscientific mental health training Some observers perceive a gap between scientific theory and its application—in particular, the application of unsupported or unsound clinical practices. Critics say there has been an increase in the number of mental health training programs that do not instill scientific competence. Practices such as "facilitated communication for infantile autism"; memory-recovery techniques including body work; and other therapies, such as rebirthing and reparenting, may be dubious or even dangerous, despite their popularity. These practices, however, are outside the mainstream practices taught in clinical psychology doctoral programs. Ethics Ethical standards in the discipline have changed over time. Some famous past studies are today considered unethical and in violation of established codes (the Canadian Code of Conduct for Research Involving Humans, and the Belmont Report). The American Psychological Association has advanced a set of ethical principles and a code of conduct for the profession. The most important contemporary standards include informed and voluntary consent. After World War II, the Nuremberg Code was established because of Nazi abuses of experimental subjects. Later, most countries (and scientific journals) adopted the Declaration of Helsinki. In the U.S., the National Institutes of Health established the Institutional Review Board in 1966, and in 1974 adopted the National Research Act (HR 7724). All of these measures encouraged researchers to obtain informed consent from human participants in experimental studies. A number of influential but ethically dubious studies led to the establishment of this rule; such studies included the MIT-Harvard Fernald School radioisotope studies, the Thalidomide tragedy, the Willowbrook hepatitis study, and Stanley Milgram's studies of obedience to authority. Humans Universities have ethics committees dedicated to protecting the rights (e.g., voluntary nature of participation in the research, privacy) and well-being (e.g., minimizing distress) of research participants. University ethics committees evaluate proposed research to ensure that researchers protect the rights and well-being of participants; an investigator's research project cannot be conducted unless approved by such an ethics committee. The ethics code of the American Psychological Association originated in 1951 as "Ethical Standards of Psychologists". This code has guided the formation of licensing laws in most American states. It has changed multiple times over the decades since its adoption. In 1989, the APA revised its policies on advertising and referral fees to negotiate the end of an investigation by the Federal Trade Commission. The 1992 incarnation was the first to distinguish between "aspirational" ethical standards and "enforceable" ones. Members of the public have a five-year window to file ethics complaints about APA members with the APA ethics committee; members of the APA have a three-year window. Some of the ethical issues considered most important are the requirement to practice only within the area of competence, to maintain confidentiality with the patients, and to avoid sexual relations with them. Another important principle is informed consent, the idea that a patient or research subject must understand and freely choose a procedure they are undergoing. Some of the most common complaints against clinical psychologists include sexual misconduct. Other animals Research on other animals is governed by university ethics committees. Research on nonhuman animals cannot proceed without permission of the ethics committee, of the researcher's home institution. Ethical guidelines state that using non-human animals for scientific purposes is only acceptable when the harm (physical or psychological) done to animals is outweighed by the benefits of the research. Psychologists can use certain research techniques on animals that could not be used on humans. Comparative psychologist Harry Harlow drew moral condemnation for isolation experiments on rhesus macaque monkeys at the University of Wisconsin–Madison in the 1970s. The aim of the research was to produce an animal model of clinical depression. Harlow also devised what he called a "rape rack", to which the female isolates were tied in normal monkey mating posture. In 1974, American literary critic Wayne C. Booth wrote that, "Harry Harlow and his colleagues go on torturing their nonhuman primates decade after decade, invariably proving what we all knew in advance—that social creatures can be destroyed by destroying their social ties." He writes that Harlow made no mention of the criticism of the morality of his work. Animal research is influential in psychology, while still being debated among academics. The testing of animals for research has led to medical breakthroughs in human medicine. Many psychologists argue animal experimentation is essential for human advancement, but must be regulated by the government to ensure ethicality. References Sources Baker, David B. (ed.). The Oxford Handbook of the History of Psychology. Oxford University Press (Oxford Library of Psychology), 2012. Brock, Adrian C. (ed.). Internationalizing the History of Psychology. New York University Press, 2006. Cina, Carol. "Social Science for Whom? A Structural History of Social Psychology." Doctoral dissertation, accepted by the State University of New York at Stony Brook, 1981. Cocks, Geoffrey. Psychotherapy in the Third Reich: The Göring Institute, second edition. New Brunswick, NJ: Transaction Publishers, 1997. Forgas, Joseph P., Kipling D. Williams, & Simon M. Laham. Social Motivation: Conscious and Unconscious Processes. Cambridge University Press, 2005. Guthrie, Robert. Even the Rat was White: A Historical View of Psychology. Second edition. Boston, Allyn and Bacon (Viacon), 1998. Herman, Ellen. "Psychology as Politics: How Psychological Experts Transformed Public Life in the United States 1940–1970." Doctoral dissertation accepted by Brandeis University, 1993. Hock, Roger R. Forty Studies That Changed Psychology: Explorations Into the History of Psychological Research. Fourth edition. Upper Saddle River, NJ: Prentice Hall, 2002. Morgan, Robert D., Tara L. Kuther, & Corey J. Habben. Life After Graduate School in Psychology: Insider's Advice from New Psychologists. New York: Psychology Press (Taylor & Francis Group), 2005. Severin, Frank T. (ed.). Humanistic Viewpoints in Psychology: A Book of Readings. New York: McGraw Hill, 1965. ISBN Shah, James Y., and Wendi L. Gardner. Handbook of Motivation Science. New York: The Guilford Press, 2008. Wallace, Edwin R., IV, & John Gach (eds.), History of Psychiatry and Medical Psychology; New York: Springer, 2008; Weiner, Bernard. Human Motivation. Hoboken, NJ: Taylor and Francis, 2013. Weiner, Irving B. Handbook of Psychology. Hoboken, NJ: John Wiley & Sons, 2003. Volume 1: History of Psychology. Donald K. Freedheim, ed. Volume 2: Research Methods in Psychology. John A. Schinka & Wayne F. Velicer, eds. Volume 3: Biological Psychology. Michela Gallagher & Randy J. Nelson, eds. Volume 4: Experimental Psychology. Alice F. Healy & Robert W. Proctor, eds. Volume 8: Clinical Psychology. George Stricker, Thomas A. Widiger, eds. Further reading External links American Psychological Association Association for Psychological Science Behavioural sciences Cognitive behavioral therapy

Deinstitutionalization in the United States

The United States has experienced two waves of deinstitutionalization, the process of replacing long-stay psychiatric hospitals with less isolated community mental health services for those diagnosed with a mental disorder or developmental disability. The first wave began in the 1950s and targeted people with mental illness. The second wave began roughly 15 years later and focused on individuals who had been diagnosed with a developmental disability. Deinstitutionalization continues today, though the movements are growing smaller as fewer people are sent to institutions. Numerous social forces led to a move for deinstitutionalization; researchers generally give credit to six main factors: criticisms of public mental hospitals, incorporation of mind-altering drugs in treatment, support from President Kennedy for federal policy changes, shifts to community-based care, changes in public perception, and individual states' desires to reduce costs from mental hospitals. Criticisms of public mental hospitals The public's awareness of conditions in mental institutions began to increase during World War II. Conscientious objectors (COs) of the war were assigned to alternative positions which suffered from manpower shortages. Around 2,000 COs were assigned to work in understaffed mental institutions. In 1946, an exposé in Life magazine detailed the shortfalls of many mental health facilities. This exposé was one of the first featured articles about the quality of mental institutions. Following WWII, articles and exposés about the mental hospital conditions bombarded popular and scholarly magazines and periodicals. The COs from the 1946 Life exposé formed the National Mental Health Foundation, which raised public support and successfully convinced states to increase funding for mental institutions. Five years later, the National Mental Health Foundation merged with the Hygiene and Psychiatric Foundation to form the National Association of Mental Health. During WWII, it was found that 1 out of 8 men considered for military service was rejected based on a neurological or psychiatric problem. This increased awareness of the prevalence of mental illnesses, and people began to realize the costs associated with admission to mental institutions (i.e. cost of lost productivity and of mental health services). Since numerous individuals suffering from mental illness had served in the military, many began to believe that more knowledge about mental illness and better services would not only benefit those who served but also national security as a whole. Congress passed the National Mental Health Act of 1946, which created the National Institute of Mental Health (NIMH). NIMH was pivotal in funding research for the developing mental health field. In New York ARC v. Rockefeller, parents of 5,000 residents at the Willowbrook State School in Staten Island, New York, filed suit over the inhumane living conditions at that institution, where residents were abused and neglected. A 1972 television broadcast from the Willowbrook State School, titled "Willowbrook: The Last Great Disgrace", outraged the general public. However, it took three years from the time the lawsuit documents were filed before the consent judgement was signed. In 1975, the consent judgement was signed, and it committed New York state to improve community placement for the now designated "Willowbrook Class". The Willowbrook State School was closed in 1987, and all but about 150 of the former Willowbrook residents were moved to group homes by 1992. In 1973, a federal district court ruled in Souder v. Brennan that patients in mental health institutions must be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938 whenever they performed any activity that conferred an economic benefit on an institution. Following this ruling, institutional peonage was outlawed, as evidenced in Pennsylvania's Institutional Peonage Abolishment Act of 1973. Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible." Alternatives Pharmacotherapy During the 1950s, new drugs became available and were incorporated into treatment for the mentally ill. The new drugs effectively reduced severe symptoms, allowing the mentally ill to live in environments less stringent than institutions, such as halfway houses, nursing homes, or their own homes. Drug therapy also allowed many mentally ill to obtain employment. Shift to community-based care In general, professionals, civil rights leaders, and humanitarians saw the shift from institutional confinement to local care as the appropriate approach. The deinstitutionalization movement started off slowly but gained momentum as it adopted philosophies from the Civil Rights Movement. During the 1960s, deinstitutionalization increased dramatically, and the average length of stay within mental institutions decreased by more than half. Many patients began to be placed in community care facilities instead of long-term care institutions. Partial hospitalization A successful community-based alternative to institutionalization or inpatient hospitalization is partial hospitalization. Partial hospitalization programs are typically offered by hospitals, and they provide less than 24 hours per day treatment in which patients commute to the hospital or treatment center up to seven days a week and reside in their normal residences when not attending the program. Patients in partial hospitalization programs show the same or greater levels of improvement as their inpatient counterparts, and unlike inpatient hospitalization, these individuals are able to maintain their familial and social roles during treatment. Partial hospitalization allows for a smoother and less expensive transition between inpatient hospitalization and community life. Some patients are able to avoid inpatient hospitalization altogether by participating in a partial hospitalization program, and many are able to shorten the length of their inpatient hospitalization by participating in a partial hospitalization program. By eliminating or reducing the length of inpatient hospital stays, diversion to partial hospitalization programs is one important component to the process of deinstitutionalization in the United States. Intensive outpatient programs Intensive outpatient programs are a crucial component of the community-based care that has replaced inpatient hospitalization and institutionalization in many cases. Intensive outpatient programs provide a more cost-effective outpatient alternative to inpatient hospitalization that allows patients to receive intensive psychiatric care while still remaining in their communities, going to school, or holding a job. These programs combine psychotherapy with pharmacotherapy, group therapy, substance abuse counseling, and related services in a very structured and time-intensive format, typically three hours a day, three days a week, but up to five days a week. They are a less time-intensive step down from partial hospitalization, but they can provide greater support than weekly therapy appointments alone. IOPs can serve as a transition between inpatient hospitalization and less intensive weekly therapy when a patient requires a greater level of care. Diversion into intensive outpatient programs has reduced the number of individuals in institutionalized settings. President Kennedy In 1955, the Joint Commission on Mental Health and Health was authorized to investigate problems related to the mentally ill. President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had been lobotomized at the age of 23 at the request of her father. Shortly after his inauguration, Kennedy appointed a special President's Panel of Mental Retardation. The panel included professionals and leaders of the organization. In 1962, the panel published a report with 112 recommendations to better serve the mentally ill. In conjunction with the Joint Commission on Mental Health and Health, the Presidential Panel of Mental Retardation, and Kennedy's influence, two important pieces of legislation were passed in 1963: the Maternal and Child Health and Mental Retardation Planning Amendments, which increased funding for research on the prevention of retardation, and the Community Mental Health Act, which provided funding for community facilities that served people with mental disabilities. Both acts furthered the process of deinstitutionalization. However, less than a month after signing the new legislation, JFK was assassinated and could not see the plan through. The community mental health centers never received stable funding, and even 15 years later less than half the promised centers were built. Changing public opinion While public opinion of the mentally ill has improved somewhat, it is still often stigmatized. Advocacy movements in support of mental health have emerged. These movements focus on reducing stigma and discrimination and increasing support groups and awareness. The consumer or ex-patient movement, began as protests in the 1970s, forming groups such as Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI). Many of the participants consisted of ex-patients of mental institutions who felt the need to challenge the system's treatment of the mentally ill. Initially, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy, anti-psychotic medication, and coercive psychiatry. Many of these advocacy groups were successful in the judiciary system. In 1975, the United States Court of Appeals for the First Circuit ruled in favor of the Mental Patient's Liberation Front of Rogers v. Okin, establishing the right of a patient to refuse treatment. A 1975 award-winning film, One Flew Over the Cuckoo's Nest, sent a message regarding the rights of those committed involuntarily. That same year, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with a 1978 ruling further restricting states from confining anyone involuntarily for mental illness. NAMI successfully lobbied to improve mental health services and gain equality of insurance coverage for mental illnesses. In 1996, the Mental Health Parity Act was enacted into law, realizing the mental health movement's goal of equal insurance coverage. In 1955, there were 340 psychiatric hospital beds for every 100,000 US citizens. In 2005, that number had diminished to 17 per 100,000. Reducing costs As hospitalization costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalization. The 1965 amendments to Social Security shifted about 50% of the mental health care costs from states to the federal government, motivating the government to promote deinstitutionalization. The increase in homelessness was seen as related to deinstitutionalization. Studies from the late 1980s indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse. A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. When laws were enacted requiring communities to take more responsibility for mental health care, necessary funding was often absent, and jail became the default option, being cheaper than psychiatric care. In summer 2009, author and columnist Heather Mac Donald stated in City Journal, "jails have become society's primary mental institutions, though few have the funding or expertise to carry out that role properly ... at Rikers, 28 percent of the inmates require mental health services, a number that rises each year." See also Involuntary hospitalization of Joyce Patricia Brown References History of mental health in the United States

Educational psychology

Educational psychology is the branch of psychology concerned with the scientific study of human learning. The study of learning processes, from both cognitive and behavioral perspectives, allows researchers to understand individual differences in intelligence, cognitive development, affect, motivation, self-regulation, and self-concept, as well as their role in learning. The field of educational psychology relies heavily on quantitative methods, including testing and measurement, to enhance educational activities related to instructional design, classroom management, and assessment, which serve to facilitate learning processes in various educational settings across the lifespan. Educational psychology can in part be understood through its relationship with other disciplines. It is informed primarily by psychology, bearing a relationship to that discipline analogous to the relationship between medicine and biology. It is also informed by neuroscience. Educational psychology in turn informs a wide range of specialties within educational studies, including instructional design, educational technology, curriculum development, organizational learning, special education, classroom management, and student motivation. Educational psychology both draws from and contributes to cognitive science and the learning sciences. In universities, departments of educational psychology are usually housed within faculties of education, possibly accounting for the lack of representation of educational psychology content in introductory psychology textbooks. The field of educational psychology involves the study of memory, conceptual processes, and individual differences (via cognitive psychology) in conceptualizing new strategies for learning processes in humans. Educational psychology has been built upon theories of operant conditioning, functionalism, structuralism, constructivism, humanistic psychology, Gestalt psychology, and information processing. Educational psychology has seen rapid growth and development as a profession in the last twenty years. School psychology began with the concept of intelligence testing leading to provisions for special education students, who could not follow the regular classroom curriculum in the early part of the 20th century. Another main focus of school psychology was to help close the gap for children of colour, as the fight against racial inequality and segregation was still very prominent, during the early to mid-1900s. However, "school psychology" itself has built a fairly new profession based upon the practices and theories of several psychologists among many different fields. Educational psychologists are working side by side with psychiatrists, social workers, teachers, speech and language therapists, and counselors in an attempt to understand the questions being raised when combining behavioral, cognitive, and social psychology in the classroom setting. History As a field of study, educational psychology is fairly new and was not considered a specific practice until the 20th century. Reflections on everyday teaching and learning allowed some individuals throughout history to elaborate on developmental differences in cognition, the nature of instruction, and the transfer of knowledge and learning. These topics are important to education and, as a result, they are important in understanding human cognition, learning, and social perception. Antiquity Some of the ideas and issues pertaining to educational psychology date back to the time of Plato and Aristotle. Philosophers as well as sophists discussed the purpose of education, training of the body and the cultivation of psycho-motor skills, the formation of good character, the possibilities and limits of moral education. Some other educational topics they spoke about were the effects of music, poetry, and the other arts on the development of the individual, role of the teacher, and the relations between teacher and student. Plato saw knowledge acquisition as an innate ability, which evolves through experience and understanding of the world. This conception of human cognition has evolved into a continuing argument of nature vs. nurture in understanding conditioning and learning today. Aristotle, on the other hand, ascribed to the idea of knowledge by association or schema. His four laws of association included succession, contiguity, similarity, and contrast. His studies examined recall and facilitated learning processes. Early Modern era John Locke is considered one of the most influential philosophers in post-renaissance Europe, a time period that began around the mid-1600s. Locke is considered the "Father of English Psychology". One of Locke's most important works was written in 1690, named An Essay Concerning Human Understanding. In this essay, he introduced the term "tabula rasa" meaning "blank slate." Locke explained that learning was attained through experience only and that we are all born without knowledge. He followed by contrasting Plato's theory of innate learning processes. Locke believed the mind was formed by experiences, not innate ideas. Locke introduced this idea as "empiricism", or the understanding that knowledge is only built on knowledge and experience. In the late 1600s, John Locke advanced the hypothesis that people learn primarily from external forces. He believed that the mind was like a blank tablet (tabula rasa), and that successions of simple impressions give rise to complex ideas through association and reflection. Locke is credited with establishing "empiricism" as a criterion for testing the validity of knowledge, thus providing a conceptual framework for later development of experimental methodology in the natural and social sciences. In the 18th century the philosopher Jean-Jacques Rousseau espoused a set of theories which would become highly influential in the field of education, particularly through his philosophical novel Emile, or On Education. Despite stating that the book should not be used as a practical guide to nurturing children, the pedagogical approach outlined in it was lauded by Enlightenment contemporaries including Immanuel Kant and Johann Wolfgang von Goethe. Rousseau advocated a child-centered approach to education, and that the age of the child should be accounted for in choosing what and how to teach them. In particular he insisted on the primacy of experiential education, in order to develop the child's ability to reason autonomously. Rousseau's philosophy influenced educational reformers including Johann Bernhard Basedow, whose practice in his model school the Philanthropinum drew upon his ideas, as well as Johann Heinrich Pestalozzi. More generally Rousseau's thinking had significant direct and indirect influence on the development of pedagogy in Germany, Switzerland and the Netherlands. In addition, Jean Piaget's stage-based approach to child development has been observed to have parallels to Rousseau's theories. Before 1890 Philosophers of education such as Juan Vives, Johann Pestalozzi, Friedrich Fröbel, and Johann Herbart had examined, classified and judged the methods of education centuries before the beginnings of psychology in the late 1800s. Juan Vives Juan Vives (1493–1540) proposed induction as the method of study and believed in the direct observation and investigation of the study of nature. His studies focused on humanistic learning, which opposed scholasticism and was influenced by a variety of sources including philosophy, psychology, politics, religion, and history. He was one of the first prominent thinkers to emphasize that the location of a school is important to learning. He suggested that a school should be located away from disturbing noises; the air quality should be good and there should be plenty of food for the students and teachers. Vives emphasized the importance of understanding individual differences of the students and suggested practice as an important tool for learning. Vives introduced his educational ideas in his writing, "De anima et vita" in 1538. In this publication, Vives explores moral philosophy as a setting for his educational ideals; with this, he explains that the different parts of the soul (similar to that of Aristotle's ideas) are each responsible for different operations, which function distinctively. The first book covers the different "souls": "The Vegetative Soul"; this is the soul of nutrition, growth, and reproduction, "The Sensitive Soul", which involves the five external senses; "The Cogitative soul", which includes internal senses and cognitive facilities. The second book involves functions of the rational soul: mind, will, and memory. Lastly, the third book explains the analysis of emotions. Johann Pestalozzi Johann Pestalozzi (1746–1827), a Swiss educational reformer, emphasized the child rather than the content of the school. Pestalozzi fostered an educational reform backed by the idea that early education was crucial for children, and could be manageable for mothers. Eventually, this experience with early education would lead to a "wholesome person characterized by morality." Pestalozzi has been acknowledged for opening institutions for education, writing books for mother's teaching home education, and elementary books for students, mostly focusing on the kindergarten level. In his later years, he published teaching manuals and methods of teaching. During the time of The Enlightenment, Pestalozzi's ideals introduced "educationalization". This created the bridge between social issues and education by introducing the idea of social issues to be solved through education. Horlacher describes the most prominent example of this during The Enlightenment to be "improving agricultural production methods." Johann Herbart Johann Herbart (1776–1841) is considered the father of educational psychology. He believed that learning was influenced by interest in the subject and the teacher. He thought that teachers should consider the students' existing mental sets—what they already know—when presenting new information or material. Herbart came up with what are now known as the formal steps. The 5 steps that teachers should use are: Review material that has already been learned by the student Prepare the student for new material by giving them an overview of what they are learning next Present the new material. Relate the new material to the old material that has already been learned. Show how the student can apply the new material and show the material they will learn next. 1890–1920 There were three major figures in educational psychology in this period: William James, G. Stanley Hall, and John Dewey. These three men distinguished themselves in general psychology and educational psychology, which overlapped significantly at the end of the 19th century. William James (1842–1910) The period of 1890–1920 is considered the golden era of educational psychology when aspirations of the new discipline rested on the application of the scientific methods of observation and experimentation to educational problems. From 1840 to 1920 37 million people immigrated to the United States. This created an expansion of elementary schools and secondary schools. The increase in immigration also provided educational psychologists the opportunity to use intelligence testing to screen immigrants at Ellis Island. Darwinism influenced the beliefs of the prominent educational psychologists. Even in the earliest years of the discipline, educational psychologists recognized the limitations of this new approach. The pioneering American psychologist William James commented that: James is the father of psychology in America, but he also made contributions to educational psychology. In his famous series of lectures Talks to Teachers on Psychology, published in 1899, James defines education as "the organization of acquired habits of conduct and tendencies to behavior". He states that teachers should "train the pupil to behavior" so that he fits into the social and physical world. Teachers should also realize the importance of habit and instinct. They should present information that is clear and interesting and relate this new information and material to things the student already knows about. He also addresses important issues such as attention, memory, and association of ideas. Alfred Binet Alfred Binet published Mental Fatigue in 1898, in which he attempted to apply the experimental method to educational psychology. In this experimental method he advocated for two types of experiments, experiments done in the lab and experiments done in the classroom. In 1904 he was appointed the Minister of Public Education. This is when he began to look for a way to distinguish children with developmental disabilities. Binet strongly supported special education programs because he believed that "abnormality" could be cured. The Binet-Simon test was the first intelligence test and was the first to distinguish between "normal children" and those with developmental disabilities. Binet believed that it was important to study individual differences between age groups and children of the same age. He also believed that it was important for teachers to take into account individual students' strengths and also the needs of the classroom as a whole when teaching and creating a good learning environment. He also believed that it was important to train teachers in observation so that they would be able to see individual differences among children and adjust the curriculum to the students. Binet also emphasized that practice of material was important. In 1916 Lewis Terman revised the Binet-Simon so that the average score was always 100. The test became known as the Stanford-Binet and was one of the most widely used tests of intelligence. Terman, unlike Binet, was interested in using intelligence test to identify gifted children who had high intelligence. In his longitudinal study of gifted children, who became known as the Termites, Terman found that gifted children become gifted adults. Edward Thorndike Edward Thorndike (1874–1949) supported the scientific movement in education. He based teaching practices on empirical evidence and measurement. Thorndike developed the theory of instrumental conditioning or the law of effect. The law of effect states that associations are strengthened when it is followed by something pleasing and associations are weakened when followed by something not pleasing. He also found that learning is done a little at a time or in increments, learning is an automatic process and its principles apply to all mammals. Thorndike's research with Robert Woodworth on the theory of transfer found that learning one subject will only influence your ability to learn another subject if the subjects are similar. This discovery led to less emphasis on learning the classics because they found that studying the classics does not contribute to overall general intelligence. Thorndike was one of the first to say that individual differences in cognitive tasks were due to how many stimulus-response patterns a person had rather than general intellectual ability. He contributed word dictionaries that were scientifically based to determine the words and definitions used. The dictionaries were the first to take into consideration the users' maturity level. He also integrated pictures and easier pronunciation guide into each of the definitions. Thorndike contributed arithmetic books based on learning theory. He made all the problems more realistic and relevant to what was being studied, not just to improve the general intelligence. He developed tests that were standardized to measure performance in school-related subjects. His biggest contribution to testing was the CAVD intelligence test which used a multidimensional approach to intelligence and was the first to use a ratio scale. His later work was on programmed instruction, mastery learning, and computer-based learning: John Dewey John Dewey (1859–1952) had a major influence on the development of progressive education in the United States. He believed that the classroom should prepare children to be good citizens and facilitate creative intelligence. He pushed for the creation of practical classes that could be applied outside of a school setting. He also thought that education should be student-oriented, not subject-oriented. For Dewey, education was a social experience that helped bring together generations of people. He stated that students learn by doing. He believed in an active mind that was able to be educated through observation, problem-solving, and enquiry. In his 1910 book How We Think, he emphasizes that material should be provided in a way that is stimulating and interesting to the student since it encourages original thought and problem-solving. He also stated that material should be relative to the student's own experience. Jean Piaget Jean Piaget (1896–1980) was one of the most powerful researchers in of developmental psychology during the 20th century. He developed the theory of cognitive development. The theory stated that intelligence developed in four different stages. The stages are the sensorimotor stage from birth to 2 years old, the preoperational state from 2 to 7 years old, the concrete operational stage from 7 to 10 years old, and the formal operational stage from 12 years old and up. He also believed that learning was constrained to the child's cognitive development. Piaget influenced educational psychology because he was the first to believe that cognitive development was important and something that should be paid attention to in education. Most of the research on Piagetian theory was carried out by American educational psychologists. 1920–present The number of people receiving a high school and college education increased dramatically from 1920 to 1960. Because very few jobs were available to teens coming out of eighth grade, there was an increase in high school attendance in the 1930s. The progressive movement in the United States took off at this time and led to the idea of progressive education. John Flanagan, an educational psychologist, developed tests for combat trainees and instructions in combat training. In 1954 the work of Kenneth Clark and his wife on the effects of segregation on black and white children was influential in the Supreme Court case Brown v. Board of Education. From the 1960s to present day, educational psychology has switched from a behaviorist perspective to a more cognitive-based perspective because of the influence and development of cognitive psychology at this time. Jerome Bruner Jerome Bruner is notable for integrating Piaget's cognitive approaches into educational psychology. He advocated for discovery learning where teachers create a problem solving environment that allows the student to question, explore and experiment. In his book The Process of Education Bruner stated that the structure of the material and the cognitive abilities of the person are important in learning. He emphasized the importance of the subject matter. He also believed that how the subject was structured was important for the student's understanding of the subject and that it was the goal of the teacher to structure the subject in a way that was easy for the student to understand. In the early 1960s, Bruner went to Africa to teach math and science to school children, which influenced his view as schooling as a cultural institution. Bruner was also influential in the development of MACOS, Man: a Course of Study, which was an educational program that combined anthropology and science. The program explored human evolution and social behavior. He also helped with the development of the head start program. He was interested in the influence of culture on education and looked at the impact of poverty on educational development. Benjamin Bloom Benjamin Bloom (1903–1999) spent over 50 years at the University of Chicago, where he worked in the department of education. He believed that all students can learn. He developed the taxonomy of educational objectives. The objectives were divided into three domains: cognitive, affective, and psychomotor. The cognitive domain deals with how we think. It is divided into categories that are on a continuum from easiest to more complex. The categories are knowledge or recall, comprehension, application, analysis, synthesis, and evaluation. The affective domain deals with emotions and has 5 categories. The categories are receiving phenomenon, responding to that phenomenon, valuing, organization, and internalizing values. The psychomotor domain deals with the development of motor skills, movement, and coordination and has 7 categories that also go from simplest to most complex. The 7 categories of the psychomotor domain are perception, set, guided response, mechanism, complex overt response, adaptation, and origination. The taxonomy provided broad educational objectives that could be used to help expand the curriculum to match the ideas in the taxonomy. The taxonomy is considered to have a greater influence internationally than in the United States. Internationally, the taxonomy is used in every aspect of education from the training of the teachers to the development of testing material. Bloom believed in communicating clear learning goals and promoting an active student. He thought that teachers should provide feedback to the students on their strengths and weaknesses. Bloom also did research on college students and their problem-solving processes. He found that they differ in understanding the basis of the problem and the ideas in the problem. He also found that students differ in process of problem-solving in their approach and attitude toward the problem. Nathaniel Gage Nathaniel Gage (1917–2008) is an important figure in educational psychology as his research focused on improving teaching and understanding the processes involved in teaching. He edited the book Handbook of Research on Teaching (1963), which helped develop early research in teaching and educational psychology. Gage founded the Stanford Center for Research and Development in Teaching, which contributed research on teaching as well as influencing the education of important educational psychologists. Perspectives Behavioral Applied behavior analysis, a research-based science utilizing behavioral principles of operant conditioning, is effective in a range of educational settings. For example, teachers can alter student behavior by systematically rewarding students who follow classroom rules with praise, stars, or tokens exchangeable for sundry items. Despite the demonstrated efficacy of awards in changing behavior, their use in education has been criticized by proponents of self-determination theory, who claim that praise and other rewards undermine intrinsic motivation. There is evidence that tangible rewards decrease intrinsic motivation in specific situations, such as when the student already has a high level of intrinsic motivation to perform the goal behavior. But the results showing detrimental effects are counterbalanced by evidence that, in other situations, such as when rewards are given for attaining a gradually increasing standard of performance, rewards enhance intrinsic motivation. Many effective therapies have been based on the principles of applied behavior analysis, including pivotal response therapy which is used to treat autism spectrum disorders. Cognitive Among current educational psychologists, the cognitive perspective is more widely held than the behavioral perspective, perhaps because it admits causally related mental constructs such as traits, beliefs, memories, motivations, and emotions. Cognitive theories claim that memory structures determine how information is perceived, processed, stored, retrieved and forgotten. Among the memory structures theorized by cognitive psychologists are separate but linked visual and verbal systems described by Allan Paivio's dual coding theory. Educational psychologists have used dual coding theory and cognitive load theory to explain how people learn from multimedia presentations. The spaced learning effect, a cognitive phenomenon strongly supported by psychological research, has broad applicability within education. For example, students have been found to perform better on a test of knowledge about a text passage when a second reading of the passage is delayed rather than immediate (see figure). Educational psychology research has confirmed the applicability to the education of other findings from cognitive psychology, such as the benefits of using mnemonics for immediate and delayed retention of information. Problem solving, according to prominent cognitive psychologists, is fundamental to learning. It resides as an important research topic in educational psychology. A student is thought to interpret a problem by assigning it to a schema retrieved from long-term memory. A problem students run into while reading is called "activation." This is when the student's representations of the text are present during working memory. This causes the student to read through the material without absorbing the information and being able to retain it. When working memory is absent from the reader's representations of the working memory, they experience something called "deactivation." When deactivation occurs, the student has an understanding of the material and is able to retain information. If deactivation occurs during the first reading, the reader does not need to undergo deactivation in the second reading. The reader will only need to reread to get a "gist" of the text to spark their memory. When the problem is assigned to the wrong schema, the student's attention is subsequently directed away from features of the problem that are inconsistent with the assigned schema. The critical step of finding a mapping between the problem and a pre-existing schema is often cited as supporting the centrality of analogical thinking to problem-solving. Cognitive view of intelligence Each person has an individual profile of characteristics, abilities, and challenges that result from predisposition, learning, and development. These manifest as individual differences in intelligence, creativity, cognitive style, motivation, and the capacity to process information, communicate, and relate to others. The most prevalent disabilities found among school age children are attention deficit hyperactivity disorder (ADHD), learning disability, dyslexia, and speech disorder. Less common disabilities include intellectual disability, hearing impairment, cerebral palsy, epilepsy, and blindness. Although theories of intelligence have been discussed by philosophers since Plato, intelligence testing is an invention of educational psychology and is coincident with the development of that discipline. Continuing debates about the nature of intelligence revolve on whether it can be characterized by a single factor known as general intelligence, multiple factors (e.g., Gardner's theory of multiple intelligences), or whether it can be measured at all. In practice, standardized instruments such as the Stanford-Binet IQ test and the WISC are widely used in economically developed countries to identify children in need of individualized educational treatment. Children classified as gifted are often provided with accelerated or enriched programs. Children with identified deficits may be provided with enhanced education in specific skills such as phonological awareness. In addition to basic abilities, the individual's personality traits are also important, with people higher in conscientiousness and hope attaining superior academic achievements, even after controlling for intelligence and past performance. Developmental Developmental psychology, and especially the psychology of cognitive development, opens a special perspective for educational psychology. This is so because education and the psychology of cognitive development converge on a number of crucial assumptions. First, the psychology of cognitive development defines human cognitive competence at successive phases of development. Education aims to help students acquire knowledge and develop skills that are compatible with their understanding and problem-solving capabilities at different ages. Thus, knowing the students' level on a developmental sequence provides information on the kind and level of knowledge they can assimilate, which, in turn, can be used as a frame for organizing the subject matter to be taught at different school grades. This is the reason why Piaget's theory of cognitive development was so influential for education, especially mathematics and science education. In the same direction, the neo-Piagetian theories of cognitive development suggest that in addition to the concerns above, sequencing of concepts and skills in teaching must take account of the processing and working memory capacities that characterize successive age levels. Second, the psychology of cognitive development involves understanding how cognitive change takes place and recognizing the factors and processes which enable cognitive competence to develop. Education also capitalizes on cognitive change, because the construction of knowledge presupposes effective teaching methods that would move the student from a lower to a higher level of understanding. Mechanisms such as reflection on actual or mental actions vis-à-vis alternative solutions to problems, tagging new concepts or solutions to symbols that help one recall and mentally manipulate them are just a few examples of how mechanisms of cognitive development may be used to facilitate learning. Finally, the psychology of cognitive development is concerned with individual differences in the organization of cognitive processes and abilities, in their rate of change, and in their mechanisms of change. The principles underlying intra- and inter-individual differences could be educationally useful, because knowing how students differ in regard to the various dimensions of cognitive development, such as processing and representational capacity, self-understanding and self-regulation, and the various domains of understanding, such as mathematical, scientific, or verbal abilities, would enable the teacher to cater for the needs of the different students so that no one is left behind. Constructivist Constructivism is a category of learning theory in which emphasis is placed on the agency and prior "knowing" and experience of the learner, and often on the social and cultural determinants of the learning process. Educational psychologists distinguish individual (or psychological) constructivism, identified with Piaget's theory of cognitive development, from social constructivism. The social constructivist paradigm views the context in which the learning occurs as central to the learning itself. It regards learning as a process of enculturation. People learn by exposure to the culture of practitioners. They observe and practice the behavior of practitioners and 'pick up relevant jargon, imitate behavior, and gradually start to act in accordance with the norms of the practice'. So, a student learns to become a mathematician through exposure to mathematician using tools to solve mathematical problems. So in order to master a particular domain of knowledge it is not enough for students to learn the concepts of the domain. They should be exposed to the use of the concepts in authentic activities by the practitioners of the domain. A dominant influence on the social constructivist paradigm is Lev Vygotsky's work on sociocultural learning, describing how interactions with adults, more capable peers, and cognitive tools are internalized to form mental constructs. "Zone of Proximal Development" (ZPD) is a term Vygotsky used to characterize an individual's mental development. He believed that tasks individuals can do on their own do not give a complete understanding of their mental development. He originally defined the ZPD as “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers.” He cited a famous example to make his case. Two children in school who originally can solve problems at an eight-year-old developmental level (that is, typical for children who were age 8) might be at different developmental levels. If each child received assistance from an adult, one was able to perform at a nine-year-old level and one was able to perform at a twelve-year-old level. He said “This difference between twelve and eight, or between nine and eight, is what we call the zone of proximal development.” He further said that the ZPD “defines those functions that have not yet matured but are in the process of maturation, functions that will mature tomorrow but are currently in an embryonic state.” The zone is bracketed by the learner's current ability and the ability they can achieve with the aid of an instructor of some capacity. Vygotsky viewed the ZPD as a better way to explain the relation between children's learning and cognitive development. Prior to the ZPD, the relation between learning and development could be boiled down to the following three major positions: 1) Development always precedes learning (e.g., constructivism): children first need to meet a particular maturation level before learning can occur; 2) Learning and development cannot be separated, but instead occur simultaneously (e.g., behaviorism): essentially, learning is development; and 3) learning and development are separate, but interactive processes (e.g., gestaltism): one process always prepares the other process, and vice versa. Vygotsky rejected these three major theories because he believed that learning should always precede development in the ZPD. According to Vygotsky, through the assistance of a more knowledgeable other, a child can learn skills or aspects of a skill that go beyond the child's actual developmental or maturational level. The lower limit of ZPD is the level of skill reached by the child working independently (also referred to as the child's developmental level). The upper limit is the level of potential skill that the child can reach with the assistance of a more capable instructor. In this sense, the ZPD provides a prospective view of cognitive development, as opposed to a retrospective view that characterizes development in terms of a child's independent capabilities. The advancement through and attainment of the upper limit of the ZPD is limited by the instructional and scaffolding-related capabilities of the more knowledgeable other (MKO). The MKO is typically assumed to be an older, more experienced teacher or parent, but often can be a learner's peer or someone their junior. The MKO need not even be a person, it can be a machine or book, or other source of visual and/or audio input. Elaborating on Vygotsky's theory, Jerome Bruner and other educational psychologists developed the important concept of instructional scaffolding, in which the social or information environment offers supports for learning that are gradually withdrawn as they become internalized. Jean Piaget's Cognitive Development Jean Piaget was interested in how an organism adapts to its environment. Piaget hypothesized that infants are born with a schema operating at birth that he called "reflexes". Piaget identified four stages in cognitive development. The four stages are sensorimotor stage, pre-operational stage, concrete operational stage, and formal operational stage. Conditioning and learning To understand the characteristics of learners in childhood, adolescence, adulthood, and old age, educational psychology develops and applies theories of human development. Often represented as stages through which people pass as they mature, developmental theories describe changes in mental abilities (cognition), social roles, moral reasoning, and beliefs about the nature of knowledge. For example, educational psychologists have conducted research on the instructional applicability of Jean Piaget's theory of development, according to which children mature through four stages of cognitive capability. Piaget hypothesized that children are not capable of abstract logical thought until they are older than about 11 years, and therefore younger children need to be taught using concrete objects and examples. Researchers have found that transitions, such as from concrete to abstract logical thought, do not occur at the same time in all domains. A child may be able to think abstractly about mathematics but remain limited to concrete thought when reasoning about human relationships. Perhaps Piaget's most enduring contribution is his insight that people actively construct their understanding through a self-regulatory process. Piaget proposed a developmental theory of moral reasoning in which children progress from a naïve understanding of morality based on behavior and outcomes to a more advanced understanding based on intentions. Piaget's views of moral development were elaborated by Lawrence Kohlberg into a stage theory of moral development. There is evidence that the moral reasoning described in stage theories is not sufficient to account for moral behavior. For example, other factors such as modeling (as described by the social cognitive theory of morality) are required to explain bullying. Rudolf Steiner's model of child development interrelates physical, emotional, cognitive, and moral development in developmental stages similar to those later described by Piaget. Developmental theories are sometimes presented not as shifts between qualitatively different stages, but as gradual increments on separate dimensions. Development of epistemological beliefs (beliefs about knowledge) have been described in terms of gradual changes in people's belief in: certainty and permanence of knowledge, fixedness of ability, and credibility of authorities such as teachers and experts. People develop more sophisticated beliefs about knowledge as they gain in education and maturity. Motivation Motivation is an internal state that activates, guides and sustains behavior. Motivation can have several impacting effects on how students learn and how they behave towards subject matter: Provide direction towards goals. Enhance cognitive processing abilities and performance. Direct behavior toward specific goals. Lead to increased effort and energy. Increase initiation of and persistence in activities. Educational psychology research on motivation is concerned with the volition or will that students bring to a task, their level of interest and intrinsic motivation, the personally held goals that guide their behavior, and their belief about the causes of their success or failure. As intrinsic motivation deals with activities that act as their own rewards, extrinsic motivation deals with motivations that are brought on by consequences or punishments. A form of attribution theory developed by Bernard Weiner describes how students' beliefs about the causes of academic success or failure affect their emotions and motivations. For example, when students attribute failure to lack of ability, and ability is perceived as uncontrollable, they experience the emotions of shame and embarrassment and consequently decrease effort and show poorer performance. In contrast, when students attribute failure to lack of effort, and effort is perceived as controllable, they experience the emotion of guilt and consequently increase effort and show improved performance. The self-determination theory (SDT) was developed by psychologists Edward Deci and Richard Ryan. SDT focuses on the importance of intrinsic and extrinsic motivation in driving human behavior and posits inherent growth and development tendencies. It emphasizes the degree to which an individual's behavior is self-motivated and self-determined. When applied to the realm of education, the self-determination theory is concerned primarily with promoting in students an interest in learning, a value of education, and a confidence in their own capacities and attributes. Motivational theories also explain how learners' goals affect the way they engage with academic tasks. Those who have mastery goals strive to increase their ability and knowledge. Those who have performance approach goals strive for high grades and seek opportunities to demonstrate their abilities. Those who have performance avoidance goals are driven by fear of failure and avoid situations where their abilities are exposed. Research has found that mastery goals are associated with many positive outcomes such as persistence in the face of failure, preference for challenging tasks, creativity, and intrinsic motivation. Performance avoidance goals are associated with negative outcomes such as poor concentration while studying, disorganized studying, less self-regulation, shallow information processing, and test anxiety. Performance approach goals are associated with positive outcomes, and some negative outcomes such as an unwillingness to seek help and shallow information processing. Locus of control is a salient factor in the successful academic performance of students. During the 1970s and '80s, Cassandra B. Whyte did significant educational research studying locus of control as related to the academic achievement of students pursuing higher education coursework. Much of her educational research and publications focused upon the theories of Julian B. Rotter in regard to the importance of internal control and successful academic performance. Whyte reported that individuals who perceive and believe that their hard work may lead to more successful academic outcomes, instead of depending on luck or fate, persist and achieve academically at a higher level. Therefore, it is important to provide education and counseling in this regard. Technology Instructional design, the systematic design of materials, activities, and interactive environments for learning, is broadly informed by educational psychology theories and research. For example, in defining learning goals or objectives, instructional designers often use a taxonomy of educational objectives created by Benjamin Bloom and colleagues. Bloom also researched mastery learning, an instructional strategy in which learners only advance to a new learning objective after they have mastered its prerequisite objectives. Bloom discovered that a combination of mastery learning with one-to-one tutoring is highly effective, producing learning outcomes far exceeding those normally achieved in classroom instruction. Gagné, another psychologist, had earlier developed an influential method of task analysis in which a terminal learning goal is expanded into a hierarchy of learning objectives connected by prerequisite relationships. The following list of technological resources incorporate computer-aided instruction and intelligence for educational psychologists and their students: Intelligent tutoring system Cognitive tutor Cooperative learning Collaborative learning Problem-based learning Computer-supported collaborative learning Constructive alignment Technology is essential to the field of educational psychology, not only for the psychologist themselves as far as testing, organization, and resources, but also for students. Educational psychologists who reside in the K-12 setting focus most of their time on special education students. It has been found that students with disabilities learning through technology such as iPad applications and videos are more engaged and motivated to learn in the classroom setting. Liu et al. explain that learning-based technology allows for students to be more focused, and learning is more efficient with learning technologies. The authors explain that learning technology also allows for students with social-emotional disabilities to participate in distance learning. Applications Teaching Research on classroom management and pedagogy is conducted to guide teaching practice and form a foundation for teacher education programs. The goals of classroom management are to create an environment conducive to learning and to develop students' self-management skills. More specifically, classroom management strives to create positive teacher-student and peer relationships, manage student groups to sustain on-task behavior, and use counseling and other psychological methods to aid students who present persistent psychosocial problems. Introductory educational psychology is a commonly required area of study in most North American teacher education programs. When taught in that context, its content varies, but it typically emphasizes learning theories (especially cognitively oriented ones), issues about motivation, assessment of students' learning, and classroom management. A developing Wikibook about educational psychology gives more detail about the educational psychology topics that are typically presented in preservice teacher education. Special education Secondary Education Lesson plan Counseling Training In order to become an educational psychologist, students can complete an undergraduate degree of their choice. They then must go to graduate school to study education psychology, counseling psychology, or school counseling. Most students today are also receiving their doctoral degrees in order to hold the "psychologist" title. Educational psychologists work in a variety of settings. Some work in university settings where they carry out research on the cognitive and social processes of human development, learning and education. Educational psychologists may also work as consultants in designing and creating educational materials, classroom programs and online courses. Educational psychologists who work in K–12 school settings (closely related are school psychologists in the US and Canada) are trained at the master's and doctoral levels. In addition to conducting assessments, school psychologists provide services such as academic and behavioral intervention, counseling, teacher consultation, and crisis intervention. However, school psychologists are generally more individual-oriented towards students. Many high schools and colleges are increasingly offering educational psychology courses, with some colleges offering it as a general education requirement. Similarly, colleges offer students opportunities to obtain a Ph.D. in educational psychology. Within the UK, students must hold a degree that is accredited by the British Psychological Society (either undergraduate or at the master's level) before applying for a three-year doctoral course that involves further education, placement, and a research thesis. In recent years, many university training programs in the US have included curriculum that focuses on issues of race, gender, disability, trauma, and poverty, and how those issues affect learning and academic outcomes. A growing number of universities offer specialized certificates that allow professionals to work and study in these fields (i.e. autism specialists, trauma specialists). Employment outlook Anticipated to grow by 18–26%, employment for psychologists in the United States is expected to grow faster than most occupations in 2014. One in four psychologists is employed in educational settings. In the United States, the median salary for psychologists in primary and secondary schools is US$58,360 as of May 2004. In recent decades, the participation of women as professional researchers in North American educational psychology has risen dramatically. Methods of research As opposed to some other fields of educational research, quantitative methods are the predominant mode of inquiry in educational psychology, but qualitative and mixed-methods studies are also common. Educational psychology, as much as any other field of psychology relies on a balance of observational, correlational, and experimental study designs. Given the complexities of modeling dependent data and psychological variables in school settings, educational psychologists have been at the forefront of the development of several common statistical tools, including psychometric methods, meta-analysis, regression discontinuity and latent variable modeling. See also – an educational psychology action research method References Further reading Barry, W.J. (2012). Challenging the Status Quo Meaning of Educational Quality: Introducing Transformational Quality (TQ) Theory©. Educational Journal of Living Theories. 4, 1-29. http://ejolts.net/node/191 External links Educational Psychology Resources by Athabasca University Division 15 of the American Psychological Association Psychology of Education Section of the British Psychological Society Explorations in Learning & Instructional Design: Theory Into Practice Database (archived 30 September 2011) Classics in the History of Psychology The Standards for Educational and Psychological Testing The Psychology of Educational Quality-Transformational Quality (TQ) Theory (video on YouTube)

Mind

The mind is that which thinks, feels, perceives, imagines, remembers, and wills. The totality of mental phenomena, it includes both conscious processes, through which an individual is aware of external and internal circumstances, and unconscious processes, which can influence an individual without intention or awareness. Traditionally, minds were often conceived as separate entities that can exist on their own but are more commonly understood as capacities of material brains in the contemporary discourse. The mind plays a central role in most aspects of human life but its exact nature is disputed. Some characterizations focus on internal aspects, saying that the mind is private and transforms information. Others stress its relation to outward conduct, understanding mental phenomena as dispositions to engage in observable behavior. The mind–body problem is the challenge of explaining the relation between matter and mind. The dominant position today is physicalism, which says that everything is material, meaning that minds are certain aspects or features of some material objects. The evolutionary history of the mind is tied to the development of the nervous system, which led to the formation of brains. As brains became more complex, the number and capacity of mental functions increased with particular brain areas dedicated to specific mental functions. Individual human minds also develop as they learn from experience and pass through psychological stages in the process of aging. Some people are affected by mental disorders, for which certain mental capacities do not function as they should. It is widely accepted that animals have some form of mind, but it is controversial to which animals this applies. The topic of artificial minds poses similar challenges, with theorists discussing the possibility and consequences of creating them using computers. The main fields of inquiry studying the mind include psychology, neuroscience, cognitive science, and philosophy. They tend to focus on different aspects of the mind and employ different methods of investigation, ranging from empirical observation and neuroimaging to conceptual analysis and thought experiments. The mind is relevant to many other fields, including epistemology, anthropology, religion, and education. Definition The mind is the totality of psychological phenomena and capacities, encompassing consciousness, thought, perception, feeling, mood, motivation, behavior, memory, and learning. The term is sometimes used in a more narrow sense to refer only to higher or more abstract cognitive functions associated with reasoning and awareness. Minds were traditionally conceived as immaterial substances or independent entities and contrasted with matter and body. In the contemporary discourse, they are more commonly seen as features of other entities and are often understood as capacities of material brains. The precise definition of mind is disputed and while it is generally accepted that some non-human animals also have mind, there is no agreement on where exactly the boundary lies. Despite these disputes, there is wide agreement that mind plays a central role in most aspects of human life as the seat of consciousness, emotions, thoughts, and sense of personal identity. Various fields of inquiry study the mind; the main ones include psychology, cognitive science, neuroscience, and philosophy. The words psyche and mentality are usually used as synonyms of mind. They are often employed in overlapping ways with the terms soul, spirit, cognition, intellect, intelligence, and brain but their meanings are not exactly the same. Some religions understand the soul as an independent entity that constitutes the immaterial essence of human beings, is of divine origin, survives bodily death, and is immortal. The word spirit has various additional meanings not directly associated with mind, such as a vital principle animating living beings or a supernatural being inhabiting objects or places. Cognition encompasses certain types of mental processes in which knowledge is acquired and information processed. The intellect is one mental capacity responsible for thought, reasoning, and understanding and is closely related to intelligence as the ability to acquire, understand, and apply knowledge. The brain is the physical organ responsible for most or all mental functions. The modern English word mind originates from the Old English word , meaning "memory". This term gave rise to the Middle English words , , and , resulting in a slow expansion of meaning to cover all mental capacities. The original meaning is preserved in expressions like call to mind and keep in mind. Cognates include the Old High German , the Gothic , the ancient Greek , the Latin , and the Sanskrit . Forms The mind encompasses many phenomena, including perception, memory, thought, imagination, motivation, emotion, attention, learning, and consciousness. Perception is the process of interpreting and organizing sensory information to become acquainted with the environment. This information is acquired through sense organs receptive to various types of physical stimuli, which correspond to different forms of perception, such as vision, hearing, touch, smell, and taste. The sensory information received this way is a form of raw data that is filtered and processed to actively construct a representation of the world and the objects within it. This complex process underlying perceptual experience is shaped by many factors, including the individual's past experiences, cultural background, beliefs, knowledge, and expectations. Memory is the mechanism of storing and retrieving information. Episodic memory handles information about specific past events in one's life and makes this information available in the present. When a person remembers what they had for dinner yesterday, they employ episodic memory. Semantic memory handles general knowledge about the world that is not tied to any specific episodes. When a person recalls that the capital of Japan is Tokyo, they usually access this general information without recalling the specific instance when they learned it. Procedural memory is memory of how to do things, such as riding a bicycle or playing a musical instrument. Another distinction is between short-term memory, which holds information for brief periods, usually with the purpose of completing specific cognitive tasks, and long-term memory, which can store information indefinitely. Thinking involves the processing of information and the manipulation of concepts and ideas. It is a goal-oriented activity that often happens in response to experiences as a symbolic process aimed at making sense of them, organizing their information, and deciding how to respond. Logical reasoning is a form of thinking that starts from a set of premises and aims to arrive at a conclusion supported by these premises. This is the case when deducing that "Socrates is mortal" from the premises "Socrates is a man" and "all men are mortal". Problem-solving is a closely related process that consists of several steps, such as identifying a problem, developing a plan to address it, implementing the plan, and assessing whether it worked. Thinking in the form of decision-making involves considering possible courses of action to assess which one is the most beneficial. As a symbolic process, thinking is deeply intertwined with language and some theorists hold that all thought happens through the medium of language. Imagination is a creative process of internally generating mental images. Unlike perception, it does not directly depend on the stimulation of sensory organs. Similar to dreaming, these images are often derived from previous experiences but can include novel combinations and elements. Imagination happens during daydreaming and plays a key role in art and literature but can also be used to come up with novel solutions to real-world problems. Motivation is an internal state that propels individuals to initiate, continue, or terminate goal-directed behavior. It is responsible for the formation of intentions to perform actions and affects what goals someone pursues, how much effort they invest in the activity, and how long they engage in it. Motivation is affected by emotions, which are temporary experiences of positive or negative feelings like joy or anger. They are directed at and evaluate specific events, persons, or situations. They usually come together with certain physiological and behavioral responses. Attention is an aspect of other mental processes in which mental resources like awareness are directed towards certain features of experience and away from others. This happens when a driver focuses on the traffic while ignoring billboards on the side of the road. Attention can be controlled voluntarily in the pursuit of specific goals but can also occur involuntarily when a strong stimulus captures a person's attention. Attention is relevant to learning, which is the ability of the mind to acquire new information and permanently modify its understanding and behavioral patterns. Individuals learn by undergoing experiences, which helps them adapt to the environment. Conscious and unconscious An influential distinction is between conscious and unconscious mental processes. Consciousness is the awareness of external and internal circumstances. It encompasses a wide variety of states, such as perception, thinking, fantasizing, dreaming, and altered states of consciousness. In the case of phenomenal consciousness, the awareness involves a direct and qualitative experience of mental phenomena, like the auditory experience of attending a concert. Access consciousness, by contrast, refers to an awareness of information that is accessible to other mental processes but not necessarily part of current experience. For example, the information stored in a memory may be accessible when drawing conclusions or guiding actions even when the person is not explicitly thinking about it. Unconscious or nonconscious mental processes operate without the individual's awareness but can still influence mental phenomena on the level of thought, feeling, and action. Some theorists distinguish between preconscious, subconscious, and unconscious states depending on their accessibility to conscious awareness. When applied to the overall state of a person rather than specific processes, the term unconscious implies that the person lacks any awareness of their environment and themselves, like during a coma. The unconscious mind plays a central role in psychoanalysis as the part of the mind that contains thoughts, memories, and desires not accessible to conscious introspection. According to Sigmund Freud, the psychological mechanism of repression keeps disturbing phenomena, like unacceptable sexual and aggressive impulses, from entering consciousness to protect the individual. Psychoanalytic theory studies symptoms caused by this process and therapeutic methods to avoid them by making the repressed thoughts accessible to conscious awareness. Other distinctions Mental states are often divided into sensory and propositional states. Sensory states are experiences of sensory qualities, often referred to as qualia, like colors, sounds, smells, pains, itches, and hunger. Propositional states involve an attitude towards a content that can be expressed by a declarative sentence. When a person believes that it is raining, they have the propositional attitude of belief towards the content "it is raining". Different types of propositional states are characterized by different attitudes towards their content. For instance, it is also possible to hope, fear, desire, or doubt that it is raining. A mental state or process is rational if it is based on good reasons or follows the norms of rationality. For example, a belief is rational if it relies on strong supporting evidence and a decision is rational if it follows careful deliberation of all the relevant factors and outcomes. Mental states are irrational if they are not based on good reasons, such as beliefs caused by faulty reasoning, superstition, or cognitive biases, and decisions that give into temptations instead of following one's best judgment. Mental states that fall outside the domain of rational evaluation are arational rather than irrational. There is controversy regarding which mental phenomena lie outside this domain; suggested examples include sensory impressions, feelings, desires, and involuntary responses. Another contrast is between dispositional and occurrent mental states. A dispositional state is a power that is not exercised. If a person believes that cats have whiskers but does not think about this fact, it is a dispositional belief. By activating the belief to consciously think about it or use it in other cognitive processes, it becomes occurrent until it is no longer actively considered or used. The great majority of a person's beliefs are dispositional most of the time. Faculties and modules Traditionally, the mind was subdivided into mental faculties understood as capacities to perform certain functions or bring about certain processes. An influential subdivision in the history of philosophy was between the faculties of intellect and will. The intellect encompasses mental phenomena aimed at understanding the world and determining what to believe or what is true; the will is concerned with practical matters and what is good, reflected in phenomena like desire, decision-making, and action. The exact number and nature of the mental faculties are disputed and more fine-grained subdivisions have been proposed, such as dividing the intellect into the faculties of understanding and judgment or adding sensibility as an additional faculty responsible for sensory impressions. In contrast to the traditional view, more recent approaches analyze the mind in terms of mental modules rather than faculties. A mental module is an inborn system of the brain that automatically performs a particular function within a specific domain without conscious awareness or effort. In contrast to faculties, the concept of mental modules is normally used to provide a more limited explanation restricted to certain low-level cognitive processes without trying to explain how they are integrated into higher-level processes such as conscious reasoning. Many low-level cognitive processes responsible for visual perception have this automatic and unconscious nature. In the case of visual illusions like the Müller-Lyer illusion, the underlying processes continue their operation and the illusion persists even after a person has become aware of the illusion, indicating the mechanical and involuntary nature of the process. Other examples of mental modules concern cognitive processes responsible for language processing and facial recognition. Theories of the nature of mind Theories of the nature of mind aim to determine what all mental states have in common. They seek to discover the "mark of the mental", that is, the criteria that distinguish mental from non-mental phenomena. Epistemic criteria say that the unique feature of mental states is how people know about them. For example, if a person has a toothache, they have direct or non-inferential knowledge that they are in pain. But they do not have this kind of knowledge of the physical causes of the pain and may have to consult external evidence through visual inspection or a visit to the dentist. Another feature commonly ascribed to mental states is that they are private, meaning that others do not have this kind of direct access to a person's mental state and have to infer it from other observations, like the pain behavior of the person with the toothache. Some philosophers claim that knowledge of some or all mental states is infallible, for instance, that a person cannot be mistaken about whether they are in pain. A related view states that all mental states are either conscious or accessible to consciousness. According to this view, when a person actively remembers the fact that the Eiffel Tower is in Paris then this state is mental because it is part of consciousness; when the person does not think about it, this belief is still a mental state because the person could bring it to consciousness by thinking about it. This view denies the existence of a "deep unconsciousness", that is, unconscious mental states that cannot in principle become conscious. Another theory says that intentionality is the mark of the mental. A state is intentional if it refers to or represents something. For example, if a person perceives a piano or thinks about it then the mental state is intentional because it refers to a piano. This view distinguishes between original and derivative intentionality. Mental states have original intentionality while some non-mental phenomena have derivative intentionality. For instance, the word piano and a picture of a piano are intentional in a derivative sense: they do not directly refer to a piano but if a person looks at them, they may evoke in this person a mental state that refers to a piano. Philosophers who disagree that all mental states are intentional cite examples such as itches, tickles, and pains as possible exceptions. According to behaviorism, mental states are dispositions to engage in certain publicly observable behavior as a reaction to particular external stimuli. This view implies that mental phenomena are not private internal states but are accessible to empirical observation like regular physical phenomena. Functionalism agrees that mental states do not depend on the exact internal constitution of the mind and characterizes them instead in regard to their functional role. Unlike behaviorism, this role is not limited to behavioral patterns but includes other factors as well. For example, part of the functional role of pain is given by its relation to bodily injury and its tendency to cause behavioral patterns like moaning and other mental states, like a desire to stop the pain. Computationalism, a similar theory prominent in cognitive science, defines minds in terms of cognitions and computations as information processors. Theories under the umbrella of externalism emphasize the mind's dependency on the environment. According to this view, mental states and their contents are at least partially determined by external circumstances. For example, some forms of content externalism hold that it can depend on external circumstances whether a belief refers to one object or another. The extended mind thesis states that external circumstances not only affect the mind but are part of it, like a diary or a calculator extend the mind's capacity to store and process information. The closely related view of enactivism holds that mental processes involve an interaction between organism and environment. Relation to matter Mind–body problem The mind–body problem is the difficulty of providing a general explanation of the relationship between mind and body, for example, of the link between thoughts and brain processes. Despite their different characteristics, mind and body interact with each other, like when a bodily change causes mental discomfort or when a limb moves because of an intention. According to substance dualism, minds or souls exist as distinct substances that have mental states while material things are another type of substance. This view implies that, at least in principle, minds can exist without bodies. Property dualism is another view, saying that mind and matter are not distinct individuals but different properties that apply to the same individual. Monist views, by contrast, state that reality is made up of only one kind. According to idealists, everything is mental. They understand material things as mental constructs, for example, as ideas or perceptions. According to neutral monists, the world is at its most fundamental level neither physical nor mental but neutral. They see physical and mental concepts as convenient but superficial ways to describe reality. The monist view most influential in contemporary philosophy is physicalism, also referred to as materialism, which states that everything is physical. According to eliminative physicalism, there are no mental phenomena, meaning that things like beliefs and desires do not form part of reality. Reductive physicalists defend a less radical position: they say that mental states exist but can, at least in principle, be completely described by physics without the need for special sciences like psychology. For example, behaviorists aim to analyze mental concepts in terms of observable behavior without resorting to internal mental states. Type identity theory also belongs to reductive physicalism and says that mental states are the same as brain states. While non-reductive physicalists agree that everything is physical, they say that mental concepts describe physical reality on a more abstract level that cannot be achieved by physics. According to functionalism, mental concepts do not describe the internal constitution of physical substances but functional roles within a system. One consequence of this view is that mind does not depend on brains but can also be realized by other systems that implement the corresponding functional roles, possibly also computers. The hard problem of consciousness is a central aspect of the mind–body problem: it is the challenge of explaining how physical states can give rise to conscious experience. Its main difficulty lies in the subjective and qualitative nature of consciousness, which is unlike typical physical processes. The hard problem of consciousness contrasts with the "easy problems" of explaining how certain aspects of consciousness function, such as perception, memory, or learning. Brain areas and processes Another approach to the relation between mind and matter uses empirical observation to study how the brain works and which brain areas and processes are associated with specific mental phenomena. The brain is the central organ of the nervous system and is present in all vertebrates and the majority of invertebrates. The human brain is of particular complexity and consists of about 86 billion neurons, which communicate with one another via synapses. They form a complex neural network and cognitive processes emerge from their electrical and chemical interactions. The human brain is divided into regions that are associated with different functions. The main regions are the hindbrain, midbrain, and forebrain. The hindbrain and the midbrain are responsible for many biological functions associated with basic survival while higher mental functions, ranging from thoughts to motivation, are primarily localized in the forebrain. The primary operation of many of the main mental phenomena is located in specific areas of the forebrain. The prefrontal cortex is responsible for executive functions, such as planning, decision-making, problem-solving, and working memory. The role of the sensory cortex is to process and interpret sensory information, with different subareas dedicated to different senses, like the visual and the auditory areas. A central function of the hippocampus is the formation and retrieval of long-term memories. It belongs to the limbic system, which plays a key role in the regulation of emotions through the amygdala. The motor cortex is responsible for planning, executing, and controlling voluntary movements. Broca's area is a separate region dedicated to speech production. The activity of the different areas is additionally influenced by neurotransmitters, which are signaling molecules that enhance or inhibit different types of neural communication. For example, dopamine influences motivation and pleasure while serotonin affects mood and appetite. The close interrelation of brain processes and the mind is seen by the effect that physical changes of the brain have on the mind. For instance, the consumption of psychoactive drugs, like caffeine, antidepressants, alcohol, and psychedelics, temporarily affects brain chemistry with diverse effects on the mind, ranging from increased attention to mood changes, impaired cognitive functions, and hallucinations. Long-term changes to the brain in the form of neurodegenerative diseases and brain injuries can lead to permanent alterations in mental functions. Alzheimer's disease in its first stage deteriorates the hippocampus, reducing the ability to form new memories and recall existing ones. An often-cited case of the effects of brain injury is Phineas Gage, whose prefrontal cortex was severely damaged during a work accident when an iron rod pierced through his skull and brain. Gage survived the accident but his personality and social attitude changed significantly as he became more impulsive, irritable, and anti-social while showing little regard for social conventions and an impaired ability to plan and make rational decisions. Not all these changes were permanent and Gage managed to recover and adapt in some areas. Development Evolution The mind has a long evolutionary history starting with the development of the nervous system and the brain. While it is generally accepted today that mind is not exclusive to humans and various non-human animals have some form of mind, there is no consensus at which point exactly the mind emerged. The evolution of mind is usually explained in terms of natural selection: genetic variations responsible for new or improved mental capacities, like better perception or social dispositions, have an increased chance of being passed on to future generations if they are beneficial to survival and reproduction. Minimal forms of information processing are already found in the earliest forms of life 4 to 3.5 billion years ago, like the abilities of bacteria and eukaryotic unicellular organisms to sense the environment, store this information, and react to it. Nerve cells emerged with the development of multicellular organisms more than 600 million years ago as a way to process and transmit information. About 600 to 550 million years ago, an evolutionary bifurcation happened into radially symmetric organisms with ring-shaped nervous systems or a nerve net, like jellyfish, and organisms with bilaterally symmetric bodies, whose nervous systems tend to be more centralized. About 540 million years ago, vertebrates evolved within the group of bilaterally organized organisms. All vertebrates, like birds and mammals, have a central nervous system including a complex brain with specialized functions while invertebrates, like clams and insects, either have no brains or tend to have simple brains. With the evolution of vertebrates, their brains tended to grow and the specialization of the different brain areas tended to increase. These developments are closely related to changes in limb structures, sense organs, and living conditions with a close correspondence between the size of a brain area and the importance of its function to the organism. An important step in the evolution of mammals about 200 million years ago was the development of the neocortex, which is responsible for many higher-order brain functions. The size of the brain relative to the body further increased with the development of primates, like monkeys, about 65 million years ago and later with the emergence of the first hominins about 7–5 million years ago. Anatomically modern humans appeared about 300,000 to 200,000 years ago. Various theories of the evolutionary processes responsible for human intelligence have been proposed. The social intelligence hypothesis says that the evolution of the human mind was triggered by the increased importance of social life and its emphasis on mental abilities associated with empathy, knowledge transfer, and meta-cognition. According to the ecological intelligence hypothesis, the main value of the increased mental capacities comes from their advantages in dealing with a complex physical environment through processes like behavioral flexibility, learning, and tool use. Other suggested mechanisms include the effects of a changed diet with energy-rich food and general benefits from an increased speed and efficiency of information processing. Individual Besides the development of mind in general in the course of history, there is also the development of individual human minds. Some of the individual changes vary from person to person as a form of learning from experience, like forming specific memories or acquiring particular behavioral patterns. Others are more universal developments as psychological stages that all or most humans go through as they pass through early childhood, adolescence, adulthood, and old age. These developments cover various areas, including intellectual, sensorimotor, linguistic, emotional, social, and moral developments. Some factors affect the development of mind before birth, such as nutrition, maternal stress, and exposure to harmful substances like alcohol during pregnancy. Early childhood is marked by rapid developments as infants learn voluntary control over their bodies and interact with their environment on a basic level. Typically after about one year, this covers abilities like walking, recognizing familiar faces, and producing individual words. On the emotional and social levels, they develop attachments with their primary caretakers and express emotions ranging from joy to anger, fear, and surprise. An influential theory by Jean Piaget divides the cognitive development of children into four stages. The sensorimotor stage from birth until two years is concerned with sensory impressions and motor activities while learning that objects remain in existence even when not observed. In the preoperational stage until seven years, children learn to interpret and use symbols in an intuitive manner. They start employing logical reasoning to physical objects in the concrete operational stage until eleven years and extend this capacity in the following formal operational stage to abstract ideas as well as probabilities and possibilities. Other important processes shaping the mind in this period are socialization and enculturation, at first through primary caretakers and later through peers and the schooling system. Psychological changes during adolescence are provoked both by physiological changes and being confronted with a different social situation and new expectations from others. An important factor in this period is change to the self-concept, which can take the form of an identity crisis. This process often involves developing individuality and independence from parents while at the same time seeking closeness and conformity with friends and peers. Further developments in this period include improvements to the reasoning ability and the formation of a principled moral viewpoint. The mind also changes during adulthood but in a less rapid and pronounced manner. Reasoning and problem-solving skills improve during early and middle adulthood. Some people experience the mid-life transition as a midlife crisis involving an inner conflict about personal identity, often associated with anxiety, a sense of lack of accomplishments in life, and an awareness of mortality. Intellectual faculties tend to decline in later adulthood, specifically the ability to learn complex unfamiliar tasks and later also the ability to remember, while people tend to become more inward-looking and cautious. Non-human Animal It is commonly acknowledged today that animals have some form of mind, but it is controversial to which animals this applies and how their mind differs from the human mind. Different conceptions of the mind lead to different responses to this problem; when understood in a very wide sense as the capacity to process information, the mind is present in all forms of life, including insects, plants, and individual cells; on the other side of the spectrum are views that deny the existence of mentality in most or all non-human animals based on the idea that they lack key mental capacities, like abstract rationality and symbolic language. The status of animal minds is highly relevant to the field of ethics since it affects the treatment of animals, including the topic of animal rights. Discontinuity views state that the minds of non-human animals are fundamentally different from human minds and often point to higher mental faculties, like thinking, reasoning, and decision-making based on beliefs and desires. This outlook is reflected in the traditionally influential position of defining humans as "rational animals" as opposed to all other animals. Continuity views, by contrast, emphasize similarities and see the increased human mental capacities as a matter of degree rather than kind. Central considerations for this position are the shared evolutionary origin, organic similarities on the level of brain and nervous system, and observable behavior, ranging from problem-solving skills, animal communication, and reactions to and expressions of pain and pleasure. Of particular importance are the questions of consciousness and sentience, that is, to what extent non-human animals have a subjective experience of the world and are capable of suffering and feeling joy. Artificial Some of the difficulties of assessing animal minds are also reflected in the topic of artificial minds, that is, the question of whether computer systems implementing artificial intelligence should be considered a form of mind. This idea is consistent with some theories of the nature of mind, such as functionalism and its idea that mental concepts describe functional roles, which are implemented by biological brains but could in principle also be implemented by artificial devices. The Turing test is a traditionally influential procedure to test artificial intelligence: a person exchanges messages with two parties, one of them a human and the other a computer. The computer passes the test if it is not possible to reliably tell which party is the human and which one is the computer. While there are computer programs today that may pass the Turing test, this alone is usually not accepted as conclusive proof of mindedness. For some aspects of mind, it is controversial whether computers can, in principle, implement them, such as desires, feelings, consciousness, and free will. This problem is often discussed through the contrast between weak and strong artificial intelligence. Weak or narrow artificial intelligence is limited to specific mental capacities or functions. It focuses on a particular task or a narrow set of tasks, like autonomous driving, speech recognition, or theorem proving. The goal of strong AI, also termed artificial general intelligence, is to create a complete artificial person that has all the mental capacities of humans, including consciousness, emotion, and reason. It is controversial whether strong AI is possible; influential arguments against it include John Searle's Chinese Room Argument and Hubert Dreyfus's critique based on Heideggerian philosophy. Mental health and disorder Mental health is a state of mind characterized by internal equilibrium and well-being in which mental capacities function as they should. Some theorists emphasize positive features such as the abilities of a person to realize their potential, express and modulate emotions, cope with adverse life situations, and fulfill their social role. Negative definitions, by contrast, see mental health as the absence of mental illness in the form of mental disorders. Mental disorders are abnormal patterns of thought, emotion, or behavior that deviate not only from how a mental capacity works on average but from the norm of how it should work while usually causing some form of distress. The content of those norms is controversial and there are differences from culture to culture; for example, homosexuality was historically considered a mental disorder by medical professionals, a view which only changed in the second half of 20th century. There is a great variety of mental disorders, each associated with a different form of malfunctioning. Anxiety disorders involve intense and persistent fear that is disproportionate to the actual threat and significantly impairs everyday life, like social phobias, which involve irrational fear of certain social situations. Anxiety disorders also include obsessive–compulsive disorder, for which the anxiety manifests in the form of intrusive thoughts that the person tries to alleviate by following compulsive rituals. Mood disorders cause intensive moods or mood swings that are inconsistent with the external circumstances and can last for extensive periods. For instance, people affected by bipolar disorder experience extreme mood swings between manic states of euphoria and depressive states of hopelessness. Personality disorders are characterized by enduring patterns of maladaptive behavior that significantly impair regular life, like paranoid personality disorder, which leads people to be deeply suspicious of the motives of others without rational basis. Psychotic disorders are among the most severe mental illnesses and involve a distorted relation to reality in the form of hallucinations and delusions, as seen in schizophrenia. Other disorders include dissociative disorders and eating disorders. The biopsychosocial model identifies three types of causes of mental disorders: biological, cognitive, and environmental factors. Biological factors include bodily causes, in particular neurological influences and genetic predispositions. On the cognitive level, maladaptive beliefs and patterns of thought can be responsible. Environmental factors involve cultural influences and social events that may trigger the onset of a disorder. There are various approaches to treating mental disorders, and the most suitable treatment usually depends on the type of disorder, its cause, and the individual's overall condition. Psychotherapeutic methods use personal interaction with a therapist to change patterns of thinking, feeling, and acting. Psychoanalysis aims to help patients resolve conflicts between the conscious and the unconscious mind. Cognitive behavioral therapy focuses on conscious mental phenomena to identify and change irrational beliefs and negative thought patterns. Behavior therapy, a related approach, relies on classical conditioning to unlearn harmful behaviors. Humanistic therapies try to help people gain insight into their self-worth and empower them to resolve their problems. Drug therapies use medication to alter the brain chemistry involved in the disorder through substances like antidepressants, antipsychotics, mood stabilizers, and anxiolytics. Fields and methods of inquiry Various fields of inquiry study the mind, including psychology, neuroscience, philosophy, and cognitive science. They differ from each other in the aspects of mind they investigate and the methods they employ in the process. The study of the mind poses various problems since it is difficult to directly examine, manipulate, and measure it. Trying to circumvent this problem by investigating the brain comes with new challenges of its own, mainly because of the brain's complexity as a neural network consisting of billions of neurons, each with up to 10,000 links to other neurons. Psychology Psychology is the scientific study of mind and behavior. It investigates conscious and unconscious mental phenomena, including perception, memory, feeling, thought, decision, intelligence, and personality. It is further interested in their outward manifestation in the form of observable behavioral patterns and how these patterns depend on external circumstances and are shaped by learning. Psychology is a wide discipline that includes many subfields. Cognitive psychology is interested in higher-order mental activities like thinking, problem-solving, reasoning, and concept formation. Biological psychology seeks to understand the underlying mechanisms on the physiological level and how they depend on genetic transmission and the environment. Developmental psychology studies the development of the mind from childhood to old age while social psychology examines the influence of social contexts on mind and behavior. Personality psychology investigates personality, exploring how characteristic patterns of thought, feeling, and behavior develop and vary among individuals. Further subfields include comparative, clinical, educational, occupational, and neuropsychology. Psychologists use a great variety of methods to study the mind. Experimental approaches set up a controlled situation, either in the laboratory or the field, in which they modify independent variables and measure their effects on dependent variables. This approach makes it possible to identify causal relations between the variables. For example, to determine whether people with similar interests (independent variable) are more likely to become friends (dependent variables), participants of a study could be paired with either similar or dissimilar participants. After giving the pairs time to interact, it is assessed whether the members of similar pairs have more positive attitudes toward one another than the members of dissimilar pairs. Correlational methods examine the strength of association between two variables without establishing a causal relationship between them. The survey method presents participants with a list of questions aimed at eliciting information about their mental attitudes, behavior, and other relevant factors. It analyzes how participants respond to questions and how answers to different questions correlate with one another. Surveys usually have a large number of participants in contrast to case studies, which focus on an in-depth examination of a single subject or a small group of subjects, often to examine rare phenomena or explore new fields. Further methods include longitudinal studies, naturalistic observation, and phenomenological description of experience. Neuroscience Neuroscience is the study of the nervous system. Its primary focus is the central nervous system and the brain in particular, but it also investigates the peripheral nervous system mainly responsible for connecting the central nervous system to the limbs and organs. Neuroscience examines the implementation of mental phenomena on a physiological basis. It covers various levels of analysis; on the small scale, it studies the molecular and cellular basis of the mind, dealing with the constitution of and interaction between individual neurons; on the large scale, it analyzes the architecture of the brain as a whole and its division into regions with different functions. Neuroimaging techniques are of particular importance as the main research methods of neuroscientists. Functional magnetic resonance imaging (fMRI) measures changes in the magnetic field of the brain associated with blood flow. Areas of increased blood flow indicate that the corresponding brain region is particularly active. Positron emission tomography (PET) uses radioactive substances to detect a range of metabolic changes in the brain. Electroencephalography (EEG) measures the electrical activity of the brain, usually by placing electrodes on the scalp and measuring the voltage differences between them. These techniques are often employed to measure brain changes under particular circumstances, for example, while engaged in a specific cognitive task. Important insights are also gained from patients and laboratory animals with brain damage in particular areas to assess the function of the damaged area and how its absence affects the remaining brain. Philosophy of mind Philosophy of mind examines the nature of mental phenomena and their relation to the physical world. It seeks to understand the "mark of the mental", that is, the features that all mental states have in common. It further investigates the essence of different types of mental phenomena, such as beliefs, desires, emotions, intentionality, and consciousness while exploring how they are related to one another. Philosophy of mind also examines solutions to the mind–body problem, like dualism, idealism, and physicalism, and assesses arguments for and against them. It asks whether people have a free will or the ability to choose their actions, and how this ability contrasts with the idea that everthing is determined by preceding causes. While philosophers of mind also include empirical considerations in their inquiry, they differ from fields like psychology and neuroscience by giving significantly more emphasis to non-empirical forms of inquiry. One such method is conceptual analysis, which aims to clarify the meaning of concepts, like mind and intention, by decomposing them to identify their semantic parts. Thought experiments are often used to evoke intuitions about abstract theories to assess their coherence and plausibility: philosophers imagine a situation relevant to a theory and employ counterfactual thinking to assess the possible consequences of this theory, as in Mary the color scientist, philosophical zombies, and brain in a vat-scenarios. Because of the subjective nature of the mind, the phenomenological method is also commonly used to analyze the structure of consciousness by describing experience from the first-person perspective. Cognitive science Cognitive science is the interdisciplinary study of mental processes. It aims to overcome the challenge of understanding something as complex as the mind by integrating research from diverse fields ranging from psychology and neuroscience to philosophy, linguistics, and artificial intelligence. Unlike these disciplines, it is not a unified field but a collaborative effort. One difficulty in synthesizing their insights is that each of these disciplines explores the mind from a different perspective and level of abstraction while using different research methods to arrive at its conclusion. Cognitive science aims to overcome this difficulty by relying on a unified conceptualization of minds as information processors. This means that mental processes are understood as computations that retrieve, transform, store, and transmit information. For example, perception retrieves sensory information from the environment and transforms it to extract meaningful patterns that can be used in other mental processes, such as planning and decision-making. Cognitive science relies on different levels of description to analyze cognitive processes; the most abstract level focuses on the basic problem the process is supposed to solve and the reasons why the organism needs to solve it; the intermediate level seeks to uncover the algorithm as a formal step-by-step procedure to solve the problem; the most concrete level asks how the algorithm is implemented through physiological changes on the level of the brain. Another methodology to deal with the complexity of the mind is to analyze the mind as a complex system composed of individual subsystems that can be studied independently of one another. Relation to other fields The mind is relevant to many fields. In epistemology, the problem of other minds is the challenge of explaining how it is possible to know that people other than oneself have a mind. The difficulty arises from the fact that people directly experience their own minds but do not have the same access to the minds of others. According to a common view, it is necessary to rely on perception to observe the behavior of others and then infer that they have a mind based on analogical or abductive reasoning. Closely related to this problem is theory of mind in psychology, which is the ability to understand that other people possess beliefs, desires, intentions, and feelings that may differ from one's own. Anthropology is interested in how different cultures conceptualize the nature of mind and its relation to the world. These conceptualizations affect the way people understand themselves, experience illness, and interpret ritualistic practices as attempts to commune with spirits. Some cultures do not draw a strict boundary between mind and world by allowing that thoughts can pass directly into the world and manifest as beneficial or harmful forces. Others strictly separate the mind as an internal phenomenon without supernatural powers from external reality. Sociology is a related field concerned with the connections between mind, society, and behavior. The concept of mind plays a central role in various religions. Buddhists say that there is no enduring self underlying mental activity and analyze the mind as a stream of constantly changing experiences characterized by five aspects or "aggregates": material form, feelings, perception, volition, and consciousness. Hindus, by contrast, affirm the existence of a permanent self. In an influential analogy, the human mind is compared to a horse-drawn chariot: the horses are the senses, which lure the sense mind corresponding to the reins through sensual pleasures but are controlled by the charioteer embodying the intellect while the self is a passenger. In traditional Christian philosophy, mind and soul are closely intertwined as the immaterial aspect of humans that may survive bodily death. Islamic thought distinguishes between the mind, spirit, heart, and self as interconnected aspects of the spiritual dimension of humans. Daoism and Confucianism use the concept of heart-mind as the center of cognitive and emotional life, encompassing thought, understanding, will, desire, and mood. In the field of education, the minds of students are shaped through the transmission of knowledge, skills, and character traits as a process of socialization and enculturation. This is achieved through different teaching methods including the contrast between group work and individual learning and the use of instructional media. Teacher-centered education positions the teacher as the central authority controlling the learning process whereas in student-centered education, students have a more active role in shaping classroom activities. The choice of the most effective method to develop the minds of the learners is determined by various factors, including the topic and the learner's age and skill level. The mind is a frequent subject of pseudoscientific inquiry. Phrenology was an early attempt to correlate mental functions with specific brain areas. While its central claims about predicting mental traits by measuring bumps on the skull did not survive scientific scrutiny, the underlying idea that certain mental functions are localized in particular regions of the brain is now widely accepted. Parapsychologists seek to discover and study paranormal mental abilities ranging from clairvoyance to telepathy and telekinesis. See also References Notes Citations Sources External links Concepts in metaphysics Concepts in the philosophy of mind Psychological concepts

Resocialization

Resocialization or resocialisation (British English) is the process by which one's sense of social values, beliefs, and norms are re-engineered. The process is deliberately carried out in military boot camps through an intense social process or may take place in a total institution. An important thing to note about socialization is that what can be learned can be unlearned. That forms the basis of resocialization: to unlearn and to relearn. Resocialization can be defined also as a process by which individuals, defined as inadequate according to the norms of a dominant institution, are subjected to a dynamic redistribution of those values, attitudes and abilities to allow them to function according to the norms of the said dominant institutions. That definition relates more to a jail sentence. If individuals exhibit deviance, society delivers the offenders to a total institution, where they can be rehabilitated. Resocialization varies in its severity. A mild resocialization might be involved in moving to a different country. One who does so may need to learn new social customs and norms such as language, eating, dress, and talking customs. A more drastic example of resocialization is joining a military or a cult, and the most severe example would be if one suffers from a loss of all memories and so would have to relearn all of society's norms. The first stage of resocialization is the destruction of an individual's former beliefs and confidence. Institutions The goal of total institutions is resocialization, which radically alters residents' personalities by deliberate manipulation of their environment. A total institution refers to an institution in which one is totally immersed and controls all of one's day-to-day life. All activity occurs in a single place under a single authority. Examples of a total institution include prisons, fraternity houses, and the military. Resocialization is a two-part process. First, the institutional staff try to erode the residents' identities and independence. Strategies to erode identities include forcing individuals to surrender all personal possessions, get uniform haircuts and wear standardized clothing. Independence is eroded by subjecting residents to humiliating and degrading procedures. Examples are strip searches, fingerprinting, and assigning serial numbers or code names to replace the residents' given names. The second part of resocialization process involves the systematic attempt to build a different personality or self. That is generally done through a system of rewards and punishments. The privilege of being allowed to read a book, watch television, or make a phone call can be a powerful motivator for conformity. Conformity occurs when individuals change their behavior to fit in with the expectations of an authority figure or the expectations of the larger group. No two people respond to resocialization programs in the same manner. Some residents are found to be "rehabilitated," but others might become bitter and hostile. As well, over a long period of time, a strictly-controlled environment can destroy a person's ability to make decisions and live independently, which is known as institutionalisation, a negative outcome of total institution that prevents an individual from ever functioning effectively in the outside world again. (Sproule, 154–155) Resocialization is also evident in individuals who have never been "socialized" in the first place or have not been required to behave socially for an extended period of time. Examples include feral children (never socialized) or inmates who have been in solitary confinement. Socialization is a lifelong process. Adult socialization often includes learning new norms and values that are very different from those associated with the culture in which the person was raised. The process can be voluntary. Currently, joining a volunteer military qualifies as an example of voluntary resocialization. The norms and values associated with military life are different from those associated with civilian life (Riehm, 2000). The sociologist Erving Goffman studied resocialization in mental institutions. He characterized the mental institution as a total institution, one in which virtually every aspect of the inmates' lives is controlled by the institution and calculated to serve the institution's goals. For example, the institution requires patients to comply with certain regulations, even when that is not necessarily in the best interest of individuals. In Military Those who join the military enter a new social realm in which they become socialized as military members. Resocialization is defined as a "process wherein an individual, defined as inadequate according to the norms of a dominant institution(s), is subjected to a dynamic program of behavior intervention aimed at instilling and/or rejuvenating those values, attitudes, and abilities which would allow... to function according to the norms of said dominant institution(s)." Boot camp serves as an example for understanding how military members are resocialized within the total institution of the military. According to Fox and Pease (2012), the purpose of military training, like boot camp, is to "promote the willing and systematic subordination of one’s own individual desires and interests to those of one’s unit and, ultimately, country." To accomplish it, all aspects of military members' lives exist within the same military institution and are controlled by the same "institutional authorities" (drill instructors) and are done to accomplish the goals of the total institution. The individual's "civil[ian] identity, with its built-in restraints is eradicated, or at least undermined and set aside in favor of the warrior identity and its central focus upon killing." This warrior identity or ethos, is the mindset and group of values that all United States armed forces aim to instill in their members. Leonard Wong in “Leave No Man Behind: Recovering America’s Fallen Warriors,” describes the warrior ethos as placing the mission above all else, not accepting defeat, not ever quitting, and never leaving another American behind. Military training prepares individuals for combat by promoting traditional ideas of masculinity, like training individuals to disregard their bodies' natural reactions to run from fear, have pain or show emotions. Although resocialization through military training can create a sense of purpose in military members, it can also create mental and emotional distress when members are unable to achieve set standards and expectations. Military members, in part, find purpose and meaning through resocialization because the institution provides access to symbolic and material resources, helping military members construct meaningful identities. Fox and Pease state, "like any social identity, military identity is always an achievement, something dependent upon conformity to others' expectations and their acknowledgment. The centrality of performance testing in the military, and the need to 'measure up,' heightens this dependence. Although resocialization through military training can create a sense of purpose in military members, it also has the likelihood to create mental and emotional distress when members are unable to achieve set standards and expectations." In the first couple of days, the most important aspect of basic training is the surrender of their identity. Recruits in basic training are exposed to a degrading process, where leaders break down the recruits’ civilian selves and essentially give them a new identity. The recruits go through a brutal, humbling, and physically and emotionally exhausting process. They are subjected to their new norms, language, rules, and identity. Recruits shed their clothes and hair, which are the physical representation of their old identities. The processes happen very quickly and allows no time for recruits to think over the loss of their identity and so the recruits have no chance to regret their decisions. Drill sergeants then give the young men and women a romanticized view on what it is to be a soldier and how manly it is. When the training starts, it is physically demanding and gets harder every week. The recruits are constantly insulted and put down to break down their pride and destroy their ability to resist the change that they are undergoing. Drill sergeants put up a facade that tells their recruits that finishing out basic training sets them apart from all of the others who fail. However, almost all recruits succeed and graduate from basic training. The training is also set up with roles. There are three younger drill sergeants closer to the recruits in age and one senior drill sergeant, who becomes a father figure to the new recruits. The company commander plays a god-like role, which the recruits look up to. The people in the roles will become role models and authority figures but also help to create a sense of loyalty to the entire organization. Recruits are made to march in a formation in which every person moves the same way at the same time, which causes a sense of unity. It makes the recruits feel less like individuals and more like parts of a group. They sing in cadence to boost morale and to make the group feel important. Drill sergeants also feed the group small doses of triumphs to keep the soldiers proud and feeling accomplished. According to Jeff Parker Knight, the ultimate function for these songs is described as “marching precision,” but Knight argues that these jodies have a secondary socialization purpose that creates a type of “rite of passage” for the recruits. These jody performances, “reflect martial attitudes, and, as symbolic action, help to induce attitude changes in initiates.” The troop also undergoes group punishment, which unifies the unit. Generally, the similar hatred of something will bring everyone together. In this case, group punishment allows all the recruits to hate the drill sergeants and the punishment but to find unity within their unit. They will encourage others to push themselves and create shared hardships. In Prisons Prisons have two different types of re-socialization. The first type is that prisoners must learn the new normal behaviors that apply to their new environment. The second type is the prisoners must partake in rehabilitation measures to help fix their deviant ways. When the individual violates the dominant society's norms, the criminal system subjects them to a form of re-socialization called criminal rehabilitation. Rehabilitation aims to bring an inmate's real behavior closer to that of most individuals, who make up the dominant society. The ideal societal behavior is highly valued in many societies, mainly because it serves to protect and promote the well-being of most of the society's members. In rehabilitation, the system strips the criminal of his prior socialization of criminal behavior, including the techniques of committing a crime and the specific motives, drives, rationalizations, and attitudes. Criminal behavior is learned behavior and so can be unlearned. The first step towards rehabilitation is the choice of milieu. That is the type of interactions the deviant has with the people around him in custody. Usually, that is determined after psychological and sociological screenings are performed on the criminal. The second step is diagnosis, a continual process influenced by feedback from the individual's behavior. The next stage is treatment, which is dependent on the diagnosis. Whether it is treating an addiction or redefining the values of a person, the treatment is what socializes the criminal back to societal norms. References Conley, Dalton. You May Ask Yourself: An Introduction to Thinking like a Sociologist. New York: W.W. Norton, 2011. Print. Ferguson, Susan J., ed. Mapping the Social Landscape: Readings in Sociology. Boston: McGraw-Hill, 2002. Print. Kennedy, Daniel B., and August Kerber. Resocialization, an American Experiment. New York: Behavioral Publications, 1973. Print. Sociological terminology Social influence Majority–minority relations

Sundowning

Sundowning, or sundown syndrome, is a neurological phenomenon associated with increased confusion and restlessness in people with delirium or some form of dementia. It is most commonly associated with Alzheimer's disease but is also found in those with other forms of dementia. The term sundowning was coined by nurse Lois K. Evans in 1987 due to the timing of the person's increased confusion beginning in the late afternoon and early evening. For people with sundown syndrome, a multitude of behavioral problems begin to occur and are associated with long-term adverse outcomes. Sundowning seems to occur more frequently during the middle stages of Alzheimer's disease and mixed dementia and seems to subside with the progression of the person's dementia. People are generally able to understand that this behavioral pattern is abnormal. Research shows that 20–45% of people with Alzheimer's will experience some variation of sundowning confusion. However, despite lack of an official diagnosis of sundown syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), there is currently a wide range of reported prevalence. Relevance The following social, economic, and physiological adverse outcomes are correlated with individuals affected by sundowning and their caregivers: Long-term admission to psychiatric care facilities. Prolonged hospital admission with recurrent visits that increase financial burden. Steeper cognitive decline in Alzheimer's disease. Decreased quality of life. Increased stress and burnout of caregivers due to the timing of sundowning symptom onset. Symptoms Symptoms are not limited to but may include: Increased general confusion as natural light begins to fade and increased shadows appear. Agitation and mood swings. Individuals may become fairly frustrated with their own confusion as well as aggravated by noise. Individuals being found yelling and becoming increasingly upset with their caregiver are not uncommon. Mental and physical fatigue increase with the setting of the sun. This fatigue can play a role in the individual's irritability. An individual may experience an increase in restlessness while trying to sleep. Restlessness can often lead to pacing and or wandering which can be potentially harmful for an individual in a confused state. Hallucinations (visual and/or auditory) and paranoia can cause increased anxiety and resistance to care. Causes While the specific causes of sundowning have not been empirically proven, some evidence suggests that circadian rhythm disruption increases sundowning behaviors. In humans, sunset triggers a biochemical cascade that involves a reduction of dopamine levels and a shift towards melatonin production as the body prepares for sleep. In individuals with dementia, melatonin production may be decreased, which may interrupt other neurotransmitter systems. Other causes or precipitating factors that may lead to sundown syndrome may include hormonal changes, disturbances in REM sleep, individual and/or caregiver fatigue, inappropriate medication use, or being predisposed to behavioral disorders from chronic neurological diseases. Resources in an institution's environment can also play a role as a symptom trigger. A reduced number of staff in the evening can attribute to more unmet needs and a lower threshold for agitation for individuals with sundown syndrome. Sundowning should be distinguished from delirium, and could be presumed to be delirium when it appears as a new behavioral pattern until a causal link between sunset and behavioral disturbance is established. People with established sundowning and no obvious medical illness may be suffering from impaired circadian regulation, or may be affected by nocturnal aspects of their institutional environment such as shift changes, increased noise, or reduced staffing (which leads to fewer opportunities for social interaction). Delirium is generally an acute event that can span over a time period of hours to days. Disturbances in circadian rhythms It is thought that with the development of plaques and tangles associated with Alzheimer's disease there might be a disruption within the suprachiasmatic nucleus (SCN). The SCN is located in the hypothalamus and is associated with regulating sleep patterns by maintaining circadian rhythms, which are strongly associated with external light and dark cues. A disruption within the suprachiasmatic nucleus would seem to be an area that could cause the types of confusion that are seen in sundowning. However, finding evidence for this is difficult, as an autopsy is needed to analyze this disruption properly. By the time a person experiencing Alzheimer's has died, they have usually surpassed the level of brain damage (and associated dementia) that would be associated with sundowning. This hypothesis is, however, supported by the effectiveness of melatonin, a natural hormone, to decrease behavioral symptoms associated with sundowning. The pineal gland produces melatonin when signaled by the SCN to help maintain circadian rhythms. Melatonin supplementation can be administered to older adults as their natural hormonal production decreases over time. Serotonin has also been observed to potentially have a key role in the regulation of circadian rhythm as research has shown that serotonergic agonism in the SCN results in "phase shifts" in portions of the light-dark cycle. In addition to the effects on circadian rhythm, serotonin is also known to be involved in the regulation of aggression. Due to the serotonergic signaling deficiencies of Alzheimer's disease, it has been commonly reported that deficiencies in serotonin have been associated with worsening circadian rhythm or aggression. Risk factors Elderly people often experience multiple comorbidities that may contribute to the phenomenon of sundowning syndrome through neurodegeneration. Neurological disorders: Alzheimer's disease, Parkinson's disease, Huntington's disease, Lewy body dementia, fronto-temporal dementia, subcortical dementia. Neurobehavioral disorders: anxiety and depression. Cerebrovascular disease risk factors: hypertension, smoking, obesity. Genetic predisposition: presence of the ApoE4 allele has associations with sundown syndrome in peoples experiencing Alzheimer's disease. Treatment Treatment of sundown syndrome may vary based upon when agitated behavior is observed throughout the day. Non-pharmacological treatments If possible, a consistent sleeping schedule and daily routine that a patient is comfortable with can reduce confusion and agitation. If the person's condition permits, having increased daily activity incorporated into their schedule can help promote an earlier bed time and need for sleep. Check for over-napping. People may wish to take naps during the day, but unintentionally getting too much sleep will affect nighttime sleep. Physical activity is a treatment for Alzheimer's and a way to encourage night sleep. Caffeine is a (fast-working) brain stimulant, but should be limited at night if a night's sleep is needed. Caregivers may try letting people choose their own sleeping arrangements each night, wherever they feel most comfortable sleeping, as well as allow for a dim light in the room to alleviate confusion associated with an unfamiliar place. Light therapy can help regulate circadian rhythms. Older adults can struggle to receive consistent sunlight due to bedrest and institutional limitations. Mood and spatial positioning improvements have been noted in peoples experiencing dementia with exposure to indoor light, but evidence is currently inconclusive. Reducing the amount of overwhelming noise in the late afternoon or early evening can help the transition to sleep. Music therapy, aromatherapy, acupressure, psychosocial support, caregiver education, multi-sensory stimulation, and simulated presence therapy are possible treatment pathways, but evidence is currently lacking in clinical practice. Exercising at consistent times daily has been proposed to improve circadian rhythm and reduce the symptoms of sundown syndrome in people with Alzheimer's and dementia. It has also been observed that people with Alzheimer's walking at morning or afternoon hours had improvements in sundowning symptoms. Pharmacological treatments Some evidence supports the use of melatonin to induce sleep. The length of time required for a person to transition from fully awake to asleep has been shown to be more regular in melatonin users. Better memory and more positive emotional states have also been observed in peoples experiencing Alzheimer's disease. Drug classes such as hypnotics, benzodiazepines, acetylcholinesterase inhibitors (AChIs), N-methyl D-aspartic acid antagonists (NMDA), selective serotonin reuptake inhibitors (SSRIs), and sedative antipsychotics have been used to treat sundowning, but their side effects limit their overall effectiveness in a risk versus benefit balance. Various side effects in the risk category include increased fall risk, vivid dreams, or nocturnal agitation. Research directions There are several pathways in the pipeline for scientists seeking therapeutic options for sundowning syndrome. NADH cytochrome C reductase is an enzyme involved in the synthesis of neuron energy. Stress, hypometabolism, and oxidative damage may decrease physiologic reserve in the elderly and can lead to a decrease in neuron energy production and an increase in neuron damage. Thioredoxin reductase is an antioxidant that neutralizes oxidative free radicals that can cause cell death. The brain is vulnerable to oxidative free radicals because it receives 20% of the human body's oxygen supply. Finding a way to maintain the thioredoxin reductase pathway can decrease plaque formation and SCN degeneration. Inflammatory stress in mouse models can provide a pathway for studying neurodegeneration. It is hypothesized that neurodegeneration has a relationship with inflammatory cytokines such as IL-1β. The role of cytokines in sundowning can improve our understanding of the pathology. Injection of chemogenetic ligands into the eye to stimulate the SCN through the retinohypothalamic tract is another possible treatment for sundown syndrome as a similar strategy has been thought to have potential with regards to therapy for mood-related disorders. Controversy In addition to sundown syndrome not being officially recognized in the DSM-5, there is also the thought that sundown syndrome may be a phenomenon of caretakers' perception of patient agitation in the early afternoon to evening. Some studies have observed sundown syndrome occurring at times other than sunset which may suggest the symptoms associated with sundown syndrome are time-dependent rather than occurring specifically at sundown. References Alzheimer's disease Circadian rhythm Sleep disorders Psychopathological syndromes

Identity formation

Identity formation, also called identity development or identity construction, is a complex process in which humans develop a clear and unique view of themselves and of their identity. Self-concept, personality development, and values are all closely related to identity formation. Individuation is also a critical part of identity formation. Continuity and inner unity are healthy identity formation, while a disruption in either could be viewed and labeled as abnormal development; certain situations, like childhood trauma, can contribute to abnormal development. Specific factors also play a role in identity formation, such as race, ethnicity, and spirituality. The concept of personal continuity, or personal identity, refers to an individual posing questions about themselves that challenge their original perception, like "Who am I?" The process defines individuals to others and themselves. Various factors make up a person's actual identity, including a sense of continuity, a sense of uniqueness from others, and a sense of affiliation based on their membership in various groups like family, ethnicity, and occupation. These group identities demonstrate the human need for affiliation or for people to define themselves in the eyes of others and themselves. Identities are formed on many levels. The micro-level is self-definition, relations with people, and issues as seen from a personal or an individual perspective. The meso-level pertains to how identities are viewed, formed, and questioned by immediate communities and/or families. The macro-level are the connections among and individuals and issues from a national perspective. The global level connects individuals, issues, and groups at a worldwide level. Identity is often described as finite and consisting of separate and distinct parts (e.g., family, cultural, personal, professional). Theories Many theories of development have aspects of identity formation included in them. Two theories directly address the process of identity formation: Erik Erikson's stages of psychosocial development (specifically the Identity versus Role Confusion stage), James Marcia's identity status theory, and Jeffrey Arnett's theories of identity formation in emerging adulthood. Erikson's theory of identity vs. role confusion Erikson's theory is that people experience different crises or conflicts throughout their lives in eight stages. Each stage occurs at a certain point in life and must be successfully resolved to progress to the next stage. The particular stage relevant to identity formation takes place during adolescence: Identity versus Role Confusion. The Identity versus Role Confusion stage involves adolescents trying to figure out who they are in order to form a basic identity that they will build on throughout their life, especially concerning social and occupational identities. They ask themselves the existential questions: "Who am I?" and "What can I be?" They face the complexities of determining one's own identity. Erikson stated that this crisis is resolved with identity achievement, the point at which an individual has extensively considered various goals and values, accepting some and rejecting others, and understands who they are as a unique person. When an adolescent attains identity achievement, they are ready to enter the next stage of Erikson's theory, Intimacy versus Isolation, where they will form strong friendships and a sense of companionship with others. If the Identity versus Role Confusion crisis is not positively resolved, an adolescent will face confusion about future plans, particularly their roles in adulthood. Failure to form one's own identity leads to failure to form a shared identity with others, which can lead to instability in many areas as an adult. The identity formation stage of Erik Erikson's theory of psychosocial development is a crucial stage in life. Marcia's identity status theory Marcia created a structural interview designed to classify adolescents into one of four statuses of identity. The statuses are used to describe and pinpoint the progression of an adolescent's identity formation process. In Marcia's theory, identity is operationally defined as whether an individual has explored various alternatives and made firm commitments to an occupation, religion, sexual orientation, and a set of political values. The four identity statuses in James Marcia's theory are: Identity Diffusion (also known as Role Confusion): The opposite of identity achievement. The individual has not resolved their identity crisis yet by failing to commit to any goals or values and establish a future life direction. In adolescents, this stage is characterized by disorganized thinking, procrastination, and avoidance of issues and actions. Identity Foreclosure: This occurs when teenagers conform to an identity without exploring what suits them best. For instance, teenagers might follow the values and roles of their parents or cultural norms. They might also foreclose on a negative identity, or the direct opposite of their parents' values or cultural norms. Identity Moratorium: This postpones identity achievement by providing temporary shelter. This status provides opportunities for exploration, either in breadth or in-depth. Examples of moratoria common in American society include college or the military. Identity Achievement: This status is attained when the person has solved the identity issues by making commitments to goals, beliefs, and values after an extensive exploration of different areas. Jeffrey Arnett's Theories on Identity Formation in Emerging Adulthood Jeffrey Arnett's theory states that identity formation is most prominent in emerging adulthood, consisting of ages 18–25. Arnett holds that identity formation consists of indulging in different life opportunities and possibilities to eventually make important life decisions. He believes this phase of life includes a broad range of opportunities for identity formation, specifically in three different realms. These three realms of identity exploration are: Love: In emerging adulthood, individuals explore love to find a profound sense of intimacy. While trying to find love, individuals often explore their identity by focusing on questions such as: "Given the kind of person I am, what kind of person do I wish to have as a partner through life?" Work: Work opportunities that people get involved in are now centered around the idea that they are preparing for careers that they might have throughout adulthood. Individuals explore their identity by asking themselves questions such as: "What kind of work am I good at?", "What kind of work would I find satisfying for the long term", or "What are my chance of getting a job in the field that seems to suit me best?" Worldviews: It is common for those in the stage of emerging adulthood to attend college. There they may be exposed to different worldviews, compared to those they were raised in, and become open to altering their previous worldviews. Individuals who don't attend college also believe that as adult they should also decide what their beliefs and values are. Self-concept Self-concept, or self-identity, is the set of beliefs and ideas an individual has about themselves. Self-concept is different from self-consciousness, which is an awareness of one's self. Components of the self-concept include physical, psychological, and social attributes, which can be influenced by the individual's attitudes, habits, beliefs, and ideas; they cannot be condensed into the general concepts of self-image or self-esteem. Multiple types of identity come together within an individual and can be broken down into the following: cultural identity, professional identity, ethnic and national identity, religious identity, gender identity, and disability identity. Cultural identity Cultural identity is formation of ideas an individual takes based on the culture they belong to. Cultural identity relates to but is not synonymous with identity politics. There are modern questions of culture that are transferred into questions of identity. Historical culture also influences individual identity, and as with modern cultural identity, individuals may pick and choose aspects of cultural identity, while rejecting or disowning other associated ideas. Professional identity Professional identity is the identification with a profession, exhibited by an aligning of roles, responsibilities, values, and ethical standards as accepted by the profession. In business, professional identity is the professional self-concept that is founded upon attributes, values, and experiences. A professional identity is developed when there is a philosophy that is manifested in a distinct corporate culture – the corporate personality. A business professional is a person in a profession with certain types of skills that sometimes require formal training or education. Career development encompasses the total dimensions of psychological, sociological, educational, physical, economic, and chance that alter a person's career practice across the lifespan. Career development also refers to the practices from a company or organization that enhance someone's career or encourages them to make practical career choices. Training is a form of identity setting, since it not only affects knowledge but also affects a team member's self-concept. On the other hand, knowledge of the position introduces a new path of less effort to the trainee, which prolongs the effects of training and promotes a stronger self-concept. Other forms of identity setting in an organization include Business Cards, Specific Benefits by Role, and Task Forwarding. Ethnic and national identity An ethnic identity is an identification with a certain ethnicity, usually on the basis of a presumed common genealogy or ancestry. Recognition by others as a distinct ethnic group is often a contributing factor to developing this identity. Ethnic groups are also often united by common cultural, behavioral, linguistic, ritualistic, or religious traits. Processes that result in the emergence of such identification are summarized as ethnogenesis. Various cultural studies and social theory investigate the question of cultural and ethnic identities. Cultural identity adheres to location, gender, race, history, nationality, sexual orientation, religious beliefs, and ethnicity. National identity is an ethical and philosophical concept where all humans are divided into groups called nations. Members of a "nation" share a common identity and usually a common origin, in the sense of ancestry, parentage, or descent. Religious identity A religious identity is the set of beliefs and practices generally held by an individual, involving adherence to codified beliefs and rituals and study of ancestral or cultural traditions, writings, history, mythology, and faith and mystical experience. Religious identity refers to the personal practices related to communal faith along with rituals and communication stemming from such conviction. This identity formation begins with an association in the parents' religious contacts, and individuation requires that the person chooses the same or different religious identity than that of their parents. Gender identity In sociology, gender identity describes the gender with which a person identifies (i.e., whether one perceives oneself to be a man, a woman, outside of the gender binary), but can also be used to refer to the gender that other people attribute to the individual on the basis of what they know from gender role indications (social behavior, clothing, hairstyle, etc.). Gender identity may be affected by a variety of social structures, including the person's ethnic group, employment status, religion or irreligion, and family. It can also be biological in the sense of puberty. Disability identity Disability identity refers to the particular disabilities that an individual identifies with. This may be something as obvious as a paraplegic person identifying as such, or something less prominent such as a deaf person regarding themselves as part of a local, national, or global community of Deaf People Culture. Disability identity is almost always determined by the particular disabilities that an individual is born with, though it may change later in life if an individual later becomes disabled or when an individual later discovers a previously overlooked disability (particularly applicable to mental disorders). In some rare cases, it may be influenced by exposure to disabled people as with body integrity dysphoria. Political identity Political identities often form the basis of public claims and mobilization of material and other resources for collective action. One theory that explores how this occurs is social movement theory. According to Charles Tilly, the interpretation of our relationship to others ("stories") create the rationale and construct of political identity. The capacity for action is constrained by material resources and sometimes perceptions that can be manipulated by using communication strategies that support the creation of illusory ties. Interpersonal identity development Interpersonal identity development comes from Marcia's Identity Status Theory, and refers to friendship, dating, gender roles, and recreation as tools to maturity in a psychosocial aspect of an individual. Social relation can refer to a multitude of social interactions regulated by social norms between two or more people, with each having a social position and performing a social role. In a sociological hierarchy, social relation is more advanced than behavior, action, social behavior, social action, social contact, and social interaction. It forms the basis of concepts like social organization, social structure, social movement, and social system. Interpersonal identity development is composed of three elements: Categorization: Assigning everyone into categories. Identification: Associating others with certain groups. Comparison: Comparing groups. Interpersonal identity development allows an individual to question and examine various personality elements, such as ideas, beliefs, and behaviors. The actions or thoughts of others create social influences that change an individual. Examples of social influence can be seen in socialization and peer pressure, which can affect a person's behavior, thinking about one's self, and subsequent acceptance or rejection of how other people attempt to influence the individual. Interpersonal identity development occurs during exploratory self-analysis and self-evaluation, and ends at various times to establish an easy-to-understand and consolidative sense of self or identity. Interaction During interpersonal identity development, an exchange of propositions and counter-propositions occurs, resulting in a qualitative transformation of the individual. The aim of interpersonal identity development is to resolve the undifferentiated facets of an individual, which are found to be indistinguishable from others. Given this, and with other admissions, the individual is led to a contradiction between the self and others, and forces the withdrawal of the undifferentiated self as truth. To resolve the incongruence, the person integrates or rejects the encountered elements, which results in a new identity. During each of these exchanges, the individual must resolve the exchange before facing future ones. The exchanges are endless since the changing world constantly presents exchanges between individuals and thus allows individuals to redefine themselves constantly. Collective identity Collective identity is a sense of belonging to a group (the collective). If it is strong, an individual who identifies with the group will dedicate their lives to the group over individual identity: they will defend the views of the group and take risks for the group, often with little to no incentive or coercion. Collective identity often forms through a shared sense of interest, affiliation, or adversity. The cohesiveness of the collective identity goes beyond the community, as the collective experiences grief from the loss of a member. Social support Individuals gain a social identity and group identity from their affiliations in various groups, which include: family, ethnicity, education and occupational status, friendship, dating, and religion. Family One of the most important affiliations is that of the family, whether they be biological, extended, or even adoptive families. Each has its own influence on identity through the interaction that takes place between the family members and with the individual. Researchers and theorists state that an individual's identity (more specifically an adolescent's identity) is influenced by the people around them and the environment in which they live. If a family does not have integration, it is likely to cause identity diffusion (one of James Marcia's four identity statuses, where an individual has not made commitments and does not try to make them), and applies to both males and females. Peer relationships Morgan and Korobov performed a study in order to analyze the influence of same-sex friendships in the development of one's identity. This study involved the use of 24 same-sex college student friendship triads, consisting of 12 males and 12 females, with a total of 72 participants. Each triad was required to have known each other for a minimum of six months. A qualitative method was chosen, as it is the most appropriate in assessing the development of identity. Semi-structured group interviews took place, where the students were asked to reflect on stories and experiences concerning relationship problems. The results showed five common responses when assessing these relationship problems: joking about the relationship's problems, providing support, offering advice, relating others' experiences to their own similar experiences, and providing encouragement. The results concluded that adolescents actively construct their identities through common themes of conversation between same-sex friendships; in this case, involving relationship issues. The common themes of conversation that close peers seem to engage in helping to further their identity formation in life. Influences on identity Cognitive influences Cognitive development influences identity formation. When adolescents are able to think abstractly and reason logically, they have an easier time exploring and contemplating possible identities. When an adolescent has advanced cognitive development and maturity, they tend to resolve identity issues more so than age mates that are less cognitively developed. When identity issues are solved quicker and better, there is more time and effort put into developing that identity. Scholastic influences Adolescents that have a post-secondary education tend to make more concrete goals and stable occupational commitments. Going to college or university can influence identity formation in a productive way. The opposite can also be true, where identity influences education and academics. Education's effect on identity can be beneficial for the individual's identity; the individual becomes educated on different approaches and paths to take in the process of identity formation. Sociocultural influences Sociocultural influences are those of a broader social and historical context. For example, in the past, adolescents would likely just adopt the job or religious beliefs that were expected of them or that were akin to their parents. Today, adolescents have more resources to explore identity choices and more options for commitments. This influence is becoming less significant due to the growing acceptance of identity options that were once less accepted. Many of the identity options from the past are becoming unrecognized and less popular today. The changing sociocultural situation is forcing individuals to develop a unique identity based on their own aspirations. Sociocultural influences play a different role in identity formation now than they have in the past. Parenting influences The type of relationship that adolescents have with their parents has a significant role in identity formation. For example, when there is a solid and positive relationship between parents and adolescents, they are more likely to feel freedom in exploring identity options for themselves. A study found that for boys and girls, identity formation is positively influenced by parental involvement, specifically in the areas of support, social monitoring, and school monitoring. In contrast, when the relationship is not as close and the fear of rejection or discontentment from the parent or other guardians is present, they are more likely to feel less confident in forming a separate identity from their parents. Cyber-socializing and the Internet The Internet is becoming an extension of the expressive dimension of adolescence. On the Internet, youth talk about their lives and concerns, design the content that they make available to others, and assess the reactions of others to it in the form of optimized and electronically mediated social approval. When connected, youth speak of their daily routines and lives. With each post, image or video they upload, they can ask themselves who they are and try out profiles that differ from the ones they practice in the "real" world. See also Otium Poverty Workism Self-Schema Social theory Social defeat Lev Vygotsky Social stigma Social identity Self-discovery Peer pressure Cultural identity Erving Goffman Religious Values Consumer culture Moral development Identity performance Wishful Identification George Herbert Mead In-group and out-group Symbolic interactionism Social comparison theory Identification (psychology) Identity crisis (psychology) Genealogical bewilderment Values (Western philosophy) Georg Wilhelm Friedrich Hegel References Sources Further reading A Erdman, A Study of Bisexual Identity Formation. 2006. A Portes, D MacLeod, What Shall I Call Myself? Hispanic Identity Formation in the Second Generation. Ethnic and Racial Studies, 1996. AS Waterman, Identity Formation: Discovery or Creation? The Journal of Early Adolescence, 1984. AS Waterman, Finding Someone to be: Studies on the Role of Intrinsic Motivation in Identity Formation. Identity: An International Journal of Theory and Research, 2004. A Warde, Consumption, Identity-Formation and Uncertainty. Sociology, 1994. A Wendt, Collective Identity Formation and the International State. The American Political Science Review, 1994. CA Willard, 1996 — Liberalism and the Problem of Knowledge: A New Rhetoric for Modern Democracy, Chicago: University of Chicago Press. ; OCLC 260223405 CG Levine, JE Côté, JE Cãotâ, Identity Formation, Agency, and Culture: a social psychological synthesis. 2002. G Robert, C Bate, C Pope, J Gabbay, A le May, Processes and dynamics of identity formation in professional organizations. 2007. HL Minton, GJ McDonald, Homosexual identity formation as a developmental process. MD Berzonsky, Self-construction over the life-span: A process perspective on identity formation. Advances in personal construct theory, 1990. RB Hall, (Reviewer) Uses of the Other: 'The East' in European Identity Formation (by IB Neumann) University of Minnesota Press, Minneapolis, 1999. 248 pages. International Studies Review Vol.3, Issue 1, Pages 101-111 VC Cass, Sexual orientation identity formation: A Western phenomenon. Textbook of homosexuality and mental health, 1996. External links A positive approach to the identity formation of biracial children ". ematusov.soe.udel.edu Identity: An International Journal of Theory and Research. "Identity" is the official journal of the Society for Research on Identity Formation. Social philosophy Conceptions of self Career development Identity (social science)

Alice in Wonderland syndrome

Alice in Wonderland Syndrome (AIWS), also known as Todd's Syndrome or Dysmetropsia, is a neurological disorder that distorts perception. People with this syndrome may experience distortions in their visual perception of objects, such as appearing smaller (micropsia) or larger (macropsia), or appearing to be closer (pelopsia) or farther (teleopsia) than they are. Distortion may also occur for senses other than vision. The cause of Alice in Wonderland Syndrome is currently not known, but it has often been associated with migraines, head trauma, or viral encephalitis caused by Epstein–Barr Virus Infection. It is also theorized that AIWS can be caused by abnormal amounts of electrical activity, resulting in abnormal blood flow in the parts of the brain that process visual perception and texture. Although there are cases of Alice in Wonderland Syndrome in both adolescents and adults, it is most commonly seen in children. Classification The classification is not universally agreed upon in literature, however, some authors distinguish true Alice in Wonderland syndrome based solely on symptoms related to alterations in a person's body image. In contrast, they utilize the term "Alice in Wonderland-like syndrome" to encompass symptoms associated with changes in perception of vision, time, hearing, touch, or other external perceptions. Due to the classification of all the clinical features seen in Alice in Wonderland, the table below illustrates theses features and symptoms by type with Type C having a combination of Type A and Type B symptoms. Signs and symptoms With over 60 associated symptoms, AIWS affects the sense of vision, sensation, touch, and hearing, as well as the perception of one's body image. Migraines, nausea, dizziness, and agitation are also commonly associated symptoms with Alice in Wonderland syndrome. Less frequent symptoms also include: loss of limb control and coordination, memory loss, lingering touch and sound sensations, and emotional instability. Alice in Wonderland syndrome is often associated with distortion of sensory perception, which involves visual, somatosensory, and non-visual symptoms. AIWS is characterized by the individual being able to recognize the distortion in the perception of their own body and is episodic. AIWS episodes vary in length from person to person. Episodes typically last from a few minutes to an hour, and each episode may vary in experience. Visual distortions Individuals with AIWS can experience illusions of expansion, reduction, or distortion of their body image, such as microsomatognosia (feeling that their own body or body parts are shrinking), or macrosomatognosia (feeling that their body or body parts are growing taller or larger). These changes in perception are collectively known as metamorphopsias, or Lilliputian hallucinations, which refer to objects appearing either smaller or larger than reality. People with certain neurological diseases may also experience similar visual hallucinations. Within the category of Lilliputian hallucinations, people may experience either micropsia or macropsia. Micropsia is an abnormal visual condition, usually occurring in the context of visual hallucination, in which the affected person sees objects as being smaller than they are in reality. Macropsia is a condition where the individual sees everything larger than it is. These visual distortions are sometimes classified as "Alice in Wonderland-like syndrome" instead of true Alice in Wonderland syndrome but are often still classified as Alice in Wonderland syndrome by health professionals and researchers since the distinction is not official. Other distortions include teleopsia (objects are perceived further than they actually are) and pelopsia (objects are perceived closer than they actually are). Depersonalization/derealization Along with size, mass, and shape distortions of the body, those with Alice in Wonderland syndrome often experience a feeling of disconnection from one's own body, feelings, thoughts, and environment known as depersonalization-derealization disorder. Depersonalization is a term specifically used to express a true detachment from their personal self and identity. It is described as being an observer completely outside of their own actions and behaviors. Derealization is seen as "dreamlike, empty, lifeless, or visually distorted." Drug and alcohol use can exacerbate this symptom into psychosis. Hearing and time distortions Individuals experiencing Alice in Wonderland syndrome can also often experience paranoia as a result of disturbances in sound perception. These disturbances can include the amplification of soft sounds or the misinterpretation of common sounds. Other auditory changes include distortion in pitch and tone and hearing indistinguishable and strange voices, noises, or music. A person affected by AIWS may also lose a sense of time, a problem similar to the lack of spatial perspective brought on by visual distortion. This condition is known as tachysensia. For those with tachysensia, time may seem to pass very slowly, similar to an LSD experience, and the lack of time and space perspective can also lead to a distorted sense of velocity. For example, an object could be moving extremely slowly in reality, but to a person experiencing time distortions, it could seem that the object was sprinting uncontrollably along a moving walkway, leading to severe, overwhelming disorientation. Having symptoms of tachysensia is correlated with various underlying conditions, including substance use, migraine, epilepsy, head trauma, and encephalitis. Regardless of an individual's disease diagnosis, tachysensia is often included as a symptom associated with Alice in Wonderland Syndrome since it is classified as a perceptual distortion. Therefore, a person can be described as having Alice in Wonderland syndrome even if that person is experiencing tachysensia due to an underlying condition. Causes Because AlWS is not commonly diagnosed and documented, it is difficult to estimate what the main causes are. The cause of over half of the documented cases of Alice in Wonderland syndrome is unknown. Complete and partial forms of the AIWS exist in a range of other disorders, including epilepsy, intoxicants, infectious states, fevers, and brain lesions. Furthermore, the syndrome is commonly associated with migraines, as well as excessive screen use in dark spaces and the use of psychoactive drugs. It can also be the initial symptom of the Epstein–Barr virus (see mononucleosis), and a relationship between the syndrome and mononucleosis has been suggested. Within this suggested relationship, Epstein–Barr virus appears to be the most common cause in children, while for adults it is more commonly associated with migraines. Infectious diseases A 2021 review found that infectious diseases are the most common cause of Alice in Wonderland syndrome, especially in pediatrics. Some of these infectious agents included Epstein–Barr virus, Varicella Zoster virus, Influenza, Zika, Coxsackievirus, Plasmodium falciparum protozoa, and Mycoplasma pneumonia/Streptococcus pyogenes bacteria. The Association of Alice in Wonderland syndrome is most commonly seen with the Epstein-Barr virus. However, pathogenesis is not well understood beyond these reviews. In some instances, Alice in Wonderland syndrome was reported to be associated with an Influenza A infection. Cerebral hypotheses Alice in Wonderland syndrome can be caused by abnormal amounts of electrical activity resulting in abnormal blood flow in the parts of the brain that process visual perception and texture. Nuclear medical techniques using technetium, performed on individuals during episodes of Alice in Wonderland syndrome, have demonstrated that Alice in Wonderland Syndrome is associated with reduced cerebral perfusion in various cortical regions (frontal, parietal, temporal and occipital), both in combination and in isolation. One hypothesis is that any condition resulting in a decrease in perfusion of the visual pathways or visual control centers of the brain may be responsible for the syndrome. For example, one study used single photon emission computed tomography to demonstrate reduced cerebral perfusion in the temporal lobe in people with Alice in Wonderland syndrome. Other theories suggest the syndrome is a result of non-specific cortical dysfunction (e.g. from encephalitis, epilepsy, decreased cerebral blood flow), or reduced blood flow to other areas of the brain. Other theories suggest that distorted body image perceptions stem from within the parietal lobe. This has been demonstrated by the production of body image disturbances through electrical stimulation of the posterior parietal cortex. Other researchers suggest that metamorphopsias, or visual distortions, may be a result of reduced perfusion of the non-dominant posterior parietal lobe during migraine episodes. Throughout all the neuroimaging studies, several cortical regions (including the temporoparietal junction within the parietal lobe, and the visual pathway, specifically the occipital lobe) are associated with the development of Alice in Wonderland syndrome symptoms.[1] Migraines 1 in 10 people who experience migraines have symptoms of Alice in Wonderland syndrome. The role of migraines in Alice in Wonderland syndrome is still not understood, but both vascular and electrical theories have been suggested. For example, visual distortions may be a result of transient, localized ischemia in areas of the visual pathway during migraine attacks. In addition, a spreading wave of depolarization of cells (particularly glial cells) in the cerebral cortex during migraine attacks can eventually activate the trigeminal nerve's regulation of the vascular system. The intense cranial pain during migraines is due to the connection of the trigeminal nerve with the thalamus and thalamic projections onto the sensory cortex. Alice in Wonderland syndrome symptoms can precede, accompany, or replace the typical migraine symptoms. Typical migraines (aura, visual derangements, hemicrania headache, nausea, and vomiting) are both a cause and an associated symptom of Alice in Wonderland Syndrome. Alice in Wonderland Syndrome is associated with macrosomatognosia which can mostly be experienced during migraine auras. Genetic and environmental influence While there currently is no identified genetic locus/loci associated with Alice in Wonderland syndrome, observations suggest that a genetic component may exist but the evidence so far is inconclusive. There is also an established genetic component for migraines which may be considered to be a possible cause and influence for hereditary Alice in Wonderland syndrome. Though most frequently described in children and adolescents, observational studies have found that many parents of children experiencing Alice in Wonderland syndrome have also experienced similar symptoms themselves, though often unrecognized. Family history may then be a potential risk factor for Alice in Wonderland syndrome. One example of environmental influences on the incidence of Alice in Wonderland syndrome includes the drug use and toxicity of topiramate. Other reports of tyramine usage and the association with Alice in Wonderland syndrome has been reported but current evidence is inconclusive. Further research is required to establish the genetic and environmental influences on Alice in Wonderland syndrome. The neuronal effect of cortical spreading depression (CSD) on TPO-C may demonstrate the link between migraines and Alice in Wonderland Syndrome. As children experience Alice in Wonderland Syndrome more than adults, it is hypothesized that structural differences in the brain between children and adults may play a role in the development of this syndrome. Diagnosis Alice in Wonderland syndrome is not part of any major classifications like the ICD-10 and the DSM-5. Since there are no established diagnostic criteria for Alice in Wonderland syndrome, and because Alice in Wonderland syndrome is a disturbance of perception rather than a specific physiological condition, there is likely to be a large degree of variability in the diagnostic process and thus it can be poorly diagnosed. Often, the diagnosis can be presumed when other causes have been ruled out. Additionally, Alice in Wonderland syndrome can be presumed if the patient presents symptoms along with migraines and complains of onset during the day (although it can also occur at night). Ideally, a definite diagnosis requires a thorough physical examination, proper history taking from episodes and occurrences, and a concrete understanding of the signs and symptoms of Alice in Wonderland syndrome for differential diagnosis. A person experiencing Alice in Wonderland syndrome may be reluctant to describe their symptoms out of fear of being labeled with a psychiatric disorder, which can contribute to the difficulty in diagnosing Alice in Wonderland syndrome. In addition, younger individuals may struggle to describe their unusual symptoms, and thus, one recommended approach is to encourage children to draw their visual illusions during episodes. Cases that are suspected should warrant tests and exams such as blood tests, ECG, brain MRI, and other antibody tests for viral antibody detection. Differential diagnosis requires three levels of conceptualization. Symptoms need to be distinguished from other disorders that involve hallucinations and illusions. It is usually easy to rule out psychosis as those with Alice in Wonderland syndrome are typically aware that their hallucinations and distorted perceptions are not 'real'. Once these symptoms are distinguished and identified, the most likely cause needs to be established. Finally, the diagnosed condition needs to be evaluated to see if the condition is responsible for the symptoms that the individual is presenting. Given the wide variety of metamorphopsias and other distortions, it is not uncommon for Alice in Wonderland syndrome to be misdiagnosed or confused with other etiologies. Anatomical relation An area of the brain that is important to the development of Alice in Wonderland syndrome is the temporal-parietal-occipital carrefour (TPO-C), where TPO-C region is the meeting point of temporooccipital, parietooccipital, and temporoparietal junctions in the brain. The TPO-C region is also crucial as it is the location where somatosensory and visual information are interpreted by the brain to generate any internal or external manifestations. Thus, modifications to these regions of the brain may trigger the cause of Alice in Wonderland Syndrome and body schema disorders simultaneously . Depending on which portion of the brain is damaged, the symptoms of Alice in Wonderland syndrome may differ. For example, it has been reported that injury to the anterior portion of the brain is more likely to be correlated to more complex and a wider range of symptoms, whereas damage to the occipital region has mainly been associated with only simple visual disturbances. Prognosis The symptoms of Alice in Wonderland syndrome themselves are not physically harmful for the experiencer. Since there is no established treatment for Alice in Wonderland syndrome, prognosis varies between patients and is based on whether an underlying cause has been identified. In many cases, the intensity of the episodes and symptoms decline. Since it is predominately a benign condition, treatment isn't always required. Limitations of the prognosis of Alice in Wonderland syndrome are due to the disorder's low prevalence. Because of this, symptoms require careful evaluation and observation by healthcare professionals. Some cases include reoccurring symptoms in which other medical conditions have to be ruled out before diagnosing AIWS If Alice in Wonderland Syndrome is caused by underlying conditions, symptoms typically occur during the underlying disease and can last from few days to months. In most cases, symptoms may disappear either spontaneously, with the treatment of underlying causes, or after reassurances that symptoms are momentary and harmless. In some cases, individuals experience only a few episodes of symptoms. In other cases, symptoms may repeat over several episodes before resolution. In rare cases, symptoms continue to manifest years after the initial experience, sometimes with the development of new visual disorders or migraines. In these cases, medication can be introduced to counteract some of these distortions and manifestations. However, medications may also have inducing effects. Treatment At present (2024), Alice in Wonderland Syndrome has no standardized treatment plan. Tests including electroencephalogram (EEG) and magnetic resonance imaging (MRI) are used to view brain activity to examine possible brain injury or deficits. Since symptoms of Alice in Wonderland syndrome often disappear, either spontaneously on their own, or with the treatment of the underlying disease, most clinical and non-clinical Alice in Wonderland Syndrome cases are considered to be benign. In cases of Alice in Wonderland syndrome caused by underlying chronic disease, however, symptoms tend to reappear during the active phase of the underlying cause (e.g., migraine, epilepsy). If treatment of Alice in Wonderland Syndrome is determined necessary and useful, it should be focused on treating the suspected underlying disease. Treatment of these underlying conditions mostly involves prescription medications such as antiepileptics, migraine prophylaxis, antivirals, or antibiotics. Antipsychotics are rarely used in treating Alice in Wonderland Syndrome symptoms due to their minimal effectiveness. There are also rare cases in which these prescription medications ,specifically antipsychotics, may worsen psychosis and psychotic symptoms due to the severity of distortions. In 2011, a patient was examined for having verbal auditory hallucinations (VAHs) and functional MRI (fMRI) was employed to localize cerebral activity during self-reported VAHs. Repetitive transcranial magnetic stimulation (rTSMS) was used on the patient's Brodmann's area 40, in charge of meaning and phonology, at a frequency of 1 Hz at T3P3. After the second week of treatment, all VAHs and sensory distortions have no effected on the patient and went through a full remission. Follow up appointments were conducted with no signs of any symptoms. By month 8, the symptoms returned. A second treatment was done with complete remission. Migraine prophylaxis Treatment methods revolving around migraine prophylaxis include medications and following a low-tyramine diet. Drugs that may be used to prevent migraines include anticonvulsants, antidepressants, calcium channel blockers, and beta blockers. Other treatments that have been explored for migraines include repetitive transcranial magnetic stimulation (rTMS). However, further research is needed to establish the effectiveness of this treatment regime. Epidemiology The lack of established diagnostic criteria or large-scale epidemiological studies, low awareness of the syndrome, and the unstandardized diagnosis criteria and definition for Alice in Wonderland syndrome mean that the exact prevalence of the syndrome is currently unknown. One study on 3,224 adolescents in Japan demonstrated the occurrence of macropsia and micropsia to be 6.5% in boys and 7.3% in girls, suggesting that the symptoms of Alice in Wonderland syndrome may not be particularly rare. This also seems to suggest a difference in the male-to-female ratio of people with Alice in Wonderland syndrome. However, according to other studies, it appears that the male/female ratio is dependent on the age range being observed. Studies showed that younger males (age range of 5 to 14 years) were 2.69 times more likely to experience Alice in Wonderland syndrome than girls of the same age, while there were no significant differences between students of 13 to 15 years of age. Conversely, female students (16- to 18-year-olds) showed a significantly greater prevalence. Alice in Wonderland syndrome is more frequently seen in children and young adults. The average age of the start of Alice in Wonderland syndrome is six years old, but it is typical for some people to experience the syndrome from childhood up to their late twenties. Because many parents who have Alice in Wonderland syndrome report their children having it as well, the condition is thought possibly to be hereditary. Some parents report not realizing they have experienced Alice in Wonderland syndrome symptoms until after their children have been diagnosed, further indicating that many cases of Alice in Wonderland syndrome likely go unrecognized and under-reported. Research is still being expanded upon and developed on this syndrome in a multitude of different regions and specialties. Future studies are encouraged to include global collaborative efforts that may help improve understanding of Alice in Wonderland syndrome and its epidemiology. History The syndrome is sometimes called Todd's syndrome, about a description of the condition in 1955 by Dr. John Todd (1914–1987), a British consultant psychiatrist at High Royds Hospital at Menston in West Yorkshire ('AIWS had been described by American Neurologist Caro Lippman in 1952, but Todd's report was the most influential'). Todd discovered that several of his patients experienced severe headaches causing them to see and perceive objects as greatly out of proportion. In addition, they had altered sense of time and touch, as well as distorted perceptions of their own body. Despite having migraine headaches, none of these patients had brain tumors, damaged eyesight, or mental illness that could have accounted for these and similar symptoms. They were all able to think lucidly and could distinguish hallucinations from reality, however, their perceptions were distorted. Dr. Todd speculated that author Lewis Carroll had used his own migraine experiences as a source of inspiration for his famous 1865 novel Alice's Adventures in Wonderland. Carroll's diary reveals that, in 1856, he consulted William Bowman, an ophthalmologist, about the visual manifestations of the migraines he regularly experienced. In Carroll's diaries, he often wrote of a "bilious headache" that came coupled with severe nausea and vomiting. In 1885, he wrote that he had "experienced, for the second time, that odd optical affection of seeing moving fortifications, followed by a headache". Carroll wrote two books about Alice, the heroine after which the syndrome is named. In the story, Alice experiences several strange feelings that overlap with the characteristics of the syndrome, such as slowing time perception. In chapter two of Alice's Adventures in Wonderland (1865), Alice's body shrinks after drinking from a bottle labeled "DRINK ME", after which she consumed a cake that made her so large that she almost touched the ceiling. These features of the story describes the macropsia and micropsia that are so characteristic to this disease. These symptoms have been reported before in scientific literature, including World War I and II soldiers with occipital lesions, so Todd understood that he was not the first person to discover this phenomenon. Additionally, as early as 1933, other researchers such as Coleman and Lippman had compared these symptoms to the story of Alice in Wonderland. Caro Lippman was the first to hypothesize that the bodily changes that Alice encounters mimicked those of Lewis Carroll's migraine symptoms. Others suggest that Carroll may have familiarized himself with these distorted perceptions through his knowledge of hallucinogenic mushrooms. It has been suggested that Carroll would have been aware of mycologist Mordecai Cubitt Cooke's description of the intoxicating effects of the fungus Amanita muscaria (commonly known as the fly agaric or fly amanita), in his books The Seven Sisters of Sleep and A Plain and Easy Account of British Fungi. Notable cases In 2018 it was suggested that the Italian artist and writer Giorgio de Chirico may have suffered from the syndrome. Society and culture Gulliver's Travels Alice in Wonderland syndrome's symptom of micropsia has also been related to Jonathan Swift's novel Gulliver's Travels. It has been referred to as "Lilliput sight" and "Lilliputian hallucination", a term coined by British physician Raoul Leroy in 1909. Alice in Wonderland Alice in Wonderland syndrome was named after Lewis Carroll's 19th-century novel Alice's Adventures in Wonderland. In the story, Alice, the titular character, experiences numerous situations similar to those of micropsia and macropsia. The thorough descriptions of metamorphosis clearly described in the novel were the first of their kind to depict the bodily distortions associated with the condition. There is some speculation that Carroll may have written the story using his own direct experience with episodes of micropsia resulting from the numerous migraines he was known to experience. It has also been suggested that Carroll may have had temporal lobe epilepsy. House The condition is diagnosed in the season 8 episode "Risky Business". Secret Garden In episode ten of the Korean drama Secret Garden, the leading man, Kim Joo Won, suspects that he is suffering from Alice in Wonderland syndrome. Doctors In April 2020, a case of Alice in Wonderland syndrome was covered in an episode of the BBC daytime soap opera Doctors, when patient Hazel Gilmore (Alex Jarrett) experienced it. See also Charles Bonnet syndrome Cortical homunculus Red Queen hypothesis References External links Neurological disorders Psychopathological syndromes Epstein–Barr virus–associated diseases Symptoms and signs of mental disorders Hallucinations Alice's Adventures in Wonderland

VUCA

VUCA is an acronym based on the leadership theories of Warren Bennis and Burt Nanus, to describe or to reflect on the volatility, uncertainty, complexity and ambiguity of general conditions and situations. The U.S. Army War College introduced the concept of VUCA in 1987, to describe a more complex multilateral world perceived as resulting from the end of the Cold War. More frequent use and discussion of the term began from 2002. It has subsequently spread to strategic leadership in organizations, from for-profit corporations to education. Meaning The VUCA framework provides a lens through which organizations can interpret their challenges and opportunities. It emphasizes strategic foresight, insight, and the behavior of entities within organizations. Furthermore, it highlights both systemic and behavioral failures often associated with organizational missteps. V = Volatility: Characterizes the rapid and unpredictable nature of change. U = Uncertainty: Denotes the unpredictability of events and issues. C = Complexity: Describes the intertwined forces and issues, making cause-and-effect relationships unclear. A = Ambiguity: Points to the unclear realities and potential misunderstandings stemming from mixed messages. These elements articulate how organizations perceive their current and potential challenges. They establish the parameters for planning and policy-making. Interacting in various ways, they can either complicate decision-making or enhance the ability to strategize, plan, and progress. Essentially, VUCA lays the groundwork for effective management and leadership. The VUCA framework is a conceptual tool that underscores the conditions and challenges organizations face when making decisions, planning, managing risks, driving change, and solving problems. It primarily shapes an organization's ability to: Anticipate the key issues that emerge. Understand the repercussions of particular issues and actions. Appreciate how variables interrelate. Prepare for diverse scenarios and challenges. Interpret and tackle pertinent opportunities. VUCA serves as a guideline for fostering awareness and preparedness in various sectors, including business, the military, education, and government. It provides a roadmap for organizations to develop strategies for readiness, foresight, adaptation, and proactive intervention. Themes VUCA, as a system of thought, revolves around an idea expressed by Andrew Porteous: "Failure in itself may not be a catastrophe. Still, failure to learn from failure is." This perspective underlines the significance of resilience and adaptability in leadership. It suggests that beyond mere competencies, it is behavioural nuances, like the ability to learn from failures and adapt, that distinguish exceptional leaders from average ones. Leaders using VUCA as a guide often see change not just as inevitable but as something to anticipate. Within VUCA, several thematic areas of consideration emerge, providing a framework for introspection and evaluation: Knowledge management and sense-making: An exploration into how we organize and interpret information. Planning and readiness considerations: A reflection on our preparedness for unforeseen challenges. Process management and resource systems: A contemplation on our efficiency in resource utilization and system deployment. Functional responsiveness and impact models: Understanding our capacity to adapt to changes. Recovery systems and forward practices: An inquiry into our resilience and future-oriented strategies. Systemic failures: A philosophical dive into organizational vulnerabilities. Behavioural failures: Exploring the human tendencies that lead to mistakes. Within the VUCA system of thought, an organization's ability to navigate these challenges is closely tied to its foundational beliefs, values, and aspirations. Those enterprises that consider themselves prepared and resolved align their strategic approach with VUCA's principles, signaling a holistic awareness. The essence of VUCA philosophy also emphasizes the need for a deep-rooted understanding of one's environment, spanning technical, social, political, market, and economic realms. Psychometrics which measure fluid intelligence by tracking information processing when faced with unfamiliar, dynamic, and vague data can predict cognitive performance in VUCA environments. Social categorization Volatility Volatility is the V component of VUCA, which refers to the different situational social-categorizations of people due to specific traits or reactions that stand out in particular situations. When people act based on a specific situation, there is a possibility that the public categorizes them into a different group than they were in a previous situation. These people might respond differently to individual situations due to social or environmental cues. The idea that situational occurrences cause certain social categorization is known as volatility and is one of the main aspects of self-categorization theory. Sociologists use volatility to better understand the impacts of stereotypes and social categorization on the situation at hand and any external forces that may cause people to perceive others differently. Volatility is the changing dynamic of social categorization in environmental situations. The dynamic can change due to any shift in a situation, whether social, technical, biological, or anything else. Studies have been conducted, but finding the specific component that causes the change in situational social categorization has proven challenging. Two distinct components link individuals to their social identities. The first component is normative fit, which pertains to how a person aligns with the stereotypes and norms associated with their particular identity. For instance, when a Hispanic woman is cleaning the house, people often associate gender stereotypes with the situation, while her ethnicity is not a central concern. However, when this same woman eats an enchilada, ethnicity stereotypes come to the forefront, while her gender is not the focal point. The second social cue is comparative fit. This is when a specific characteristic or trait of a person is prominent in certain situations compared to others. For example, as mentioned by Bodenhausen and Peery, when there is one woman in a room full of men. She stands out, because she is the only one of her gender. However, all of the men are clumped together because they do not have any specific traits that stand out. Comparative fit shows that people categorize others based on the relative social context. In a particular situation, particular characteristics are made obvious because others around that individual do not possess that characteristic. However, in other cases, this characteristic may be the norm and would not be a key characteristic in the categorization process. People can be less critical of the same person in different scenarios. For example, when looking at an African American man on the street in a low-income neighborhood and the same man inside a school in a high-income neighborhood, people will be less judgmental when seeing him in school. Nothing else has changed about this man, other than his location. When individuals are spotted in certain social contexts, the basic-level categories are forgotten, and the more partial categories are brought to light. This helps to describe the problems of situational social-categorization. This also illustrates how stereotypes can shift the perspectives of those around an individual. Uncertainty Uncertainty in the VUCA framework occurs when the availability or predictability of information in events is unknown. Uncertainty often occurs in volatile environments consisting of complex unanticipated interactions. Uncertainty may occur with the intention to imply causation or correlation between the events of a social perceiver and a target. Situations where there is either a lack of information to prove why perception is in occurrence or informational availability but lack of causation, are where uncertainty is salient. The uncertainty component of the framework serves as a grey area and is compensated by the use of social categorization and/or stereotypes. Social categorization can be described as a collection of people that have no interaction but tend to share similar characteristics. People tend to engage in social categorization, especially when there is a lack of information surrounding the event. Literature suggests that default categories tend to be assumed in the absence of any clear data when referring to someone's gender or race in the essence of a discussion. Individuals often associate general references (e.g. people, they, them, a group) with the male gender, meaning people = male. This usually occurs when there is insufficient information to distinguish someone's gender clearly. For example, when discussing a written piece of information, most assume the author is male. If an author's name is unavailable (due to lack of information), it is difficult to determine the gender of the author through the context of whatever was written. People automatically label the author as male without having any prior basis of gender, thus placing the author in a social category. This social categorization happens in this example, but people will also assume someone is male if the gender is not known in many other situations as well. Social categorization occurs in the realm of not only gender, but also race. Default assumptions may be made, like in gender, to the race of an individual or a group based on prior known stereotypes. For example, race-occupation combinations such as basketball or golf players usually receive race assumptions. Without any information on the individual's race, people usually assume a basketball player is black, and a golf player is white. This is based upon stereotypes because each sport tends to be dominated by a single race. In reality, there are other races within each sport. Complexity Complexity is the C component of VUCA, which refers to the interconnectivity and interdependence of multiple parts in a system. When conducting research, complexity is a component that scholars have to keep in mind. The results of a deliberately controlled environment are unexpected because of the non-linear interaction and interdependencies within different groups and categories. In a sociological aspect, the VUCA framework is utilized in research to understand social perception in the real world and how that plays into social categorization and stereotypes. Galen V. Bodenhausen and Destiny Peery's article, Social Categorization and Stereotyping In vivo: The VUCA Challenge, focused on researching how social categories impacted the process of social cognition and perception. The strategy used to conduct the research is to manipulate or isolate a single identity of a target while keeping all other identities constant. This method clearly shows how a specific identity in a social category can change one's perception of other identities, thus creating stereotypes. There are problems with categorizing an individual's social identity due to the complexity of an individual's background. This research fails to address the complexity of the real world and the results from this highlighted an even greater picture of social categorization and stereotyping. Complexity adds many layers of different components to an individual's identity and creates challenges for sociologists trying to examine social categories. In the real world, people are far more complex than a modified social environment. Individuals identify with more than one social category, which opens the door to a more profound discovery about stereotyping. Results from research conducted by Bodenhausen reveal that specific identities are more dominant than others. Perceivers who recognize these distinct identities latch on to them and associate their preconceived notion of such identity and make initial assumptions about the individuals and hence stereotypes are created. Conversely, perceivers who share some identities with the target tend to be more open-minded. They consider multiple social identities simultaneously, a phenomenon known as cross-categorization effects. Some social categories are nested within larger categorical structures, making subcategories more salient to perceivers. Cross-categorization can trigger both positive and negative effects. On the positive side, perceivers become more open-minded and motivated to delve deeper into their understanding of the target, moving beyond dominant social categories. However, cross-categorization can also result in social invisibility, where some cross-over identities diminish the visibility of others, leading to "intersectional invisibility" where neither social identity stands out distinctly and is overlooked. Ambiguity Ambiguity is the A component of VUCA. This refers to when the general meaning of something is unclear even when an appropriate amount of information is provided. Many get confused about the meaning of ambiguity. It is similar to the idea of uncertainty, but they have different factors. Uncertainty is when relevant information is unavailable and unknown, and ambiguity where relevant information is available but the overall meaning is still unknown. Both uncertainty and ambiguity exist in our culture today. Sociologists use ambiguity to determine how and why an answer has been developed. Sociologists focus on details such as if there was enough information present and if the subject had the full knowledge necessary to make a decision. and why did he/she come to their specific answer. Ambiguity is considered one of the leading causes of conflict within organizations. Ambiguity often prompts individuals to make assumptions, including those related to race, gender, sexual orientation, and even class stereotypes. When people possess some information but lack a complete answer, they tend to generate their own conclusions based on the available relevant information. For instance, as Bodenhausen notes, we may occasionally encounter individuals who possess a degree of androgyny, making it challenging to determine their gender. In such cases, brief exposure might lead to misclassifications based on gender-atypical features, such as very long hair on a man or very short hair on a woman. Ambiguity can result in premature categorizations, potentially leading to inaccurate conclusions due to the absence of crucial details. Sociologists suggest that ambiguity can fuel racial stereotypes and discrimination. In a South African study, white participants were shown images of racially mixed faces and asked to categorize them as European or African. Since all the participants were white, they struggled to classify these mixed-race faces as European and instead labeled them as African. This difficulty arose due to the ambiguity present in the images. The only information available to the participants was the subjects' skin tone and facial features. Despite having this information, the participants still couldn't confidently determine the ethnicity because the individuals didn't precisely resemble their own racial group. Responses and revisions Levent Işıklıgöz has suggested that the C of VUCA be changed from complexity to chaos, arguing that it is more suitable according to our era. Bill George, a professor of management practice at Harvard Business School, argues that VUCA calls for a leadership response which he calls VUCA 2.0: Vision, understanding, courage and adaptability. George's response seems a minor adaptation of Bob Johansen's VUCA prime: Vision, understanding, clarity and agility German academic Ali Aslan Gümüsay adds "paradox" to the acronym, calling it VUCA + paradox or VUCAP. See also Antifragile (disambiguation) Cynefin framework Fear, uncertainty, and doubt (FUD) Global Simplicity Index Goldilocks process Innovation butterfly Software bug References Business models

Schema (psychology)

In psychology and cognitive science, a schema (: schemata or schemas) describes a pattern of thought or behavior that organizes categories of information and the relationships among them. It can also be described as a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information, such as a mental schema or conceptual model. Schemata influence attention and the absorption of new knowledge: people are more likely to notice things that fit into their schema, while re-interpreting contradictions to the schema as exceptions or distorting them to fit. Schemata have a tendency to remain unchanged, even in the face of contradictory information. Schemata can help in understanding the world and the rapidly changing environment. People can organize new perceptions into schemata quickly as most situations do not require complex thought when using schema, since automatic thought is all that is required. People use schemata to organize current knowledge and provide a framework for future understanding. Examples of schemata include mental models, social schemas, stereotypes, social roles, scripts, worldviews, heuristics, and archetypes. In Piaget's theory of development, children construct a series of schemata, based on the interactions they experience, to help them understand the world. History "Schema" comes from the Greek word schēmat or schēma, meaning "figure". Prior to its use in psychology, the term "schema" had primarily seen use in philosophy. For instance, "schemata" (especially "transcendental schemata") are crucial to the architectonic system devised by Immanuel Kant in his Critique of Pure Reason. Early developments of the idea in psychology emerged with the gestalt psychologists (founded originally by Max Wertheimer) and Jean Piaget. The term schéma was introduced by Piaget in 1923. In Piaget's later publications, action (operative or procedural) schémes were distinguished from figurative (representational) schémas, although together they may be considered a schematic duality. In subsequent discussions of Piaget in English, schema was often a mistranslation of Piaget's original French schéme. The distinction has been of particular importance in theories of embodied cognition and ecological psychology. This concept was first described in the works of British psychologist Frederic Bartlett, who drew on the term body schema used by neurologist Henry Head in 1932. In 1952, Jean Piaget, who was credited with the first cognitive development theory of schemas, popularized this ideology. By 1977, it was expanded into schema theory by educational psychologist Richard C. Anderson. Since then, other terms have been used to describe schema such as "frame", "scene", and "script". Schematic processing Through the use of schemata, a heuristic technique to encode and retrieve memories, the majority of typical situations do not require much strenuous processing. People can quickly organize new perceptions into schemata and act without effort. The process, however, is not always accurate, and people may develop illusory correlations, which is the tendency to form inaccurate or unfounded associations between categories, especially when the information is distinctive. Nevertheless, schemata can influence and hamper the uptake of new information, such as when existing stereotypes, giving rise to limited or biased discourses and expectations, lead an individual to "see" or "remember" something that has not happened because it is more believable in terms of his/her schema. For example, if a well-dressed businessman draws a knife on a vagrant, the schemata of onlookers may (and often do) lead them to "remember" the vagrant pulling the knife. Such distortion of memory has been demonstrated. (See below.) Furthermore, it has also been seen to affect the formation of episodic memory in humans. For instance, one is more likely to remember a pencil case in an office than a skull, even if both were present in the office, when tested on certain recall conditions. Schemata are interrelated and multiple conflicting schemata can be applied to the same information. Schemata are generally thought to have a level of activation, which can spread among related schemata. Through different factors such as current activation, accessibility, priming, and emotion, a specific schema can be selected. Accessibility is how easily a schema can come to mind, and is determined by personal experience and expertise. This can be used as a cognitive shortcut, meaning it allows the most common explanation to be chosen for new information. With priming (an increased sensitivity to a particular schema due to a recent experience), a brief imperceptible stimulus temporarily provides enough activation to a schema so that it is used for subsequent ambiguous information. Although this may suggest the possibility of subliminal messages, the effect of priming is so fleeting that it is difficult to detect outside laboratory conditions. Background research Frederic Bartlett The original concept of schemata is linked with that of reconstructive memory as proposed and demonstrated in a series of experiments by Frederic Bartlett. Bartlett began presenting participants with information that was unfamiliar to their cultural backgrounds and expectations while subsequently monitoring how they recalled these different items of information (stories, etc). Bartlett was able to establish that individuals' existing schemata and stereotypes influence not only how they interpret "schema-foreign" new information but also how they recall the information over time. One of his most famous investigations involved asking participants to read a Native American folk tale, "The War of the Ghosts", and recall it several times up to a year later. All the participants transformed the details of the story in such a way that it reflected their cultural norms and expectations, i.e. in line with their schemata. The factors that influenced their recall were: Omission of information that was considered irrelevant to a participant; Transformation of some of the details, or of the order in which events, etc., were recalled; a shift of focus and emphasis in terms of what was considered the most important aspects of the tale; Rationalization: details and aspects of the tale that would not make sense would be "padded out" and explained in an attempt to render them comprehensible to the individual in question; Cultural shifts: the content and the style of the story were altered in order to appear more coherent and appropriate in terms of the cultural background of the participant. Bartlett's work was crucially important in demonstrating that long-term memories are neither fixed nor unchanging but are constantly being adjusted as schemata evolve with experience. His work contributed to a framework of memory retrieval in which people construct the past and present in a constant process of narrative/discursive adjustment. Much of what people "remember" is confabulated narrative (adjusted and rationalized) which allows them to think of the past as a continuous and coherent string of events, even though it is probable that large sections of memory (both episodic and semantic) are irretrievable or inaccurate at any given time. An important step in the development of schema theory was taken by the work of D.E. Rumelhart describing the understanding of narrative and stories. Further work on the concept of schemata was conducted by W.F. Brewer and J.C. Treyens, who demonstrated that the schema-driven expectation of the presence of an object was sometimes sufficient to trigger its incorrect recollection. An experiment was conducted where participants were requested to wait in a room identified as an academic's study and were later asked about the room's contents. A number of the participants recalled having seen books in the study whereas none were present. Brewer and Treyens concluded that the participants' expectations that books are present in academics' studies were enough to prevent their accurate recollection of the scenes. In the 1970s, computer scientist Marvin Minsky was trying to develop machines that would have human-like abilities. When he was trying to create solutions for some of the difficulties he encountered he came across Bartlett's work and concluded that if he was ever going to get machines to act like humans he needed them to use their stored knowledge to carry out processes. A frame construct was a way to represent knowledge in machines, while his frame construct can be seen as an extension and elaboration of the schema construct. He created the frame knowledge concept as a way to interact with new information. He proposed that fixed and broad information would be represented as the frame, but it would also be composed of slots that would accept a range of values; but if the world did not have a value for a slot, then it would be filled by a default value. Because of Minsky's work, computers now have a stronger impact on psychology. In the 1980s, David Rumelhart extended Minsky's ideas, creating an explicitly psychological theory of the mental representation of complex knowledge. Roger Schank and Robert Abelson developed the idea of a script, which was known as a generic knowledge of sequences of actions. This led to many new empirical studies, which found that providing relevant schema can help improve comprehension and recall on passages. Schemata have also been viewed from a sociocultural perspective with contributions from Lev Vygotsky, in which there is a transactional relationship between the development of a schema and the environment that influences it, such that the schema does not develop independently as a construct in the mind, but carries all the aspects of the history, social, and cultural meaning which influences its development. Schemata are not just scripts or frameworks to be called upon, but are active processes for solving problems and interacting with the world. However, schemas can also contribute to influential outside sociocultural perspectives, like the development of racism tendencies, disregard for marginalized communities and cultural misconceptions. Modification New information that falls within an individual's schema is easily remembered and incorporated into their worldview. However, when new information is perceived that does not fit a schema, many things can happen. One of the most common reactions is for a person to simply ignore or quickly forget the new information they acquired. This can happen on an unconscious level—meaning, unintentionally an individual may not even perceive the new information. People may also interpret the new information in a way that minimizes how much they must change their schemata. For example, Bob thinks that chickens do not lay eggs. He then sees a chicken laying an egg. Instead of changing the part of his schema that says "chickens don't lay eggs", he is likely to adopt the belief that the animal in question that he has just seen laying an egg is not a real chicken. This is an example of disconfirmation bias, the tendency to set higher standards for evidence that contradicts one's expectations. This is also known as cognitive dissonance. However, when the new information cannot be ignored, existing schemata must be changed or new schemata must be created (accommodation). Jean Piaget (1896–1980) was known best for his work with development of human knowledge. He believed knowledge was constructed on cognitive structures, and he believed people develop cognitive structures by accommodating and assimilating information. Accommodation is creating new schema that will fit better with the new environment or adjusting old schema. Accommodation could also be interpreted as putting restrictions on a current schema, and usually comes about when assimilation has failed. Assimilation is when people use a current schema to understand the world around them. Piaget thought that schemata are applied to everyday life and therefore people accommodate and assimilate information naturally. For example, if this chicken has red feathers, Bob can form a new schemata that says "chickens with red feathers can lay eggs". This schemata, in the future, will either be changed or removed entirely. Assimilation is the reuse of schemata to fit the new information. For example, when a person sees an unfamiliar dog, they will probably just integrate it into their dog schema. However, if the dog behaves strangely, and in ways that does not seem dog-like, there will be an accommodation as a new schema is formed for that particular dog. With accommodation and assimilation comes the idea of equilibrium. Piaget describes equilibrium as a state of cognition that is balanced when schema are capable of explaining what it sees and perceives. When information is new and cannot fit into a previous existing schema, disequilibrium can happen. When disequilibrium happens, it means the person is frustrated and will try to restore the coherence of his or her cognitive structures through accommodation. If the new information is taken then assimilation of the new information will proceed until they find that they must make a new adjustment to it later down the road, but for now the person remains at equilibrium again. The process of equilibration is when people move from the equilibrium phase to the disequilibrium phase and back into equilibrium. In view of this, a person's new schemata may be an expansion of the schemata into a subtype. This allows for the information to be incorporated into existing beliefs without contradicting them. An example in social psychology would be the combination of a person's beliefs about women and their beliefs about business. If women are not generally perceived to be in business, but the person meets a woman who is, a new subtype of businesswoman may be created, and the information perceived will be incorporated into this subtype. Activation of either woman or business schema may then make further available the schema of "businesswoman". This also allows for previous beliefs about women or those in business to persist. Rather than modifying the schemata related to women or to business persons, the subtype is its own category. Self-schema Schemata about oneself are considered to be grounded in the present and based on past experiences. Memories are framed in the light of one's self-conception. For example, people who have positive self-schemata (i.e. most people) selectively attend to flattering information and ignore unflattering information, with the consequence that flattering information is subject to deeper encoding, and therefore superior recall. Even when encoding is equally strong for positive and negative feedback, positive feedback is more likely to be recalled. Moreover, memories may even be distorted to become more favorable: for example, people typically remember exam grades as having been better than they actually were. However, when people have negative self views, memories are generally biased in ways that validate the negative self-schema; people with low self-esteem, for instance, are prone to remember more negative information about themselves than positive information. Thus, memory tends to be biased in a way that validates the agent's pre-existing self-schema. There are three major implications of self-schemata. First, information about oneself is processed faster and more efficiently, especially consistent information. Second, one retrieves and remembers information that is relevant to one's self-schema. Third, one will tend to resist information in the environment that is contradictory to one's self-schema. For instance, students with a particular self-schema prefer roommates whose view of them is consistent with that schema. Students who end up with roommates whose view of them is inconsistent with their self-schema are more likely to try to find a new roommate, even if this view is positive. This is an example of self-verification. As researched by Aaron Beck, automatically activated negative self-schemata are a large contributor to depression. According to Cox, Abramson, Devine, and Hollon (2012), these self-schemata are essentially the same type of cognitive structure as stereotypes studied by prejudice researchers (e.g., they are both well-rehearsed, automatically activated, difficult to change, influential toward behavior, emotions, and judgments, and bias information processing). The self-schema can also be self-perpetuating. It can represent a particular role in society that is based on stereotype, for example: "If a mother tells her daughter she looks like a tom boy, her daughter may react by choosing activities that she imagines a tom boy would do. Conversely, if the mother tells her she looks like a princess, her daughter might choose activities thought to be more feminine." This is an example of the self-schema becoming self-perpetuating when the person at hand chooses an activity that was based on an expectation rather than their desires. Schema therapy Schema therapy was founded by Jeffrey Young and represents a development of cognitive behavioral therapy (CBT) specifically for treating personality disorders. Early maladaptive schemata are described by Young as broad and pervasive themes or patterns made up of memories, feelings, sensations, and thoughts regarding oneself and one's relationships with others; they can be a contributing factor to treatment outcomes of mental disorders and the maintenance of ideas, beliefs, and behaviors towards oneself and others. They are considered to develop during childhood or adolescence, and to be dysfunctional in that they lead to self-defeating behavior. Examples include schemata of abandonment/instability, mistrust/abuse, emotional deprivation, and defectiveness/shame. Schema therapy blends CBT with elements of Gestalt therapy, object relations, constructivist and psychoanalytic therapies in order to treat the characterological difficulties which both constitute personality disorders and which underlie many of the chronic depressive or anxiety-involving symptoms which present in the clinic. Young said that CBT may be an effective treatment for presenting symptoms, but without the conceptual or clinical resources for tackling the underlying structures (maladaptive schemata) which consistently organize the patient's experience, the patient is likely to lapse back into unhelpful modes of relating to others and attempting to meet their needs. Young focused on pulling from different therapies equally when developing schema therapy. Cognitive behavioral methods work to increase the availability and strength of adaptive schemata while reducing the maladaptive ones. This may involve identifying the existing schema and then identifying an alternative to replace it. Difficulties arise as these types of schema often exist in absolutes; modification then requires replacement to be in absolutes, otherwise the initial belief may persist. The difference between cognitive behavioral therapy and schema therapy according to Young is the latter "emphasizes lifelong patterns, affective change techniques, and the therapeutic relationship, with special emphasis on limited reparenting". He recommended this therapy would be ideal for clients with difficult and chronic psychological disorders. Some examples would be eating disorders and personality disorders. He has also had success with this therapy in relation to depression and substance abuse. See also Cultural schema theory Memetics Personal construct theory Primal world beliefs Relational frame theory Social cognition Speed reading References External links Huitt, W. (2018). Understanding reality: The importance of mental representations. In W. Huitt (Ed.), Becoming a Brilliant Star: Twelve core ideas supporting holistic education (pp. 65-81). IngramSpark. Cognitive psychology Cognitive science Psychological adjustment Psychological theories

Emotional Freedom Techniques

Emotional Freedom Techniques (EFT) is a technique that stimulates acupressure points by pressuring, tapping or rubbing while focusing on situations that represent personal fear or trauma. EFT draws on various theories of alternative medicine – including acupuncture, neuro-linguistic programming, energy medicine, and Thought Field Therapy (TFT). EFT also combines elements of exposure therapy, cognitive behavioral therapy and somatic stimulation. It is best known through Gary Craig's EFT Handbook, published in the late 1990s, and related books and workshops by a variety of teachers. EFT and similar techniques are often discussed under the umbrella term "energy psychology." Advocates claim that the technique may be used to treat a wide variety of physical and psychological disorders, and as a simple form of self-administered therapy. The Skeptical Inquirer describes the foundations of EFT as "a hodgepodge of concepts derived from a variety of sources, [primarily] the ancient Chinese philosophy of chi, which is thought to be the 'life force' that flows throughout the body." The existence of this life force is "not empirically supported." EFT has no benefit as a therapy beyond (1) the placebo effect or (2) any known effective psychological techniques that may be provided in addition to the purported "energy" technique. It is generally characterized as pseudoscience, and it has not garnered significant support in clinical psychology. Process During a typical EFT session, the person will focus on a specific issue while tapping on "end points of the body's energy meridians." EFT tapping exercises combine elements of cognitive restructuring and exposure techniques with acupoint stimulation. The technique instructs individuals to tap on meridian endpoints of the body – such as the top of the head, eye brows, under eyes, side of eyes, chin, collar bone, and under the arms. While tapping, they recite specific phrases that target an emotional component of a physical symptom. According to the EFT Manual, the procedure consists of the participant rating the emotional intensity of their reaction on a Subjective Units of Distress Scale (SUDS) – i.e., a Likert scale for subjective measures of distress, calibrated 0 to 10 – then repeating an orienting affirmation while rubbing or tapping specific points on the body. Some practitioners incorporate eye movements or other tasks. The emotional intensity is then rescored and repeated until no changes are noted in the emotional intensity. Mechanism Proponents of EFT and other similar treatments believe that tapping/stimulating acupuncture points provide the basis for significant improvement in psychological problems. However, the theory and mechanisms underlying the supposed effectiveness of EFT have "no evidentiary support" "in the entire history of the sciences of biology, anatomy, physiology, neurology, physics, or psychology." Researchers have described the theoretical model for EFT as "frankly bizarre" and "pseudoscientific." One review noted that one of the highest quality studies found no evidence that the location of tapping points made any difference, and attributed effects to well-known psychological mechanisms, including distraction and breathing therapy. An article in the Skeptical Inquirer argued that there is no plausible mechanism to explain how the specifics of EFT could add to its effectiveness, and they have been described as unfalsifiable and therefore pseudoscientific. Evidence has not been found for the existence of meridians. Research quality EFT has no useful effect as a therapy beyond the placebo effect or any known-effective psychological techniques that may be used with the purported "energy" technique, but proponents of EFT have published material claiming otherwise. Their work, however, is flawed and hence unreliable: high-quality research has never confirmed that EFT is effective. A 2009 review found "methodological flaws" in research studies that had reported "small successes" for EFT and the related Tapas Acupressure Technique. The review concluded that positive results may be "attributable to well-known cognitive and behavioral techniques that are included with the energy manipulation. Psychologists and researchers should be wary of using such techniques, and make efforts to inform the public about the ill effects of therapies that advertise miraculous claims." A 2016 systematic review found that EFT was effective in reducing anxiety compared to controls, but also called for more research to establish the relative efficacy to that of established treatments. Reception A Delphi poll of an expert panel of psychologists rated EFT on a scale describing how discredited EFT has been in the field of psychology. On average, this panel found EFT had a score of 3.8 on a scale from 1.0 to 5.0, with 3.0 meaning "possibly discredited" and a 4.0 meaning "probably discredited." A book examining pseudoscientific practices in psychology characterized EFT as one of a number of "fringe psychotherapeutic practices," and a psychiatry handbook states EFT has "all the hallmarks of pseudoscience." EFT, along with its predecessor, Thought Field Therapy, has been dismissed with warnings to avoid their use by publications such as The Skeptic's Dictionary and Quackwatch. Proponents of EFT and other energy psychology therapies have been "particularly interested" in seeking "scientific credibility" despite the implausible proposed mechanisms for EFT. A 2008 review by energy psychology proponent David Feinstein concluded that energy psychology was a potential "rapid and potent treatment for a range of psychological conditions." However, this work by Feinstein has been widely criticized. One review criticized Feinstein's methodology, noting he ignored several research papers that did not show positive effects of EFT, and that Feinstein did not disclose his conflict of interest as an owner of a website that sells energy psychology products such as books and seminars, contrary to the best practices of research publication. Another review criticized Feinstein's conclusion, which was based on research of weak quality and instead concluded that any positive effects of EFT are due to the more traditional psychological techniques rather than any putative "energy" manipulation. A book published on the subject of evidence-based treatment of substance abuse called Feinstein's review "incomplete and misleading" and an example of a poorly performed evidence-based review of research. Feinstein published another review in 2012, concluding that energy psychology techniques "consistently demonstrated strong effect sizes and other positive statistical results that far exceed chance after relatively few treatment sessions." This review was also criticized, where again it was noted that Feinstein dismissed higher quality studies which showed no effects of EFT, in favor of methodologically weaker studies which did show a positive effect. In response to a literature review by D. Feinstein on "Manual Stimulation of Acupuncture Points", published in 2023 in the Journal of Psychotherapy Integration, Cassandra L. Bonessa, Rory Pfundb, and David F. Tolin publish, in the same journal, a critical analysis of 3 meta-analyses highlighted by this study. By using the AMSTAR2 analysis criteria, they come to the conclusion that these were poorly carried out and that their quality is “Critically low”. The three researchers call EFT pseudo-science and an “unsinkable rubber duck”. References External links Short BBC video describing EFT Energy therapies Manual therapy Emotion Pseudoscience

Motivational interviewing

Motivational interviewing (MI) is a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. It is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed, and departs from traditional Rogerian client-centered therapy through this use of direction, in which therapists attempt to influence clients to consider making changes, rather than engaging in non-directive therapeutic exploration. The examination and resolution of ambivalence is a central purpose, and the counselor is intentionally directive in pursuing this goal. MI is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship. Core concepts evolved from experience in the treatment of problem drinkers, and MI was first described by Miller (1983) in an article published in the journal Behavioural and Cognitive Psychotherapy. Miller and Rollnick elaborated on these fundamental concepts and approaches in 1991 in a more detailed description of clinical procedures. MI has demonstrated positive effects on psychological and physiological disorders according to meta-analyses. Overview Motivational interviewing (MI) is a person-centered strategy. It is used to elicit patient motivation to change a specific negative behavior. MI engages clients, elicits change talk and evokes patient motivation to make positive changes. For example, change talk can be elicited by asking the patient questions such as: "How might you like things to be different?" or "How does __ interfere with things that you would like to do?" Unlike clinical interventions and treatment, MI is the technique where the interviewer (clinician) assists the interviewee (patient) in changing a behavior by expressing their acceptance of the interviewee without judgement. By this, MI incorporates the idea that every single patient may be in differing stages of readiness levels and may need to act accordingly to the patient's levels and current needs. Change may occur quickly or may take considerable time, depending on the client. Knowledge alone is usually not sufficient to motivate change within a client, and challenges in maintaining change should be thought of as the rule, not the exception. The incorporation of MI can help patients resolve their uncertainties and hesitancies that may stop them from their inherent want of change in relation to a certain behavior or habit. At the same time, it can be seen that MI ensures that the participants are viewed more as team members to solve a problem rather than a clinician and patient. Hence, this technique can be attributed to a collaboration that respects sense of self and autonomy. To be more successful at motivational interviewing, a clinician must have a strong sense of "purpose, clear strategies and skills for such purposes". This ensures that the clinician knows what goals they are trying to achieve prior to entering into motivational interviewing. Additionally, clinicians need to have well-rounded and established interaction skills including asking open ended questions, reflective listening, affirming and reiterating statements back to the patient. Such skills are used in a dynamic where the clinician actively listens to the patient then repackages their statements back to them while highlighting what they have done well. In this way, it can improve their self-confidence for change. Furthermore, at the same time the clinician needs to keep in mind the following five principles when practicing MI. Express empathy This means to listen and express empathy to patients through the use of reflective listening. In this step, the clinician listens and presents ideas the patient has discussed in a different way, rather than telling the patient what to do. This hopes to ensure that the patient feels respected and that there are no judgments given when they express their thoughts, feelings and experiences but instead, shows the patient that the clinician is genuinely interested about the patient and their circumstances. This aims to strengthen the relationship between the two parties and ensures it is a collaboration, and allows the patient to feel that the clinician is supportive and therefore will be more willing to be open about their real thoughts. Develop discrepancy This means to assist patients in developing discrepancies between the current self and what they want to be like in the future after a change has taken place. The main goal of this principle is to increase the patient's awareness that there are consequences to their current behaviors. This allows the patient to realize the negative aspects and issues caused by the particular behavior that MI is trying to change. This realization can help and encourage the patient towards a dedication to change as they can see the discrepancy between their current behavior and desired behavior. It is important that the patient be the one making the arguments for change and realize their discrepancies themselves. An effective way to do this is for the clinician to participate in active reflective listening and repacking what the patient has told them and delivering it back to them. Avoid arguments During the course of MI the clinician may be inclined to argue with a patient, especially when they are ambivalent about their change and this is especially true when "resistance" is met from the patient. If the clinician tries to enforce a change, it could exacerbate the patient to become more withdrawn and can cause degeneration of what progress had been made thus far and decrease rapport with the patient. Arguments can cause the patient to become defensive and draw away from the clinician which is counterproductive and diminishes any progress that may have been made. When patients become a little defensive and argumentative, it usually is a sign to change the plan of attack. The biggest progress made towards behavior change is when the patient makes their own arguments instead of the clinician presenting it to them. Roll with resistance "Rolling with resistance" is now an outdated concept in MI; in the third edition of Miller & Rollnick's textbook Motivational Interviewing: Helping People Change, the authors indicated that they had completely abandoned the word "resistance" as well as the term "rolling with resistance", due to the term's tendency to blame the client for problems in the therapy process and obscure different aspects of ambivalence. "Resistance", as the idea was previously conceptualized before it was abandoned in MI, can come in many forms such as arguing, interrupting, denying and ignoring. Part of successful MI is to approach the "resistance" with professionalism, in a way that is non-judgmental and allows the patient to once again affirm and know that they have their autonomy and that it is their choice when it comes to their change. Support self-efficacy Strong self-efficacy can be a significant predictor of success in behavior change. In many patients there is an issue of the lack of self-efficacy. They may have tried multiple times on their own to create a change in their behavior (e.g. trying to cease smoking, losing weight, sleep earlier) and because they have failed it causes them to lose their confidence and hence lowers their self-efficacy. Therefore, it is clear to see how important it is for the patient to believe that they are self-efficacious and it is the clinician's role to support them by means of good MI practice and reflective listening. By reflecting on what the patient had told them, the clinician can accentuate the patient's strengths and what they have been successful in (e.g. commending a patient who had stopped smoking for a week instead of straining on the fact they failed). By highlighting and suggesting to the patient areas in which they have been successful, this can be incorporated into future attempts and can improve their confidence and efficacy to believe that they are capable of change. While there are as many differences in technique, the underlying spirit of the method remains the same and can be characterized in a few key points: Motivation to change is elicited from the client, and is not imposed from outside forces. It is the client's task, not the counsellor's, to articulate and resolve the client's ambivalence. Direct persuasion is not an effective method for resolving ambivalence. The counselling style is generally quiet and elicits information from the client. The counsellor is directive, in that they help the client to examine and resolve ambivalence. Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction. The therapeutic relationship resembles a partnership or companionship. Ultimately, practitioners must recognize that motivational interviewing involves collaboration not confrontation, evocation not education, autonomy rather than authority, and exploration instead of explanation. Effective processes for positive change focus on goals that are small, important to the client, specific, realistic, and oriented in the present and/or future. Four processes There are four steps used in motivational interviewing. These help to build trust and connection between the patient and the clinician, focus on areas that may need to be changed and find out the reasons the patient may have for changing or holding onto a behavior. This helps the clinician to support and assist the patient in their decision to change their behavior and plan steps to reach this behavioral change. These steps do not always happen in this order. Engaging In this step, the clinician gets to know the patient and understands what is going on in the patient's life. The patient needs to feel comfortable, listened to and fully understood from their own point of view. This helps to build trust with the patient and builds a relationship where they will work together to achieve a shared goal. The clinician must listen and show empathy without trying to fix the problem or make a judgement. This allows the patient to open up about their reasons for change, hopes, expectations as well as the barriers and fears that are stopping the patient from changing. The clinician must ask open ended questions which helps the patient to give more information about their situation, so they feel in control and that they are participating in the decision-making process and the decisions are not being made for them. This creates an environment that is comfortable for the patient to talk about change. The more trust the patient has towards the clinician, the more likely it is reduce resistance, defensiveness, embarrassment or anger the patient may feel when talking about a behavioural issue. Overall, the patient is more likely to come back to follow up appointments, follow an agreed plan and get the benefit of the treatment. Focusing This is where the clinician helps the patient find and focus on an area that is important to them, where they are unsure or are struggling to make a change. This step is also known as the "WHAT?" of change. The goal is for the clinician to understand what is important to the patient without pushing their own ideas on the patient. The clinician needs to ask questions to understand the reasons if and why the patient would be motivated to change and choose a goal to reach together. The patient must feel that they share the control with the clinician about the direction and agree on a goal. The clinician will then aim to help the patient order the importance of their goals and point out the current behaviors that get in the way of achieving their new goal or "develop discrepancy" between their current and desired behaviors. The focus or goal can come from the patient, situation or the clinician. There are three styles of focusing; directing, where the clinician can direct the patient towards a particular area for change; following, where the clinician let the patient decide the goal and be led by the patient's priorities, and; guiding, where the clinician leads the patient to uncover an area of importance. Evoking In this step the clinician asks questions to get the patient to open up about their reasons for change. This step is also known as the "WHY?" of change. Often when a patient puts this into words it reinforces their reasons to change and they find out they have more reasons to change rather than to stay the same. Usually, there is one reason that is stronger than the others to motivate the patient to change their behavior. The clinician needs to listen and recognise "change talk", where the patient is uncovering how they would go about change and are coming up with their own solutions to their problems. The clinician should support and encourage the patient when they talk about ways and strategies to change, as the patient is more likely to follow a plan they set for themselves. When the patient is negative or is resisting change the clinician should "roll with resistance" where they don't affirm or encourage the negative points but highlight the ways and reasons the person has come up with to change. The clinician must resist arguing or the "righting reflex" where they want to fix the problem or challenge the patient's negative thoughts. This comes across as they are not working together and causes the patient to resist change even more. The clinician's role is to ask questions that guide the patient to come up with their own solution to change. The best time to give advice is if the patient asks for it, if the patient is stuck with coming up with ideas, the clinician can ask permission to give advice and then give details, but only after the patient has come up with their own ideas first. If the clinician focuses more on their own reasons they believe the patient should change this would not come across as genuine to the patient and this would reduce the bond they made in the engaging process. Planning In this step the clinician helps the patient in planning how to change their behavior and encourages their commitment to change. This step is also known as the "HOW?" of change. The clinician asks questions to judge how ready the patient is to change and helps to guide the patient in coming up with their own step by step action plan. They can help to strengthen the patient's commitment to changing, by supporting and encouraging when the patient uses "commitment talk" or words that show their commitment to change. In this step the clinician can listen and recognize areas that may need more work to get to the core motivation to change or help the patient to overcome uneasiness that is still blocking their behavioral change. In doing this, they help to strengthen the patients motivation and support that they are capable of achieving this goal on their own. The clinician should help the patient to come up with SMART goals which are; Specific, Measurable, Achievable, Relevant and Time bound. This helps to set benchmarks and measure how their behavior has changed towards their new goal. Adaptations Motivational enhancement therapy Motivational enhancement therapy is a time-limited four-session adaptation used in Project MATCH, a US-government-funded study of treatment for alcohol problems and the Drinkers' Check-up, which provides normative-based feedback and explores client motivation to change in light of the feedback. Motivational interviewing is supported by over 200 randomized controlled trials across a range of target populations and behaviors including substance use disorders, health-promotion behaviours, medical adherence, and mental health issues. Pre-contemplation Motivational Interviewing with individuals in the pre-contemplation stage of the stages of change represent a use case in which Motivational Interviewing processes excel beyond other methods. If the patient/client/individual is in this stage, they may not be consciously aware of, accepting of, or consider they have a problem. Motivational interviewers in this situation are trained to use processes like rolling with resistance which reduces a client's need to repeat and reframe their own sustain talk. Additionally Motivational Interviewing adapts to this stage by adapting the *change target*. Clients starting in pre-contemplation stage of change are unlikely to jump 3 steps to the action stage of change. By adapting the change target talented Motivational Interviewers can help clients to advance 1 stage of change into the "contemplation stage". Motivational interviewing groups MI groups are highly interactive, focused on positive change, and harness group processes for evoking and supporting positive change. They are delivered in four phases: Engaging the group Evoking member perspectives Broadening perspectives and building momentum for change Moving into action Behaviour Change Counselling (BCC) Behaviour change counselling (BCC) is an adaptation of MI which focuses on promoting behavior change in a healthcare setting using brief consultations. BCC's main goal is to understand the patient's point of view, how they're feeling and their idea of change. It was created with a "more modest goal in mind", as it simply aims to "help the person talk through the why and how of change" and encourage behavior change. It focuses on patient-centered care and is based on several overlapping principles of MI, such as respect for patient choice, asking open-ended questions, empathetic listening and summarizing. Multiple behavior change counselling tools were developed to assess and scale the effectiveness of behaviour change counselling in promoting behavior change such as the Behaviour Change Counselling Index (BECCI) and the Behaviour Change Counselling Scale (BCCS). Behaviour Change Counselling Scale (BCCS) The Behaviour Change Counselling Scale (BCCS) is a tool used to assess lifestyle counselling using BCC, focusing on feedback on the skill achieved. "Items of BCCS were scored on 1-7 Likert scales and items were tallied into 4 sub-scales, reflecting the 3 skill-sets: MI and readiness assessment, behavior modification, and emotion management". The data obtained is then presented on: item characteristics, sub-scale characteristics, interrater reliability, test-retest reliability and construct validity. Based on a study conducted by Vallis, the results suggest that BCCS is a potentially useful tool in assessing BCC and aid to training practitioners as well as assessing training outcomes. Behaviour Change Counselling Index (BECCI) The Behaviour Change Counselling Index (BECCI) is a BCC tool that assesses general practitioner behavior and incites behavior change through talking about change, encouraging the patient to think about change and respecting the patient's choices in regards to behavior change. BECCI was developed to assess a practitioner's competence in the use of Behaviour Change Counselling (BCC) methods to elicit behavior change. Used primarily for the use of learning practitioners in a simulated environment to practice and learn the skills of BCC. It "provides valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention". Rather than the result and response from the patient, the tool emphasizes and measures the practitioner's behaviors, skills and attitude. Results from the study show that after receiving training in BCC, practitioners show great improvement based on BECCI. However, as BECCI has only been used in a simulated clinical environment, more study is required to assess its reliability in a real patient environment. Furthermore, it focuses heavily on practitioner behavior rather than patient behavior. Therefore, BECCI may be useful for trainers to assess the reliability and effectiveness of BCC skills but further research and use is required, especially in a real consultation environment. Technology Assisted Motivational Interview (TAMI) Technology Assisted Motivational Interview (TAMI) is "used to define adaptations of MI delivered via technology and various types of media". This may include technological devices and creations such as computers, mobile phones, telephones, videos and animations. A review of multiple studies shows the potential effectiveness of the use of technology in delivering motivational interviewing consultations to encourage behavior change. However, some limitations include: the lack of empathy that may be expressed through the use of technology and the lack of face-to-face interaction may either produce a positive or negative effect on the patient. Further studies are required to determine whether face-to-face consultations to deliver MI is more effective in comparison to those delivered via technology. Limitations Underlying mental health conditions Patients with an underlying mental illness present one such limitation to motivational interviewing. In a case where the patient has an underlying mental illness such as depression, anxiety, bipolar disorder, schizophrenia or other psychosis, more intensive therapy may be required to induce a change. In these instances, the use of motivational interviewing as a technique to treat outward-facing symptoms, such as not brushing teeth, may be ineffective where the root cause of the problem stems from the mental illness. Some of the patients may act like listening to the interviewer just to veil their underlying mental health issue. When working with these patients, it is important to recognize the limitations of behaviorally-focused counseling and motivational interviewing. The treating therapists should, therefore, ensure the patient is referred to the correct medical or psychological professional to address the cause of the behavior, and not simply one of the symptoms. Motivation Professionals attempting to encourage people to make a behavioral change often underestimate the effect of motivation. Simply advising clients how detrimental their current behavior is and providing advice on how to change their behavior will not work if the client lacks motivation. Many people have full knowledge of how dangerous smoking is yet they continue the practice. Research has shown that a client's motivation to alter behavior is largely influenced by the way the therapist relates to them. Therapist/client trust Clients who don't like or trust their health care professionals are likely to become extremely resistant to change. In order to prevent this, the therapist must take time to foster an environment of trust. Even when the therapist can clearly identify the issues at hand it is important that the patient feels the session is collaborative and that they are not being lectured to. Confrontational approaches by therapists will inhibit the process. Time limitations Time limits placed on therapists during consultations also have the potential to impact significantly on the quality of motivational interviewing. Appointments may be limited to a brief or single visit with a patient; for example, a client may attend the dentist with a toothache due to a cavity. The oral health practitioner or dentist may be able to broach the subject of a behavior change, such as flossing or diet modification but the session duration may not be sufficient when coupled with other responsibilities the health practitioner has to the health and wellbeing of the patient. For many clients, changing habits may involve reinforcement and encouragement which is not possible in a single visit. Some patients, once treated, may not return for a number of years or may even change practitioners or practices, meaning the motivational interview is unlikely to have sufficient effect. Training deficiencies While psychologists, mental health counselors, and social workers are generally well trained and practiced in delivering motivational interviewing, other health-care professionals are generally provided with only a few hours of basic training. Although perhaps able to apply the underpinning principles of motivational interviewing, these professionals generally lack the training and applied skills to truly master the art of dealing with the patient's resistant statements in a collaborative manner. It is important that therapists know their own limitations and are prepared to refer clients to other professionals when required. To address training difficulties, one study outlines successful evidence-based modalities (e.g., workshops, ongoing coaching, etc.) for training busy clinical providers in motivational interviewing. Group treatment Although studies are somewhat limited, it appears that delivering motivational interviewing, in a group may be less effective than when delivered one-on-one. Research continues into this area however what is clear is that groups change the dynamics of a situation and the therapist needs to ensure that group control is maintained and input from group members does not derail the process for some clients. Applications Motivational interviewing was initially developed for the treatment of substance use disorder, but MI is continuously being applied across health fields and beyond that. The following fields have used the technique of MI. Brief intervention Brief intervention and MI are both techniques used to empower behavioral change within individuals. Behavioral interventions "generally refer to opportunistic interventions by non-specialists (e.g. GPs) offered to patients who may be attending for some unrelated condition". Due to speculation in the health industry the use of brief intervention has been deemed to be used too loosely and the implementation of MI is increasing rapidly. Classroom management Motivational interviewing has been incorporated into managing a classroom. Due to the nature of MI where it elicits and evokes behavioral change within an individual it has shown to be effective in a classroom especially when provoking behavior change within an individual. In association with MI, the classroom check-up method is incorporated which is a consultation model that addresses the need for classroom level support. Coaching Motivational interviewing has been implemented in coaching, specifically health-based coaching to aid in a better lifestyle for individuals. A study titled "Motivational interviewing-based health coaching as a chronic care intervention" was conducted to evaluate if MI had an impact on individuals health who were assessed as chronically ill. The study's results showed that the group that MI was applied to had "improved their self-efficacy, patient activation, lifestyle change and perceived health status". Environmental sustainability Initially, in the early 1980s, motivational interviewing was implemented and formulated to elicit behavioral change in individuals suffering from substance use disorder. However, MI is based on the work of Psychologist Carl Rogers, Unconditional Positive Regard, and has shown to be applicable in hundreds of behavioral use cases. This includes applications of Motivational Interviewing to environmental sustainability. One view of climate change's cause is a global effect from billions of people choosing thousands of behaviors. Motivational Interviewing is effective at evoking thoughts, feelings, and action towards change and this includes readiness for change towards greater personal sustainable choices. Applications have included use by citizens for interacting with elected representatives on climate policy, interfamilial discussions based on listening instead of judgement and education. New use cases by environmental NGO's, and municipal governments include facilitating new personal choices in the scopes of waste management, home energy use, water use, personal transportation habits, consumption habits and many other environmental applications. Mental disorders Motivational interviewing was originally developed by William R. Miller and Stephen Rollnick in the 1980s in order to aid people with substance use disorders. However, it has also been implemented to help aid in established models with mental disorders such as anxiety and depression. Currently an established model known as cognitive behavioral therapy (CBT) is being implemented to aid in these issues. Research suggests that with collaborating motivational interviewing and CBT has proved to be effective as they have both shown to be effective. A study was conducted as a randomized cluster trial that suggests that when MI was implemented it "associated with improved depressive symptoms and remission rate". There is currently insufficient research papers to prove the effect of MI in mental disorders. However, it is increasingly being applied and more research is going into it. Dual diagnosis Dual diagnosis can be defined as a "term that is used to describe when a person is experiencing both mental health problems and substance misuse". Motivational interviewing is used as a preventative measure for individuals suffering from both a mental health issue and substance misuse due to the nature of MI eliciting behavioral change in individuals. Problem gambling Gambling issues are on the rise and it is becoming a struggle for therapists to maintain it. Research suggests that many individuals "even those who actively seek and start gambling treatment, do not receive the full recommended course of therapy". Motivational interviewing has been widely used and adapted by therapists to overcome gambling issues, it is used in collaboration with cognitive behavioral therapy and self-directed treatments. The goal of using MI in an individual who is having issues with gambling is to recognize and overcome those barriers and "increase overall investment in therapy by supporting an individual's commitment to changing problem behaviours". Parenting Motivational interviewing is implemented to evoke behavioral change in an individual. Provoking behavioral change includes the recognizing of the issue from an individual. A research study was conducted using motivational interviewing to help promote oral regime and hygiene within children under the supervision of a parent. In this study the experimental group was parents who received MI education in a "pamphlet, watched a videotape, as well as received an MI counselling session and six follow-up telephone calls". Children in the MI group, "exhibited significantly less new cavities (decayed or filled surfaces)" than children in the control group. This suggests that the application of MI with parenting can significantly impact children's outcomes. Substance dependence Motivational interviewing was initially developed in order to aid people with substance use, specifically alcohol. However, MI has been implemented in other substance use or dependence treatments. Research that was conducted utilized MI with a cocaine-detoxification program. This research had found that for the 105 randomly assigned patients, "completers who received MI increased use of behavioural coping strategies and had fewer cocaine-positive urine samples on beginning the primary treatment". This evidence suggests that the application of MI for cocaine dependence may have a positive impact in aiding the individual to overcome this issue. A 2016 Cochrane review focused on alcohol misuse in young adults in 84 trials found no substantive, meaningful benefits for MI for preventing alcohol misuse or alcohol-related problems. Stigma Reduction Stigma is the deleterious, structural force that devalues members of groups that hold undesirable characteristics. In the case of people living with HIV (PLHIV), HIV-related stigma has negative effects on health outcomes, including non-optimal medication adherence, lower visit adherence, higher depression, and overall lower quality of life. HIV-related stigma causes PLHIV to lose social standing due to their HIV positive status, and therefore, eliminating stigma against PLHIV, is a high priority. A study conducted in 2021 found that Healthy Choices, an intervention that was developing using Motivational Enhancement Therapy, an adaptation of Motivational Interviewing, was associated with reductions in stigma among youth living with HIV. While the authors suggest that their findings should be replicated, this study provides a basis for including Motivational Interviewing in stigma reduction research. See also Motivational interviewing: What is MI and how can it be applied in everyday life? (Wikiversity) Motivational therapy Transtheoretical model References Sources Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall. . Brennan, T. (1982) Commitment to Counseling: Effects of Motivational Interviewing and Contractual Agreements on Help-seeking Attitudes and Behavior. Doctoral Thesis:University.of Nebraska. Herman, K. C., Reinke, W.M., Frey, A.J., & Shepard, S.A. (2013). Motivational interviewing in schools: Strategies for engaging parents, teachers, and students. New York: Springer. Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press. Miller, W. R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People to Change, 2nd ed. New York: Guilford Press. Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing, Helping People Change, 3rd ed. New York: Guilford Press. Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25–37. Patterson, D. A. (2008). Motivational interviewing: Does it increase retention in outpatient treatment? Substance Abuse, 29(1), 17–23. Patterson, D. A. (2009). Retaining Addicted & HIV-Infected Clients in Treatment Services. Saarbrücken, Germany: VDM Publishing House Ltd. . Prochaska, J. O. (1983). "Self changers vs. therapy changers vs.Schachter." American Psychologist 38: 853–854. Reinke, W. M., Herman, K. C., & Sprick, R. (2011). Motivational Interviewing for Effective Classroom Management: The Classroom Check-Up. New York: Guilford Press. . Rogers, Carl (1961). On becoming a person: A therapist's view of psychotherapy. London: Constable. . Rollnick, S., Miller, W. R., & Butler, C. C. (2007). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press. . Wagner, C. C., Ingersoll, K. S., With Contributors (2012). Motivational Interviewing in Groups. New York: Guilford Press. Motivation Counseling Addiction Addiction medicine

Occupational health psychology

Occupational health psychology (OHP) is an interdisciplinary area of psychology that is concerned with the health and safety of workers. OHP addresses a number of major topic areas including the impact of occupational stressors on physical and mental health, the impact of involuntary unemployment on physical and mental health, work-family balance, workplace violence and other forms of mistreatment, psychosocial workplace factors that affect accident risk and safety, and interventions designed to improve and/or protect worker health. Although OHP emerged from two distinct disciplines within applied psychology, namely, health psychology and industrial and organizational psychology, for a long time the psychology establishment, including leaders of industrial/organizational psychology, rarely dealt with occupational stress and employee health, creating a need for the emergence of OHP. OHP has also been informed by other disciplines, including occupational medicine, sociology, industrial engineering, and economics, as well as preventive medicine and public health. OHP is thus concerned with the relationship of psychosocial workplace factors to the development, maintenance, and promotion of workers' health and that of their families. The World Health Organization and the International Labour Organization estimate that exposure to long working hours causes an estimated 745,000 workers to die from ischemic heart disease and stroke in 2016, mediated by occupational stress. Historical overview Origins The Industrial Revolution prompted thinkers, such as Karl Marx with his theory of alienation, to concern themselves with the nature of work and its impact on workers. Taylor's (1911) Principles of Scientific Management as well as Mayo's research in the late 1920s and early 1930s on workers at the Hawthorne Western Electric plant helped to inject the impact of work on workers into the subject matter psychology addresses. About the time Taylorism arose, Hartness reconsidered worker-machine interaction and its impact on worker psychology. The creation in 1948 of the Institute for Social Research (ISR) at the University of Michigan was important because of ISR's research on occupational stress and employee health. Research published in the 1950s and extending to the 1970s helped lead to the emergence of OHP. For example, in the U.K. Trist and Bamforth (1951) found that the reduction in miner autonomy that accompanied organizational changes in English coal mining operations adversely affected morale. Arthur Kornhauser's work in the early 1960s on the mental health of automobile workers in Michigan also contributed to the development of the field. A 1971 study by Gardell examined the impact of work organization on mental health in Swedish pulp and paper mill workers and engineers. Research on the impact of unemployment on mental health was conducted at the University of Sheffield's Institute of Work Psychology. In 1970 Kasl and Cobb documented the impact of unemployment on blood pressure in U.S. factory workers. Recognition as a field of study A number of individuals are associated with the creation of the term "occupational health psychology" or "occupational health psychologist." They include Feldman (1985), Everly (1986), and Raymond, Wood, and Patrick (1990). In 1988, in response to a dramatic increase in the number of stress-related worker compensation claims in the U.S., the National Institute for Occupational Safety and Health (NIOSH) "recognized stress-related psychological disorders as a leading occupational health risk" (p. 201). With the increased recognition of the impact of job stress on a range of problems, NIOSH found that their stress-related programs were significantly increasing in prominence. In 1990, Raymond et al. argued in the widely read American Psychologist that the time has come for doctoral-level psychologists to get interdisciplinary OHP training, integrating health psychology with public health, because creating healthy workplaces should be a goal for psychology. Emergence as a discipline Established in 1987, Work & Stress is the first and "longest established journal in the fast developing discipline that is occupational health psychology." Three years later, the American Psychological Association (APA) and NIOSH jointly organized the Work, Stress, and Health conference in Washington, DC, the first international conference devoted to OHP. The conference has since become biennial. In 1996, the first issue of the Journal of Occupational Health Psychology was published by APA. That same year, the International Commission on Occupational Health created the Work Organisation and Psychosocial Factors (ICOH-WOPS) scientific committee, which focused primarily on OHP. In 1999, the European Academy of Occupational Health Psychology (EA-OHP) was established at the first European Workshop on Occupational Health Psychology in Lund, Sweden. That workshop is considered to be the first EA-OHP conference, the first of a continuing series of biennial conferences EA-OHP organizes and devotes to OHP research and practice. In 2000 the informal International Coordinating Group for Occupational Health Psychology (ICGOHP) was founded for the purpose of facilitating OHP-related research, education, and practice as well as coordinating international conference scheduling. Also in 2000, the journal Work & Stress became associated with the EA-OHP. In 2005, the Society for Occupational Health Psychology (SOHP) was established in the United States. In 2008, SOHP joined with APA and NIOSH in co-sponsoring the Work, Stress, and Health conferences. In addition, EA-OHP and SOHP began to coordinate biennial conferences schedules such that the organizations' conferences would take place on alternate years, minimizing scheduling conflicts. In 2017, SOHP and Springer began to publish an OHP-related journal Occupational Health Science. Research methods The main aims of OHP research is to understand how working conditions affect worker health, use that knowledge to design interventions to protect and improve worker health, and evaluate the effectiveness of such interventions. The research methods used in OHP are similar to those used in other branches of psychology. Standard research designs Self-report survey methodology is the most used approach in OHP research. Cross-sectional designs are commonly used; case-control designs have been employed much less frequently. Longitudinal designs including prospective cohort studies and experience sampling studies can examine relationships over time. OHP-related research devoted to evaluating health-promoting workplace interventions has relied on quasi-experimental designs, (less commonly) experimental approaches, and (rarely) natural experiments. Quantitative methods Statistical methods commonly used in other areas of psychology are also used in OHP-related research. Statistical methods range from simple descriptive statistics to complex structural equation modeling and hierarchical linear modeling (HLM is also known as multilevel modeling.) HLM can better adjust for similarities between employees and is especially well suited to evaluating the lagged impact of work stressors on health outcomes; in this research context HLM can help minimize censoring and is well-suited to experience-sampling studies. Meta-analyses have been used to aggregate data (modern approaches to meta-analyses rely on HLM), and draw conclusions across multiple studies. OHP researchers studying the structural validity of their most commonly used assessment instruments employ exploratory structural equation modeling bifactor analyses. Qualitative research methods Qualitative research methods used on OHP research include the following: interviews, focus groups, self-reported, written descriptions of stressful incidents at work. first-hand observation of workers on the job, and participant observation. Important theoretical models in OHP research Three influential theoretical models in OHP research are the demand-control-support, effort-reward imbalance, and demand-resources models; another but less contemporary model is the person-environment fit model. Demand-control-support model The most influential model in OHP research has been the original demand-control model. According to the model, the combination of low levels of work-related decision latitude (i.e., autonomy and control over the job) combined with high workloads (high levels of work demands) can be particularly harmful to workers because the combination can lead to "job strain," i.e., to poorer mental or physical health. The model suggests not only that these two job factors are related to poorer health but that high levels of decision latitude on the job will buffer or reduce the adverse health impact of high levels of demands. Research has clearly supported the idea that decision latitude and demands relate to strains, but research findings about buffering have been mixed with only some studies providing support. The demand-control model asserts that job control can come in two broad forms: skill discretion and decision authority. Skill discretion refers to the level of skill and creativity required on the job and the flexibility a worker is permitted in deciding what skills to use (e.g., opportunity to use skills, similar to job variety). Decision authority refers to workers being able to make decisions about their work (e.g., having autonomy). These two forms of job control are traditionally assessed together in a composite measure of decision latitude; there is, however, some evidence that the two types of job control may not be similarly related to health outcomes. About a decade after Karasek first introduced the demand-control model, Johnson, Hall, and Theorell (1989), in the context of research on heart disease, extended the model to include social isolation. Johnson et al. labeled the combination of high levels of demands, low levels of control, and low levels of coworker support "iso-strain." The resulting expanded model has been labeled the demand–control–support (DCS) model. Research that followed the development of this model has suggested that one or more of the components of the DCS model (high psychological workload, low control, and lack of social support), if not the exact combination represented by iso-strain, have adverse effects of physical and mental health. Effort-reward imbalance model After the DCS model, the second most influential model in OHP research has been the effort-reward imbalance (ERI) model. It links job demands to the rewards employees receive for their work. That model holds that high work-related effort coupled with low control over extrinsic (e.g., pay) and job-related intrinsic (e.g., recognition) rewards triggers high levels of activation of neurohormonal pathways that, cumulatively, are thought to exert adverse effects on mental and physical health. Job demands-resources model An alternative model, the job demands-resources (JD-R) model, grew out of the DCS model. In the JD-R model, the category of demands (workload) remains more or less the same as in the DCS model although the JD-R model more specifically includes physical demands. Resources, however, are defined as job-relevant features that help workers achieve work-related goals, lessen job demands, or stimulate personal growth. Control and support as per the DCS model are subsumed under resources. Resources can be external (provided by the organization) or internal (part of a worker's personal make-up, for example self-confidence or quantitative skills). In addition to control and support, resources encompassed by the model can also include physical equipment, software, realistic performance feedback from supervisors, the worker's own coping strategies, etc. There has not, however, been as much research on the JD-R model as there has been on the constituents of the DC or DCS model. Person-environment fit model The person-environment (P-E) fit model is concerned with the extent to which a worker's abilities and personality dovetail with the tasks his/her job requires. The closeness of the person-job match influences the individual's health. One scholar observed that "an element of [the P-E fit research program] was loosely motivated by Darwinian theory, namely, the importance of the fit between the person and his or her environment" (p. 26). For the best possible outcomes, it is important that employees' skills, attitudes, abilities, and resources complement the demands of their job. The wider the gap or misfit—and this misfit can be either subjective or objective—between the worker and his/her work environment, the greater the risk of the worker experiencing mental and physical health problems. Misfit can also lead to lower productivity and other work problems. The P–E fit model was popular in the 1970s and the early 1980s. Since the late 1980s interest in the model has diminished largely because of problems representing P–E discrepancies mathematically and in statistical models linking P-E fit to strain. Research on psychosocial risk factors for poor health outcomes Cardiovascular disease Research has identified health-behavioral and biological factors that are related to increased risk for cardiovascular disease (CVD). These risk factors include smoking, obesity, low density lipoprotein (the "bad" cholesterol), lack of exercise, and blood pressure. Psychosocial working conditions are also risk factors for CVD. In a case-control study involving two large U.S. data sets, Murphy (1991) found that hazardous work situations, jobs that required vigilance and responsibility for others, and work that required attention to devices were related to increased risk for cardiovascular disability. These included jobs in transportation (e.g., air traffic controllers, airline pilots, bus drivers, locomotive engineers, truck drivers), preschool teachers, and craftsmen. Among 30 studies involving men and women, most have found an association between workplace stressors and CVD. Fredikson, Sundin, and Frankenhaeuser (1985) found that reactions to psychological stressors include increased activity in the brain axes that play an important role in the regulation of blood pressure, particularly ambulatory blood pressure. A meta-analysis and systematic review involving 29 samples linked jobs that combine high workload and little autonomy/discretion/decision latitude (high-strain jobs) to elevated ambulatory blood pressure. Belkić et al. (2000) found that many of the 30 studies covered in their review revealed that decision latitude and psychological workload exerted independent effects on CVD; two studies found synergistic effects, consistent with the strictest version of the demand-control model. A review of 17 longitudinal studies having reasonably high internal validity found that 8 showed a significant relation between the combination of low levels of decision latitude and high workload and CVD and 3 more showed a nonsignificant relation. The findings, however, were clearer for men than for women, on whom data were more sparse. Fishta and Backé's review-of-reviews also links work-related psychosocial stress to elevated risk of CVD in men. In a massive (n > 197,000) longitudinal study that combined data from 13 independent studies, Kivimäki et al. (2012) found that, controlling for other risk factors, having a high-strain job at baseline increased the risk of CVD in initially healthy workers by between 20 and 30% over a follow-up period that averaged 7.5 years. In this study the effects were similar for men and women. Meta-analytic research also links high-strain jobs to stroke. There is evidence that, consistent with the ERI model, high work-related effort coupled with low control over job-related rewards adversely affects cardiovascular health. At least five studies of men have linked effort-reward imbalance with CVD. Another large study links ERI to the incidence of coronary disease. Job-related burnout, depression, and cardiovascular health There is evidence from a prospective study that job-related burnout, controlling for traditional risk factors, such as smoking and hypertension, increases the risk of heart disease over the course of the next three and a half years in workers who were initially disease-free. Meta-analytic and other evidence, however, suggests that what is termed burnout is a depressive condition. Meta-analytic and other evidence indicates that depression is a risk factor for cardiovascular disease and cardiovascular-related mortality. Job loss and physical health Research has suggested that job loss adversely affects cardiovascular health as well as health in general. Musculoskeletal disorders Musculoskeletal disorders (MSDs) involve injury and pain to the joints and muscles. Approximately 2.5 million workers in the US have MSDs, which is the third most common cause of disability and early retirement for American workers. In Europe MSDs are the most often reported workplace health problem. The development of musculoskelelatal problems cannot be solely explained in the basis of biomechanical factors (e.g., repetitive motion) although such factors are major contributors to MSD risk. Evidence has accumulated to show that psychosocial workplace factors (e.g., high-strain jobs) also contribute to the development of musculoskeletal problems. Systematic reviews and meta-analyses of high-quality longitudinal studies have indicated that psychosocial working conditions (e.g., supportive coworkers, monotonous work) are related to the development of MSDs. Workplace mistreatment There are many forms of workplace mistreatment ranging from relatively minor discourtesies to serious cases of bullying and violence. Workplace incivility Workplace incivility has been defined as "low-intensity deviant behavior with ambiguous intent to harm the target....Uncivil behaviors are characteristically rude and discourteous, displaying a lack of regard for others" (p. 457). Incivility is distinct from violence. Examples of workplace incivility include insulting comments, denigration of the target's work, spreading false rumors, social isolation, etc. A summary of research conducted in Europe suggests that workplace incivility is common there. In research on more than 1000 U.S. civil service workers, more than 70% of the sample experienced workplace incivility in the past five years. Compared to men, women were more exposed to incivility; incivility was associated with psychological distress and reduced job satisfaction. Abusive supervision Abusive supervision is the extent to which a supervisor engages in a pattern of behavior that harms subordinates. Workplace bullying Although definitions of workplace bullying vary, it involves a repeated pattern of harmful behaviors directed towards an individual by one or more others who, singly or collectively, have more power than the target. Workplace bullying is sometimes termed mobbing. Sexual harassment Sexual harassment is behavior that denigrates or mistreats an individual due to his or her gender, creates an offensive workplace, and interferes with an individual being able to perform his or her job. Workplace violence Workplace violence is a significant health hazard for employees, both physically and psychologically. Nonfatal assault Most workplace assaults are nonfatal, with an annual physical assault rate of 6% in the U.S. Assaultive behavior in the workplace often produces injury, psychological distress, and economic loss. One study of California workers found a rate of 72.9 non-fatal, officially documented assaults per 100,000 workers per year, with workers in the education, retail, and health care sectors subject to excess risk. A Minnesota workers' compensation study found that women workers had a twofold higher risk of being injured in an assault than men, and health and social service workers, transit workers, and members of the education sector were at high risk for injury compared to workers in other economic sectors. A West Virginia workers' compensation study found that workers in the health care sector and, to a lesser extent, the education sector were at elevated risk for assault-related injury. Another workers' compensation study found that excessively high rates of assault-related injury in schools, healthcare, and, to a lesser extent, banking. In addition to the physical injury that results from workplace violence, individuals who witness such violence without being directly victimized are at increased risk for experiencing adverse psychological effects, including high levels of distress and arousal, as found in a study of Los Angeles teachers. Homicide In 1996 there were 927 work-associated homicides in the United States, in a labor force that numbered approximately 132,616,000. The rate works out to be about 7 homicides per million workers for the one year. Men are more likely to be victims of workplace homicide than women. Mental disorder Research has found that psychosocial workplace factors are among the risk factors for a number of categories of mental disorder.<ref name = "Madsen">Madsen, I. E. H., Nyberg, S. T., Magnusson Hanson, L. L., Ferrie, J. E., Ahola, K., Alfredsson, L., Batty, G. D., Bjorner, J. B., Borritz, M., Burr, H., Chastang, J.-F., de Graaf, R., Dragano, N., Hamer, M., Jokela, M., Knutsson, A., Koskenvuo, M., Koskinen, A., Leineweber, C., … Kivimäki, M. (2017). Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data. Psychological Medicine, 47', 1342–1356. https://doi.org/ 10.1017/S003329171600355X</ref> Increased consumption of alcohol Workplace factors have been found to be related to increased alcohol consumption as well as alcohol use disorder and dependence of employees. Rates of excessive alcohol use can vary by occupation, with high rates in the construction and transportation industries as well as among waiters and waitresses. Within the transportation sector, heavy truck drivers and material movers were shown to be at especially high risk. A prospective study of ECA subjects who were followed one year after the initial interviews provided data on newly incident cases of alcohol use disorder. The study found that workers in jobs that combined low control with high physical demands were at increased risk of developing alcohol problems although the findings were confined to men. Depression Using data from the ECA study, Eaton, Anthony, Mandel, and Garrison (1990) found that members of three occupational groups, lawyers, secretaries, and special education teachers (but not other types of teachers) showed elevated rates of DSM-III major depression, adjusting for social demographic factors. The ECA study involved representative samples of American adults from five geographical areas, providing relatively unbiased estimates of the risk of mental disorder by occupation; however, because the data were cross-sectional, no conclusions bearing on cause-and-effect relations are warranted. Evidence from a Canadian prospective study indicated that individuals in the highest quartile of occupational stress (high-strain jobs as per the demand-control model) are at increased risk of experiencing an episode of major depression. A literature review and meta-analysis links high demands, low control, and low support to clinical depression. A meta-analysis that pooled the results of 11 well-designed longitudinal studies indicated that a number of facets of the psychosocial work environment (e.g., low decision latitude, high psychological workload, lack of social support at work, effort-reward imbalance, and job insecurity) increase the risk of common mental disorders such as depression. Personality disorders Depending on the diagnosis, severity and individual, and the job itself, personality disorders can be associated with difficulty coping with work or the workplace, potentially leading to problems with others by interfering with interpersonal relationships. Indirect effects also play a role; for example, impaired educational progress or complications outside of work, such as substance use disorders and co-morbid mental disorders, can affect patients. However, personality disorders can also bring about above-average work abilities by increasing competitive drive or causing them to exploit their co-workers.Ettner, S.L., Maclean, J.C., & French, M.T. (2011). Does having a dysfunctional personality hurt your career? Axis II personality disorders and labor market outcomes. Industrial Relations, 50, 149–173. Schizophrenia In a case-control study, Link, Dohrenwend, and Skodol (1986) compared schizophrenic patients to two comparison groups, depressed individuals and well controls. Prior to their first episode of the disorder, the schizophrenic patients were more likely than the well controls and the depressed subjects to have had jobs characterized by "noisesome" work characteristics; noisesome work characteristics refer to noise, humidity, heat, cold, etc. The jobs tended to be of higher status than other blue collar jobs, suggesting that downward drift in already-affected individuals does not account for the finding. One explanation involving a diathesis-stress model suggests that the job-related stressors helped precipitate the first episode in already-vulnerable individuals. There is some supporting evidence from the Epidemiologic Catchment Area (ECA) study. Psychological distress Longitudinal studies have suggested adverse working conditions can contribute to increases in psychological distress. Psychological distress refers to negative affect, regardless of whether the individuals meet criteria for a psychiatric disorder.Frank, J.D. (1973). Persuasion and healing. Baltimore: The Johns Hopkins Press. Psychological distress is often expressed in affective (depressive), psychophysical or psychosomatic (e.g., headaches, stomachaches, etc.), and anxiety symptoms. The relation of adverse working conditions to psychological distress is thus an important avenue of research. A literature review and meta-analysis of high-quality longitudinal studies link high demands, low control, and low support to distress symptoms. Lower levels of job satisfaction are also related to increased distress and negative health outcomes.House, J.S. (1974). Occupational stress and coronary heart disease: A review and theoretical integration. Journal of Health and Social Behavior, 15, 12–27. Psychosocial working conditions Parkes (1982) studied the relation of working conditions to psychological distress in British student nurses. She found that in her "natural experiment," student nurses experienced higher levels of distress and lower levels of job satisfaction in medical wards than in surgical wards; compared to surgical wards, medical wards make greater affective demands on the nurses. In another study, Frese (1985) concluded that objective working conditions (e.g., noise, ambiguities, conflicts) give rise to subjective stress and psychosomatic symptoms in blue collar German workers. In addition to the above studies, a number of other well-controlled longitudinal studies have implicated work stressors in the development of psychological distress and reduced job satisfaction.Dormann, C., & Zapf, D. (2002). Social stressors at work, irritation, and depressive symptoms: Accounting for unmeasured third variables in a multi-wave study. Journal of Occupational and Organizational Psychology, 75, 33–58. Unemployment A comprehensive meta-analysis involving 86 studies indicated that involuntary job loss is linked to increased psychological distress. The impact of involuntary unemployment was comparatively weaker in countries that had greater income equality and better social safety nets. The research evidence also indicates that poorer mental health slightly, but significantly, increases the risk of later job loss. Economic insecurity Some OHP research is concerned with (a) understanding the impact of economic crises on individuals' physical and mental health and well-being and (b) calling attention to personal and organizational means for ameliorating the impact of such a crisis. Economic insecurity contributes, at least partly, to psychological distress and work-family conflict. Ongoing job insecurity, even in the absence of job loss, is related to higher levels of depressive symptoms, psychological distress, and worse overall health. Work-family balance Employees must balance their working lives with their home lives. Work–family conflict is a situation in which the demands of work conflict with the demands of family or vice versa, making it difficult to adequately do both, giving rise to distress.Greenhaus, J.G., & Allen, T. (2011). Work-family balance: A review and extension. In J.C. Quick & L.E. Tetrick (Eds.), Handbook of occupational health psychology (2nd ed., pp. 165–183). Washington DC, American Psychological Association. Although more research has been conducted on work-family conflict, there is also the phenomenon of work-family enhancement, which occurs when positive effects carry over from one domain into the other. Accidents and safety Psychosocial factors can influence the risk of occupational accidents that can lead to employee injury or death. One prominent psychosocial factor is the organization's safety climate. Safety climate refers to employees' shared beliefs regarding the priority the organization assigns to safety relative to the organization's other goals. Research on workplace interventions to improve or protect worker health A number of stress management interventions have emerged that have shown demonstrable effects in reducing job stress. Cognitive behavioral interventions have tended to have greatest impact on stress reduction. Industrial organizations OHP interventions often concern both the health of the individual and the health of the organization. Adkins (1999) described the development of one such intervention, an organizational health center (OHC) at a California industrial complex. The OHC helped to improve both organizational and individual health as well as help workers manage job stress. Innovations included labor-management partnerships, suicide risk reduction, conflict mediation, and occupational mental health support. OHC practitioners also coordinated their services with previously underutilized local community services in the same city, thus reducing redundancy in service delivery. Hugentobler, Israel, and Schurman (1992) detailed a different, multi-layered intervention in a mid-sized Michigan manufacturing plant. The hub of the intervention was the Stress and Wellness Committee (SWC) which solicited ideas from workers on ways to improve both their well-being and'' productivity. Innovations the SWC developed included improvements that ensured two-way communication between workers and management and reduction in stress resulting from diminished conflict over issues of quantity versus quality. Both the interventions described by Adkins and Hugentobler et al. had a positive impact on productivity. OHP research at the National Institute for Occupational Safety and Health NIOSH has a research agenda aimed reducing the incidence of preventable work-related disorders and accidents. For example, NIOSH research has aimed at reducing the problem of sleep apnea among heavy-truck and tractor-trailer drivers and, concomitantly, the life-threatening accidents to which the disorders lead. Another goal of NIOSH has been to improve the health and safety of workers who are assigned to shift work or who work long hours. A third example of NIOSH's efforts is the goal of reducing the incidence of falls among iron workers. Military and first responders The Mental Health Advisory Teams of the United States Army employ OHP-related interventions with combat troops. OHP also has a role to play in interventions aimed at helping first responders. Modestly scaled interventions Schmitt (2007) described three different modestly scaled OHP-related interventions that helped workers abstain from smoking, exercise more frequently, and lose weight. Other OHP interventions included a campaign to improve the rates of hand washing, an effort to get workers to walk more often, and a drive to get employees to be more compliant with regard to taking prescribed medicines. The interventions tended reduce organization health-care costs. Health promotion Organizations can play a role in promoting healthy behaviors in employees by providing resources to encourage such behaviors. These behaviors can be in areas such as reduction of sedentary behaviour exercise, nutrition, and smoking cessation. Prevention Although the dimensions of the problem of workplace violence vary by economic sector, one sector, education, has had some limited success in introducing programmatic, psychologically based efforts to reduce the level of violence. Research suggests that there continue to be difficulties in successfully "screening out applicants [for jobs] who may be prone to engaging in aggressive behavior," suggesting that aggression-prevention training of existing employees may be an alternative to screening. Only a small number of studies evaluating the effectiveness of training programs to reduce workplace violence have been documented. Total Worker Health Because many companies have implemented worker safety and health measures in a fragmented way, a new approach to worker safety and health has emerged in response, driven by efforts advanced by NIOSH. NIOSH trademarked that approach, naming it Total Worker Health. Total Worker Health involves the coordination of evidence-based (a) health promotion practices at the level of the individual worker and (b) umbrella-like health and safety practices at the level of the organizational unit. Total Worker Health–type interventions integrate health protection and health promotion components. Health promotion components are more individually oriented, in other words, oriented toward the wellness and/or well-being of individual workers. An example of such a component is a smoking cessation program. Umbrella-like health and safety practices are ordinarily implemented at the level of the unit or the organization. An example of such a component is that of introducing, factory-wide, equipment to reduce worker exposures to aerosols. Total Worker Health-type interventions (i.e., interventions that integrate individual employee health promotion components and organizational-level occupational safety/heath components) can prevent work-related disorder and reduce injury. See also References Further reading External links List of academic journals that publish OHP-related articles by Paul Spector European Academy of Occupational Health Psychology Society for Occupational Health Psychology Applied psychology Psychology Behavioural sciences Occupational safety and health

Post-acute-withdrawal syndrome

Post-acute withdrawal syndrome (PAWS) is a hypothesized set of persistent impairments that occur after withdrawal from alcohol, opiates, benzodiazepines, antidepressants, and other substances. Infants born to mothers who used substances of dependence during pregnancy may also experience a PAWS. While PAWS has been frequently reported by those withdrawing from opiate and alcohol dependence, the research has limitations. Protracted benzodiazepine withdrawal has been observed to occur in some individuals prescribed benzodiazepines. Drug use, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and during the withdrawal state. In some cases these substance-induced psychiatric disorders can persist long after detoxification from amphetamine, cocaine, opioid, and alcohol use, causing prolonged psychosis, anxiety or depression. A protracted withdrawal syndrome can occur with symptoms persisting for months to years after cessation of substance use. Benzodiazepines, opioids, alcohol, and any other drug may induce prolonged withdrawal and have similar effects, with symptoms sometimes persisting for years after cessation of use. Psychosis including severe anxiety and depression are commonly induced by sustained alcohol, opioid, benzodiazepine, and other drug use which in most cases abates with prolonged abstinence. Any continued use of drugs or alcohol may increase anxiety, psychosis, and depression levels in some individuals. In almost all cases drug-induced psychiatric disorders fade away with prolonged abstinence, although permanent damage to the brain and nervous system may be caused by continued substance use. Signs and symptoms Symptoms can sometimes come and go with wave-like re-occurrences or fluctuations in severity of symptoms. Common symptoms include impaired cognition, irritability, depressed mood, and anxiety; all of which may reach severe levels which can lead to relapse. The protracted withdrawal syndrome from benzodiazepines, opioids, alcohol and other addictive substances can produce symptoms identical to generalized anxiety disorder as well as panic disorder. Due to the sometimes prolonged nature and severity of benzodiazepine, opioid and alcohol withdrawal, abrupt cessation is not advised. Hypothesized symptoms of PAWS are: Psychosocial dysfunction Anhedonia Depression Impaired interpersonal skills Obsessive-compulsive behaviour Feelings of guilt Autonomic disturbances Pessimistic thoughts Impaired attentional control Lack of initiative Craving Inability to think clearly Memory problems Emotional overreactions or numbness Sleep disturbances Extreme fatigue Physical coordination problems Stress sensitivity Increased sensitivity to pain Panic disorder Psychosis Generalized anxiety disorder Sleep disturbance (dreams of using, behaviors associated with the life style) Mourning (the change in lifestyle) Symptoms occur intermittently, but are not always present. They are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short while or longer. Any of the following may trigger a temporary return or worsening of the symptoms of PAWS: Stressful and/or frustrating situations Multitasking Feelings of anxiety, fearfulness or anger Social conflicts Unrealistic expectations of oneself Post-acute benzodiazepine withdrawal Disturbances in mental function can persist for several months or years after withdrawal from benzodiazepines. Psychotic depression persisting for more than a year following benzodiazepine withdrawal has been documented in the medical literature. The patient had no prior psychiatric history. The symptoms reported in the patient included, major depressive disorder with psychotic features, including persistent depressed mood, poor concentration, decreased appetite, insomnia, anhedonia, anergia and psychomotor retardation. The patient also experienced paranoid ideation (believing she was being poisoned and persecuted by co-employees), accompanied by sensory hallucinations. Symptoms developed after abrupt withdrawal of chlordiazepoxide and persisted for 14 months. Various psychiatric medications were trialed which were unsuccessful in alleviating the symptomatology. Symptoms were completely relieved by recommending chlordiazepoxide for irritable bowel syndrome 14 months later. Another case report noted a similar phenomenon in a female patient who abruptly reduced her diazepam dosage from 30 mg to 5 mg per day. She developed electric shock sensations, depersonalization, anxiety, dizziness, left temporal lobe EEG spiking activity, hallucinations, visual perceptual and sensory distortions which persisted for years. A clinical trial of patients taking the benzodiazepine alprazolam (Xanax) for eight weeks triggered protracted symptoms of memory deficits which were still present after up to eight weeks post cessation of alprazolam. Dopamine agonist protracted withdrawal After long-term use of dopamine agonists, a withdrawal syndrome may occur during dose reduction or discontinuation with the following possible side effects: anxiety, panic attacks, dysphoria, depression, agitation, irritability, suicidal ideation, fatigue, orthostatic hypotension, nausea, vomiting, diaphoresis, generalized pain, and drug cravings. For some individuals, these withdrawal symptoms are short-lived and make a full recovery, for others a protracted withdrawal syndrome may occur with withdrawal symptoms persisting for months or years. Cause The syndrome may be in part due to persisting physiological adaptations in the central nervous system manifested in the form of continuing but slowly reversible tolerance, disturbances in neurotransmitters and resultant hyperexcitability of neuronal pathways. However, data supports "neuronal and overwhelming cognitive normalization" in regards to chronic amphetamine use and PAWS. Stressful situations arise in early recovery, and the symptoms of post acute withdrawal syndrome produce further distress. It is important to avoid or to deal with the triggers that make post acute withdrawal syndrome worse. The types of symptomatology and impairments in severity, frequency, and duration associated with the condition vary depending on the drug of use. Treatment The condition gradually improves over a period of time which can range from six months to several years in more severe cases. Flumazenil was found to be more effective than placebo in reducing feelings of hostility and aggression in patients who had been free of benzodiazepines for 4 to 266 weeks. This may suggest a role for flumazenil in treating protracted benzodiazepine withdrawal symptoms. Acamprosate has been found to be effective in alleviating some of the post acute withdrawal symptoms of alcohol withdrawal. Carbamazepine or trazodone may also be effective in the treatment of post acute withdrawal syndrome in regards to alcohol use. Cognitive behavioral therapy can also help the post acute withdrawal syndrome especially when cravings are a prominent feature. See also Alcohol withdrawal syndrome Antidepressant discontinuation syndrome Benzodiazepine withdrawal syndrome Opioid use disorder References Adverse effects of psychoactive drugs Withdrawal syndromes

IMRAD

In scientific writing, IMRAD or IMRaD (Introduction, Methods, Results, and Discussion) is a common organizational structure (a document format). IMRaD is the most prominent norm for the structure of a scientific journal article of the original research type. Overview Original research articles are typically structured in this basic order Introduction – Why was the study undertaken? What was the research question, the tested hypothesis or the purpose of the research? Methods – When, where, and how was the study done? What materials were used or who was included in the study groups (patients, etc.)? Results – What answer was found to the research question; what did the study find? Was the tested hypothesis true? Discussion – What might the answer imply and why does it matter? How does it fit in with what other researchers have found? What are the perspectives for future research? The plot and the flow of the story of the IMRaD style of writing are explained by a 'wine glass model' or hourglass model. Writing, compliant with IMRaD format (IMRaD writing) typically first presents "(a) the subject that positions the study from the wide perspective", "(b) outline of the study", develops through "(c) study method", and "(d) the results", and concludes with "(e) outline and conclusion of the fruit of each topics", and "(f) the meaning of the study from the wide and general point of view". Here, (a) and (b) are mentioned in the section of the "Introduction", (c) and (d) are mentioned in the section of the "Method" and "Result" respectively, and (e) and (f) are mentioned in the section of the "Discussion" or "Conclusion". In this sense, to explain how to line up the information in IMRaD writing, the 'wine glass model' (see the pattern diagram shown in Fig.1) will be helpful (see pp 2–3 of the Hilary Glasman-deal ). As mentioned in abovementioned textbook, the scheme of 'wine glass model' has two characteristics. The first one is "top-bottom symmetric shape", and the second one is "changing width" i.e. "the top is wide and it narrows towards the middle, and then widens again as it goes down toward the bottom". The First one, "top-bottom symmetric shape", represents the symmetry of the story development. Note the shape of the top trapezoid (representing the structure of Introduction) and the shape of the trapezoid at the bottom are reversed. This is expressing that the same subject introduced in Introduction will be taken up again in suitable formation for the section of Discussion/Conclusion in these section in the reversed order. (See the relationship between abovementioned (a), (b) and (e), (f).) The Second one, "the change of the width" of the schema shown in Fig.1, represents the change of generality of the view point. As along the flow of the story development, when the viewpoints are more general, the width of the diagram is expressed wider, and when they are more specialized and focused, the width is expressed narrower. As the standard format of academic journals The IMRAD format has been adopted by a steadily increasing number of academic journals since the first half of the 20th century. The IMRAD structure has come to dominate academic writing in the sciences, most notably in empirical biomedicine. The structure of most public health journal articles reflects this trend. Although the IMRAD structure originates in the empirical sciences, it now also regularly appears in academic journals across a wide range of disciplines. Many scientific journals now not only prefer this structure but also use the IMRAD acronym as an instructional device in the instructions to their authors, recommending the use of the four terms as main headings. For example, it is explicitly recommended in the "Uniform Requirements for Manuscripts Submitted to Biomedical Journals" issued by the International Committee of Medical Journal Editors (previously called the Vancouver guidelines): The text of observational and experimental articles is usually (but not necessarily) divided into the following sections: Introduction, Methods, Results, and Discussion. This so-called "IMRAD" structure is not an arbitrary publication format but rather a direct reflection of the process of scientific discovery. Long articles may need subheadings within some sections (especially Results and Discussion) to clarify their content. Other types of articles, such as case reports, reviews, and editorials, probably need to be formatted differently. The IMRAD structure is also recommended for empirical studies in the 6th edition of the publication manual of the American Psychological Association (APA style). The APA publication manual is widely used by journals in the social, educational and behavioral sciences. Benefits The IMRAD structure has proved successful because it facilitates literature review, allowing readers to navigate articles more quickly to locate material relevant to their purpose. But the neat order of IMRAD rarely corresponds to the actual sequence of events or ideas of the research presented; the IMRAD structure effectively supports a reordering that eliminates unnecessary detail, and allows the reader to assess a well-ordered and noise-free presentation of the relevant and significant information. It allows the most relevant information to be presented clearly and logically to the readership, by summarizing the research process in an ideal sequence and without unnecessary detail. Caveats The idealised sequence of the IMRAD structure has on occasion been criticised for being too rigid and simplistic. In a radio talk in 1964 the Nobel laureate Peter Medawar criticised this text structure for not giving a realistic representation of the thought processes of the writing scientist: "… the scientific paper may be a fraud because it misrepresents the processes of thought that accompanied or gave rise to the work that is described in the paper". Medawar's criticism was discussed at the XIXth General Assembly of the World Medical Association in 1965. While respondents may argue that it is too much to ask from such a simple instructional device to carry the burden of representing the entire process of scientific discovery, Medawar's caveat expressed his belief that many students and faculty throughout academia treat the structure as a simple panacea. Medawar and others have given testimony both to the importance and to the limitations of the device. Abstract considerations In addition to the scientific article itself a brief abstract is usually required for publication. The abstract should, however, be composed to function as an autonomous text, even if some authors and readers may think of it as an almost integral part of the article. The increasing importance of well-formed autonomous abstracts may well be a consequence of the increasing use of searchable digital abstract archives, where a well-formed abstract will dramatically increase the probability for an article to be found by its optimal readership. Consequently, there is a strong recent trend toward developing formal requirements for abstracts, most often structured on the IMRAD pattern, and often with strict additional specifications of topical content items that should be considered for inclusion in the abstract. Such abstracts are often referred to as structured abstracts. The growing importance of abstracts in the era of computerized literature search and information overload has led some users to modify the IMRAD acronym to AIMRAD, in order to give due emphasis to the abstract. Heading style variations Usually, the IMRAD article sections use the IMRAD words as headings. A few variations can occur, as follows: Many journals have a convention of omitting the "Introduction" heading, based on the idea that the reader who begins reading an article does not need to be told that the beginning of the text is the introduction. This print-era proscription is fading since the advent of the Web era, when having an explicit "Introduction" heading helps with navigation via document maps and collapsible/expandable TOC trees. (The same considerations are true regarding the presence or proscription of an explicit "Abstract" heading.) In some journals, the "Methods" heading may vary, being "Methods and materials", "Materials and methods", or similar phrases. Some journals mandate that exactly the same wording for this heading be used for all articles without exception; other journals reasonably accept whatever each submitted manuscript contains, as long as it is one of these sensible variants. The "Discussion" section may subsume any "Summary", "Conclusion", or "Conclusions" section, in which case there may or may not be any explicit "Summary", "Conclusion", or "Conclusions" subheading; or the "Summary"/"Conclusion"/"Conclusions" section may be a separate section, using an explicit heading on the same heading hierarchy level as the "Discussion" heading. Which of these variants to use as the default is a matter of each journal's chosen style, as is the question of whether the default style must be forced onto every article or whether sensible inter-article flexibility will be allowed. The journals which use the "Conclusion" or "Conclusions" along with a statement about the "Aim" or "Objective" of the study in the "Introduction" is following the newly proposed acronym "IaMRDC" which stands for "Introduction with aim, Materials and Methods, Results, Discussion, and Conclusion." Other elements that are typical although not part of the acronym Disclosure statements (see main article at conflicts of interest in academic publishing) Reader's theme that is the point of this element's existence: "Why should I (the reader) trust or believe what you (the author) say? Are you just making money off of saying it?" Appear either in opening footnotes or a section of the article body Subtypes of disclosure: Disclosure of funding (grants to the project) Disclosure of conflict of interest (grants to individuals, jobs/salaries, stock or stock options) Clinical relevance statement Reader's theme that is the point of this element's existence: "Why should I (the reader) spend my time reading what you say? How is it relevant to my clinical practice? Basic research is nice, other people's cases are nice, but my time is triaged, so make your case for 'why bother'" Appear either as a display element (sidebar) or a section of the article body Format: short, a few sentences or bullet points Ethical compliance statement Reader's theme that is the point of this element's existence: "Why should I believe that your study methods were ethical?" "We complied with the Declaration of Helsinki." "We got our study design approved by our local institutional review board before proceeding." "We got our study design approved by our local ethics committee before proceeding." "We treated our animals in accordance with our local Institutional Animal Care and Use Committee." Diversity, equity, and inclusion statement Reader's theme that is the point of this element's existence: "Why should I believe that your study methods consciously included people?" (for example, avoided inadvertently underrepresenting some people—participants or researchers—by race, ethnicity, sex, gender, or other factors) "We worked to ensure that people of color and transgender people were not underrepresented among the study population." "One or more of the authors of this paper self-identifies as living with a disability." "One or more of the authors of this paper self-identifies as transgender." Additional standardization (reporting guidelines) In the late 20th century and early 21st, the scientific communities found that the communicative value of journal articles was still much less than it could be if best practices were developed, promoted, and enforced. Thus reporting guidelines (guidelines for how best to report information) arose. The general theme has been to create templates and checklists with the message to the user being, "your article is not complete until you have done all of these things." In the 1970s, the ICMJE (International Committee of Medical Journal Editors) released the Uniform Requirements for Manuscripts Submitted to Biomedical Journals (Uniform Requirements or URM). Other such standards, mostly developed in the 1990s through 2010s, are listed below. The academic medicine community is working hard on trying to raise compliance with good reporting standards, but there is still much to be done; for example, a 2016 review of instructions for authors in 27 emergency medicine journals found insufficient mention of reporting standards, and a 2018 study found that even when journals' instructions for authors mention reporting standards, there is a difference between a mention or badge and enforcing the requirements that the mention or badge represents. The advent of a need for best practices in data sharing has expanded the scope of these efforts beyond merely the pages of the journal article itself. In fact, from the most rigorous versions of the evidence-based perspective, the distance to go is still quite formidable. FORCE11 is an international coalition that has been developing standards for how to share research data sets properly and most effectively. Most researchers cannot be familiar with all of the many reporting standards that now exist, but it is enough to know which ones must be followed in one's own work, and to know where to look for details when needed. Several organizations provide help with this task of checking one's own compliance with the latest standards: The EQUATOR Network The BioSharing collaboration (biosharing.org) Several important webpages on this topic are: NLM's list at Research Reporting Guidelines and Initiatives: By Organization The EQUATOR Network's list at Reporting guidelines and journals: fact & fiction TRANSPOSE (Transparency in Scholarly Publishing for Open Scholarship Evolution), "a grassroots initiative to build a crowdsourced database of journal policies," allowing faster and easier lookup and comparison, and potentially spurring harmonization Relatedly, SHERPA provides compliance-checking tools, and AllTrials provides a rallying point, for efforts to enforce openness and completeness of clinical trial reporting. These efforts stand against publication bias and against excessive corporate influence on scientific integrity. See also Case report Case series Eight-legged essay Five paragraph essay IRAC Journal Article Tag Suite (JATS) Literature review Meta-analyses Schaffer paragraph References Writing Academic publishing Scientific documents Technical communication Style guides for technical and scientific writing Academic terminology Medical publishing

Medical anthropology

Medical anthropology studies "human health and disease, health care systems, and biocultural adaptation". It views humans from multidimensional and ecological perspectives. It is one of the most highly developed areas of anthropology and applied anthropology, and is a subfield of social and cultural anthropology that examines the ways in which culture and society are organized around or influenced by issues of health, health care and related issues. The term "medical anthropology" has been used since 1963 as a label for empirical research and theoretical production by anthropologists into the social processes and cultural representations of health, illness and the nursing/care practices associated with these. Furthermore, in Europe the terms "anthropology of medicine", "anthropology of health" and "anthropology of illness" have also been used, and "medical anthropology", was also a translation of the 19th century Dutch term "medische anthropologie". This term was chosen by some authors during the 1940s to refer to philosophical studies on health and illness. Historical background The relationship between anthropology, medicine and medical practice is well documented. General anthropology occupied a notable position in the basic medical sciences (which correspond to those subjects commonly known as pre-clinical). However, medical education started to be restricted to the confines of the hospital as a consequence of the development of the clinical gaze and the confinement of patients in observational infirmaries. The hegemony of hospital clinical education and of experimental methodologies suggested by Claude Bernard relegate the value of the practitioners' everyday experience, which was previously seen as a source of knowledge represented by the reports called medical geographies and medical topographies both based on ethnographic, demographic, statistical and sometimes epidemiological data. After the development of hospital clinical training the basic source of knowledge in medicine was experimental medicine in the hospital and laboratory, and these factors together meant that over time mostly doctors abandoned ethnography as a tool of knowledge. Most, not all because ethnography remained during a large part of the 20th century as a tool of knowledge in primary health care, rural medicine, and in international public health. The abandonment of ethnography by medicine happened when social anthropology adopted ethnography as one of the markers of its professional identity and started to depart from the initial project of general anthropology. The divergence of professional anthropology from medicine was never a complete split. The relationships between the two disciplines remained constant during the 20th century, until the development of modern medical anthropology in the 1960s and 1970s. A book by Saillant & Genest describes development of medical anthropology as a field of study, and some of the main theoretical and intellectual actual debates. Some popular topics that are covered by medical anthropology are mental health, sexual health, pregnancy and birth, aging, addiction, nutrition, disabilities, infectious disease, non-communicable diseases (NCDs), global epidemics and disaster management. Medical sociology Peter Conrad notes that medical sociology studies some of the same phenomena as medical anthropology but argues that medical anthropology has different origins, originally studying medicine within non-western cultures and using different methodologies. He argues that there was some convergence between the disciplines, as medical sociology started to adopt some of the methodologies of anthropology such as qualitative research and began to focus more on the patient, and medical anthropology started to focus on western medicine. He argued that more interdisciplinary communication could improve both disciplines. Popular medicine and medical systems For much of the 20th century, the concept of popular medicine, or folk medicine, has been familiar to both doctors and anthropologists. Doctors, anthropologists, and medical anthropologists used these terms to describe the resources, other than the help of health professionals, which European or Latin American peasants used to resolve any health problems. The term was also used to describe the health practices of aborigines in different parts of the world, with particular emphasis on their ethnobotanical knowledge. This knowledge is fundamental for isolating alkaloids and active pharmacological principles. Furthermore, studying the rituals surrounding popular therapies served to challenge Western psychopathological categories, as well as the relationship in the West between science and religion. Doctors were not trying to turn popular medicine into an anthropological concept, rather they wanted to construct a scientifically based medical concept which they could use to establish the cultural limits of biomedicine. Biomedicine is the application of natural sciences and biology to the diagnosis of a disease. Often in the Western culture, this is ethnomedicine. Examples of this practice can be found in medical archives and oral history projects. The concept of folk medicine was taken up by professional anthropologists in the first half of the twentieth century to demarcate between magical practices, medicine and religion and to explore the role and the significance of popular healers and their self-medicating practices. For them, popular medicine was a specific cultural feature of some groups of humans which was distinct from the universal practices of biomedicine. If every culture had its own specific popular medicine based on its general cultural features, it would be possible to propose the existence of as many medical systems as there were cultures and, therefore, develop the comparative study of these systems. Those medical systems which showed none of the syncretic features of European popular medicine were called primitive or pretechnical medicine according to whether they referred to contemporary aboriginal cultures or to cultures predating Classical Greece. Those cultures with a documentary corpus, such as the Tibetan, traditional Chinese or Ayurvedic cultures, were sometimes called systematic medicines. The comparative study of medical systems is known as ethnomedicine, which is the way an illness or disease is treated in one's culture, or, if psychopathology is the object of study, ethnopsychiatry (Beneduce 2007, 2008), transcultural psychiatry (Bibeau, 1997) and anthropology of mental illness (Lézé, 2014). Under this concept, medical systems would be seen as the specific product of each ethnic group's cultural history. Scientific biomedicine would become another medical system and therefore a cultural form that could be studied as such. This position, which originated in the cultural relativism maintained by cultural anthropology, allowed the debate with medicine and psychiatry to revolve around some fundamental questions: The relative influence of genotypical and phenotypical factors in relation to personality and certain forms of pathology, especially psychiatric and psychosomatic pathologies. The influence of culture on what a society considers to be normal, pathological or abnormal. The verification in different cultures of the universality of the nosological categories of biomedicine and psychiatry. The identification and description of diseases belonging to specific cultures that have not been previously described by clinical medicine. These are known as ethnic disorders and, more recently, as culture-bound syndromes, and include the evil eye and tarantism among European peasants, being possessed or in a state of trance in many cultures, and nervous anorexia, nerves and premenstrual syndrome in Western societies. Since the end of the 20th century, medical anthropologists have had a much more sophisticated understanding of the problem of cultural representations and social practices related to health, disease and medical care and attention. These have been understood as being universal with very diverse local forms articulated in transactional processes. The link at the end of this page is included to offer a wide panorama of current positions in medical anthropology. Applied medical anthropology In the United States, Canada, Mexico, and Brazil, collaboration between anthropology and medicine was initially concerned with implementing community health programs among ethnic and cultural minorities and with the qualitative and ethnographic evaluation of health institutions (hospitals and mental hospitals) and primary care services. Regarding the community health programs, the intention was to resolve the problems of establishing these services for a complex mosaic of ethnic groups. The ethnographic evaluation involved analyzing the interclass conflicts within the institutions which had an undesirable effect on their administrative reorganization and their institutional objectives, particularly those conflicts among the doctors, nurses, auxiliary staff and administrative staff. The ethnographic reports show that interclass crises directly affected therapeutic criteria and care of the ill. They also contributed new methodological criteria for evaluating the new institutions resulting from the reforms as well as experimental care techniques such as therapeutic communities. The ethnographic evidence supported the criticisms of the institutional custodialism and contributed decisively to policies of deinstitutionalizing psychiatric and social care in general and led to in some countries such as Italy, a rethink of the guidelines on education and promoting health. The empirical answers to these questions led to the anthropologists being involved in many areas. These include: developing international and community health programs in developing countries; evaluating the influence of social and cultural variables in the epidemiology of certain forms of psychiatric pathology (transcultural psychiatry); studying cultural resistance to innovation in therapeutic and care practices; analysing healing practices toward immigrants; and studying traditional healers, folk healers and empirical midwives who may be reinvented as health workers (the so-called barefoot doctors). Also, since the 1960s, biomedicine in developed countries has been faced by a series of problems which stipulate inspection of predisposing social or cultural factors, which have been reduced to variables in quantitative protocols and subordinated to causal biological or genetic interpretations. Among these the following are of particular note: a) The transition between a dominant system designed for acute infectious pathology to a system designed for chronic degenerative pathology without any specific etiological therapy. b) The emergence of the need to develop long term treatment mechanisms and strategies, as opposed to incisive therapeutic treatments. c) The influence of concepts such as quality of life in relation to classic biomedical therapeutic criteria. Added to these are the problems associated with implementing community health mechanisms. These problems are perceived initially as tools for fighting against unequal access to health services. However, once a comprehensive service is available to the public, new problems emerge from ethnic, cultural or religious differences, or from differences between age groups, genders or social classes. If implementing community care mechanisms gives rise to one set of problems, then a whole new set of problems also arises when these same mechanisms are dismantled and the responsibilities which they once assumed are placed back on the shoulders of individual members of society. In all these fields, local and qualitative ethnographic research is indispensable for understanding the way patients and their social networks incorporate knowledge on health and illness when their experience is nuanced by complex cultural influences. These influences result from the nature of social relations in advanced societies and from the influence of social communication media, especially audiovisual media and advertising. Fields As medical anthropology has not standardised, consistent fields have not been established. In general, we may consider the following six basic fields: the development of systems of medical knowledge and medical care the patient-physician relationship the integration of alternative medical systems in culturally diverse environments the interaction of social, environmental and biological factors which influence health and illness both in the individual and the community as a whole the critical analysis of interaction between psychiatric services and migrant populations the impact of biomedicine and biomedical technologies in non-Western settings Other subjects that have become central to the medical anthropology worldwide are violence and social suffering as well as other issues that involve physical and psychological harm and suffering that are not a result of illness. On the other hand, there are fields that intersect with medical anthropology in terms of research methodology and theoretical production, such as cultural psychiatry and transcultural psychiatry or ethnopsychiatry. Training All medical anthropologists are trained in anthropology as their main discipline. Many come from the health professions such as medicine or nursing, whereas others come from the other backgrounds such as psychology, social work, social education or sociology. Cultural and transcultural psychiatrists are trained as anthropologists and, naturally, psychiatric clinicians. Training in medical anthropology is normally acquired at a master's (M.A. or M.Sc.) and doctoral level. A fairly comprehensive account of different postgraduate training courses in different countries can be found on the website of the Society of Medical Anthropology of the American Anthropological Association. See also Biological anthropology Critical medical anthropology Cultural ecology Culture-bound syndrome Disability anthropology Ecological anthropology Epidemiological transition Ethnomedicine Medical sociology William Abel Caudill References Further reading The following books present a global panorama on international medical anthropology, and can be useful as handbooks for beginners, students interested or for people who need a general text on this topic. Albretch GL, Fitzpatrick R Scrimshaw S, (2000) Handbook of Social Studies in Health and Medicine. London: Sage. Anderson, Robert (1996) Magic, Science and Health. The Aims and the Achievements of Medical Anthropology. Fort Worth, Harcourt Brace. Baer, Hans; Singer, Merrill; & Susser, Ida (2003)Medical Anthropology and the World System. Westport, CT: Praeger. Bibeau, Gilles (1997), "Cultural Psychiatry in a Creolizing World. Questions for a New Research Agenda", Transcultural Psychiatry, 34-1: 9–41. Brown PJ, ed.(1998) Understanding and Applying Medical Anthropology. Mountain View. Comelles, Josep M.; Dongen, Els van (eds.) (2002). Themes in Medical Anthropology. Perugia: Fondazione Angelo Celli Argo. Dongen, Els; Comelles, Josep M. (2001). Medical Anthropology and Anthropology. Perugia: Fondazione Angelo Celli Argo. Farmer, Paul (1999) Infections and Inequalities: The Modern Plagues. Berkeley, University of California Press. Farmer, Paul (2003) Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, University of California Press. Geest, Sjaak van der; Rienks, Ari (1998) The Art of Medical Anthropology. Readings. Amsterdam, Het Spinhuis. Universiteit van Amsterdam. Good, Byron, Michael M. J. Fischer, Sarah S. Willen, Mary-Jo DelVecchio Good, Eds. (2010) A Reader in Medical Anthropology: Theoretical Trajectories, Emergent Realities. Malden, MA: Wiley-Blackwell. Gray, A y Seale, C (eds.) (2001) Health and disease: a reader. Buckingham-Philadelphia, PA: Open University Press. Hahn, Robert A. (1995) Sickness and healing : an anthropological perspective. New Haven: Yale University Press. Hahn, Robert A. and Marcia Inhorn (eds.) (2010) Anthropology and Public Health, Second Edition: Bridging Differences in Culture and Society.Oxford University Press Helman, Cecil (1994) Culture Health and Illness. An Introduction for Health Professionals. London: Butterworth-Heinemann (new Fifth ed.). Janzen JM (2002) The Social Fabric of Health. An Introduction to Medical Anthropology, New York: McGraw-Hill. Johnson, Thomas; Sargent, C. (comps.) (1992), Medical Anthropology. Contemporary Theory and Method (reedition as Sargent i Johnson, 1996). Westport, Praeger. Landy, David (editor) Disease, and Healing: Studies in Medical Anthropology. New York: Macmillan. Lock, M & Nguyen, Vinh-Kim (2010) An Anthropology of Biomedicine, Wiley-Blackwell. Loustaunan MO, Sobo EJ. (1997) The Cultural Context of Health, Illness and Medicine. Westport, Conn.: Bergin & Garvey. Nichter, Mark. (2008) 'Global health : why cultural perceptions, social representations, and biopolitics matter' Tucson: The University of Arizona Press. Pool, R and Geissler, W. (2005). Medical Anthropology. Buckingham: Open University Press. Samson C. (1999) Health Studies. A critical and Cross-Cultural Reader. Oxford, Blackwell. Singer, Merrill and Baer, Hans (2007) Introducing Medical Anthropology: A Discipline in Action. Lanham, AltaMira Press. Trevathan, W, Smith, EO, McKenna JJ (1999) Evolutionary Medicine: an interpretation in evolutionary perspective. Oxford University Press Trevathan, W, Smith, EO, McKenna J (2007) Evolutionary Medicine and Health: New Perspectives. Oxford University Press. Wiley, AS (2008) Medical anthropology: a biocultural approach. University of Southern California External links Society for Medical Anthropology Anthropology

Adolescent health

Adolescent health, or youth health, is the range of approaches to preventing, detecting or treating young people's health and well-being. The term adolescent and young people are often used interchangeably, as are the terms Adolescent Health and Youth Health. Young people's health is often complex and requires a comprehensive, biopsychosocial approach. Adolescent health risks Because adolescence represents a life stage of increasing psychosocial independence, but one of limited legal and social rights (for those who have not reached the legal age of adulthood where they reside), adolescent health exists at the intersection of many forces often outside of the control of individual young people. Some young people might have a history of adverse childhood experiences (ACEs), or may be actively living in or experiencing the situations described as ACEs. The Adverse Childhood Experiences Study suggests that ACEs are common, and are predictive of adverse physical health outcomes (ischemic heart disease, cancer, chronic lung disease) in adults. Social, cultural and environmental factors are all important areas of focus in adolescent health. Young people have specific health problems and developmental needs that differ from those of children or adults: The causes of ill-health in adolescents are mostly psychosocial rather than biological. Young people often engage in health risk behaviours that reflect the processes of adolescent development: experimentation and exploration, including using drugs and alcohol, sexual behaviour, and other risk taking that affect their physical and mental health. Adolescent health also encompasses children's and young people's sexual and reproductive health (SRH). The World Health Organization describes the leading health-related problems in the age group 10 – 19 years to include: Road traffic accidents Drowning Violence Alcohol and drugs Tobacco Mental health Communicable disease (such as HIV, Tuberculosis) Early pregnancy and childbirth Environmental health Overweight Nutrition Physical activity Young people often lack awareness of the risks of harm associated with certain behaviours, or may overestimate the risks of some behaviours while underestimating the risks of others. They may be in the process of developing protective skills and behaviors, or may lack knowledge about how and where to seek help for their health concerns. By intervening at this early life stage, many chronic conditions later in life can be prevented. In addition to intervention on young people's knowledge around the risks of health-related behaviors, it is crucial to acknowledge that adolescents under the legal age of majority are often occupying an idiosyncratic legal, economic, and social state, where their rights to access confidential medical services, or to consent to preventative medical care is highly dependent on the laws and practices of where they reside. For example, in the US,  the legal rights of minors to consent to screening and treatment for sexually transmitted infections (STIs) varies on a state by state level, and the right to confidential access to these services varies as well. In a majority of US states, a minor may legally consent to testing and treatment starting at age 12 or 14, but 18 US states allow a physician to inform a minor's parents that their child has requested or has received STI screening or treatment if the physician deems it in the patient's best interests. At the same time, adolescents as an age group do not have the same economic power as adults, and may be unable to pay for or transport themselves to medical screening or treatment, whether for physical or behavioral health issues. An emphasis on individual risk behaviors may obfuscate the role of institutional barriers to performing protective health behaviors. Key principles Evidence-based practices include harm reduction and health promotion to intervene early in the life course and illness trajectory. Adoption of unhealthy behaviors are evident particularly during life stages involving transition such as the commencement of university where physical inactivity, sedentary activity and poor dietary habits prevail. Youth health is founded on collaborative approaches that address social justice. Youth development approaches include youth empowerment and youth participation. Their aim is to promote youth rights, youth voice and youth engagement. Access to health-care services Studies about young people's access to healthcare have identified major barriers including concerns about confidentiality, practitioners attitudes and communication style, environment, availability of services, cost and the developmental characteristics of young people. Marginalised young people can have greater difficulty accessing health services and need support to navigate the health system. The World Health Organization 'Global standards for quality health-care services for adolescents' include: Adolescents' health literacy Community support Appropriate package of services Providers' competencies Facility characteristics Equity and non-discrimination Standard Data and quality improvement Adolescents' participation Key health services for young people Youth Health includes adolescent medicine as a speciality, along with other primary and tertiary care services. Health services for young people include mental health services, child protection, drug and alcohol services, sexual health services. General Practitioners work alongside multidisciplinary health practitioners including psychology, social Work and Youth health nursing and school health services. Youth work and youth development services support and engage young people. Web based supports, such as Reach Out!, provide early intervention. Youth health services ('one-stop-shops' for young people) are specialist services providing multi-disciplinary, primary health care to young people. Focusing on engaging disadvantaged young people, they deliver flexible and unique services to young people in relaxed and comfortable youth-friendly environments. Youth health services work in partnership with other government and non-government services. Youth health services provide a range of entry-points and non-threatening services (such as creative arts, basic services such as showers and laundries, a drop in service, sports and recreational facilities), which encourage young people to connect with the service on their own terms. They also provide informal links to other support services and sectors including education, housing, financial support and legal services, offering support to young people who are dealing with complex issues. Youth health services understand the need to respond immediately to young people's requests for support and assistance and they share a common operating philosophy, which values social justice, equity, and a holistic view of young people's health and well-being. Capacity building organisations support the Youth Health sector by providing access to information and resources, conducting research and providing training. Effects of discrimination Social-emotional distress In a comprehensive review of research literature including 126 different studies that analyzed the relationship between perceived discrimination and social-emotional distress with effect sizes from small to moderate, perceived discrimination was shown to correlate with many social-emotional distresses for adolescents (Benner et al., 2018). Additionally, the study found that the more an adolescent perceived they were a victim of discrimination, the more likely it is that they will also report experiences with depression, anxiety, loneliness, and stress. Risky health behaviors Adolescents who report more discrimination also tend to report engaging in more risky health behaviors such as delinquency, anger, and other externalizing behaviors Other risky health behaviors include substance abuse and risky sexual behaviors like unprotected sex and sex with multiple partners. The data was taken from 71 different studies that analyze the relationship between perceived discrimination and risky health behaviors with effect sizes from small to moderate. The relationship between risky health behaviors in adolescents and discrimination can be partially explained by a greater tendency for school administrators to discipline minority students more often and more severely than other students (Mallett, 2016). This increase in discipline can lead to further delinquent and externalizing behaviors as they spend less time in the classroom environment. Academics Perceived discrimination has also been linked to lower academic performance in adolescents. Students who feel they face discrimination are more likely to have lower grade point averages (GPA), more absences, less engagement in class, and lower academic motivation. The data was taken from 73 different studies that analyze the relationship between perceived discrimination and academic outcomes in all areas with small effect sizes. The increased frequency of discipline also takes class time away from students which could contribute to their lowered academic outcomes. With less time in the classroom they do not receive the same amount of instruction that students in the classroom receive. Research The American teen study Reliable research in adolescent sexual behavior has been subject to political interventions in the past, particularly with funding availability, and the formal peer review process. Reasons for political interventions pertaining to research in adolescent sexual behavior is rooted in conservative ideologies from political figures and activist organizations. These groups tend not to support funding for abstinence education rather than programming that might inadvertently support teenage sexual behavior. These political interventions result in less of an understanding of long-term adolescent risk-taking sexual behavior and thus disease prevention. The American Teen Study, which began in May 1991, was a peer-reviewed study on adolescent sexual risk-taking behavior whose funding from the National Institute of Child Health and Human Development was shut down by former secretary of Health and Human Services (HHS), Louis Sullivan. This cancellation led to further amendments created to halt the National Institutes of Health from funding research in adult and adolescent sexual behavior studies because conservative political figures such as, Gary Bauer, believed there was enough literature on this subject. However, the data meant to be collected from the American Teen Study was critical for accurately understanding the dynamics of how adolescents may come into contact with sexually transmitted infections, such as HIV, and how to further prevent adolescents from being infected. The need for data The American Teen Study acknowledged that there is insufficient data required for assessing rates of sexually transmitted infections among adolescents, which creates a barrier for trying to prevent infection rates and treatment of infections. HIV seroprevalence surveys, evaluating archived data on AIDS infections in the past, and adolescent risk-taking behaviors are the various types of data needed for accurately assessing the HIV infection trends among adolescents. Seroprevalence surveys give an idea about the rates of HIV infections among various groups of people, however, using this data solely is not always externally valid as it is not completely feasible to produce accurate rates of HIV among all of the groups being measured. Evaluating archived data of AIDS infections in the past is useful for obtaining an idea of how current HIV trends may be, but this data is not separated by age, which does not allow researchers to distinguish whether decreasing rates are applicable to adolescents. However, by integrating both of these methods, and further incorporating data on adolescent sexual behavior, the information would be more effective with determining HIV rates among various groups of adolescents. In addition, for future studies, researchers must incorporate comprehensive sample sizes, perform various research design types, understand the social norms that may influence risk-taking behaviors, and also be consistent with replicating research studies as risk-taking trends among adolescents may change. Overall, this data is needed in order to understand and effectively prevent infections of sexual transmitted infections, however, political figures policing peer-reviewed research studies gets in the way of obtaining this information. Peer review process Political interventions on peer-reviewed research may affect the integrity of the sciences, and political figures rescinding funding for certain studies they do not accept also affects the well-being of all individuals. It is recommended for specialist peer reviewers to have the freedom in being able to allocate funding for certain research studies, while also allowing a justified veto of funding decisions to be made by the HHS secretary if studies are later deemed as unethical. This reform is mindful that specialist peer reviewers will not be driven by personal bias, but instead by assuring that research funded is ethical, just, and neutral to the objective of the study, such as the American Teen Study. Organizations International Alliance for Child and Adolescent Mental Health and Schools International Association for Adolescent Health International Childhood and Youth Research Network (ICYRNet) World Health Organization - Adolescent Health Australian Association for Adolescent Health Canadian Association for Adolescent Health New Zealand Aotearoa Adolescent Health and Development The York Centre for Children, Youth, and Families SpunOut.ie Irish National Youth Website The Royal College of Psychiatrists, UK Youth Advolution for Health (Singapore) See also Adolescent and young adult oncology Adolescent Medicine Lancet Commission on Adolescent Health and Wellbeing Youth Risk Behavior Survey Advocates for Youth Freechild Project References Adolescent medicine

Convalescence

Convalescence is the gradual recovery of health and strength after illness or injury. Details It refers to the later stage of an infectious disease or illness when the patient recovers and returns to previous health, but may continue to be a source of infection to others even if feeling better. In this sense, "recovery" can be considered a synonymous term. This also sometimes includes patient care after a major surgery, under which they are required to visit the doctor for regular check-ups. Convalescent care facilities are sometimes recognized by the acronym TCF (Transitional Convalescent Facilities). Traditionally, time has been allowed for convalescence to happen. Nowadays, in some instances, where there is a shortage of hospital beds or of trained staff, medical settings can feel rushed and may have drifted away from a focus on convalescence. See also Rehabilitation, therapy to control a medical condition such as an addiction Recuperation (recovery), a period of physical or mental recovery Recuperation (sociology), a sociological concept Relapse, reappearance of symptoms Remission, absence of symptoms in chronic diseases References External links Health care Medical phenomena

EHealth

eHealth describes healthcare services which are supported by digital processes, communication or technology such as electronic prescribing, Telehealth, or Electronic Health Records (EHRs). The use of electronic processes in healthcare dated back to at least the 1990s. Usage of the term varies as it covers not just "Internet medicine" as it was conceived during that time, but also "virtually everything related to computers and medicine". A study in 2005 found 51 unique definitions. Some argue that it is interchangeable with health informatics with a broad definition covering electronic/digital processes in health while others use it in the narrower sense of healthcare practice using the Internet. It can also include health applications and links on mobile phones, referred to as mHealth or m-Health. Key components of eHealth include electronic health records (EHRs), telemedicine, health information exchange, mobile health applications, wearable devices, and online health information. These technologies enable healthcare providers, patients, and other stakeholders to access, manage, and exchange health information more effectively, leading to improved communication, decision-making, and overall healthcare outcomes. Types The term can encompass a range of services or systems that are at the edge of medicine/healthcare and information technology, including: Electronic health record: enabling the communication of patient data between different healthcare professionals (GPs, specialists etc.); Computerized physician order entry: a means of requesting diagnostic tests and treatments electronically and receiving the results ePrescribing: access to prescribing options, printing prescriptions to patients and sometimes electronic transmission of prescriptions from doctors to pharmacists Clinical decision support system: providing information electronically about protocols and standards for healthcare professionals to use in diagnosing and treating patients Telemedicine: physical and psychological diagnosis and treatments at a distance, including telemonitoring of patients functions and videoconferencing; Telerehabilitation: providing rehabilitation services over a distance through telecommunications. Telesurgery: use robots and wireless communication to perform surgery remotely. Teledentistry: exchange clinical information and images over a distance. Consumer health informatics: use of electronic resources on medical topics by healthy individuals or patients; Health knowledge management: e.g. in an overview of latest medical journals, best practice guidelines or epidemiological tracking (examples include physician resources such as Medscape and MDLinx); Virtual healthcare teams: consisting of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care) mHealth or m-Health: includes the use of mobile devices in collecting aggregate and patient-level health data, providing healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vitals, and direct provision of care (via mobile telemedicine); Medical research using grids: powerful computing and data management capabilities to handle large amounts of heterogeneous data. Health informatics / healthcare information systems: also often refer to software solutions for appointment scheduling, patient data management, work schedule management and other administrative tasks surrounding health. There can be integrated data collection platforms for devices and standards and require extended research. Internet Based Sources for Public Health Surveillance (Infoveillance). Contested Definition Several authors have noted the variable usage in the term; from being specific to the use of the Internet in healthcare to being generally around any use of computers in healthcare. Various authors have considered the evolution of the term and its usage and how this maps to changes in health informatics and healthcare generally. Oh et al., in a 2005 systematic review of the term's usage, offered the definition of eHealth as a set of technological themes in health today, more specifically based on commerce, activities, stakeholders, outcomes, locations, or perspectives. One thing that all sources seem to agree on is that e-health initiatives do not originate with the patient, though the patient may be a member of a patient organization that seeks to do this, as in the e-Patient movement. eHealth literacy eHealth literacy is defined as "the ability to seek, find, understand and appraise health information from electronic sources and apply knowledge gained to addressing or solving a health problem." According to this definition, eHealth literacy encompasses six types of literacy: traditional (literacy and numeracy), information, media, health, computer, and scientific. Of these, media and computer literacies are unique to the Internet context, with eHealth media literacy being the awareness of media bias or perspective, the ability to discern both explicit and implicit meaning from media messages, and to derive meaning from media messages. The literature includes other definitions of perceived media capability or efficacy, but these were not specific to health information on the Internet. Having the composite skills of eHealth literacy allows health consumers to achieve positive outcomes from using the Internet for health purposes. eHealth literacy has the potential to both protect consumers from harm and empower them to fully participate in informed health-related decision making. People with high levels of eHealth literacy are also more aware of the risk of encountering unreliable information on the Internet On the other hand, the extension of digital resources to the health domain in the form of eHealth literacy can also create new gaps between health consumers. eHealth literacy hinges not on the mere access to technology, but rather on the skill to apply the accessed knowledge. The efficiency of eHealth also heavily relies on the efficiency and ease of use regarding technology being used by the patient. A high understanding of technology will not overcome the obstacles of overcomplicated technology being used by patients that are physically and mentally hindered. The population of elderly people surpassed the number of children for the first time in history in 2018. A more multi-faceted approach is necessary for this age group, because they are more susceptible to chronic disease, contraindications of medication, and other age-related setbacks like forgetfulness. Ehealth offers services that can be very helpful for all of these scenarios, making an elderly patient's quality of life substantially better with proper use. Data exchange One of the factors blocking the use of e-health tools from widespread acceptance is the concern about privacy issues regarding patient records, most specifically the EPR (Electronic patient record). This main concern has to do with the confidentiality of the data. There is also concern about non-confidential data. Each medical practice has its own jargon and diagnostic tools, so to standardize the exchange of information, various coding schemes may be used in combination with international medical standards. Systems that deal with these transfers are often referred to as Health Information Exchange (HIE). Of the forms of e-health already mentioned, there are roughly two types; front-end data exchange and back-end exchange. Front-end exchange typically involves the patient, while back-end exchange does not. A common example of a rather simple front-end exchange is a patient sending a photo taken by mobile phone of a healing wound and sending it via email to the family doctor for control. Such an action may avoid the cost of an expensive visit to the hospital. A common example of a back-end exchange is when a patient on vacation visits a doctor who then may request access to the patient's health records, such as medicine prescriptions, x-ray photographs, or blood test results. Such an action may reveal allergies or other prior conditions that are relevant to the visit. Thesaurus Successful e-health initiatives such as e-Diabetes have shown that for data exchange to be facilitated either at the front-end or the back-end, a common thesaurus is needed for terms of reference. Various medical practices in chronic patient care (such as for diabetic patients) already have a well defined set of terms and actions, which makes standard communication exchange easier, whether the exchange is initiated by the patient or the caregiver. In general, explanatory diagnostic information (such as the standard ICD-10) may be exchanged insecurely, and private information (such as personal information from the patient) must be secured. E-health manages both flows of information, while ensuring the quality of the data exchange. Early adopters Patients living with long term conditions (also called chronic conditions) over time often acquire a high level of knowledge about the processes involved in their own care, and often develop a routine in coping with their condition. For these types of routine patients, front-end e-health solutions tend to be relatively easy to implement. E-mental health E-mental health is frequently used to refer to internet based interventions and support for mental health conditions. However, it can also refer to the use of information and communication technologies that also includes the use of social media, landline and mobile phones. E-mental health services can include information; peer support services, computer and internet based programs, virtual applications and games as well as real time interaction with trained clinicians. Programs can also be delivered using telephones and interactive voice response (IVR). Mental disorders includes a range of conditions such as alcohol and drug use disorders, mood disorders such as depression, dementia and Alzheimer's disease, delusional disorders such as schizophrenia and anxiety disorders. The majority of e-mental health interventions have focused on the treatment of depression and anxiety. There are also E-mental health programs available for other interventions such as smoking cessation, gambling, and post-disaster mental health. Advantages and disadvantages E-mental health has a number of advantages such as being low cost, easily accessible and providing anonymity to users. However, there are also a number of disadvantages such as concerns regarding treatment credibility, user privacy and confidentiality. Online security involves the implementation of appropriate safeguards to protect user privacy and confidentiality. This includes appropriate collection and handling of user data, the protection of data from unauthorized access and modification and the safe storage of data. Technical difficulties are another potential disadvantage. With almost all forms of technology, there will be unintended difficulties or malfunctions, which doesn't exclude tablets, computers, and wireless medical devices. Ehealth is also very dependent on the patient having functional Wi-Fi, which can be an issue that cannot be fixed without an expert. E-mental health has been gaining momentum in the academic research as well as practical arenas in a wide variety of disciplines such as psychology, clinical social work, family and marriage therapy, and mental health counseling. Testifying to this momentum, the E-Mental Health movement has its own international organization, the International Society for Mental Health Online. However, e-Mental health implementation into clinical practice and healthcare systems remains limited and fragmented. Programs There are at least five programs currently available to treat anxiety and depression. Several programs have been identified by the UK National Institute for Health and Care Excellence as cost effective for use in primary care. These include Fearfighter, a text based cognitive behavioral therapy program to treat people with phobias, and Beating the Blues, an interactive text, cartoon and video CBT program for anxiety and depression. Two programs have been supported for use in primary care by the Australian Government. The first is Anxiety Online, a text based program for the anxiety, depressive and eating disorders, and the second is THIS WAY UP, a set of interactive text, cartoon and video programs for the anxiety and depressive disorders. Another is iFightDepression a multilingual, free to use, web-based tool for self-management of less severe forms of depression, for use under guidance of a GP or psychotherapist. There are a number of online programs relating to smoking cessation. QuitCoach is a personalised quit plan based on the users response to questions regarding giving up smoking and tailored individually each time the user logs into the site. Freedom From Smoking takes users through lessons that are grouped into modules that provide information and assignments to complete. The modules guide participants through steps such as preparing to quit smoking, stopping smoking and preventing relapse. Other internet programs have been developed specifically as part of research into treatment for specific disorders. For example, an online self-directed therapy for problem gambling was developed to specifically test this as a method of treatment. All participants were given access to a website. The treatment group was provided with behavioural and cognitive strategies to reduce or quit gambling. This was presented in the form of a workbook which encouraged participants to self-monitor their gambling by maintaining an online log of gambling and gambling urges. Participants could also use a smartphone application to collect self-monitoring information. Finally participants could also choose to receive motivational email or text reminders of their progress and goals. An internet based intervention was also developed for use after Hurricane Ike in 2009. During this study, 1,249 disaster-affected adults were randomly recruited to take part in the intervention. Participants were given a structured interview then invited to access the web intervention using a unique password. Access to the website was provided for a four-month period. As participants accessed the site they were randomly assigned to either the intervention. those assigned to the intervention were provided with modules consisting of information regarding effective coping strategies to manage mental health and health risk behaviour. eHealth programs have been found to be effective in treating borderline personality disorder (BPD). Cybermedicine Cybermedicine is the use of the Internet to deliver medical services, such as medical consultations and drug prescriptions. It is the successor to telemedicine, wherein doctors would consult and treat patients remotely via telephone or fax. Cybermedicine is already being used in small projects where images are transmitted from a primary care setting to a medical specialist, who comments on the case and suggests which intervention might benefit the patient. A field that lends itself to this approach is dermatology, where images of an eruption are communicated to a hospital specialist who determines if referral is necessary. The field has also expanded to include online "ask the doctor" services that allow patients direct, paid access to consultations (with varying degrees of depth) with medical professionals (examples include Bundoo.com, Teladoc, and Ask The Doctor). A Cyber Doctor, known in the UK as a Cyber Physician, is a medical professional who does consultation via the internet, treating virtual patients, who may never meet face to face. This is a new area of medicine which has been utilized by the armed forces and teaching hospitals offering online consultation to patients before making their decision to travel for unique medical treatment only offered at a particular medical facility. Self-monitoring healthcare devices Self-monitoring is the use of sensors or tools which are readily available to the general public to track and record personal data. The sensors are usually wearable devices and the tools are digitally available through mobile device applications. Self-monitoring devices were created for the purpose of allowing personal data to be instantly available to the individual to be analyzed. As of now, fitness and health monitoring are the most popular applications for self-monitoring devices. The biggest benefit to self-monitoring devices is the elimination of the necessity for third party hospitals to run tests, which are both expensive and lengthy. These devices are an important advancement in the field of personal health management. Self-monitoring healthcare devices exist in many forms. An example is the Nike+ FuelBand, which is a modified version of the original pedometer. This device is wearable on the wrist and allows one to set a personal goal for a daily energy burn. It records the calories burned and the number of steps taken for each day while simultaneously functioning as a watch. To add to the ease of the user interface, it includes both numeric and visual indicators of whether or not the individual has achieved his or her daily goal. Finally, it is also synced to an iPhone app which allows for tracking and sharing of personal record and achievements. Other monitoring devices have more medical relevance. A well-known device of this type is the blood glucose monitor. The use of this device is restricted to diabetic patients and allows users to measure the blood glucose levels in their body. It is extremely quantitative and the results are available instantaneously. However, this device is not as independent of a self-monitoring device as the Nike+ Fuelband because it requires some patient education before use. One needs to be able to make connections between the levels of glucose and the effect of diet and exercise. In addition, the users must also understand how the treatment should be adjusted based on the results. In other words, the results are not just static measurements. The demand for self-monitoring health devices is skyrocketing, as wireless health technologies have become especially popular in the last few years. In fact, it is expected that by 2016, self-monitoring health devices will account for 80% of wireless medical devices. The key selling point for these devices is the mobility of information for consumers. The accessibility of mobile devices such as smartphones and tablets has increased significantly within the past decade. This has made it easier for users to access real-time information in a number of peripheral devices. There are still many future improvements for self-monitoring healthcare devices. Although most of these wearable devices have been excellent at providing direct data to the individual user, the biggest task which remains at hand is how to effectively use this data. Although the blood glucose monitor allows the user to take action based on the results, measurements such as the pulse rate, EKG signals, and calories do not necessarily serve to actively guide an individual's personal healthcare management. Consumers are interested in qualitative feedback in addition to the quantitative measurements recorded by the devices. eHealth During COVID-19 The pandemic that impacted the entire world made it extremely difficult for vast amounts of people to receive adequate healthcare in person. Elderly citizens and people with chronic health conditions were at more risk than the average healthy human, therefore they were more adversely affected than most. The switch from in-person to telehealth appointments and interventions was necessary to reduce the risks of spreading and/or contracting the disease. The forced use of telehealth during the pandemic highlighted its strengths and weaknesses, which accelerated the progression of this medium. The user feedback on eHealth during the COVID-19 pandemic was very positive, and consequently many patients and healthcare providers reported that they will continue to use this method of healthcare following the pandemic. In developing countries eHealth in general, and telemedicine in particular, is a vital resource to remote regions of emerging and developing countries but is often difficult to establish because of the lack of communications infrastructure. For example, in Benin, hospitals often can become inaccessible due to flooding during the rainy season and across Africa, the low population density, along with severe weather conditions and the difficult financial situation in many African states, has meant that the majority of the African people are badly disadvantaged in medical care. Telemedicine in Nepal is becoming popular tool to improve health care delivery in order to combat difficult landscape. In many regions there is not only a significant lack of facilities and trained health professionals, but also no access to eHealth because there is also no internet access in remote villages, or even a reliable electricity supply. Approximately 13 percent of people who live in Kenya have health insurance. A majority of the total health expenditure in sub-Saharan Africa was paid out-of-pocket, which forces millions into poverty yearly. A Kenyan service by the name of M-PESA may offer a solution to this problem. This mobile platform provides full transparency of patients needs and allows access to medical products and the ability to efficiently manage their funding. Internet connectivity, and the benefits of eHealth, can be brought to these regions using satellite broadband technology, and satellite is often the only solution where terrestrial access may be limited, or poor quality, and one that can provide a fast connection over a vast coverage area. Evaluation While eHealth has become an indispensable facet of healthcare in the past 5 years, there are still barriers preventing it from reaching its full potential. Knowledge of the socio-economic performance of eHealth is limited, and findings from evaluations are often challenging to transfer to other settings. Socio-economic evaluations of some narrow types of mHealth can rely on health economic methodologies, but larger scale eHealth may have too many variables, and tortuous, intangible cause and effect links may need a wider approach. There are no international guidelines for the usage of eHealth due to many variables such as ignorance on the matter, infrastructure issues, quality of healthcare professionals and lack of healthcare plans. It should also be stated that the effectiveness of eHealth is also dependent on the patient's condition. Some researchers believe that online healthcare may be most efficient as a supplement to in-person care. See also Personal Science Human Enhancement Quantified self Center for Telehealth and E-Health Law eHealthInsurance EUDRANET European Institute for Health Records Health 2.0 Telehealth Seth Roberts References Further reading External links Health informatics Telemedicine

Mental illness in media

Mental illnesses, also known as psychiatric disorders, are often inaccurately portrayed in the media. Films, television programs, books, magazines, and news programs often stereotype the mentally ill as being violent, unpredictable, or dangerous, unlike the great majority of those who experience mental illness. As media is often the primary way people are exposed to mental illnesses, when portrayals are inaccurate, they further perpetuate stereotypes, stigma, and discriminatory behavior. When the public stigmatizes the mentally ill, people with mental illnesses become less likely to seek treatment or support for fear of being judged or rejected by the public. However, with proper support, not only are most of those with psychiatric disorders able to function adequately in society, but many are able to work successfully and make substantial contributions to society. History According to the Robert Wood Foundation, the primary way Americans gain information about mental illnesses is through mass media, more specifically, television and news. Furthermore, when it comes to believing ideas presented about mental illness, the public more often aligns their perceptions closer to mass media portrayals than information presented by experts in the field. In 2006, Heather Stuart published an article, "Media Portrayal of Mental Illness and its Treatments," discussing how the image of mental illness is mainly negative and those with mental illnesses are often labeled as violent and criminal. As the general public has little access to or experience with clinical psychology, their information about psychiatric patients is primarily obtained from the mass media. With limited knowledge gained through their own experiences, it is feared that the images and stories encountered via mass media can affect the decisions and judgments the public makes when it comes to their own lives or forming their political or social opinions, furthering the public's rejection of psychiatric patients. As the media often perpetuates stereotypes with the use of discriminatory language, misinformation, and mischaracterizations of mental illness, these negative media representations have become the focus of scholarly attention. Film and television When it comes to portrayals in entertainment, depictions typically represent mentally ill characters as being recognizably different, often exaggerating their mannerisms and appearance to further distinguish them from neurotypical characters. Throughout the last century of filmmaking, they have most commonly been portrayed as villains, often either the victims or perpetrators of violence, and generally dangerous. Evolution of mental illness representation in film An overused trope used in film and television is depicting villains or murderers as mentally ill. This trope has evolved throughout the history of filmmaking and cinema. First introduced in the early 1900s, films like Dr. Mabuse, the Gambler(1922) and The Black Cat (1934) depicted the mentally ill villains as mad, evil doctors. Then, with the rise of Alfred Hitchcock films, he introduced the serial killer in Psycho (1960), whose character trope was subsequently used in films like Homicidal (1961), Maniac (1963), Paranoiac (1963), and Nightmare (1963). The 1970s and 1980s brought the popular "slasher" film genre, introducing iconic horror characters such as Michael Myers, Jason, and Freddy Kruger from the franchises Halloween, Friday the 13th, and A Nightmare on Elm Street, respectively. Violent depictions of mental illness The negative stigma that surrounds mental illness has real-life consequences for those who experience these illnesses. Many studies, both in the form of experimental designs and surveys, have concluded that media exposure does affect the stigmatization of mental illness. Despite the media's common depictions of mentally ill characters being violent or engaging in criminal activities, it is much less common in the real world than the media makes it seem. Of the 40+ million people in the U.S. who are classified as experiencing mental illness, violence or criminality occurs only in 10-12% of mental illness cases. However, as film and television programs utilize this trope for dramatic storytelling, the public often falsely assumes that the real world mirrors the mass media depictions. Scholars began analyzing this trend in the 1950s, yet the issue persists into the 21st century. In the late 1950s, the concern regarding mass media portrayals of mental illness started becoming more prominent. At the time, television network censors were used to determine the level of viewing (adults only, family-friendly, or needed altered content) that was appropriate based on the film's content. George Gerbner, before he developed cultivation theory, studied the films that were censored and found that in 1951, only five films contained representations of mental illness. However, by 1957, the number rose to 170 films, demonstrating the growing concern over misrepresentations and their effects. Although the concern over the effects began to grow, the violent depictions remained the same. In a 1989 longitudinal study conducted by the Cultural Indicators Project, they analyzed the portrayal of mentally ill characters on 1,215 television programs between 1969 and 1985. They found that 3 out of 4 characters were involved in violent situations, either becoming victims of violence or perpetrating it. In addition to the mentally ill characters having violent tendencies, they also were distancing themselves from loved ones, and often did not work. Finally, nearly 50 years after one of the inaugural studies that analyzed the overuse of mentally ill, violent characters in media, the misconception persists, even into the 21st century. Diefenbach and West conducted a cultivation study that examined 84 hours of prime-time television among major networks in April 2003. They found that mentally ill characters on television were much more likely to commit violent crimes than real-world statistics. Only 4% of people with mental illnesses in the real world are characterized as violent, while 37% of mentally ill characters on television are portrayed as violent. Portrayals in film Sideways gives an accurate depiction of depression. Depression (major depressive disorder) is characterized as a mood disorder that causes severe feelings of sadness and disinterest. One of the movie's main characters, Miles Raymond, is shown to exhibit several signs of depression, some of which include using substances (alcohol) in an attempt to cope with the failures and losses in his life, not having hope for his future, and having a consistently depressed mood. Julien Donkey Boy gives an accurate depiction of schizophrenia. Schizophrenia is one of the most commonly misunderstood mental illnesses, yet over 2 million people suffer from this illness within the U.S. The term schizophrenia comes from Eugen Bleuler and translates to “split psyche,” as the psyche is split into many disorganized parts. Symptoms include, but are not limited to, delusions, hallucinations, and disturbances in thoughts and emotions. These symptoms prohibit those suffering from this illness from leading a normal life, causing social and occupational dysfunction, often necessitating hospitalization. The movie features a man named Julien, who exhibits several signs of schizophrenia. One of these signs includes having conversations with people who are not there in reality. Silver Linings Playbook gives an accurate depiction of bipolar disorder. Bipolar disorder is a mental illness characterized by a dysregulation of mood, often accompanied by depressive and manic episodes, anxiety, hyperactivity, irregular sleep, aggressiveness, and irritability. This story follows a family as they navigate the realities of helping their son after he returns home from treatment for bipolar disorder. Girl, Interrupted gives an accurate depiction of borderline personality disorder. Borderline personality disorder is a mental illness that affects a person's ability to manage or control their emotions effectively. It can affect how people view themselves and the people around them, causing instability and an inability to foster healthy relationships. This film follows a young woman's journey living in a psychiatric facility in the 1960s, her medical treatment, and how this affects her relationships with herself and other characters. The Perks of Being a Wallflower gives an accurate portrayal of post-traumatic stress disorder. Post-traumatic stress disorder is a condition that can develop after a person experiences or witnesses a traumatic event. Symptoms can include persistent thoughts of the event, severe anxiety, and nightmares. PTSD typically manifests in one of four ways: intrusive memories, avoidance, negative thoughts or moods, and changes in physical or emotional reactions. This film follows high school freshman Charlie as he navigates platonic and romantic relationships amid his childhood trauma of sexual abuse by a close family member. Portrayals in television Television is part of over 90% of households in the U.S., so naturally, mass media shapes how viewers perceive the world around them. In terms of mental illness portrayals, television has been a pioneer in representing these illnesses across thousands of programs in nearly a century's worth of content. While not all representations have been accurate or positive, there is a significant rise in the effort to depict honest and truthful accounts of mental illness. Reality television When it comes to reality television, there are programs specifically dedicated to showcasing the lives and resulting struggles of people experiencing specific mental illnesses. For example, the hit television show on the A&E network, Hoarders, showcases one or two individuals and their obsessive-compulsive disorder. Throughout an episode, each individual works with a psychologist or psychiatrist, professional organizer, or an “extreme cleaning specialist” specializing in treating this disorder. Another program on the A&E network, Intervention, introduces audiences to people dealing with substance abuse. This program, in a similar format to Hoarders, follows the story of either one or two individuals who suffer from substance dependence. During an episode, the audience follows the individuals' daily lives and is introduced to the reality of living with this dependence. The individuals are then confronted with an ultimatum in which they must decide whether to seek rehabilitation or risk losing family, friends, shelter, and, in most cases, financial assistance. This documentary-style television program is valuable because it educates viewers about the entire intervention process, from being introduced to the intervention process itself to the proper way to handle an individual with addiction. It also effectively decreases the stigma of therapy and demonstrates the effectiveness of interventions. Children's television Although it may seem that children's television programs would be unlikely to contain messages regarding or depictions of mental illness, many do contain references. A study conducted on various New Zealand Children's television shows showed that a mental illness reference appeared in 59 out of 128 episodes studied. Of those 59 episodes, there were 159 references to mental illness, most often consisting of vocabulary and character descriptions. The terms "mad," "crazy," and "losing your mind" were above the three most common vocabulary references. Consistent with film portrayals, character appearances consisted of disfigured facial features (teeth, noses, etc.) and disfigured extremities. Approaches of streaming media platforms The rise in popularity of streaming content on platforms such as Netflix, Hulu, Max, and Amazon Prime Video brought easier media access for viewers, as well as decreased regulation of content for television. Since it has become easier for the public to access different media forms, including movies, TV series, or other programs worldwide, the popular streaming service Netflix demonstrates different approaches to mental illness with various portrayals. Amongst the series Netflix provided, the recent study exploring the series 13 Reasons Why found that the representations of mental-health phenomena positively influence the individual’s perceptions in understanding perceived norms regarding mental health problems, such as reaching out to others for support and discussing suicide with people for prevention. 13 Reasons Why is a Netflix original with the plot surrounding a high school female, Hannah Baker, who commits suicide in the season one finale. Controversy around this TV show has arisen, especially surrounding the idea of linking Baker's suicide to a form of anger and revenge. Some argue that there is too much emphasis on how Hannah committed suicide, including the graphic visuals, and not enough focus on the true reasons behind ending her life. Others also emphasize how shows such as 13 Reasons Why simply skim over and cover only the surface of these issues and thus somehow desensitize something as important as suicide. For example, this specific show was accused of not talking much about mental health in its first season (besides the suicide itself). Furthermore, The National Alliance on Mental Health (NAMI) additionally argues that the depiction of a "planned out suicide" is damaging, as suicides are rarely planned. News Similar to depictions of mental illness in entertainment, news programs and publications tend to misrepresent the causes, symptoms, and treatments of mental illnesses. More often than not, the central message conveyed is that people with mental illnesses are violent, criminal, dangerous, and should be avoided. Furthermore, when it comes to news media, only the most exciting and oversensationalized stories tend to make headlines. This influx of violent stories involving mentally ill people makes these cases seem more common than in reality. When covering topics surrounding mental illness, journalists are more likely to interview family members or people close to a person with mental illness rather than the person experiencing mental illness themselves. This tendency eliminates the possibility of audiences engaging in parasocial contact with people experiencing mental illness firsthand. The parasocial contact hypothesis posits that positive portrayals of minority groups in media help to reduce stigmas and stereotypes surrounding these groups. When audiences are granted the opportunity to engage in parasocial contact, they tend to form more positive attitudes, thoughts, and beliefs about the illness and the people experiencing it. Therefore, when mentally ill people are denied the opportunity to speak for themselves, the public is more likely to form unfavorable opinions of them and their illnesses. Looking forward, as the public is becoming increasingly aware of the impact mass media can have on the public's perception of mental illnesses, journalists are encouraged to utilize The Associated Press Stylebook when reporting on mental illnesses. These guidelines help mitigate the use of slang and discriminatory language. Similarly, The World Health Organization also provides guidelines for news outlets when discussing suicide to prevent cases of the Werther Effect. However, even with strict guidelines and models, news coverage of mental illnesses can create significant controversy, both for the news outlet and the journalists themselves. Controversy within the news industry In 2012, India Knight wrote a column in The Sunday Times of London about depression. In response, Alastair Campbell, a columnist at The Huffington Post, described his distress at her writing that "'everybody gets depressed'" and that "there is no stigma in depression." Campbell discussed the inappropriateness of Knight's word choices. In writing that "everybody gets depressed," he commented, she showed that she was part of a group that does not believe that clinical depression is a disease. Campbell claimed that Knight's article reinforced the reality that there is still stigma surrounding depression. He noted that even in the medical profession, people are afraid to mention to their employers that they have depression because they would not be fully understood as they would be if they suffered from a "physical illness." Campbell wrote of the struggle to bring understanding to mental illness, and described Knight's article as "unhelpful, potentially damaging and certainly show[ing that] we still have quite a way to go." Portrayals in news Inaccurate portrayals of mental health in the news ultimately affect the audience's thoughts, attitudes, opinions, and beliefs, not only for the mentally ill but also for the illnesses themselves, the treatment required, and the public policy necessary to implement initiatives for change. However, these dramatic stories may not be the only culprit for swaying public opinion. Consistent patterns of misinformation, framing, and one-sided perspectives have the same ability to shape public perception. In 1991, a content analysis of United Press International stories found that stories about psychiatric patients usually involved violent crimes. In a similar study by Wahl, Wood, and Richards, they analyzed the common themes present in 1999 stories about mental illness amongst six major newspapers: The New York Times, The Washington Post, St. Louis Post-Dispatch, The Boston Globe, Los Angeles Times, and the St. Petersburg Times (Tampa Bay Times). Of the 300 randomly selected stories containing the phrase “mental illness,” dangerousness was the overwhelming theme across all six publications, with 26% involving violence or criminal activity by a mentally ill person. The consistent pattern of linking mental illness and violence not only leads to the public being fearful or avoidant of mentally ill people but also less likely to offer or support community care. Furthermore, when news outlets depict mentally ill people as violent, there is a resulting increased demand by the public for “forced treatment,” as exemplified in the tragedy that led to New York’s establishment of Kendra’s Law. In 1999, Andrew Goldstein pushed Kendra Webdale onto New York City subway tracks. The following news stories labeled Goldstein as “The Subway Psycho” and subsequently advocated for his banishment from public streets. This uprising led to the establishment of Kendra’s Law, which allowed the court to order those with mental illnesses to outpatient treatment programs. The over-saturation of stories linking mental illness and violence prohibits mentally ill people from leading a normal life. Many employers are resistant to hiring those with a history of or current struggle with mental illness. Although the Equal Employment Opportunity Commission establishes guidelines to discourage hiring discrimination, the stigma persists into the workplace. Finally, the saturation of stories about violent or criminal mentally ill people overshadows the need for positive or even neutral stories. When it comes to coverage of mental illness in the news, the stories are overwhelmingly negative and tend to focus only on the dysfunction or disability aspects. Stories of recovery or accomplishment are rarely shared. This consistent framing of stories about mental illness ultimately leads to a myriad of effects. Effects of media portrayals The media is indirectly responsible for shaping the public’s perceptions of mental illness. Although severely inaccurate portrayals often produce negative effects, there can also be positive outcomes. Positive effects As the public becomes more aware of the stereotypical nature of mental illness depictions, there is an increasing number of studies being done to examine how media messages can positively affect audiences by decreasing stigma. Research has found that news stories are much more likely to produce positive audience comments and reactions if they use counter-stigmatism in their storytelling rather than stereotypes and discriminatory language. In a more specific sense, media portraying a realistic account of mental illness can give medical professionals a glimpse into the life and realities of living with such an illness. The research regarding the educational aspects of the film for nurse students from all fields suggested that the films of different genres, including life stories, adventures, and others, provided practical insights into understanding the patient experience and perspectives in different environments. Another research also found the positive aspects of the movies for educational purposes on students in medical (clinical) fields. The films provide valuable lessons for individuals in understanding the specific cases and appropriate treatment plans for patients. Even though there are some concerns that movies are not intended for educational purposes but for entertainment, researchers suggest that films provide positive outcomes in students’ learning experiences. Regarding the positive roles of film in education, a case study analyzing students in medical fields found that the appropriate use of movies can provide helpful ideas in applying practical skills related to the medical fields, such as medical ethics, doctor-patient relationships, and mental illness. Negative effects However, there are concerns regarding the role of movies in shaping the younger individual’s perceptions of defining mental illness. Previous research regarding the film One Flew Over the Cuckoo’s Nest (1975) with college students found that the portrayal of mental illness can negatively influence the individual’s attitudes regarding individuals with mental illness, psychiatric institutions, and associated factors, leading to discrimination and general lack of opportunity for work, housing, and finding community for those experiencing mental illness. The public's misconception of certain mental illnesses poses a more significant threat than their negative opinions and judgments of those with issues with mental health. It may alter their ability to recognize signs and symptoms of certain mental illnesses in themselves or people they know if they are not consistent with the image they have come to know and recognize through media. Many people believe that the mental health content in mass media is checked by professionals for accuracy and, therefore, safe to believe and gather conclusions from. However, as many television shows do no such thing, people are led to believe inaccurate portrayals. Furthermore, mass media’s depiction of mental illnesses causing violent or dangerous behavior may lead the public to believe that mentally ill people are more likely to harm others than in reality. This phenomenon can lead to the public being less likely to help or visit friends and family who are experiencing mental illness. In a previous research study, the researchers found that the representation of the “outcast” character with mental illness in a movie tends to get negative evaluations from the children. Regarding this, the study found that it could make the children stick with the significant levels of stigmatization in negatively labeling individuals with mental illness even when they grow up. Other research specifically focused on a particular film, Joker, found that the depiction of individuals with mental illness appears to be negative towards the audience. Regarding this, the researchers demonstrated the concerns that the film Joker could aggravate the self-stigma of individuals with mental illness with an emphasis on negative depictions. Another troubling effect is that stereotypical imagery, coupled with the lack of alternative viewpoints, further dissuades mentally ill people from seeking help or treatment. Due to the generally negative view of mental illnesses, regardless of whether or not it is based on truth, those who experience mental illness often feel dejected, embarrassed, or shameful about their diagnoses. These feelings may lead people with mental illnesses to distance themselves from loved ones and often avoid seeking help or treatment due to fear of rejection. Celebrity suicides Another negative effect that misrepresentation of mental illnesses through the news can cause is copycat suicide. As with the deaths of celebrities Kate Spade and Robin Williams, an abundance of media and news coverage occurs. A Columbia University study revealed that "suicides rose nearly 10% higher than expected in the months following Robin Williams' death in August 2014," especially involving the method used by Robin Williams himself (a 32% increase). These results support the idea of suicide contagion, which the U.S. Department of Health & Human Services (HHS) defines as "the exposure to suicide or suicidal behaviors within one's family, one's peer group, or through media reports of suicide and can result in an increase in suicide and suicidal behaviors." Social media and mental health portrayal Mental illness is often discussed on social media and several studies have noted a link between it and severe psychiatric disorders. Studies such as one in 1998 led by Robert E. Kraut indicated that Internet can have an impact on a person's daily life and that increased amounts of time online can have a detrimental impact on interpersonal relationships and social interactions, which can in turn lead to increased depression and alienation. Today, social media platforms such as Twitter or Instagram have increased the amount of personal interaction with other users. There is current research that explores the role social media has in assisting people find resources and networks to support one's mental health. The interconnectivity between users through social media has encouraged many to seek help with professionals while also reducing the stigma surrounding mental illnesses. Though these claims are still being researched, there is a notable rise in communication within social media as a whole. The Scottish Health Survey conducted a study monitoring screen time and mental health in individuals. The research concluded that adults ages 16–99 who watch TV more than three hours a day were more likely to have poor mental health. 3 hours or more of television or screen time in children lead to a downward trend in mental health positivity. The study concluded that there is a correlation between screen time and a decline in mental health. TikTok TikTok has especially become a social media platform where mental health and illnesses are talked about more freely. The National institutes of Health (NIH) released in 2015 that more than 1/3 of Americans use the internet to help "diagnose their ailments", including mental illnesses. TikTok videos promoting either self-diagnosis or possible symptoms of different illnesses has caused an increase of internet users to believe they have a disorder, when in reality they may or may not. Additionally, TikTok keeps up with the latest trends, and some trends touch upon mental health (positively or negatively, depending on the point of view). One trend, as explained by the Philadelphia Magazine, uses intermittent fasting to heal anxiety. However, some individuals, including licensed counselors such as Akua K. Boateng argue that this advice is actually very detrimental in actually promoting bad mental habits instead, including the possible development of eating disorders. Other trends, including "What I eat in a day" Tiktoks, have been also labeled as harmful by health professionals, since these videos may lead viewers to habits of unhealthy comparison and goals of developing the "societal accepted body". With a majority of these videos reaching women especially, many believe that viewers may become more vulnerable, leading to unhealthy eating habits. Tumblr There exists a large population of self-identified mentally ill users on Tumblr, where the ability to post more unfiltered content led to individuals arguably sensationalizing and glamorizing mental illnesses and suicide. A thesis on Tumblr poetry explains how "the site serves as both a place of relief for people with mental health disorders, or even just every day growing pains, but it can also act as an enabling source for users who use the site as an echo chamber for their own problematic coping mechanisms, implying a groupthink problem that can exist in this kind of digital space." Tumblr staff attempted to prevent the use of their platform for romanticizing mental illness by changing their policies in 2012 to prohibit content actively promoting or depicting self harm and showing Public Service Announcements instead of results when users search keywords related to self-harm, such as "proana," "thinspo," "thinspiration," "purge," "bulimia," "anorexic," and more. YouTube While mass media often further cements stereotypes and stigmas among the public, social media platforms like YouTube can be a place for online users to discuss the culture of discrimination and prejudice surrounding mental health and advocate for change. Platforms like YouTube that encourage people to contribute and challenge the norms have opened up opportunities to change the discourse surrounding mental health and mental illness portrayals. Vlogging, or "autopathography," has become an excellent tool for those experiencing mental illness to regain their agency by sharing their own stories and perspectives on the illnesses themselves. This stream-of-consciousness approach has been shown to garner more public support as audiences feel more personally connected to the stories told. Theoretical approaches Cultivation theory George Gerbner's cultivation theory suggests heavy media exposure leads to a distorted view of reality. First-order cultivation leads viewers to believe that the social environment present within media reflects the real-world. Second-order cultivation leads to viewers forming attitudes, opinions, and beliefs due to this media exposure. Therefore, when people encounter the same portrayals and patterns of mental illness through the media, they form beliefs that are consistent with those portrayals. As the number of cases of violence perpetrated by mentally ill characters is higher in media than in reality, this misrepresentation can cause heavy media viewers to falsely believe that mentally ill people are more violent than they are in reality. Framing theory Framing theory is a mass communications theory that explains how information can be structured and disseminated to promote a specific view on a particular issue. In the context of mental illness portrayals, the media's framing of information about health and mental illnesses can affect an audience's attitudes and beliefs toward those illnesses. As framing is most commonly associated with negative effects, it also has the power to redefine and destigmatize mental illnesses. Confirmation bias Confirmation bias is the tendency for people to be more likely to engage with and believe ideas that confirm their preconceived notions. Mass media is not necessarily the root cause of the public's general misconception or judgment of people experiencing mental illness. It is, however, a way for people to confirm their existing beliefs and biases about mental illnesses. Parasocial contact hypothesis The parasocial contact hypothesis posits that positive portrayals of minority groups in media help to reduce stigmas and stereotypes surrounding these groups. Applying this theory to the portrayal of mental illnesses, if media represents well-rounded, accurate characters who are experiencing mental illness, it can challenge the long-standing stereotypes and work to reduce the stigma surrounding mental health. Furthermore, when in-groups and out-groups engage in positive contact, there is the possibility of challenging stereotypes and prejudice. Parasocial relationships Parasocial relationships form when audiences grow an attachment or develop a one-sided relationship with a celebrity or someone in the public eye. These relationships can garner the public's support and advocacy when the celebrity publicly shares their struggles with mental health. Furthermore, suppose these celebrities die by suicide or other mental health-related cases. In this case, fans may feel more compelled to share resources for treatment, research the illness, or participate in discussions of mental health in person and within online communities. Prosumers With the rise of social media and content curation, consumers are becoming prosumers at an increasing rate. This phenomenon is allowing the public to partake in cultural commentary on mental health and begin working to challenge and change the stigmas surrounding mental illness within online communities. Modern perception and looking ahead The portrayal of mental illness in media, including film and television shows, is presented in various forms since the advancement in technology occurs over time with easier access. The media expert suggests the public needs to become more open to learning about mental illness by understanding significant components presented in media platforms, including film and television entertainment. The journal article concerning depictions of the media on mental illness also emphasizes the importance of  having broader perceptions in understanding the different experiences of others in addressing crucial topics related to mental illness. Since it was found that the movies are also responsible for depicting various experiences of others with mental illness, the accurate portrayal of associated characteristics is significant. The 21st century has brought nuanced storytelling with mental illness representation that encourages healthy discussion regarding this often taboo topic. Consumers becoming prosumers or produsers opens the door for people to challenge the long-standing stigmas and stereotypes present within traditional media platforms. This new wave of media allows people to create content and share with communities more effectively and appropriately. In addition, first-hand accounts and an increased number of discussions about mental health in online communities are leading to the public gaining more insight into the lives of people experiencing mental illness and, as a result, garnering more empathy. See also Mental disorders in film Mental illness in fiction References Mental disorders

Behaviorism

Behaviorism is a systematic approach to understand the behavior of humans and other animals. It assumes that behavior is either a reflex elicited by the pairing of certain antecedent stimuli in the environment, or a consequence of that individual's history, including especially reinforcement and punishment contingencies, together with the individual's current motivational state and controlling stimuli. Although behaviorists generally accept the important role of heredity in determining behavior, they focus primarily on environmental events. The cognitive revolution of the late 20th century largely replaced behaviorism as an explanatory theory with cognitive psychology, which unlike behaviorism views internal mental states as explanations for observable behavior. Behaviorism emerged in the early 1900s as a reaction to depth psychology and other traditional forms of psychology, which often had difficulty making predictions that could be tested experimentally. It was derived from earlier research in the late nineteenth century, such as when Edward Thorndike pioneered the law of effect, a procedure that involved the use of consequences to strengthen or weaken behavior. With a 1924 publication, John B. Watson devised methodological behaviorism, which rejected introspective methods and sought to understand behavior by only measuring observable behaviors and events. It was not until 1945 that B. F. Skinner proposed that covert behavior—including cognition and emotions—are subject to the same controlling variables as observable behavior, which became the basis for his philosophy called radical behaviorism. While Watson and Ivan Pavlov investigated how (conditioned) neutral stimuli elicit reflexes in respondent conditioning, Skinner assessed the reinforcement histories of the discriminative (antecedent) stimuli that emits behavior; the process became known as operant conditioning. The application of radical behaviorism—known as applied behavior analysis—is used in a variety of contexts, including, for example, applied animal behavior and organizational behavior management to treatment of mental disorders, such as autism and substance abuse. In addition, while behaviorism and cognitive schools of psychological thought do not agree theoretically, they have complemented each other in the cognitive-behavioral therapies, which have demonstrated utility in treating certain pathologies, including simple phobias, PTSD, and mood disorders. Branches of behaviorism The titles given to the various branches of behaviorism include: Behavioral genetics: Proposed in 1869 by Francis Galton, a relative of Charles Darwin. Galton believed that inherited factors had a significant impact on individuals' behaviors, however did not believe nurturing was not important. Which was later discredited due to association with the eugenics movement - researchers did not want to associate with Nazi politics whether direct or indirect. Interbehaviorism: Proposed by Jacob Robert Kantor before B. F. Skinner's writings. Methodological behaviorism: John B. Watson's behaviorism states that only public events (motor behaviors of an individual) can be objectively observed. Although it was still acknowledged that thoughts and feelings exist, they were not considered part of the science of behavior. It also laid the theoretical foundation for the early approach behavior modification in the 1970s and 1980s. Often compared to the views of B.F Skinner (radical behaviorism). Methodological behaviorism "representing the logical positivist-derived philosophy of science" which is common in science today, radical focuses on the "pragmatist perspective." Psychological behaviorism: As proposed by Arthur W. Staats, unlike the previous behaviorisms of Skinner, Hull, and Tolman, was based upon a program of human research involving various types of human behavior. Psychological behaviorism introduces new principles of human learning. Humans learn not only by animal learning principles but also by special human learning principles. Those principles involve humans' uniquely huge learning ability. Humans learn repertoires that enable them to learn other things. Human learning is thus cumulative. No other animal demonstrates that ability, making the human species unique. Radical behaviorism: Skinner's philosophy is an extension of Watson's form of behaviorism by theorizing that processes within the organism—particularly, private events, such as thoughts and feelings—are also part of the science of behavior, and suggests that environmental variables control these internal events just as they control observable behaviors. Behavioral events may be observable but not all are, some are considered "private": they are accessible and noticed by only the person who is behaving. B.F. Skinner described behavior as the name for the part of the functioning of the organism that consists of its interacting or having commerce with its surrounding environment. In simple terms, how an individual interacts with its surrounding environment.[RB] Although private events cannot be directly seen by others, they are later determined through the species' overt behavior. Radical behaviorism forms the core philosophy behind behavior analysis. Willard Van Orman Quine used many of radical behaviorism's ideas in his study of knowledge and language. Teleological behaviorism: Proposed by Howard Rachlin, post-Skinnerian, purposive, close to microeconomics. Focuses on objective observation as opposed to cognitive processes. Theoretical behaviorism: Proposed by J. E. R. Staddon, adds a concept of internal state to allow for the effects of context. According to theoretical behaviorism, a state is a set of equivalent histories, i.e., past histories in which members of the same stimulus class produce members of the same response class (i.e., B. F. Skinner's concept of the operant). Conditioned stimuli are thus seen to control neither stimulus nor response but state. Theoretical behaviorism is a logical extension of Skinner's class-based (generic) definition of the operant. Two subtypes of theoretical behaviorism are: Hullian and post-Hullian: theoretical, group data, not dynamic, physiological Purposive: Tolman's behavioristic anticipation of cognitive psychology Modern-day theory: radical behaviorism B. F. Skinner proposed radical behaviorism as the conceptual underpinning of the experimental analysis of behavior. This viewpoint differs from other approaches to behavioral research in various ways, but, most notably here, it contrasts with methodological behaviorism in accepting feelings, states of mind and introspection as behaviors also subject to scientific investigation. Like methodological behaviorism, it rejects the reflex as a model of all behavior, and it defends the science of behavior as complementary to but independent of physiology. Radical behaviorism overlaps considerably with other western philosophical positions, such as American pragmatism. Although John B. Watson mainly emphasized his position of methodological behaviorism throughout his career, Watson and Rosalie Rayner conducted the infamous Little Albert experiment (1920), a study in which Ivan Pavlov's theory to respondent conditioning was first applied to eliciting a fearful reflex of crying in a human infant, and this became the launching point for understanding covert behavior (or private events) in radical behaviorism. However, Skinner felt that aversive stimuli should only be experimented on with animals and spoke out against Watson for testing something so controversial on a human. In 1959, Skinner observed the emotions of two pigeons by noting that they appeared angry because their feathers ruffled. The pigeons were placed together in an operant chamber, where they were aggressive as a consequence of previous reinforcement in the environment. Through stimulus control and subsequent discrimination training, whenever Skinner turned off the green light, the pigeons came to notice that the food reinforcer is discontinued following each peck and responded without aggression. Skinner concluded that humans also learn aggression and possess such emotions (as well as other private events) no differently than do nonhuman animals. Experimental and conceptual innovations As experimental behavioural psychology is related to behavioral neuroscience, we can date the first researches in the area were done in the beginning of 19th century. Later, this essentially philosophical position gained strength from the success of Skinner's early experimental work with rats and pigeons, summarized in his books The Behavior of Organisms and Schedules of Reinforcement. Of particular importance was his concept of the operant response, of which the canonical example was the rat's lever-press. In contrast with the idea of a physiological or reflex response, an operant is a class of structurally distinct but functionally equivalent responses. For example, while a rat might press a lever with its left paw or its right paw or its tail, all of these responses operate on the world in the same way and have a common consequence. Operants are often thought of as species of responses, where the individuals differ but the class coheres in its function-shared consequences with operants and reproductive success with species. This is a clear distinction between Skinner's theory and S–R theory. Skinner's empirical work expanded on earlier research on trial-and-error learning by researchers such as Thorndike and Guthrie with both conceptual reformulations—Thorndike's notion of a stimulus-response "association" or "connection" was abandoned; and methodological ones—the use of the "free operant", so-called because the animal was now permitted to respond at its own rate rather than in a series of trials determined by the experimenter procedures. With this method, Skinner carried out substantial experimental work on the effects of different schedules and rates of reinforcement on the rates of operant responses made by rats and pigeons. He achieved remarkable success in training animals to perform unexpected responses, to emit large numbers of responses, and to demonstrate many empirical regularities at the purely behavioral level. This lent some credibility to his conceptual analysis. It is largely his conceptual analysis that made his work much more rigorous than his peers, a point which can be seen clearly in his seminal work Are Theories of Learning Necessary? in which he criticizes what he viewed to be theoretical weaknesses then common in the study of psychology. An important descendant of the experimental analysis of behavior is the Society for Quantitative Analysis of Behavior. Relation to language As Skinner turned from experimental work to concentrate on the philosophical underpinnings of a science of behavior, his attention turned to human language with his 1957 book Verbal Behavior and other language-related publications; Verbal Behavior laid out a vocabulary and theory for functional analysis of verbal behavior, and was strongly criticized in a review by Noam Chomsky. Skinner did not respond in detail but claimed that Chomsky failed to understand his ideas, and the disagreements between the two and the theories involved have been further discussed. Innateness theory, which has been heavily critiqued, is opposed to behaviorist theory which claims that language is a set of habits that can be acquired by means of conditioning. According to some, the behaviorist account is a process which would be too slow to explain a phenomenon as complicated as language learning. What was important for a behaviorist's analysis of human behavior was not language acquisition so much as the interaction between language and overt behavior. In an essay republished in his 1969 book Contingencies of Reinforcement, Skinner took the view that humans could construct linguistic stimuli that would then acquire control over their behavior in the same way that external stimuli could. The possibility of such "instructional control" over behavior meant that contingencies of reinforcement would not always produce the same effects on human behavior as they reliably do in other animals. The focus of a radical behaviorist analysis of human behavior therefore shifted to an attempt to understand the interaction between instructional control and contingency control, and also to understand the behavioral processes that determine what instructions are constructed and what control they acquire over behavior. Recently, a new line of behavioral research on language was started under the name of relational frame theory. Education B.F. Skinner's book Verbal Behavior (1957) does not quite emphasize on language development, but to understand human behavior. Additionally, his work serves in understanding social interactions in the child's early developmental stages focusing on the topic of caregiver-infant interaction. Skinner's functional analysis of verbal behavior terminology and theories is commonly used to understand the relationship between language development but was primarily designed to describe behaviors of interest and explain the cause of those behaviors. Noam Chomsky, an American linguistic professor, has criticized and questioned Skinner's theories about the possible suggestion of parental tutoring in language development. However, there is a lack of supporting evidence where Skinner makes the statement. Understanding language is a complex topic, but can be understood through the use of two theories: Innateness and acquisition. Both theories offer a different perspective whether language is inherently "acquired" or "learned." Operant conditioning Operant conditioning was developed by B.F. Skinner in 1938 and is form of learning in which the frequency of a behavior is controlled by consequences to change behavior. In other words, behavior is controlled by historical consequential contingencies, particularly reinforcement—a stimulus that increases the probability of performing behaviors, and punishment—a stimulus that decreases such probability. The core tools of consequences are either positive (presenting stimuli following a response), or negative (withdrawn stimuli following a response). The following descriptions explains the concepts of four common types of consequences in operant conditioning: Positive reinforcement: Providing a stimulus that an individual enjoys, seeks, or craves, in order to reinforce desired behaviors. For example, when a person is teaching a dog to sit, they pair the command "sit" with a treat. The treat is the positive reinforcement to the behavior of sitting. The key to making positive reinforcement effect is to reward the behavior immediately. Negative reinforcement: Increases the frequency of a behavior, but the behavior results from removing unpleasant or unwanted stimulus. For example, a child hates being nagged (negative) to clean his room (behavior) which increases the frequency of the child cleaning his room to prevent his mother from nagging. Another example would be putting on sunscreen (behavior) before going outside to prevent sunburn (negative). Positive punishment: Providing a stimulus that an individual does not desire to decrease undesired behaviors. For example, if a child engages in an undesired behavior, then parents may spank (stimulus) the child to correct their behavior. Negative punishment: Removing a stimulus that an individual desires in order to decrease undesired behaviors. An example of this would be grounding a child for failing a test. Grounding in this example is taking away the child's ability to play video games. As long as it is clear that the ability to play video games was taken away because they failed a test, this is negative punishment. The key here is the connection to the behavior and the result of the behavior. A classical experiment in operant conditioning, for example, is the Skinner Box, "puzzle box" or operant conditioning chamber to test the effects of operant conditioning principles on rats, cats and other species. From this experiment, he discovered that the rats learned very effectively if they were rewarded frequently with food. Skinner also found that he could shape (create new behavior) the rats' behavior through the use of rewards, which could, in turn, be applied to human learning as well. Skinner's model was based on the premise that reinforcement is used for the desired actions or responses while punishment was used to stop the responses of the undesired actions that are not. This theory proved that humans or animals will repeat any action that leads to a positive outcome, and avoid any action that leads to a negative outcome. The experiment with the pigeons showed that a positive outcome leads to learned behavior since the pigeon learned to peck the disc in return for the reward of food. These historical consequential contingencies subsequently lead to (antecedent) stimulus control, but in contrast to respondent conditioning where antecedent stimuli elicit reflexive behavior, operant behavior is only emitted and therefore does not force its occurrence. It includes the following controlling stimuli: Discriminative stimulus (Sd): An antecedent stimulus that increases the chance of the organism engaging in a behavior. One example of this occurred in Skinner's laboratory. Whenever the green light (Sd) appeared, it signaled the pigeon to perform the behavior of pecking because it learned in the past that each time it pecked, food was presented (the positive reinforcing stimulus). Stimulus delta (S-delta): An antecedent stimulus that signals the organism not to perform a behavior since it was extinguished or punished in the past. One notable instance of this occurs when a person stops their car immediately after the traffic light turns red (S-delta). However, the person could decide to drive through the red light, but subsequently receive a speeding ticket (the positive punishing stimulus), so this behavior will potentially not reoccur following the presence of the S-delta. Respondent conditioning Although operant conditioning plays the largest role in discussions of behavioral mechanisms, respondent conditioning (also called Pavlovian or classical conditioning) is also an important behavior-analytic process that needs not refer to mental or other internal processes. Pavlov's experiments with dogs provide the most familiar example of the classical conditioning procedure. In the beginning, the dog was provided meat (unconditioned stimulus, UCS, naturally elicit a response that is not controlled) to eat, resulting in increased salivation (unconditioned response, UCR, which means that a response is naturally caused by UCS). Afterward, a bell ring was presented together with food to the dog. Although bell ring was a neutral stimulus (NS, meaning that the stimulus did not have any effect), dog would start to salivate when only hearing a bell ring after a number of pairings. Eventually, the neutral stimulus (bell ring) became conditioned. Therefore, salivation was elicited as a conditioned response (the response same as the unconditioned response), pairing up with meat—the conditioned stimulus) Although Pavlov proposed some tentative physiological processes that might be involved in classical conditioning, these have not been confirmed. The idea of classical conditioning helped behaviorist John Watson discover the key mechanism behind how humans acquire the behaviors that they do, which was to find a natural reflex that produces the response being considered. Watson's "Behaviourist Manifesto" has three aspects that deserve special recognition: one is that psychology should be purely objective, with any interpretation of conscious experience being removed, thus leading to psychology as the "science of behaviour"; the second one is that the goals of psychology should be to predict and control behaviour (as opposed to describe and explain conscious mental states); the third one is that there is no notable distinction between human and non-human behaviour. Following Darwin's theory of evolution, this would simply mean that human behaviour is just a more complex version in respect to behaviour displayed by other species. In philosophy Behaviorism is a psychological movement that can be contrasted with philosophy of mind. The basic premise of behaviorism is that the study of behavior should be a natural science, such as chemistry or physics. Initially behaviorism rejected any reference to hypothetical inner states of organisms as causes for their behavior, but B.F. Skinner's radical behaviorism reintroduced reference to inner states and also advocated for the study of thoughts and feelings as behaviors subject to the same mechanisms as external behavior. Behaviorism takes a functional view of behavior. According to Edmund Fantino and colleagues: "Behavior analysis has much to offer the study of phenomena normally dominated by cognitive and social psychologists. We hope that successful application of behavioral theory and methodology will not only shed light on central problems in judgment and choice but will also generate greater appreciation of the behavioral approach." Behaviorist sentiments are not uncommon within philosophy of language and analytic philosophy. It is sometimes argued that Ludwig Wittgenstein defended a logical behaviorist position (e.g., the beetle in a box argument). In logical positivism (as held, e.g., by Rudolf Carnap and Carl Hempel), the meaning of psychological statements are their verification conditions, which consist of performed overt behavior. W. V. O. Quine made use of a type of behaviorism, influenced by some of Skinner's ideas, in his own work on language. Quine's work in semantics differed substantially from the empiricist semantics of Carnap which he attempted to create an alternative to, couching his semantic theory in references to physical objects rather than sensations. Gilbert Ryle defended a distinct strain of philosophical behaviorism, sketched in his book The Concept of Mind. Ryle's central claim was that instances of dualism frequently represented "category mistakes", and hence that they were really misunderstandings of the use of ordinary language. Daniel Dennett likewise acknowledges himself to be a type of behaviorist, though he offers extensive criticism of radical behaviorism and refutes Skinner's rejection of the value of intentional idioms and the possibility of free will. Law of effect and trace conditioning Law of effect: Although Edward Thorndike's methodology mainly dealt with reinforcing observable behavior, it viewed cognitive antecedents as the causes of behavior, and was theoretically much more similar to the cognitive-behavior therapies than classical (methodological) or modern-day (radical) behaviorism. Nevertheless, Skinner's operant conditioning was heavily influenced by the Law of Effect's principle of reinforcement. Trace conditioning: Akin to B.F. Skinner's radical behaviorism, it is a respondent conditioning technique based on Ivan Pavlov's concept of a "memory trace" in which the observer recalls the conditioned stimulus (CS), with the memory or recall being the unconditioned response (UR). There is also a time delay between the CS and unconditioned stimulus (US), causing the conditioned response (CR)—particularly the reflex—to be faded over time. According to Marchand, the hippocampus is a part of the cognitive processes during trace conditioning and other forms of classical conditioning in two ways: needing to overcome stimuli or due to mre activity from complex challenges. However, results may vary due to the nature of the task and the design of the experiment . Molecular versus molar behaviorism Skinner's view of behavior is most often characterized as a "molecular" view of behavior; that is, behavior can be decomposed into atomistic parts or molecules. This view is inconsistent with Skinner's complete description of behavior as delineated in other works, including his 1981 article "Selection by Consequences". Skinner proposed that a complete account of behavior requires understanding of selection history at three levels: biology (the natural selection or phylogeny of the animal); behavior (the reinforcement history or ontogeny of the behavioral repertoire of the animal); and for some species, culture (the cultural practices of the social group to which the animal belongs). This whole organism then interacts with its environment. Molecular behaviorists use notions from melioration theory, negative power function discounting or additive versions of negative power function discounting. According to Moore, the perseverance in a molecular examination of behavior may be sign of a desire for an in-depth understanding, maybe to identify any underlying mechanism or components that contribute to comples actions. This strategy might involve elements, procedure, or variables that contribute to behaviorism. Molar behaviorists, such as Howard Rachlin, Richard Herrnstein, and William Baum, argue that behavior cannot be understood by focusing on events in the moment. That is, they argue that behavior is best understood as the ultimate product of an organism's history and that molecular behaviorists are committing a fallacy by inventing fictitious proximal causes for behavior. Molar behaviorists argue that standard molecular constructs, such as "associative strength", are better replaced by molar variables such as rate of reinforcement. Thus, a molar behaviorist would describe "loving someone" as a pattern of loving behavior over time; there is no isolated, proximal cause of loving behavior, only a history of behaviors (of which the current behavior might be an example) that can be summarized as "love". Theoretical behaviorism Skinner's radical behaviorism has been highly successful experimentally, revealing new phenomena with new methods, but Skinner's dismissal of theory limited its development. Theoretical behaviorism recognized that a historical system, an organism, has a state as well as sensitivity to stimuli and the ability to emit responses. Indeed, Skinner himself acknowledged the possibility of what he called "latent" responses in humans, even though he neglected to extend this idea to rats and pigeons. Latent responses constitute a repertoire, from which operant reinforcement can select. Theoretical behaviorism links between the brain and the behavior that provides a real understanding of the behavior, rather than a mental presumption of how brain-behavior relates. The theoretical concept of behaviorism are blended with knowledge of mental structure such as memory and expectancies associated with inflexable behaviorist stances that have traditionally forbidden the examination of the mental state. Because of its flexibility, theoretical behaviorism permits the cognitive process to have an impact on behavior. Behavior analysis and culture From its inception, behavior analysis has centered its examination on cultural occurrences (Skinner, 1953, 1961, 1971, 1974 ). Nevertheless, the methods used to tackle these occurrences have evolved. Initially, culture was perceived as a factor influencing behavior, later becoming a subject of study in itself. This shift prompted research into group practices and the potential for significant behavioral transformations on a larger scale. Following Glenn's (1986) influential work, "Metacontingencies in Walden Two,"   numerous research endeavors exploring behavior analysis in cultural contexts have centered around the concept of the metacontingency. Glenn (2003) posited that understanding the origins and development of cultures necessitates delving beyond evolutionary and behavioral principles governing species characteristics and individual learned behaviors requires analysis at a major level. Behavior informatics and behavior computing With the fast growth of big behavioral data and applications, behavior analysis is ubiquitous. Understanding behavior from the informatics and computing perspective becomes increasingly critical for in-depth understanding of what, why and how behaviors are formed, interact, evolve, change and affect business and decision. Behavior informatics and behavior computing deeply explore behavior intelligence and behavior insights from the informatics and computing perspectives. Pavel et al. (2015) found that in the realm of healthcare and health psychology, substantial evidence supports the notion that personalized health interventions yield greater effectiveness compared to standardized approaches. Additionally, researchers found that recent progress in sensor and communication technology, coupled with data analysis and computational modeling, holds significant potential in revolutionizing interventions aimed at changing health behavior. Simultaneous advancements in sensor and communication technology, alongside the field of data science, have now made it possible to comprehensively measure behaviors occurring in real-life settings. These two elements, when combined with advancements in computational modeling, have laid the groundwork for the emerging discipline known as behavioral informatics. Behavioral informatics represents a scientific and engineering domain encompassing behavior tracking, evaluation, computational modeling, deduction, and intervention. Criticisms and limitations In the second half of the 20th century, behaviorism was largely eclipsed as a result of the cognitive revolution. This shift was due to radical behaviorism being highly criticized for not examining mental processes, and this led to the development of the cognitive therapy movement. In the mid-20th century, three main influences arose that would inspire and shape cognitive psychology as a formal school of thought: Noam Chomsky's 1959 critique of behaviorism, and empiricism more generally, initiated what would come to be known as the "cognitive revolution". Developments in computer science would lead to parallels being drawn between human thought and the computational functionality of computers, opening entirely new areas of psychological thought. Allen Newell and Herbert Simon spent years developing the concept of artificial intelligence (AI) and later worked with cognitive psychologists regarding the implications of AI. The effective result was more of a framework conceptualization of mental functions with their counterparts in computers (memory, storage, retrieval, etc.). Formal recognition of the field involved the establishment of research institutions such as George Mandler's Center for Human Information Processing in 1964. Mandler described the origins of cognitive psychology in a 2002 article in the Journal of the History of the Behavioral Sciences In more recent years, several scholars have expressed reservations about the pragmatic tendencies of behaviorism. Burgos (2003) highlights the potential peril of pragmatism, noting that within William James pragmatism—widely discussed in philosophy and science, including behaviorism and behavior analysis—there exists a tolerance for anything deemed useful, even if nonsensical. Additionally, Burgos (2007) contends that pragmatism engenders a relativism that contradicts the emphasis on science as the paramount path to knowledge. Staddon (2018, as cited in Araiba, 2019) further argues that the proliferation of diversification in social science poses disadvantages by hindering healthy and open scientific communication and critique among specialized areas. Rider (1991) shares a similar concern, highlighting reduced communication between the experimental analysis of behavior and applied behavior analysis. Contrarily, diversification is portrayed as an innate and uncontrollable consequence of the environment, a natural facet contributing to species' survival. It is viewed as an integral aspect of the evolution of behaviorism. In the early years of cognitive psychology, behaviorist critics held that the empiricism it pursued was incompatible with the concept of internal mental states. Cognitive neuroscience, however, continues to gather evidence of direct correlations between physiological brain activity and putative mental states, endorsing the basis for cognitive psychology. Limitations Staddon (1993) found that Skinner's theory presents two significant deficiencies: Firstly, he downplayed the significance of processes responsible for generating novel behaviors, which it is term as "behavioral variation." Skinner primarily emphasized reinforcement as the sole determinant for selecting responses, overlooking these critical processes involved in creating new behaviors. Secondly, both Skinner and many other behaviorists of that era endorsed contiguity as a sufficient process for response selection. However, Rescorla and Wagner (1972) later demonstrated, particularly in classical conditioning, that competition is an essential complement to contiguity. They showed that in operant conditioning, both contiguity and competition are imperative for discerning cause-and-effect relationships. The influential Rescorla-Wagner model  highlights the significance of competition for limited "associative value," essential for assessing predictability. A similar formal argument was presented by Ying Zhang and John Staddon (1991, in press) concerning operant conditioning: the combination of contiguity and competition among action tendencies suffices as an assignment-of-credit mechanism capable of detecting genuine instrumental contingency between a response and its reinforcer. This mechanism delineates the limitations of Skinner's idea of adventitious reinforcement, revealing its efficacy only under stringent conditions – when the reinforcement's strengthening effect is nearly constant across instances and with very short intervals between reinforcers. However, these conditions rarely hold in reality: behavior following reinforcement tends to exhibit high variability, and superstitious behavior diminishes with extremely brief intervals between reinforcements. Behavior therapy Behavior therapy is a term referring to different types of therapies that treat mental health disorders. It identifies and helps change people's unhealthy behaviors or destructive behaviors through learning theory and conditioning. Ivan Pavlov's classical conditioning, as well as counterconditioning are the basis for much of clinical behavior therapy, but also includes other techniques, including operant conditioning—or contingency management, and modeling (sometimes called observational learning). A frequently noted behavior therapy is systematic desensitization (graduated exposure therapy), which was first demonstrated by Joseph Wolpe and Arnold Lazarus. Behavior analysis Applied behavior analysis (ABA)—also called behavioral engineering—is a scientific discipline that applies the principles of behavior analysis to change behavior. ABA derived from much earlier research in the Journal of the Experimental Analysis of Behavior, which was founded by B.F. Skinner and his colleagues at Harvard University. Nearly a decade after the study "The psychiatric nurse as a behavioral engineer" (1959) was published in that journal, which demonstrated how effective the token economy was in reinforcing more adaptive behavior for hospitalized patients with schizophrenia and intellectual disability, it led to researchers at the University of Kansas to start the Journal of Applied Behavior Analysis in 1968. Although ABA and behavior modification are similar behavior-change technologies in that the learning environment is modified through respondent and operant conditioning, behavior modification did not initially address the causes of the behavior (particularly, the environmental stimuli that occurred in the past), or investigate solutions that would otherwise prevent the behavior from reoccurring. As the evolution of ABA began to unfold in the mid-1980s, functional behavior assessments (FBAs) were developed to clarify the function of that behavior, so that it is accurately determined which differential reinforcement contingencies will be most effective and less likely for aversive punishments to be administered. In addition, methodological behaviorism was the theory underpinning behavior modification since private events were not conceptualized during the 1970s and early 1980s, which contrasted from the radical behaviorism of behavior analysis. ABA—the term that replaced behavior modification—has emerged into a thriving field. The independent development of behaviour analysis outside the United States also continues to develop. In the US, the American Psychological Association (APA) features a subdivision for Behavior Analysis, titled APA Division 25: Behavior Analysis, which has been in existence since 1964, and the interests among behavior analysts today are wide-ranging, as indicated in a review of the 30 Special Interest Groups (SIGs) within the Association for Behavior Analysis International (ABAI). Such interests include everything from animal behavior and environmental conservation to classroom instruction (such as direct instruction and precision teaching), verbal behavior, developmental disabilities and autism, clinical psychology (i.e., forensic behavior analysis), behavioral medicine (i.e., behavioral gerontology, AIDS prevention, and fitness training), and consumer behavior analysis. The field of applied animal behavior—a sub-discipline of ABA that involves training animals—is regulated by the Animal Behavior Society, and those who practice this technique are called applied animal behaviorists. Research on applied animal behavior has been frequently conducted in the Applied Animal Behaviour Science journal since its founding in 1974. ABA has also been particularly well-established in the area of developmental disabilities since the 1960s, but it was not until the late 1980s that individuals diagnosed with autism spectrum disorders were beginning to grow so rapidly and groundbreaking research was being published that parent advocacy groups started demanding for services throughout the 1990s, which encouraged the formation of the Behavior Analyst Certification Board, a credentialing program that certifies professionally trained behavior analysts on the national level to deliver such services. Nevertheless, the certification is applicable to all human services related to the rather broad field of behavior analysis (other than the treatment for autism), and the ABAI currently has 14 accredited MA and Ph.D. programs for comprehensive study in that field. Early behavioral interventions (EBIs) based on ABA are empirically validated for teaching children with autism and have been proven as such for over the past five decades. Since the late 1990s and throughout the twenty-first century, early ABA interventions have also been identified as the treatment of choice by the US Surgeon General, American Academy of Pediatrics, and US National Research Council. Discrete trial training—also called early intensive behavioral intervention—is the traditional EBI technique implemented for thirty to forty hours per week that instructs a child to sit in a chair, imitate fine and gross motor behaviors, as well as learn eye contact and speech, which are taught through shaping, modeling, and prompting, with such prompting being phased out as the child begins mastering each skill. When the child becomes more verbal from discrete trials, the table-based instructions are later discontinued, and another EBI procedure known as incidental teaching is introduced in the natural environment by having the child ask for desired items kept out of their direct access, as well as allowing the child to choose the play activities that will motivate them to engage with their facilitators before teaching the child how to interact with other children their own age. A related term for incidental teaching, called pivotal response treatment (PRT), refers to EBI procedures that exclusively entail twenty-five hours per week of naturalistic teaching (without initially using discrete trials). Current research is showing that there is a wide array of learning styles and that is the children with receptive language delays who initially require discrete trials to acquire speech. Organizational behavior management, which applies contingency management procedures to model and reinforce appropriate work behavior for employees in organizations, has developed a particularly strong following within ABA, as evidenced by the formation of the OBM Network and Journal of Organizational Behavior Management, which was rated the third-highest impact journal in applied psychology by ISI JOBM rating. Modern-day clinical behavior analysis has also witnessed a massive resurgence in research, with the development of relational frame theory (RFT), which is described as an extension of verbal behavior and a "post-Skinnerian account of language and cognition." RFT also forms the empirical basis for acceptance and commitment therapy, a therapeutic approach to counseling often used to manage such conditions as anxiety and obesity that consists of acceptance and commitment, value-based living, cognitive defusion, counterconditioning (mindfulness), and contingency management (positive reinforcement). Another evidence-based counseling technique derived from RFT is the functional analytic psychotherapy known as behavioral activation that relies on the ACL model—awareness, courage, and love—to reinforce more positive moods for those struggling with depression. Incentive-based contingency management (CM) is the standard of care for adults with substance-use disorders; it has also been shown to be highly effective for other addictions (i.e., obesity and gambling). Although it does not directly address the underlying causes of behavior, incentive-based CM is highly behavior analytic as it targets the function of the client's motivational behavior by relying on a preference assessment, which is an assessment procedure that allows the individual to select the preferred reinforcer (in this case, the monetary value of the voucher, or the use of other incentives, such as prizes). Another evidence-based CM intervention for substance abuse is community reinforcement approach and family training that uses FBAs and counterconditioning techniques—such as behavioral skills training and relapse prevention—to model and reinforce healthier lifestyle choices which promote self-management of abstinence from drugs, alcohol, or cigarette smoking during high-risk exposure when engaging with family members, friends, and co-workers. While schoolwide positive behavior support consists of conducting assessments and a task analysis plan to differentially reinforce curricular supports that replace students' disruptive behavior in the classroom, pediatric feeding therapy incorporates a liquid chaser and chin feeder to shape proper eating behavior for children with feeding disorders. Habit reversal training, an approach firmly grounded in counterconditioning which uses contingency management procedures to reinforce alternative behavior, is currently the only empirically validated approach for managing tic disorders. Some studies on exposure (desensitization) therapies—which refer to an array of interventions based on the respondent conditioning procedure known as habituation and typically infuses counterconditioning procedures, such as meditation and breathing exercises—have recently been published in behavior analytic journals since the 1990s, as most other research is conducted from a cognitive-behavior therapy framework. When based on a behavior analytic research standpoint, FBAs are implemented to precisely outline how to employ the flooding form of desensitization (also called direct exposure therapy) for those who are unsuccessful in overcoming their specific phobia through systematic desensitization (also known as graduated exposure therapy). These studies also reveal that systematic desensitization is more effective for children if used in conjunction with shaping, which is further termed contact desensitization, but this comparison has yet to be substantiated with adults. Other widely published behavior analytic journals include Behavior Modification, The Behavior Analyst, Journal of Positive Behavior Interventions, Journal of Contextual Behavioral Science, The Analysis of Verbal Behavior, Behavior and Philosophy, Behavior and Social Issues, and The Psychological Record. Cognitive-behavior therapy Cognitive-behavior therapy (CBT) is a behavior therapy discipline that often overlaps considerably with the clinical behavior analysis subfield of ABA, but differs in that it initially incorporates cognitive restructuring and emotional regulation to alter a person's cognition and emotions. Various forms of CBT have been used to treat physically experienced symptoms that disrupt individuals' livelihood, which often stem from complex mental health disorders. Complications of many trauma-induced disorders result in lack of sleep and nightmares, with cognitive behavior therapy functioning as an intervention found to reduce the average number of PTSD patients suffering from related sleep disturbance. A popularly noted counseling intervention known as dialectical behavior therapy (DBT) includes the use of a chain analysis, as well as cognitive restructuring, emotional regulation, distress tolerance, counterconditioning (mindfulness), and contingency management (positive reinforcement). DBT is quite similar to acceptance and commitment therapy, but contrasts in that it derives from a CBT framework. Although DBT is most widely researched for and empirically validated to reduce the risk of suicide in psychiatric patients with borderline personality disorder, it can often be applied effectively to other mental health conditions, such as substance abuse, as well as mood and eating disorders. A study on BPD was conducted, confirming DBT as a constructive therapeutic option for emotionally unregulated patients. Before DBT, participants with borderline personality disorder were shown images of highly emotional people and neuron activity in the amygdala was recorded via fMRI; after 1 year of consistent dialectical behavior therapy, participants were re-tested, with fMRI capturing a decrease in amygdala hyperactivity (emotional activation) in response to the applied stimulus, exhibiting increases in emotional regulation capabilities. Most research on exposure therapies (also called desensitization)—ranging from eye movement desensitization and reprocessing therapy to exposure and response prevention—are conducted through a CBT framework in non-behavior analytic journals, and these enhanced exposure therapies are well-established in the research literature for treating phobic, post-traumatic stress, and other anxiety disorders (such as obsessive-compulsive disorder, or OCD). Cognitive-based behavioral activation (BA)—the psychotherapeutic approach used for depression—is shown to be highly effective and is widely used in clinical practice. Some large randomized control trials have indicated that cognitive-based BA is as beneficial as antidepressant medications but more efficacious than traditional cognitive therapy. Other commonly used clinical treatments derived from behavioral learning principles that are often implemented through a CBT model include community reinforcement approach and family training, and habit reversal training for substance abuse and tics, respectively. Related therapies Acceptance and commitment therapy (ACT) Applied animal behavior Behavioral activation Behavior modification Behavior therapy Biofeedback Clinical behavior analysis Contingency management Desensitization Dialectical behavior therapy (DBT) Direct instruction Discrete trial training Exposure and response prevention Exposure therapy Eye movement desensitization and reprocessing Flooding (psychology) Functional analytic psychotherapy (FAP) Habit reversal training Organizational behavior management Pivotal response treatment Positive behavior support Prolonged exposure therapy Social skills training Systematic desensitization List of notable behaviorists Nathan Azrin Don Baer Albert Bandura Dermot Barnes-Holmes Vladimir Bekhterev Sidney W. Bijou Hans Eysenck Charles Ferster Jacque Fresco Edwin Ray Guthrie Betty Hart Steven C. Hayes Richard J. Herrnstein Clark L. Hull Brian Iwata Alan E. Kazdin Fred S. Keller Robert Koegel Robert (Bob) J. Kohlenberg Jon Levy Marsha M. Linehan Ole Ivar Lovaas F. Charles Mace Jack Michael Neal E. Miller O. Hobart Mowrer Charles E. Osgood Ivan Pavlov Murray Sidman B. F. Skinner Kenneth W. Spence J. E. R. Staddon Edward Thorndike Edward C. Tolman John B. Watson Montrose Wolf Joseph Wolpe See also Behavior analysis of child development Behavioral change theories Behavioral economics Behavioral neuroscience Cognitive inhibition Dog behaviorist Ethology Functionalism (philosophy of mind) Operationalization Perceptual control theory Professional practice of behavior analysis Reference in APA 7th edition format Further reading Baum, W.M. (1994) Understanding behaviorism: Behavior, Culture and Evolution. Blackwell. Cao, L.B. (2013) IJCAI2013 tutorial on behavior informatics and computing. Cao, L.B. (2014) Non-IIDness Learning in Behavioral and Social Data, The Computer Journal, 57(9): 1358–1370. Ferster, C.B. & Skinner, B.F. (1957). Schedules of reinforcement. New York: Appleton-Century-Crofts. Malott, Richard W. (2008) Principles of Behavior. Upper Saddle River, NJ: Pearson Prentice Hall. Print. Mills, John A. (2000) Control: A History of Behavioral Psychology, Paperback Edition, New York University Press. Lattal, K.A. & Chase, P.N. (2003) "Behavior Theory and Philosophy". Plenum. Rachlin, H. (1991) Introduction to modern behaviorism. (3rd edition.) New York: Freeman. Skinner, B.F. Beyond Freedom & Dignity, Hackett Publishing Co, Inc 2002. Klein, P. (2013) "Explanation of Behavioural Psychotherapy Styles". . Watson, J.B. (1913). Psychology as the behaviorist views it. Psychological Review, 20, 158–177. (on-line). Watson, J.B. (1919). Psychology from the Standpoint of a Behaviorist. Watson, J.B. (1924). Behaviorism. Zuriff, G.E. (1985). Behaviorism: A Conceptual Reconstruction , Columbia University Press. External links Philosophy of psychology Psychological theories Theory of mind Management cybernetics

Licensed professional counselor

Licensed professional counselor (LPC) is a licensure for mental health professionals in some countries. In the US, licensed professional counselors (or in some states, "licensed clinical mental health counselors" or "licensed clinical professional counselors" or "licensed mental health counselors") provide mental health and substance abuse care to millions of Americans. Licensed professional counselors (LPCs) are doctoral and master's-level mental health service providers, trained to work with individuals, families, and groups in treating mental, behavioral, and emotional problems and disorders. LPCs make up a large percentage of the workforce employed in community mental health centers, agencies, universities, hospitals, and organizations, and are employed within and covered by managed care organizations and health plans. LPCs also work with active duty military personnel and their families, as well as veterans. Licenses are awarded for professional counselors (LPC) and professional counselor supervisors (LPC-S); Licensed Professional Counselor Associates, who are accruing hours towards full licensure under supervision, may be designated with the suffix "-A"; this also applies to associate Licensed Marriage and Family Therapists (LMFT) who are designated as: LMFT-A. In the U.S., the exact title varies by state, but the other most frequently used title is licensed mental health counselor (LMHC). Several U.S. states, including Illinois, Maine, and Tennessee, have implemented a two-tier system whereby both the LPC and LCPC (or equivalent) are used. In those states, higher tier professionals are granted the privilege to practice independently. However, in most states, LPC's or LMHC's may practice independently. Licensed Professional Counselors are one of the six types of licensed mental health professionals who provide psychotherapy in the United States. LPCs are required to complete supervised clinical experience and pass a state licensing exam, which varies across different states. Examples include the National Counselor Examination for Licensure and Certification (NCE) and the National Certified Mental Health Counselor Examination (NCMHCE). Federal and state laws regulate LPCs, protecting their titles and defining their scope of practice, while also ensuring client protections. Additionally, LPCs who are members of professional associations or hold additional certifications must adhere to the respective codes of ethics of those organizations or certification bodies. Requirements for professional counselors United States LPC (or variations e.g., LCPC, LMHC, etc.) licensure is recognized in 50 states in the United States, as well as the District of Columbia, Guam, and Puerto Rico. The requirements vary from one jurisdiction to the next. Most states require some combination of a master's degree, counseling experience and supervision, as well as passing a national examination, such as the National Counselor Examination (NCE) and/or the National Clinical Mental Health Counseling Examination (NCMHCE). A summary of requirements from the state of Texas LPC board serves as an example; requirements vary from state to state. For example, practicum/internship requirements (during the master's degree) vary significantly between states (i.e.: 300 hours in Texas and 1000 hours in Vermont). Course requirements and credit amounts also vary, making reciprocity between states difficult for many licensed counselors. A master's degree or doctoral degree in counseling or a related field. Academic course work in each of the following areas: normal human growth and development; abnormal human behavior; appraisal or assessment techniques; counseling theories; counseling methods or techniques (individual and group); research; lifestyle and career development; social, cultural and family issues; and professional orientation. As part of the graduate program, a supervised practicum experience that is primarily counseling in nature. The practicum should be at least 300 clock-hours with at least 100 clock-hours of direct client contact. Academic credit for the practicum must appear on the applicant's transcript. After completion of the graduate degree and before application, an applicant must take and pass the National Counselor Exam and the Texas Jurisprudence Exam. After receiving a temporary LPC license from the board, the applicant may begin the supervised post-graduate counseling experience (internship). 3000 clock-hours with at least 1,500 being direct client contact of internship under the supervision of a board-approved supervisor is required. The 3000 clock-hours may not be completed in a period of less than 18 months." Exemptions Some states, such as Oregon, have broad exemptions that allow the practice of professional counseling without a license. In Alabama, nothing in the chapter regulating professional counseling applies to the activities, services, titles, and descriptions of persons employed, as professionals or as volunteers, in the practice of counseling for IRS recognized 501(c)(3) public and private nonprofit organizations or charities. [Alabama Code 34-8A-3-a-6] Canada In the Canadian province of Quebec, the Ordre des conseillers et conseilleres d'orientation et psychoeducateurs et psychoeducatrices du Quebec (OCCOPPQ) grants counselor licensure. The Canadian Counselling and Psychotherapy Association, CCPA offers a distinct certification, Canadian Certified Counsellor (CCC), separate from the regular professional membership. The Canadian Professional Counsellors Association (CPCA) is a national competency-based association that provides the designation of Registered Professional Counsellor (RPC) to its members. Unlike degree-based associations, a specific degree level does not automatically qualify applicants for membership. Instead, the CPCA requires core competencies in education and experience prior to taking a qualifying exam and undergoing psychological testing as part of the membership application process. Counsellors must then embark on a two-year candidacy under the supervision of an approved Clinical Supervisor prior to becoming a full member. The CPCA membership roles are a mixture of Diploma, Bachelor, Master, and PhD level degree holders, and its primary purpose is the protection of the public and the promotion of competency in the mental health profession in Canada. The Canadian Addiction Counsellors Certification Federation (CACCF) promotes, certifies and monitors the competency of addiction specific counsellors in Canada using current and effective practices, which are internationally recognized. The certifications CACCF issues and its professional conduct review process provide public protection for counsellors, employers, regulatory agencies, clients and their families. China The Ministry of Labor and Human Resources grants counselor licensure. Malaysia In Malaysia, Lembaga Kaunselor Malaysia grants counselor licensure. See also List of counseling topics Mental health counselor References Mental health occupations Counseling Professional titles and certifications

Interpretative phenomenological analysis

Interpretative phenomenological analysis (IPA) is a qualitative form of psychology research. IPA has an idiographic focus, which means that instead of producing generalization findings, it aims to offer insights into how a given person, in a given context, makes sense of a given situation. Usually, these situations are of personal significance; examples might include a major life event, or the development of an important relationship. IPA has its theoretical origins in phenomenology and hermeneutics, and many of its key ideas are inspired by the work of Edmund Husserl, Martin Heidegger, and Maurice Merleau-Ponty. IPA's tendency to combine psychological, interpretative, and idiographic elements is what distinguishes it from other approaches to qualitative, phenomenological psychology. Taking part Sometimes IPA studies involve a close examination of the experiences and meaning-making activities of only one participant. Most frequently they draw on the accounts of a small number of people (6 has been suggested as a good number, although anywhere between 3 and 15 participants for a group study can be acceptable). In either case, participants are invited to take part precisely because they can offer the researcher some meaningful insight into the topic of the study; this is called purposive sampling [i.e. it is not randomised]. Usually, participants in an IPA study are expected to have certain experiences in common with one another: the small-scale nature of a basic IPA study shows how something is understood in a given context, and from a shared perspective, a method sometimes called homogeneous sampling. More advanced IPA study designs may draw together samples that offer multiple perspectives on a shared experience (husbands and wives, for example, or psychiatrists and patients); or they may collect accounts over a period of time, to develop a longitudinal analysis. Data collection In IPA, researchers gather qualitative data from research participants using techniques such as interview, diaries, or focus group. Typically, these are approached from a position of flexible and open-ended inquiry, and the interviewer adopts a stance that is curious and facilitative (rather than, say, challenging and interrogative). IPA usually requires personally salient accounts of some richness and depth, and it requires that these accounts be captured in a way that permits the researcher to work with a detailed verbatim transcript. Data analysis Data collection does not set out to test hypotheses, and this stance is maintained in data analysis. The analyst reflects upon their own preconceptions about the data, and attempts to suspend these in order to focus on grasping the experiential world of the research participant. Transcripts are coded in considerable detail, with the focus shifting back and forth from the key claims of the participant, to the researcher's interpretation of the meaning of those claims. IPA's hermeneutic stance is one of inquiry and meaning-making, and so the analyst attempts to make sense of the participant's attempts to make sense of their own experiences, thus creating a double hermeneutic. One might use IPA if one had a research question which aimed to understand what a given experience was like (phenomenology) and how someone made sense of it (interpretation). Analysis in IPA is said to be 'bottom-up'. This means that the researcher generates codes from the data, rather than using a pre-existing theory to identify codes that might be applied to the data. IPA studies do not test theories, then, but they are often relevant to the development of existing theories. One might use the findings of a study on the meaning of sexual intimacy to gay men in close relationships, for example, to re-examine the adequacy of theories which attempt to predict and explain safe sex practices. IPA encourages an open-ended dialogue between the researcher and the participants and may, therefore, lead us to see things in a new light. After transcribing the data, the researcher works closely and intensively with the text, annotating it closely ('coding') for insights into the participants' experience and perspective on their world. As the analysis develops, the researcher catalogues the emerging codes, and subsequently begins to look for patterns in the codes. These patterns are called 'themes'. Themes are recurring patterns of meaning (ideas, thoughts, feelings) throughout the text. Themes are likely to identify both something that matters to the participants (i.e. an object of concern, topic of some import) and also convey something of the meaning of that thing, for the participants. E.g. in a study of the experiences of young people learning to drive, we might find themes like 'Driving as a rite of passage' (where one key psychosocial understanding of the meaning of learning to drive, is that it marks a cultural threshold between adolescence and adulthood). Some themes will eventually be grouped under much broader themes called 'superordinate themes'. For example, 'Feeling anxious and overwhelmed during the first driving lessons' might be a superordinate category that captures a variety of patterns in participants' embodied, emotional and cognitive experiences of the early phases of learning to drive, where sub-themes relating to, say, 'Feeling nervous', 'Worrying about losing control', and 'Struggling to manage the complexities of the task' might be found. The final set of themes are typically summarised and placed into a table or similar structure where evidence from the text is given to back up the themes produced by a quote from the text. Analysis In IPA, a good analysis is one that balances phenomenological description with insightful interpretation and anchors these interpretations in the participants' accounts. It is also likely to maintain an idiographic focus (so that particular variation are not lost), and to keep a close focus on meaning (rather than say, causal relations). A degree of transparency (contextual detail about the sample, a clear account of the process, adequate commentary on the data, key points illustrated by verbatim quotes) is also crucial to estimating the plausibility and transferability of an IPA study. Engagement with credibility issues (such as cross-validation, cooperative inquiry, independent audit, or triangulation) is also likely to increase the reader's confidence. Applications Due to an increased interest in the constructed nature of certain aspects of illness (how people perceive bodily and mental symptoms), IPA has been particularly recommended for its uses in the field of health psychology. However, while this subject-centered approach to experiencing illness is congruent with an increase in patient-centered research, IPA may have been historically most employed in health psychology due to the fact that many of its initial supporters operated careers in this field. With a general increase in the number of IPA studies published over the last decade has come to the employment of this method in a variety of fields including business (organisational psychology ), sexuality, and key life transitions such as transitioning into motherhood and living with cancer as a chronic illness. See also Action research Emic and etic Ethnography Existential phenomenology Hermeneutic phenomenology Jonathan Smith (psychologist) Participatory action research Phenomenology Triangulation (social science) Notes References Brocki J.J.M, Wearden A.J. (2006). “A critical evaluation of the use of interpretative phenomenological analysis (IPA) in health psychology”. Psychology and Health, 21(1), 87-108 Heron, J. (1996). Co-operative Inquiry: Research into the human condition. London: Sage. McGeechan, G.J., McPherson, K.E., Roberts, K, (2018). "An interpretative phenomenological analysis of the experience of living with colorectal cancer as a chronic illness". Journal of clinical nursing, 27(15-16), 3148-3156 Reid, K., Flowers, P. & Larkin, M. (2005). Exploring lived experience, The Psychologist, 18, 20-23. Shaw, R. L. (2001). Why use interpretative phenomenological analysis in Health Psychology? Health Psychology Update, 10, 48-52. Smith, J.A. (1996) "Beyond the divide between cognition and discourse: Using interpretative phenomenological analysis in health psychology". Psychology & Health, 11(2), 261-271 Smith, J., Jarman, M. & Osborne, M. (1999). Doing interpretative phenomenological analysis. In M. Murray & K. Chamberlain (Eds.), Qualitative Health Psychology. London: Sage. Smith, J.A. (1999). "Identity development during the transition to motherhood: An interpretative phenomenological analysis". Journal of reproductive and infant psychology, 17(3), 281-299 Smith, J.A. & Osborn, M. (2003) Interpretative phenomenological analysis. In J.A. Smith (Ed.), Qualitative Psychology: A Practical Guide to Research Methods. London: Sage. Smith, J.A., Flowers, P., & Larkin, M. (2009). Interpretative Phenomenological Analysis: Theory Method and Research. London: Sage. Smith, J.A. (2011). "Evaluating the contribution of interpretative phenomenological analysis". Health Psychology Review, 5(1), 9-27 External links IPA website at Birkbeck, University of London Phenomenological methodology Qualitative research

16PF Questionnaire

The Sixteen Personality Factor Questionnaire (16PF) is a self-reported personality test developed over several decades of empirical research by Raymond B. Cattell, Maurice Tatsuoka and Herbert Eber. The 16PF provides a measure of personality and can also be used by psychologists, and other mental health professionals, as a clinical instrument to help diagnose psychiatric disorders, and help with prognosis and therapy planning. The 16PF can also provide information relevant to the clinical and counseling process, such as an individual's capacity for insight, self-esteem, cognitive style, internalization of standards, openness to change, capacity for empathy, level of interpersonal trust, quality of attachments, interpersonal needs, attitude toward authority, reaction toward dynamics of power, frustration tolerance, and coping style. Thus, the 16PF instrument provides clinicians with a normal-range measurement of anxiety, adjustment, emotional stability and behavioral problems. Clinicians can use 16PF results to identify effective strategies for establishing a working alliance, to develop a therapeutic plan, and to select effective therapeutic interventions or modes of treatment. It can also be used within other areas of psychology, such as career and occupational selection. Beginning in the 1940s, Cattell used several techniques including the new statistical technique of common factor analysis applied to the English-language trait lexicon to elucidate the major underlying dimensions within the normal personality sphere. This method takes as its starting point the matrix of inter-correlations between these variables in an attempt to uncover the underlying source traits of human personality. Cattell found that personality structure was hierarchical, with both primary and secondary stratum level traits. At the primary level, the 16PF measures 16 primary trait constructs, with a version of the Big Five secondary traits at the secondary level. These higher-level factors emerged from factor-analyzing the 16 x 16 intercorrelation matrix for the sixteen primary factors themselves. The 16PF yields scores on primary and second-order "global" traits, thereby allowing a multilevel description of each individual's unique personality profile. A listing of these trait dimensions and their description can be found below. Cattell also found a third-stratum of personality organization that comprised just two overarching factors. The measurement of normal personality trait constructs is an integral part of Cattell's comprehensive theory of intrapersonal psychological variables covering individual differences in cognitive abilities, normal personality traits, abnormal (psychopathological) personality traits, dynamic motivational traits, mood states, and transitory emotional states which are all taken into account in his behavioral specification/prediction equation. The 16PF has also been translated into over 30 languages and dialects and is widely used internationally. Cattell and his co-workers also constructed downward extensions of the 16PF – parallel personality questionnaires designed to measure corresponding trait constructs in younger age ranges, such as the High School Personality Questionnaire (HSPQ) – now the Adolescent Personality Questionnaire (APQ) for ages 12 to 18 years, the Children's Personality Questionnaire (CPQ), the Early School Personality Questionnaire (ESPQ), as well as the Preschool Personality Questionnaire (PSPQ). Cattell also constructed (T-data) tests of cognitive abilities such as the Comprehensive Ability Battery (CAB) – a multidimensional measure of 20 primary cognitive abilities, as well as measures of non-verbal visuo-spatial abilities, such as the three scales of the Culture-Fair Intelligence Test (CFIT), In addition, Cattell and his colleagues constructed objective (T-data) measures of dynamic motivational traits including the Motivation Analysis Test (MAT), the School Motivation Analysis Test (SMAT), as well as the Children's Motivation Analysis Test (CMAT). As for the mood state domain, Cattell and his colleagues constructed the Eight State Questionnaire (8SQ), a self-report (Q-data) measure of eight clinically important emotional/mood states, labeled Anxiety, Stress, Depression, Regression, Fatigue, Guilt, Extraversion, and Arousal. Outline The most recent edition of the Sixteen Personality Factor Questionnaire (16PF), released in 1993, is the fifth edition (16PF5e) of the original instrument. The self-report instrument was first published in 1949; the second and third editions were published in 1956 and 1962, respectively; and the five alternative forms of the fourth edition were released between 1967 and 1969. The goal of the fifth edition revision in 1993 was to: update, improve, and simplify the language used in the test items; simplify the answer format; develop new validity scales; improve the psychometric properties of the test, including new reliability and validity data; and develop a new standardization sample (of 10,000 people) to reflect the current U.S. Census population. The 16PF Fifth Edition contains 185 multiple-choice items which are written at a fifth-grade reading level. Of these items, 76% were from the four previous 16PF editions, although many of them were re-written to simplify or update the language. The item content typically sounds non-threatening and asks simple questions about daily behavior, interests, and opinions. Item format A characteristic of the 16PF items is that, rather than asking respondents to self-assess their personality as some instruments do (e.g., "I am a warm and friendly person; I am not a worrier; I am an even tempered person."), they tend instead to ask about daily, concrete situations, e.g.: When I find myself in a boring situation, I usually "tune out" and daydream about other things. True/False. When a bit of tact and convincing is needed to get people moving, I'm usually the one who does it. True/False. Cattell argued that self-ratings relate to self-image, and are affected by self-awareness, and defensiveness about one's actual traits. The 16PF provides scores on 16 primary personality scales and five global personality scales, all of which are bi-polar (both ends of each scale have a distinct, meaningful definition). The instrument also includes three validity scales: a bi-polar Impression Management (IM) scale, an Acquiescence (ACQ) scale, and an Infrequency (INF) scale. The Impression Management (IM) scale is a bipolar scale with high scores reflecting a preponderance of socially desirable responses and low scores reflecting a preponderance of socially undesirable responses. Possible reasons for an extremely high Impression Management score include: the examinee may actually behave in highly socially desirable ways, and responses are accurate self-descriptions; responses reflect an unconscious distortion consistent with the examinee's self-image but not with their behavior; or deliberate self-presentation as behaving in a highly socially desirable manner. A low impression management score suggests an unusual willingness to admit undesirable attributes or behaviors and can occur when an examinee is unusually self-critical, discouraged, or under stress. The Acquiescence (ACQ) scale's purpose is to index the degree to which the examinee agreed with items regardless of what was being asked. A high score might indicate that the examinee misunderstood the item content, responded randomly, has an unclear self-image, or had a "yea-saying" response style. The Infrequency (INF) scale comprises the most statistically infrequent responses on the test, which are all middle (b) responses and appear in the test booklet with a question mark. A score above the 95th percentile may indicate that the examinee had trouble reading or comprehending the questions, responded randomly, experienced consistent indecisiveness about the a or c response choice, or tried to avoid making the wrong impression by choosing the middle answer rather than one of the more definitive answers. Administration Administration of the test takes about 35–50 minutes for the paper-and-pencil version and about 30 minutes by computer. The test instructions are simple and straightforward and the test is un-timed; thus, the test is generally self-administrable and can be used in either an individual or a group setting. The 16PF test was designed for adults at least age 16 and older, but there are also parallel tests for various younger age ranges (e.g., the 16PF Adolescent Personality Questionnaire). The 16PF Questionnaire has been translated into more than 30 languages and dialects. Thus the test can be administered in different languages, scored based on either local, national, or international normative samples, and computerized interpretive reports provided in about 23 different languages. The test has generally been culturally adapted (rather than just translated) in these countries, with local standardization samples plus reliability and validity information collected locally and presented in individual manuals. Scoring The test can be hand-scored using a set of scoring keys, or computer-scored by mailing-in or faxing-in the answer sheet to the publisher IPAT. There is also a software system that can be used to administer, score, and provide reports on the test results directly in the professional's office; and an Internet-based system that can also provide administration, scoring, and reports in a range of different languages. After the test has been administered there is a total score computed from each of the 16 personality factors. These totals have been created in a way to correlate to the sten scale. Scores on the 16PF are presented on a 10-point scale, or standard-ten scale. The sten scale has a mean of 5.5 and a standard deviation of 2, with scores below 4 considered low and scores above 7 considered high. The sten scales are bipolar, meaning that each end of the scale has a distinct definition and meaning. Because bipolar scales are designated with "high" or "low" for each factor, a high score should not be considered to reflect a positive personality characteristic and a low score should not be considered to reflect a negative personality characteristic. Interpretation Cattell and Schuerger provided six steps that outline how they recommend interpreting the results of the 16PF: Consider the context of the assessment. Evaluate the Response Style Indexes by first checking responses on Factor B, and then looking at scores on the Infrequency, Impression Management, and Acquiescence scales. Evaluate the Global Scale scores. Evaluate the Primary Scales in the context of the Global Scales Consider scale interactions Integrate 16PF results in relation to the assessment question There are about a dozen computer-generated interpretive reports that can be used to help interpret the test for different purposes, for example: Career Development Report Karson Clinical Report Cattell Comprehensive Personality Interpretation Teamwork Development Report, Management Potential Report, Security Selection Report Leadership Coaching Report There are also many books that help with test interpretation, for example, 16PF Interpretation in Clinical Practice (Karson, Karson, & O'Dell, 1997), The 16PF: Personality in Depth (Cattell, H.B., 1989), and Essentials of the 16PF (Cattell, H.E. & Schuerger, J.M, 2003) The 16PF traits are also included in the Psychological Evaluation Questionnaire (PEQ), which combines measures of both normal and abnormal personality traits into one test (Cattell, Cattell, Cattell, Russell, & Bedwell, 2003) Raymond Cattell's 16 Personality Factors Below is a table outlining the personality traits measured by the 16PF Questionnaire. Relationship to five-factor models In the Fourth and Fifth Editions of the 16PF, there were five global factors that seem to correspond fairly closely to the "Big Five personality traits". The Big Five (BF) trait of Openness seems to be related to 16PF Openness/Tough-mindedness, The BF trait of Conscientiousness to the 16PF Self-Control, the BF Extraversion to the 16PF Extraversion, the BF Agreeableness/Dis-Agreeableness to the 16PF Independence/Accommodation, and the BF Neuroticism to the 16PF Anxiety. In fact, the development of the Big-Five factors began in 1963 with W.T. Norman factor-analyzing responses to the same items as the 16PF, replicating Cattell's work and suggested that five factors would be sufficient. However, one big technical difference between Cattell's five Global Factors and popular five-factor models was Cattell's insistence on using oblique rotation in the factor analysis whereas Goldberg and Costa & McCrae used orthogonal rotation in their factor analysis. Oblique rotation allows the factors to correlate with each other, whereas orthogonal rotation restricts the factors from correlating with each other. Although personality traits are thought to be correlated, using orthogonal factor analysis makes the factors easier to understand and to work on statistically in research. This is one of the reasons the Big-Five traits have definitions that are different from the 16PF global factors. For example, as seen in the table below, in Cattell's model the primary personality trait of Dominance (Factor E) is strongly located in the Independence/Accommodation global factor which represents a quality of fearless, original thinking and forceful, independent actions. However, other popular big five models consider Dominance as a facet of several Big-Five traits, including Extraversion, Dis-Agreeableness, and Conscientiousness. Thus Dominance is spread across a range of Big-Five factors with little influence on any one (Cattell & Mead, 2008). Below is a table that shows how the 16 primary factors are related to the five global factors of the 16 Personality Factor theory. Compare with the Hierarchical Structure of the Big Five. Also, note that factor B is considered separate from the other factors because it is not a part of the hierarchical structure of personality in the same way as the other factors. Factor analytic strategy Assumptions shared by standardized personality tests, simply stated, are that humans possess characteristics or traits that are stable, vary from individual to individual, and can be measured. Factor analysis is a statistical procedure for reducing the redundancy in a set of intercorrelated scores. One major technique of factor analysis, the principal-components method, finds the minimum number of common factors that can account for an interrelated set of scores. Cattell's goal was to empirically determine and measure the essence of personality. Cattell used factor analysis to reduce thousands of psychological traits into what he believed to be 16 of the basic dimensions, or source traits of human personality. As a result, he created the 16PF personality test. 16PF global and primary factors History and development Cattell physical sciences background The 16PF Questionnaire was created from a fairly unusual perspective among personality tests. Most personality tests are developed to measure just the pre-conceived traits that are of interest to a particular theorist or researcher. The main author of the 16PF, Raymond B. Cattell, had a strong background in the physical sciences, especially chemistry and physics, at a time when the basic elements of the physical world were being discovered, placed in the periodic table, and used as the basis for understanding the fundamental nature of the physical world and for further inquiry. From this background in the physical sciences, Cattell developed the belief that all fields are best understood by first seeking to find the fundamental underlying elements in that domain, and then developing a valid way to measure and research these elements (Cattell, 1965). Personality research author Schuerger stated that: When Cattell moved from the physical sciences into the field of psychology in the 1920s, he described his disappointment about finding that it consisted largely of a wide array of abstract, unrelated theories and concepts that had little or no scientific bases. He found that most personality theories were based on philosophy and on personal conjecture, or were developed by medical professionals, such as Jean Charcot and Sigmund Freud, who relied on their personal intuition to reconstruct what they felt was going on inside people, based on observing individuals with serious psycho-pathological problems. Cattell (1957) described the concerns he felt as a scientist: "In psychology there is an ocean of spawning intuitions and comfortable assumptions which we share with the layman, and out of which we climb with difficulty to the plateaus of scientific objectivity....Scientific advance hinges on the introduction of measurement to the field under investigation….Psychology has bypassed the necessary descriptive, taxonomic, and metric stages through which all healthy sciences first must pass….If Aristotle and other philosophers could get no further by sheer power of reasoning in two thousand years of observation, it is unlikely that we shall do so now.... For psychology to take its place as an effective science, we must become less concerned with grandiose theory than with establishing, through research, certain basic laws of relationship." (p.3-5) Thus, Cattell's goal in creating the 16PF Questionnaire was to discover the number and nature of the fundamental traits of human personality and to develop a way to measure these dimensions. At the University of London, Cattell worked with Charles Spearman who was developing factor analysis to aid in his quest to discover the basic factors of human ability. Cattell thought that could also be applied to the area of personality. He reasoned that human personality must have basic, underlying, universal dimensions just as the physical world had basic building blocks (like oxygen and hydrogen). He felt that if the basic building blocks of personality were discovered and measured, then human behavior (e.g., creativity, leadership, altruism, or aggression) could become increasingly understandable and predictable. Lexical Hypothesis (1936) In 1936 Gordon Allport and H.S. Odbert hypothesized that: This statement has become known as the Lexical Hypothesis, which posits that if there is a word for a trait, it must be a real trait. Allport and Odbert used this hypothesis to identify personality traits by working through two of the most comprehensive dictionaries of the English language available at the time, and extracting 18,000 personality-describing words. From this gigantic list they extracted 4500 personality-describing adjectives which they considered to describe observable and relatively permanent traits. Cattell and his colleagues began a comprehensive program of international research aimed at identifying and mapping out the basic underlying dimensions of personality. Their goal was to systematically measure the widest possible range of personality concepts, in a belief that "all aspects of human personality which are or have been of importance, interest, or utility have already become recorded in the substance of language" (Cattell, R. B., 1943, p. 483). They wanted to include every known personality dimension in their investigation, and thus began with the largest existing compilation of personality traits (Allport and Odbert, 1936). Over time, they used factor analysis to reduce the massive list of traits by analyzing the underlying patterns among them. They studied personality data from different sources (e.g. objective measures of daily behavior, interpersonal ratings, and questionnaire results), and measured these traits in diverse populations, including working adults, university students, and military personnel. (Cattell, 1957, 1973). 16 Personality Factors identified (1949) The 16 Personality Factors were identified in 1949 by Raymond Cattell. He believed that in order to adequately map out personality, one had to utilize L-Data (life records or observation), Q data (information from questionnaires), and T-data (information from objective tests). The development of the 16PF Questionnaire, although confusingly named, was an attempt to develop an adequate measure of T-data. Cattell analyzed the list of 4500 adjectives and organized the list of adjectives into fewer than 171 items and asked subjects to rate people whom they knew on each of the adjectives on the list (an example of L-data because the information was gathered from observers). This allowed Cattell to narrow down to 35 terms and factor analysis in 1945, 1947 and 1948 revealed a 11 or 12 factor solution. In 1949 Cattell found that there were 4 additional factors, which he believed consisted of information that could only be provided through self-rating. This process allowed the use of ratings by observers, questionnaires, and objective measurements of actual behavior. In 1952 the ILLIAC I became available at the University of Illinois at Urbana-Champaign to be used for factor analysis. Together the original 12 factors and the 4 covert factors made up the original 16 primary personality factors. As the five factor theory gained traction and research on the 16 factors continued, subsequent analysis identified five factors underlying the 16 factors. Cattell called these global factors. The 16PF factorial structure resembles that of Szondi test and the Berufsbilder test (BTT), despite being based on different theories. Analytic study and revisions of the factors (1949–2011) Because the 16PF dimensions were developed through factor analysis, construct validity is provided by studies that confirm its factor structure. Over several decades of factor-analytic study, Cattell and his colleagues gradually refined and validated their list of underlying source traits. The search resulted in the sixteen unitary traits of the 16PF Questionnaire. These traits have remained the same over the last 50 years of research. In addition, the 16PF Questionnaire traits are part of a multi-variate personality model that provides a broader framework including developmental, environmental, and hereditary patterns of the traits and how they change across the life span (Cattell, 1973, 1979, 1980). The validity of the factor structure of the 16PF Questionnaire (the 16 primary factors and 5 global factors) has been supported by more than 60 published studies (Cattell & Krug, 1986; Conn & Rieke, 1994; Hofer and Eber, 2002). Research has also supported the comprehensiveness of the 16PF traits: all dimensions on other major personality tests (e.g., the NEO Personality Inventory, the California Psychological Inventory, the Personality Research Form, and the Myers-Briggs Type Indicator) have been found to be contained within the 16PF scales in regression and factor-analytic studies (Conn & Rieke, 1994; Cattell, 1996). Since its release in 1949, the 16PF Questionnaire has been revised four times: once in 1956, once in 1962, once in 1968, and the current version was developed in 1993. The US version of the test was also re-standardized in 2002, along with the development of forms for children and teenagers; versions for the UK, Ireland, France and the Netherlands were re-standardised in 2011. Additionally, there is a shortened form available primarily for employee selection and the questionnaire has been adapted into more than 35 languages. The questionnaire has also been validated in a range of international cultures over time. The 16PF was distributed through the Institute for Personality and Ability Testing (IPAT), founded by Cattell and based in Savoy, Illinois. In January 2003, the Institute was purchased by UK private company, OPP Limited, who administered the 16PF worldwide. It later became a subsidiary of Performance Assessment Network (PAN) which in 2017 was acquired by PSI. The original Big Five traits From the beginning of his research, Cattell found personality traits to have a multi-level, hierarchical structure (Cattell, 1946). The first goal of these researchers was to find the most fundamental primary traits of personality. Next they factor-analyzed these numerous primary traits to see if these traits had a structure of their own—i.e. if some of them naturally went together in self-defining, meaningful groupings. They consistently found that the primary traits themselves came together in particular, meaningful groupings to form broader secondary or global traits, each with its own particular focus and function within personality (Cattell & Schuerger, 2003). For example, the first global trait they found was Extraversion-Introversion. It resulted from the natural affinity of five primary traits that defined different reasons for an individual to move toward versus away from other people (see below). They found that there was a natural tendency for these traits to go together in the real world, and to define an important domain of human behavior—social behavior. This global factor Global Extraversion/Introversion (the tendency to move toward versus away from interaction with others) is composed from the following primary traits: Warmth (Factor A): the tendency to move toward others seeking closeness and connection because of genuine feelings of caring, sympathy, and concern (versus the tendency to be reserved and detached, and thus be independent and unemotional). Liveliness (Factor F): the tendency to be high-energy, fun-loving, and carefree, and to spontaneously move towards others in an animated, stimulating manner. Low-scorers tend to be more serious and self-restrained, and to be cautious, unrushed, and judicious. Social Boldness (Factor H): the tendency to seek social interaction in a confident, fearless manner, enjoying challenges, risks, and being the center of attention. Low-scorers tend to be shy and timid, and to be more modest and risk-avoidant. Forthrightness (Factor N): the tendency to want to be known by others—to be open, forthright, and genuine in social situations, and thus to be self-revealing and unguarded. Low-scorers tend to be more private and unself-revealing, and to be harder to get to know. Affiliative (Factor Q2): the tendency to seek companionship and enjoy belonging to and functioning in a group (inclusive, cooperative, good follower, willing to compromise). Low-scorers tend to be more individualistic and self-reliant and to value their autonomy. In a similar manner, these researchers found that four other primary traits consistently merged to define another global factor which they called Receptivity or Openness (versus Tough-Mindedness). This factor was made up of four primary traits that describe different kinds of openness to the world: Openness to sensitive feelings, emotions, intuition, and aesthetic dimensions (Sensitivity – Factor I) Openness to abstract, theoretical ideas, conceptual thinking, and imagination (Abstractedness – Factor M) Openness to free thinking, inquiry, exploration of new approaches, and innovative solutions (Openness-to-Change – Factor Q1) and Openness to people and their feelings (Warmth – Factor A). Another global factor, Self-Controlled (or conscientious) versus Unrestrained, resulted from the natural coming together of four primary factors that define the different ways that human beings manage to control their behavior: Rule-Consciousness (Factor G) involves adopting and conscientiously following society's accepted standards of behavior Perfectionism (Factor Q3) describes a tendency to be self-disciplined, organized, thorough, attentive to detail, and goal-oriented Seriousness (Factor F) involves a tendency to be cautious, reflective, self-restrained, and deliberate in making decisions; and Groundedness (Factor M) involves a tendency to stay focused on concrete, pragmatic, realistic solutions. Because the global factors were developed by factor-analyzing the primary traits, the meanings of the global traits were determined by the primary traits which made them up. In addition, then the global factors provide the overarching, conceptual framework for understanding the meaning and function of each of the primary traits. Thus, the two levels of personality are essentially inter-connected and inter-related. However it is the primary traits that provide a clear definition of the individual's unique personality. Two people might have exactly the same level of Extraversion, but still be quite different from each other. For example, they may both be at the 80% on Extraversion, and both tend to move toward others to the same degree, but they may be doing it for quite different reasons. One person might achieve an 80% on Extraversion by being high on Social Boldness (Factor H: confident, bold, talkative, adventurous, fearless attention-seeking) and on Liveliness (Factor F: high-energy, enthusiastic, fun-loving, impulsive), but Reserved (low on Factor A: detached, cool, unfeeling, objective). This individual would be talkative, bold, and impulsive but not very sensitive to others people's needs or feelings. The second Extravert might be high on Warmth (Factor A: kind, soft-hearted, caring and nurturing), and Group-Oriented (low Factor Q2: companionable, cooperative, and participating), but Shy (low on Factor H: timid, modest, and easily embarrassed). This second Extravert would tend to show quite different social behavior and be caring, considerate, and attentive to others but not forward, bold or loud—and thus have quite a different effect on his/her social environment. Today, the global traits of personality are commonly known as the Big Five. The Big Five traits are most important for getting an abstract, theoretical understanding of the big, overarching domains of personality, and in understanding how different traits of personality relate to each other and how different research findings relate to each other. The big-five are important for understanding and interpreting an individual's personality profile mainly in getting a broad overview of their personality make-up at the highest level of personality organization. However, it is still the scores on the more specific primary traits that define the rich, unique personality make-up of any individual. These more-numerous primary traits have repeatedly been found to be the most powerful in predicting and understanding the complexity of actual daily behavior (Ashton, 1998; Goldberg, 1999; Mershon & Gorsuch, 1988; Paunonen & Ashton, 2001). See also Minnesota Multiphasic Personality Inventory (MMPI) Neuroticism Extraversion Openness Personality Inventory (NEO-PI) Trait theory References Further reading External links 16PF l 16PF for Corporate Industry Personality Assessment Network, Inc. (PAN) which owns the IPAT Institute founded by Raymond B. Cattell The International Personality Item Pool contains scales designed to mimic the 16PFQ: an interactive implementation can be found here. Personality tests 1949 introductions

Anti-social behaviour

Antisocial behaviours, sometimes called dissocial behaviours, are actions which are considered to violate the rights of or otherwise harm others by committing crime or nuisance, such as stealing and physical attack or noncriminal behaviours such as lying and manipulation. It is considered to be disruptive to others in society. This can be carried out in various ways, which includes, but is not limited to, intentional aggression, as well as covert and overt hostility. Anti-social behaviour also develops through social interaction within the family and community. It continuously affects a child's temperament, cognitive ability and their involvement with negative peers, dramatically affecting children's cooperative problem-solving skills. Many people also label behaviour which is deemed contrary to prevailing norms for social conduct as anti-social behaviour. However, researchers have stated that it is a difficult term to define, particularly in the United Kingdom where many acts fall into its category. The term is especially used in Irish English and British English. Although the term is fairly new to the common lexicon, the word anti-social behaviour has been used for many years in the psychosocial world where it was defined as "unwanted behaviour as the result of personality disorder." For example, David Farrington, a British criminologist and forensic psychologist, stated that teenagers can exhibit anti-social behaviour by engaging in various amounts of wrongdoings such as stealing, vandalism, sexual promiscuity, excessive smoking, heavy drinking, confrontations with parents, and gambling. In children, conduct disorders could result from ineffective parenting. Anti-social behaviour is typically associated with other behavioural and developmental issues such as hyperactivity, depression, learning disabilities, and impulsivity. Alongside these issues one can be predisposed or more inclined to develop such behaviour due to one's genetics, neurobiological and environmental stressors in the prenatal stage of one's life, through the early childhood years. The American Psychiatric Association, in its Diagnostic and Statistical Manual of Mental Disorders, diagnoses persistent anti-social behaviour starting from a young age as antisocial personality disorder. Genetic factors include abnormalities in the prefrontal cortex of the brain while neurobiological risk include maternal drug use during pregnancy, birth complications, low birth weight, prenatal brain damage, traumatic head injury, and chronic illness. The World Health Organization includes it in the International Classification of Diseases as dissocial personality disorder. A pattern of persistent anti-social behaviours can also be present in children and adolescents diagnosed with conduct problems, including conduct disorder or oppositional defiant disorder under the DSM-5. It has been suggested that individuals with intellectual disabilities have higher tendencies to display anti-social behaviours, but this may be related to social deprivation and mental health problems. More research is required on this topic. Development Intent and discrimination may determine both pro-social and anti-social behaviour. Infants may act in seemingly anti-social ways and yet be generally accepted as too young to know the difference before the age of four or five. Berger states that parents should teach their children that "emotions need to be regulated, not depressed". One problem with the assumption that a behaviour that is "simply ignorant" in infants would have antisocial causes in persons older than four or five years at the same time as the latter are supposed to have more complex brains (and with it a more advanced consciousness) is that it presumes that what appears to be the same behaviour would have fewer possible causes in a more complex brain than in a less complex brain, which is criticized because a more complex brain increases the number of possible causes of what looks like the same behaviour as opposed to decreasing it. Studies have shown that in children between ages 13–14 who bully or show aggressive behaviour towards others exhibit anti-social behaviours in their early adulthood. There are strong statistical relationships that show this significant association between childhood aggressiveness and anti-social behaviours. Analyses saw that 20% of these children who exhibit anti-social behaviours at later ages had court appearances and police contact as a result of their behaviour. Many of the studies regarding the media's influence on anti-social behaviour have been deemed inconclusive. Some reviews have found strong correlations between aggression and the viewing of violent media, while others find little evidence to support their case. The only unanimously accepted truth regarding anti-social behaviour is that parental guidance carries an undoubtedly strong influence; providing children with brief negative evaluations of violent characters helps to reduce violent effects in the individual. Cause and effects Family Families greatly impact the causation of anti-social behaviour. Some other familial causes are parent history of anti-social behaviours, parental alcohol and drug abuse, unstable home life, absence of good parenting, physical abuse, parental instability (mental health issues/PTSD) and economic distress within the family. Neurobiology Studies have found that there is a link between antisocial behaviour and increased amygdala activity specifically centered around facial expressions that are based in anger. This research focuses on the fact that the symptom of over reactivity to perceived threats that comes with antisocial behaviour may be from this increase in amygdala activity. This focus on perceived threat does not include emotions centered around distress. Consumption patterns There is a small link between antisocial personality characteristics in adulthood and more TV watching as a child. The risk of early adulthood criminal conviction increased by nearly 30 percent with each hour children spent watching TV on an average weekend. Peers can also impact one's predisposition to anti-social behaviours, in particular, children in peer groups are more likely to associate with anti-social behaviours if present within their peer group. Especially within youth, patterns of lying, cheating and disruptive behaviours found in young children are early signs of anti-social behaviour. Adults must intervene if they notice their children providing these behaviours. Early detection is best in the preschool years and middle school years in best hopes of interrupting the trajectory of these negative patterns. These patterns in children can lead to conduct disorder, a disorder that allows children to rebel against atypical age-appropriate norms. Moreover, these offences can lead to oppositional defiant disorder, which allows children to be defiant against adults and create vindictive behaviours and patterns. Furthermore, children who exhibit anti-social behaviour also are more prone to alcoholism in adulthood. Intervention and treatment As a high prevalence mental health problem in children, many interventions and treatments are developed to prevent anti-social behaviours and to help reinforce pro-social behaviours. Several factors are considered as direct or indirect causes of developing anti-social behaviour in children. Addressing these factors is necessary to develop a reliable and effective intervention or treatment. Children's perinatal risk, temperament, intelligence, nutrition level, and interaction with parents or caregivers can influence their behaviours. As for parents or caregivers, their personality traits, behaviours, socioeconomic status, social network, and living environment can also affect children's development of anti-social behaviour. An individual's age at intervention is a strong predictor of the effectiveness of a given treatment. The specific kinds of anti-social behaviours exhibited, as well as the magnitude of those behaviours also impact how effective a treatment is for an individual. Behavioural parent training (BPT) is more effective to preschool or elementary school-aged children, and cognitive behavioural therapy (CBT) has higher effectiveness for adolescents. Moreover, early intervention of anti-social behaviour is relatively more promising. For preschool children, family is the main consideration for the context of intervention and treatment. The interaction between children and parents or caregivers, parenting skills, social support, and socioeconomic status would be the factors. For school-aged children, the school context also needs to be considered. The collaboration amongst parents, teachers, and school psychologists is usually recommended to help children develop the ability of resolving conflicts, managing their anger, developing positive interactions with other students, and learning pro-social behaviours within both home and school settings. Moreover, the training for parents or caregivers are also important. Their children would be more likely to learn positive social behaviours and reduce inappropriate behaviours if they become good role models and have effective parenting skills. Cognitive behavioural therapy Cognitive behavioural therapy (CBT), is a highly effective, evidence-based therapy, in relation to anti-social behaviour. This type of treatment focuses on enabling the patients to create an accurate image of the self, allowing the individuals to find the trigger of their harmful actions and changing how individuals think and act in social situations. Due to their impulsivity, their inability to form trusting relationships and their nature of blaming others when a situation arises, individuals with particularly aggressive anti-social behaviours tend to have maladaptive social cognitions, including hostile attribution bias, which lead to negative behavioural outcomes. CBT has been found to be more effective for older children and less effective for younger children. Problem-solving skills training (PSST) is a type of CBT that aims to recognize and correct how an individual thinks and consequently behaves in social environments. This training provides steps to assist people in obtaining the skill to be able to evaluate potential solutions to problems occurring outside of therapy and learn how to create positive solutions to avoid physical aggression and resolve conflict. Therapists, when providing CBT intervention to individuals with anti-social behaviour, should first assess the level of the risk of the behaviour in order to establish a plan on the duration and intensity of the intervention. Moreover, therapists should support and motivate individuals to practice the new skills and behaviours in environments and contexts where the conflicts would naturally occur to observe the effects of CBT. Behavioural parent training Behavioural parent training (BPT) or parent management training (PMT), focuses on changing how parents interact with their children and equips them with ways to recognize and change their child's maladaptive behaviour in a variety of situations. BPT assumes that individuals are exposed to reinforcements and punishments daily and that anti-social behaviour, which can be learned, is a result of these reinforcements and punishments. Since certain types of interactions between parents and children may reinforce a child's anti-social behaviour, the aim of BPT is to teach the parent effective skills to better manage and communicate with their child. This could be done by reinforcing pro-social behaviours while punishing or ignoring anti-social behaviours. It is important to note that the effects of this therapy can be seen only if the newly acquired communication methods are maintained. BPT has been found to be most effective for younger children under the age of 12. Researchers credit the effectiveness of this treatment at younger ages due to the fact that younger children are more reliant on their parents. BPT is used to treat children with conduct problems, but also for children with ADHD. According to a meta-analysis, the effectiveness of BPT is supported by short-term changes on the children's anti-social behaviour. However, whether these changes are maintained over a longer period of time is still unclear. School-based Intervention First Step to Success is an early intervention for Kindergarten to 3rd grade children who are demonstrating antisocial behaviours. First Step is a collaborative intervention between home and school. There are three important components: (1) Screening; (2) School intervention (CLASS): teaches the child appropriate behaviour through positive reinforcement; (3) Home intervention (HomeBase): teaches the parent key skills for supporting their child and the use of positive reinforcement. The classroom intervention phase (CLASS) takes about 30 days to complete and has 3 phases: (1) Coach-led; (2) Teacher-led; (3) Maintaining. The Red Card/Green Card game (red = inappropriate behaviour; green = appropriate behaviour) is played at school each day. The coach/teacher shows a red/green card as a visual cue to the target student based on their current behaviour. Points are earned if the card is on green at the end of a timed interval. If enough points are earned at the end of the game, the target child gets to choose a reward that the entire class can enjoy together (i.e., extra time at recess, playing a special game, etc.). Coaches/teachers communicate daily with parent(s) throughout the intervention. The home intervention (HomeBase) begins a few days after the classroom intervention. HomeBase builds parent's confidence in 6 specific skill areas and in parent-child activities. Coaches meet with parent(s) once weekly for 6 weeks. Parent(s) engage with the target child for 10–15 minutes daily in one-on-one time during the intervention. Overall, First Steps takes about 3 months to implement, requires minimal time from parent(s) and teachers and has shown empirically positive results in increasing prosocial behaviour in at-risk children. Psychotherapy Psychotherapy or talk therapy, although not always effective, can also be used to treat individuals with anti-social behaviour. Individuals can learn skills such as anger and violence management. This type of therapy can help individuals with anti-social behaviour bridge the gap between their feelings and behaviours, which they lack the connection previously. It is most effective when specific issues are being discussed with individuals with anti-social behaviours, rather than a broad general concept. This type of therapy works well with individuals who are at a mild to moderate stage of anti-social behaviour since they still have some sense of responsibility regarding their own problems. Mentalization-based treatment is another form of group psychotherapy shifting its focus on the relational and mental factors related to anti-social personality disorder rather than anger management and violent acts. This particular group therapy targets the mentalizing vulnerabilities and attachment patterns of patients by using a semi-structured group process focused on personal formulation and by establishing group values to promote learning from other members and generating "we-ness." When working with individuals with anti-social behaviour, therapist must be mindful of building a trusting therapeutic relationship since these individuals might have never experienced rewarding relationships. Therapists also need to be reminded that changes might take place slowly, thus an ability for noticing small changes and constant encouragement for individuals with anti-social behaviour to continue the intervention are required. Family therapy Family therapy, which is a type of psychotherapy, helps promote communication between family members, thus resolving conflicts related to anti-social behaviour. Since family exerts enormous influence over children's development, it is important to identify the behaviours that could potentially lead to anti-social behaviours in children. It is a relatively short-term therapy which involves the family members who are willing to participate. Family therapy can be used to address specific topics such as aggression. The therapy may end when the family can resolve conflicts without needing the therapists to intervene. Diagnosis There is no official diagnosis for anti-social behaviour. However, we can have a look at the official diagnosis for antisocial personality disorder (ASPD) and use it as guideline while keeping in mind that anti-social behaviour and ASPD are not to be confused. Distinguishing from antisocial personality disorder When looking at non-ASPD patients (who show anti-social behaviour) and ASPD patients, it all comes down to the same types of behaviours. However, ASPD is a personality disorder which is defined by the consistency and stability of the observed behaviour, in this case, anti-social behaviour. Antisocial personality disorder can only be diagnosed when a pattern of anti-social behaviour began being noticeable during childhood and/or early teens and remained stable and consistent across time and context. In the official DSM IV-TR for ASPD, it is specified that the anti-social behaviour has to occur outside of time frames surrounding traumatic life events or manic episodes (if the individual is diagnosed with another mental disorder). The diagnosis for ASPD cannot be done before the age of 18. For example, someone who exhibits anti-social behaviour with their family but pro-social behaviour with friends and coworkers would not qualify for ASPD because the behaviour is not consistent across context. Someone who was consistently behaving in a pro-social way and then begins exhibiting anti-social behaviour in response to a specific life event would not qualify for ASPD either because the behaviour is not stable across time. Law breaking behaviour in which the individuals are putting themselves or others at risk is considered anti-social even if it is not consistent or stable (examples: speeding, use of drugs, getting in physical conflict). In relation to the previous statement, juvenile delinquency is a core element to the diagnosis of ASPD. Individuals who begin getting in trouble with the law (in more than one area) at an abnormally early age (around 15) and keep recurrently doing so in adulthood may be suspected of having ASPD. Evidence: frustration and aggression With some limitations, research has established a correlation between frustration and aggression when it comes to anti-social behaviour. The presence of anti-social behaviour may be detected when an individual is experiencing an abnormally high amount of frustrations in their daily life routine and when those frustrations always result into aggression. The term impulsivity is commonly used to describe this behavioural pattern. Anti-social behaviour can also be detected if the aggressiveness and impulsiveness of the individual's behaviour in response to frustrations is so that it causes obstruction to social interactions and achievement of personal goals. In both of these cases, we can consider the different types of treatment and therapy previously mentioned in this article. Examples in childhood: unable to make friends, unable to follow rules, getting kicked out of school, unable to fulfill minimal levels of education (elementary school, middle school). Examples in early adulthood: unable to keep a job or an apartment, difficulty with maintaining relationships. Prognosis The prognosis of having anti-social behaviour is not very favourable due to its high stability throughout children development. Studies have shown that children who are aggressive and have conduct problems are more likely to have anti-social behaviour in adolescence. Early intervention of anti-social behaviour is relatively more effective since the anti-social pattern lasts for a shorter period of time. Moreover, since younger children would have smaller social networks and less social activities, fewer contexts need to be considered for the intervention and treatment. For adolescents, studies have shown that the influence of treatments becomes less effective. The prognosis seems to not be influenced by the duration of intervention, however; a long-term follow-up is necessary to confirm that the intervention or treatment is effective. Individuals who exhibit anti-social behaviour are more likely to use drugs and abuse alcohol. This could make the prognosis worse since he or she would less likely be involved in social activities and would become more isolated. By location United Kingdom An anti-social behaviour order (ASBO) is a civil order made against a person who has been shown, on the balance of evidence, to have engaged in anti-social behaviour. The orders, introduced in the United Kingdom by Prime Minister Tony Blair in 1998, were designed to criminalize minor incidents that would not have warranted prosecution before. The Crime and Disorder Act 1998 defines anti-social behaviour as acting in a manner that has "caused or was likely to cause harassment, alarm or distress to one or more persons not of the same household" as the perpetrator. There has been debate concerning the vagueness of this definition. However, among legal professionals in the UK there are behaviours commonly considered to fall under the definitions of anti-social behaviour. These include, but are not limited to, threatening or intimidating actions, racial or religious harassment, verbal abuse, and physical abuse. In a survey conducted by University College London during May 2006, the UK was thought by respondents to be Europe's worst country for anti-social behaviour, with 76% believing Britain had a "big or moderate problem". Current legislation governing anti-social behaviour in the UK is the Anti-Social Behaviour, Crime and Policing Act 2014 which received Royal Assent in March 2014 and came into enforcement in October 2014. This replaces tools such as the ASBO with 6 streamlined tools designed to make it easier to act on anti-social behaviour. Australia Anti-social behaviour can have a negative effect and impact on Australian communities and their perception of safety. The Western Australia Police force define anti-social behaviour as any behaviour that annoys, irritates, disturbs or interferes with a person's ability to go about their lawful business. In Australia, many different acts are classed as anti-social behaviour, such as: misuse of public space; disregard for community safety; disregard for personal well-being; acts directed at people; graffiti; protests; liquor offences; and drunk driving. It has been found that it is very common for Australian adolescents to engage in different levels of anti-social behaviour. A survey was conducted in 1996 in New South Wales, Australia, of 441, 234 secondary school students in years 7 to 12 about their involvement in anti-social activities. 38.6% reported intentionally damaging or destroying someone else's property, 22.8% admitted to having received or selling stolen goods and close to 40% confessed to attacking someone with the idea of hurting them. The Australian community are encouraged to report any behaviour of concern and play a vital role assisting police in reducing anti-social behaviour. One study conducted in 2016 established how perpetrators of anti-social behaviour may not actually intend to cause offense. The study examined anti-social behaviours (or microaggressions) within the LGBTIQ community on a university campus. The study established how many members felt that other people would often commit anti-social behaviours, however there was no explicit suggestion of any maliciousness behind these acts. Rather, it was just that the offenders were naive to the impact of their behaviour. The Western Australia Police force uses a three-step strategy to deal with anti-social behaviour. Prevention – This action uses community engagement, intelligence, training and development and the targeting of hotspots, attempting to prevent unacceptable behaviour from occurring. Response – A timely and effective response to anti-social behaviour is vital. Police provide ownership, leadership and coordination to apprehend offenders. Resolution – Identifying the underlying issues that cause anti-social behaviour and resolve these issues with the help of the community. Offenders are successfully prosecuted. Japan The 1970's, brought attention to a social and historical phenomenon called hikikomori. Often called the lost generation, with pervasive and severe social withdrawal and anti-social tendencies. Individuals with hikikomori, are commonly in their 20's or 30's, avoiding as much social interaction as possible. Japanese psychologist and leading expert on the topic, Tamaki Saito, was one of the first to present that approximately 1% of the country's population was considered hikikomori at the time. Today, it is still existent in Japan taking on new forms of seclusion by using digital tools, such as video games and internet chatting, to replace social interaction. The term Hikikomori has since been used throughout the world, in Asia, Europe, North and South America, Africa and Australia. See also References Further reading External links Anti-Social Behaviour.org.uk MIT Technology Review - How a Troll-Spotting Algorithm Learned Its Anti-antisocial Trade Behavioral addiction Criminal subcultures

Person-centered care

In health care, person-centered care is a practice in which patients actively participate in their own medical treatment in close cooperation with their health professionals. Sometimes, relatives may be involved in the creation of the patient’s health plan. The person-centered model of health care is used both for in and outpatient settings, emergency care, palliative care as well as in rehabilitation. Background The concept of person-centered care can be distinguished from a traditional treatment model which views the patient as a passive receiver of a medical intervention. Many health professionals are traditionally focused on the needs of the patients instead of their resources. Rather than the conventional way of making medical recommendations from health professionals to a patient, the person-centered care model allows for the inclusion of the patient and their relatives in making a joint design and mutual agreement on the medical plans and treatments. The overall perspective of the life situation of the patient is considered to create objectives and strategies for both short- and long-term monitoring. The concept of person-centered care has grown to be internationally associated with successful outcomes in health care. Initially, the method was developed for senior patients and patients with intellectual disabilities, albeit it has been held under scrutiny later on. Within person-centered care, the patient is considered an independent and capable individual with their own abilities to make informed decisions. Autonomy and participation are emphasized and respected. For the patient, the person-centered approach allows for involvement and extended possibilities to take responsibility for their own health and treatment. Key principles There are four vantage points that constitute the foundation of person-centered care: The health care should be based on the unique person's needs and his or her right to health The health institution should focus on the abilities of the person and encourage activity The health care should be coherent Health professionals should always approach patients with dignity, compassion and respect. They should work with an ethical perspective. Person-centered care is based on a holistic approach to health care that takes the whole person into account instead of a narrow perspective where the focus lies on the illness or the symptoms. The person-centered approach also includes the person's abilities, or resources, wishes, health and well-being as well as social and cultural factors. According to the Gothenburg model of person centered care there are three central themes to person-centered care work: the patient's narrative, the partnership and the documentation. The Partnership The health care team may consist of several different professionals with varying expertise from different health care units. The patient is a natural part of the team. Within the team, the patient and relatives have discussions with health professionals aiming to reach a mutual understanding on how to achieve safe and accurate care for the unique patient. The Documentation The personal health or care plan is designed to capture the patient's narrative. A common understanding of strategies, goals and evaluation of the outcomes should be established. The documentation should clearly state the responsibilities of each member of the team, including the patient's own role and obligations. To fully live up to the person-centered care concept, patients should have full and easy access to all information and documentation about them. For reasons of security, accessibility and cost effectiveness, all documentation should be digital and include all medical records. The person's own notes, reports of health status and the overall health plan should also be carefully documented. The collected documentation is the foundation of the health care. Person-centred care in the United Kingdom Person-centred care is a concept used in the United Kingdom by Skills for Health, in their 2017 framework; by the Health Foundation, set out in their 2016 "quick guide"; by the Social Care Institute for Excellence; by the Royal College of General Practitioners and NHS England, who have developed a Person-Centred Care toolkit; by the Health Innovation Network South London; and by the Care Quality Commission, in their regulations for service providers. The Health Innovation Network defines Person-centred care as: The concept is defined as including decision-making that is shared between services users and professionals, ensuring service users have access to advocacy, providing personal budgets for people to access services, treating people with dignity, ensuring service users have all the information they need, supporting individual choices and ensuring treatment and support are personalised and take into account people's preferences. The Royal College of GPs notes that the key question is not '"what's the matter with you" but "what matters to you". The Health Foundation states that "a commonly cited barrier is that many [service providers] believe the care they provide is already person-centred. However, the evidence shows that this is often not the case". Person-centered care research Research on person-centered care is carried out in many different universities. The University of Gothenburg Centre for Personcentred Care (GPCC), in Sweden, has been established since 2010. The center conducts interdisciplinary research funded partly by the Swedish government's investments targeted towards care sciences. Person-centered care according to McCormack A conceptual framework for person-centered care has been presented by McCormack and McCance. The holistic framework by McCormack and McCance consists of four constructs; prerequisites, the care environment, person-centred processes, and expected outcomes. Related concepts Patient-centered care is a concept that also emphasises the involvement of the patient and their families in the decision making of medical treatments. A main difference is that person-centered care describes the whole person in a wider context rather than the patient-centered approach which is based on the person's role as a patient. There is a difference between the word “patient” and “person”, still there is a widespread use of the concept of patient-centered care and person-centered care as equals. The word “patient” can be defined as a person who receives treatment for a disorder or illness. Characteristic of a patient is vulnerability and dependence. To get a deeper understanding of the word “person” we need to define the philosophical concept of personhood. Personhood is linked with responsibilities and human rights, and characteristics such as rationality and consciousness. The goal of person-centered care is for the person to live a meaningful life. The concept has a more holistic focus on the person’s uniqueness in disregard to the sickness. Patient-centered care has sprung out of resistance against the paternalistic and biomedical approach to medicine. People-centered care is an umbrella term, articulated by WHO among others, which entails the right and duty for people to actively participate in decisions at all levels of the health care systems. People-centered care focuses both on the individual's right to health, access to health care and information, but also health literacy on a collective level. Relational care with older people, which has evolved from person-centred care, considers the wellbeing and quality of life of everyone involved in a person's care, encompassing the older person, professionals, and communities within and beyond care settings. Health activation is a condition where a health care consumer is equipped, educated, and motivated to be an effective manager of their own health and use of health care services. The concepts are very similar, although person-centered care places the emphasis on the healthcare provider, whereas the term health activation is used in reference to the attitude and behavior of the patient. Good care focus on empowerment, respect, humanization, and absence of infantilization. Good care implies, on the one hand, prevention of abuse or mistreatment, and on the other, patient-centered care. Good care is measured via a self-reported questionnaire. The Good Care Scale in Nursing Homes (GCS-NH)a) has been used, which is a 62-item questionnaire that assesses empowerment, respect, humanization, and non-infantilization, by measuring how strong nursing home staff agree with each statement on a scale of 0- 4. References Further reading Paradoxes of person-centred care: A discussion paper Health care Types of health care facilities

Biomedicine

Biomedicine (also referred to as Western medicine, mainstream medicine or conventional medicine) is a branch of medical science that applies biological and physiological principles to clinical practice. Biomedicine stresses standardized, evidence-based treatment validated through biological research, with treatment administered via formally trained doctors, nurses, and other such licensed practitioners. Biomedicine also can relate to many other categories in health and biological related fields. It has been the dominant system of medicine in the Western world for more than a century. It includes many biomedical disciplines and areas of specialty that typically contain the "bio-" prefix such as molecular biology, biochemistry, biotechnology, cell biology, embryology, nanobiotechnology, biological engineering, laboratory medical biology, cytogenetics, genetics, gene therapy, bioinformatics, biostatistics, systems biology, neuroscience, microbiology, virology, immunology, parasitology, physiology, pathology, anatomy, toxicology, and many others that generally concern life sciences as applied to medicine. Overview Biomedicine is the cornerstone of modern health care and laboratory diagnostics. It concerns a wide range of scientific and technological approaches: from in vitro diagnostics to in vitro fertilisation, from the molecular mechanisms of cystic fibrosis to the population dynamics of the HIV virus, from the understanding of molecular interactions to the study of carcinogenesis, from a single-nucleotide polymorphism (SNP) to gene therapy. Biomedicine is based on molecular biology and combines all issues of developing molecular medicine into large-scale structural and functional relationships of the human genome, transcriptome, proteome, physiome and metabolome with the particular point of view of devising new technologies for prediction, diagnosis and therapy. Biomedicine involves the study of (patho-) physiological processes with methods from biology and physiology. Approaches range from understanding molecular interactions to the study of the consequences at the in vivo level. These processes are studied with the particular point of view of devising new strategies for diagnosis and therapy. Depending on the severity of the disease, biomedicine pinpoints a problem within a patient and fixes the problem through medical intervention. Medicine focuses on curing diseases rather than improving one's health. In social sciences biomedicine is described somewhat differently. Through an anthropological lens biomedicine extends beyond the realm of biology and scientific facts; it is a socio-cultural system which collectively represents reality. While biomedicine is traditionally thought to have no bias due to the evidence-based practices, Gaines & Davis-Floyd (2004) highlight that biomedicine itself has a cultural basis and this is because biomedicine reflects the norms and values of its creators. Molecular biology Molecular biology is the process of synthesis and regulation of a cell's DNA, RNA, and protein. Molecular biology consists of different techniques including Polymerase chain reaction, Gel electrophoresis, and macromolecule blotting to manipulate DNA. Polymerase chain reaction is done by placing a mixture of the desired DNA, DNA polymerase, primers, and nucleotide bases into a machine. The machine heats up and cools down at various temperatures to break the hydrogen bonds binding the DNA and allows the nucleotide bases to be added onto the two DNA templates after it has been separated. Gel electrophoresis is a technique used to identify similar DNA between two unknown samples of DNA. This process is done by first preparing an agarose gel. This jelly-like sheet will have wells for DNA to be poured into. An electric current is applied so that the DNA, which is negatively charged due to its phosphate groups is attracted to the positive electrode. Different rows of DNA will move at different speeds because some DNA pieces are larger than others. Thus if two DNA samples show a similar pattern on the gel electrophoresis, one can tell that these DNA samples match. Macromolecule blotting is a process performed after gel electrophoresis. An alkaline solution is prepared in a container. A sponge is placed into the solution and an agarose gel is placed on top of the sponge. Next, nitrocellulose paper is placed on top of the agarose gel and a paper towels are added on top of the nitrocellulose paper to apply pressure. The alkaline solution is drawn upwards towards the paper towel. During this process, the DNA denatures in the alkaline solution and is carried upwards to the nitrocellulose paper. The paper is then placed into a plastic bag and filled with a solution full of the DNA fragments, called the probe, found in the desired sample of DNA. The probes anneal to the complementary DNA of the bands already found on the nitrocellulose sample. Afterwards, probes are washed off and the only ones present are the ones that have annealed to complementary DNA on the paper. Next the paper is stuck onto an x ray film. The radioactivity of the probes creates black bands on the film, called an autoradiograph. As a result, only similar patterns of DNA to that of the probe are present on the film. This allows us the compare similar DNA sequences of multiple DNA samples. The overall process results in a precise reading of similarities in both similar and different DNA sample. Biochemistry Biochemistry is the science of the chemical processes which takes place within living organisms. Living organisms need essential elements to survive, among which are carbon, hydrogen, nitrogen, oxygen, calcium, and phosphorus. These elements make up the four macromolecules that living organisms need to survive: carbohydrates, lipids, proteins, and nucleic acids. Carbohydrates, made up of carbon, hydrogen, and oxygen, are energy-storing molecules. The simplest carbohydrate is glucose, CHO, is used in cellular respiration to produce ATP, adenosine triphosphate, which supplies cells with energy. Proteins are chains of amino acids that function, among other things, to contract skeletal muscle, as catalysts, as transport molecules, and as storage molecules. Protein catalysts can facilitate biochemical processes by lowering the activation energy of a reaction. Hemoglobins are also proteins, carrying oxygen to an organism's cells. Lipids, also known as fats, are small molecules derived from biochemical subunits from either the ketoacyl or isoprene groups. Creating eight distinct categories: fatty acids, glycerolipids, glycerophospholipids, sphingolipids, saccharolipids, and polyketides (derived from condensation of ketoacyl subunits); and sterol lipids and prenol lipids (derived from condensation of isoprene subunits). Their primary purpose is to store energy over the long term. Due to their unique structure, lipids provide more than twice the amount of energy that carbohydrates do. Lipids can also be used as insulation. Moreover, lipids can be used in hormone production to maintain a healthy hormonal balance and provide structure to cell membranes. Nucleic acids are a key component of DNA, the main genetic information-storing substance, found oftentimes in the cell nucleus, and controls the metabolic processes of the cell. DNA consists of two complementary antiparallel strands consisting of varying patterns of nucleotides. RNA is a single strand of DNA, which is transcribed from DNA and used for DNA translation, which is the process for making proteins out of RNA sequences. See also References External links Branches of biology Veterinary medicine Western culture

Homosexuality and psychology

The field of psychology has extensively studied homosexuality as a human sexual orientation. The American Psychiatric Association listed homosexuality in the DSM-I in 1952 as a "sociopathic personality disturbance," but that classification came under scrutiny in research funded by the National Institute of Mental Health. That research and subsequent studies consistently failed to produce any empirical or scientific basis for regarding homosexuality as anything other than a natural and normal sexual orientation that is a healthy and positive expression of human sexuality. As a result of this scientific research, the American Psychiatric Association removed homosexuality from the DSM-II in 1973. Upon a thorough review of the scientific data, the American Psychological Association followed in 1975 and also called on all mental health professionals to take the lead in "removing the stigma of mental illness that has long been associated" with homosexuality. In 1993, the National Association of Social Workers adopted the same position as the American Psychiatric Association and the American Psychological Association, in recognition of scientific evidence. The World Health Organization, which listed homosexuality in the ICD-9 in 1977, removed homosexuality from the ICD-10 which was endorsed by the 43rd World Health Assembly on 17 May 1990. The consensus of scientific research and clinical literature demonstrate that same-sex attractions, feelings, and behaviors are normal and positive variations of human sexuality. There is now a large body of scientific evidence that indicates that being gay, lesbian, or bisexual is compatible with normal mental health and social adjustment. Historical background The view of homosexuality as a psychological disorder has been seen in literature since research on homosexuality first began; however, psychology as a discipline has evolved over the years in its position on homosexuality. Current attitudes have their roots in religious, legal, and cultural underpinnings. Some Ancient Near Eastern communities, such as the Israelites, had strict codes forbidding homosexual activity, and when Christianity began, it adopted their Jewish predecessors attitudes surrounding homosexual activities. Among the New Testament authors Paul in particular is notable for his affirmation and reinforcement of such texts in his letters to nascent churches. Later, the Apostolic Fathers and their successors continued to speak against homosexual activity whenever they mentioned it in their writings. In the early Middle Ages the Christian Church ignored homosexuality in secular society; however, by the end of the 12th century, hostility towards homosexuality began to emerge and spread through Europe's secular and religious institutions. There were official expressions condemning the "unnatural" nature of homosexual behavior in the works of Thomas Aquinas and others. Until the 19th century, homosexual activity was referred to as "unnatural, crimes against nature", sodomy or buggery and was punishable by law, sometimes by death. As people became more interested in discovering the causes of homosexuality, medicine and psychiatry began competing with the law and religion for jurisdiction. In the beginning of the 19th century, people began studying homosexuality scientifically. At this time, most theories regarded homosexuality as a disease, which had a great influence on how it was viewed culturally. There was a paradigm shift in the mid 20th century in psychiatric science in regards to theories of homosexuality. Psychiatrists began to believe homosexuality could be cured through therapy and freedom of self, and other theories about the genetic and hormonal origin of homosexuality were becoming accepted. There were variations of how homosexuality was viewed as pathological. Some early psychiatrists such as Sigmund Freud and Havelock Ellis adopted more tolerant stances on homosexuality. Freud and Ellis believed that homosexuality was not normal, but was "unavoidable" for some people. Alfred Kinsey's research and publications about homosexuality began the social and cultural shift away from viewing homosexuality as an abnormal condition. These shifting viewpoints in the psychological studies of homosexuality are evident in its placement in the first version of the Diagnostic Statistical Manual (DSM) in 1952, and subsequent change in 1973, in which the diagnosis of ego-dystonic homosexuality replaced the DSM-II category of "sexual orientation disturbance". However, it was not until 1987 in DSM-III-R that it was entirely dropped as a mental disorder. A 2016 survey of the European Union Agency for Fundamental Rights found that many medical professionals in countries such as Bulgaria, Hungary, Italy, Latvia, Poland, Romania and Slovakia believe that homosexuality is a disease and that such interpretations continue to exist in professional materials. This goes against Council of Europe Recommendation 2010(5) which recommends that homosexuality not be treated as a disease. As of 2018, homosexuality was popularly considered a disease in Lebanon. Freud and psychoanalysis Sigmund Freud's views on homosexuality were complex. In his attempts to understand the causes and development of homosexuality, he first explained bisexuality as an "original libido endowment", by which he meant that all humans are born bisexual. He believed that the libido has a homosexual portion and a heterosexual portion, and through the course of development one wins out over the other. Some other causes of homosexuality for which he advocated included an inverted Oedipus complex where individuals begin to identify with their mother and take themselves as a love object. This love of one's self is defined as narcissism, and Freud thought that people who were high in the trait of narcissism would be more likely to develop homosexuality because loving the same sex is like an extension of loving oneself. Freud believed treatment of homosexuality was not successful because the individual does not want to give up their homosexual identity because it brings them pleasure. He used psychoanalysis and hypnotic suggestion as treatments, but showed little success. It was through this that Freud arrived at the conclusion that homosexuality was "nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness, but a variation of sexual function". He further stated that psychoanalysts "should not promise to abolish homosexuality and make normal heterosexuality take its place", as he had concluded in his own practice that attempts to change homosexual orientations were likely to be unsuccessful. While Freud himself may have come to a more accepting view of homosexuality, his legacy in the field of psychoanalysis, especially in the United States viewed homosexuality as negative, abnormal and caused by family and developmental issues. It was these views that significantly impacted the rationale for putting homosexuality in the first and second publications of the American Psychiatric Association's DSM, conceptualizing it as a mental disorder and further stigmatizing homosexuality in society. Havelock Ellis Havelock Ellis (1859–1939) was working as a teacher in Australia, when he had a revelation that he wanted to dedicate his life to exploring the issue of sexuality. He returned to London in 1879 and enrolled in St. Thomas's Hospital Medical School. He began to write, and in 1896 he co-authored Sexual Inversion with John Addington Symonds. The book was first published in German, and a year later it was translated into English. Their book explored homosexual relationships, and in a progressive approach for their time they refused to criminalize or pathologize the acts and emotions that were present in homosexual relationships. Ellis disagreed with Freud on a few points regarding homosexuality, especially regarding its development. He argued that homosexuals do not have a clear cut Oedipus complex but they do have strong feelings of inadequacy, born of fears of failure, and may also be afraid of relations with women. Ellis argued that the restrictions of society contributed to the development of same-sex love. He believed that homosexuality is not something people are born with, but that at some point humans are all sexually indiscriminate, and then narrow down and choose which sex acts to stick with. According to Ellis, some people choose to engage in homosexuality, while others will choose heterosexuality. He proposed that being "exclusively homosexual" is to be deviant because the person is a member of a minority and therefore statistically unusual, but that society should accept that deviations from the "normal" were harmless, and maybe even valuable. Ellis believed that psychological problems arose not from homosexual acts alone, but when someone "psychologically harms himself by fearfully limiting his own sex behavior". Ellis is often credited with coining the term homosexuality but in reality he despised the word because it conflated Latin and Greek roots and instead used the term invert in his published works. Soon after Sexual Inversion was published in England, it was banned as lewd and scandalous. Ellis argued that homosexuality was a characteristic of a minority, and was not acquired or a vice and was not curable. He advocated changing the laws to leave those who chose to practice homosexuality at peace, because at the time it was a punishable crime. He believed societal reform could occur, but only after the public was educated. His book became a landmark in the understanding of homosexuality. Alfred Kinsey Alfred Charles Kinsey (1894–1956) was a sexologist who founded the Institute for Sex Research, which is now known as the Kinsey Institute for Research in Sex, Gender and Reproduction. His explorations into different sexual practices originated from his study of the variations in mating practices among wasps. He developed the Kinsey Scale, which measures sexual orientation in ranges from 0 to 6 with 0 being exclusively heterosexual and 6 being exclusively homosexual. His findings indicated that there was great variability in sexual orientations. Kinsey published the books Sexual Behavior in the Human Male and Sexual Behavior in the Human Female, which brought him both fame and controversy. The prevailing approach to homosexuality at the time was to pathologize and attempt to change homosexuals. Kinsey's book demonstrated that homosexuality was more common than was assumed, suggesting that these behaviors are normal and part of a continuum of sexual behaviors. The Diagnostic and Statistical Manual The social, medical, and legal approach to homosexuality ultimately led to its inclusion in the first and second publications of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). This served to conceptualize homosexuality as a mental disorder and further stigmatize homosexuality in society. However, the evolution in scientific study and empirical data from Kinsey, Evelyn Hooker, and others confronted these beliefs, and by the 1970s psychiatrists and psychologists were radically altering their views on homosexuality. Tests such as the Rorschach, Thematic Apperception Test (TAT), and the Minnesota Multiphasic Personality Inventory (MMPI) indicated that homosexual men and women were not distinguishable from heterosexual men and women in functioning. These studies failed to support the previous assumptions that family dynamics, trauma, and gender identity were factors in the development of sexual orientation. Many psychologists have differing opinions about same-sex relationships. Some think that it is not healthy at all, some support it, and some cannot support it because of their own personal religious beliefs. Due to lack of supporting data, as well as exponentially increasing pressure from gay rights advocates, the board of directors for the American Psychiatric Association voted to declassify homosexuality as a mental disorder from the DSM-II in 1973, but the DSM retained a diagnosis that could be used for distress due to one's sexual orientation until the DSM-5 (2013). Major areas of psychological research Major psychological research into homosexuality is divided into five categories: What causes some people to be attracted to his or her own sex? What causes discrimination against people with a homosexual orientation and how can this be influenced? Does having a homosexual orientation affect one's health status, psychological functioning or general well-being? What determines successful adaptation to rejecting social climates? Why is homosexuality central to the identity of some people, but peripheral to the identity of others? How do the children of homosexual people develop? Psychological research in these areas has always been important to counteracting prejudicial attitudes and actions, and to the gay and lesbian rights movement generally. Causes of homosexuality Although no single theory on the cause of sexual orientation has yet gained widespread support, scientists favor biologically based theories. There is considerably more evidence supporting nonsocial, biological causes of sexual orientation than social ones, especially for males. Discrimination Anti-gay attitudes and behaviors (sometimes called homophobia or heterosexism) have been objects of psychological research. Such research usually focuses on attitudes hostile to gay men, rather than attitudes hostile to lesbians. Anti-gay attitudes are often found in those who do not know gay people on a personal basis. There is also a high risk for anti-gay bias in psychotherapy with lesbian, gay, and bisexual clients. One study found that nearly half of its sample had been the victim of verbal or physical violence because of their sexual orientation, usually committed by men. Such victimization is related to higher levels of depression, anxiety, anger, and symptoms of post-traumatic stress. Through the 2015 U.S. Transgender Survey, which was conducted by the National Center for Transgender Equality, transgender people of color were found to face disproportionate discrimination because of their overlapping identities. These forms of discrimination included violence, unreasonable unemployment, unfair policing, and unfair medical treatment. Research suggests that parents who respond negatively to their child's sexual orientation tended to have lower self-esteem and negative attitudes toward women, and that "negative feelings about homosexuality in parents - decreased the longer they were aware of their child's homosexuality". In addition, while research has suggested that "families with a strong emphasis on traditional values implying the importance of religion, an emphasis on marriage and having children – were less accepting of homosexuality than were low-tradition families", emerging research suggests that this may not be universal. For example, recent research published in APA's Psychology of Religion & Spirituality journal by Chana Etengoff and Colette Daiute suggests that religious family members can alternatively use religious values and texts in support of their sexual minority relative. For example, a Catholic mother of a gay man shared that she focuses on "the greatest commandment of all, which is, love". Similarly, a Methodist mother referenced Jesus in her discussion of loving her gay son, as she said, "I look at Jesus' message of love and forgiveness and that we're friends by the blood, that I don't feel that people are condemned by the actions they have done." These religious values were similarly expressed by a father who is a member of the Church of Jesus Christ of Latter-day Saints who shared the following during his discussion of the biblical prohibition against homosexuality: "Your goal, your reason for being, should be to accept and to love and to lift up ... those in need no matter who they are". Mental health issues Psychological research in this area includes examining mental health issues (including stress, depression, or addictive behavior) faced by gay and lesbian people as a result of the difficulties they experience because of their sexual orientation, physical appearance issues, eating disorders, or gender atypical behavior. Psychiatric disorders: in a Dutch study, gay men reported significantly higher rates of mood and anxiety disorders than straight men, and lesbians were significantly more likely to experience depression (but not other mood or anxiety disorders) than straight women. A research paper from the American Journal of Community Psychology states that individuals who face multiple forms of oppression tend to find their hardships more difficult to manage. In this study, it is noted that LGBTQ+ people who are disabled have reported struggling more with their oppressed statuses. Physical appearance and eating disorders: gay men tend to be more concerned about their physical appearance than straight men. Lesbian women are at a lower risk for eating disorders than heterosexual women. Gender atypical behavior: while this is not a disorder, gay men may face difficulties due to being more likely to display gender atypical behavior than heterosexual men. The difference is less pronounced between lesbians and straight women. Minority stress: stress caused from a sexual stigma, manifested as prejudice and discrimination, is a major source of stress for people with a homosexual orientation. Sexual-minority affirming groups and gay peer groups help counteract and buffer minority stress. Ego-dystonic sexual orientation: conflict between religious identity and sexual orientation can cause severe stress, causing some people to want to change their sexual orientation. Sexual orientation identity exploration can help individuals evaluate the reasons behind the desire to change and help them resolve the conflict between their religious and sexual identity, either through sexual orientation identity reconstruction or affirmation therapies. Ego-dystonic sexual orientation is a disorder where a person wishes their sexual orientation were different because of associated psychological and behavioral disorders. Sexual relationship disorder: people with a homosexual orientation in mixed-orientation marriages may struggle with the fear of the loss of their marriage. Sexual relationship disorder is a disorder where the gender identity or sexual orientation of one of the partners interferes with maintaining or forming of a relationship. Suicide The likelihood of suicide attempts is higher in both gay males and lesbians, as well as bisexual individuals of both sexes, when compared to their heterosexual counterparts. The trend of having a higher incident rate among females encompasses lesbians or bisexual females; when compared with homosexual or bisexual males, lesbians are more likely to attempt suicide. Studies dispute the exact difference in suicide rate compared to heterosexuals with a minimum of 0.8–1.1 times more likely for females and 1.5–2.5 times more likely for males. The higher figures reach 4.6 times more likely in females and 14.6 times more likely in males. Race and age play a factor in the increased risk. The highest ratios for males are attributed to young Caucasians. By the age of 25, their risk is more than halved; however, the risk for black gay males at that age steadily increases to 8.6 times more likely. Over a lifetime, the increased likelihoods are 5.7 times for white and 12.8 for black gay and bisexual males. Lesbian and bisexual females have the opposite trend, with fewer attempts during the teenager years compared to heterosexual females. Through a lifetime, the likelihood for Caucasian females is nearly triple that of their heterosexual counterparts; however, for black females there is minimal change (less than 0.1 to 0.3 difference), with heterosexual black females having a slightly higher risk throughout most of the age-based study. Gay and lesbian youth who attempt suicide are disproportionately subject to anti-gay attitudes, often have fewer skills for coping with discrimination, isolation, and loneliness, and were more likely to experience family rejection than those who do not attempt suicide. Another study found that gay and bisexual youth who attempted suicide had more feminine gender roles, adopted a non-heterosexual identity at a young age and were more likely than peers to report sexual abuse, drug abuse, and arrests for misconduct. One study found that same-sex sexual behavior, but not homosexual attraction or homosexual identity, was significantly predictive of suicide among Norwegian adolescents. Government policies have been found to mediate this relationship by legislating structural stigma. One study using cross-country data from 1991 to 2017 for 36 OECD countries established that same-sex marriage legalization is associated with a decline in youth suicide of 1.191 deaths per 100,000 youth, with the impact more pronounced for male youth relative to female youth. Another study of nationwide data from across the United States from January 1999 to December 2015 revealed that same-sex marriage is associated with a significant reduction in the rate of attempted suicide among children, with the effect being concentrated among children of a minority sexual orientation, resulting in about 134,000 fewer children attempting suicide each year in the United States. Sexual orientation identity development Coming out: many gay, lesbian and bisexual people go through a "coming out" experience at some point in their lives. Psychologists often say this process includes several stages "in which there is an awareness of being different from peers ('sensitization'), and in which people start to question their sexual identity ('identity confusion'). Subsequently, they start to explore practically the option of being gay, lesbian or bisexual and learn to deal with the stigma ('identity assumption'). In the final stage, they integrate their sexual desires into a positive understanding of self ('commitment')." However, the process is not always linear and it may differ for lesbians, gay men and bisexual individuals. Different degrees of coming out: one study found that gay men are more likely to be out to friends and siblings than to co-workers, parents, and more distant relatives. Coming out and well-being: same-sex couples who are openly gay are more satisfied in their relationships. For women who self-identify as lesbian, the more people know about her sexual orientation, the less anxiety, more positive affectivity, and greater self-esteem she has. Rejection of gay identity: various studies report that for some religious people, rejecting a gay identity appears to relieve the distress caused by conflicts between religious values and sexual orientation. After reviewing the research, Judith Glassgold, chair of the American Psychological Association sexuality task force, said some people are content in denying a gay identity and "there is no clear evidence of harm". Fluidity of sexual orientation Often, sexual orientation and sexual orientation identity are not distinguished, which can impact accurately assessing sexual identity and whether or not sexual orientation is able to change; sexual orientation identity can change throughout an individual's life, and may or may not align with biological sex, sexual behavior or actual sexual orientation. Sexual orientation is stable and unlikely to change for the vast majority of people, but some research indicates that some people may experience change in their sexual orientation, and this is more likely for women than for men. The American Psychological Association distinguishes between sexual orientation (an innate attraction) and sexual orientation identity (which may change at any point in a person's life). In a statement issued jointly with other major American medical organizations, the American Psychological Association states that "different people realize at different points in their lives that they are heterosexual, gay, lesbian, or bisexual". A 2007 report from the Centre for Addiction and Mental Health states that, "For some people, sexual orientation is continuous and fixed throughout their lives. For others, sexual orientation may be fluid and change over time". Lisa Diamond's study "Female bisexuality from adolescence to adulthood" suggests that there is "considerable fluidity in bisexual, unlabeled, and lesbian women's attractions, behaviors, and identities". Parenting LGBT parenting is the parenting of children by lesbian, gay, bisexual, and transgender (LGBT) people, as either biological or non-biological parents. Gay men have options which include "foster care, variations of domestic and international adoption, diverse forms of surrogacy (whether "traditional" or gestational), and kinship arrangements, wherein they might coparent with a woman or women with whom they are intimately but not sexually involved". LGBT parents can also include single parents; to a lesser extent, the term sometimes refers to parents of LGBT children. In the 2000 U.S. Census, 33% of female same-sex couple households and 22% of male same-sex couple households reported at least one child under eighteen living in their home. Some children do not know they have an LGBT parent; coming out issues vary and some parents may never come out to their children. Adoption by LGBT couples and LGBT parenting in general may be controversial in some countries. In January 2008, the European Court of Human Rights ruled that same-sex couples have the right to adopt a child. In the U.S., LGBT people can legally adopt, as individuals, in all fifty states. Although it is sometimes asserted in policy debates that heterosexual couples are inherently better parents than same-sex couples, or that the children of lesbian or gay parents fare worse than children raised by heterosexual parents, those assertions are not supported by scientific research literature. There is ample evidence to show that children raised by same-gender parents fare as well as those raised by heterosexual parents. Much research has documented the lack of correlation between parents' sexual orientation and any measure of a child's emotional, psychosocial, and behavioral adjustment. These data have demonstrated no risk to children as a result of growing up in a family with one or more gay parents. No research supports the widely held conviction that the gender of parents influences the well-being of the child. If gay, lesbian, or bisexual parents were inherently less capable than otherwise comparable heterosexual parents, their children would present more poorly regardless of the type of sample; this pattern has not been observed. Professor Judith Stacey of New York University, stated: "Rarely is there as much consensus in any area of social science as in the case of gay parenting, which is why the American Academy of Pediatrics and all of the major professional organizations with expertise in child welfare have issued reports and resolutions in support of gay and lesbian parental rights". These organizations include the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Psychological Association, the American Psychoanalytic Association, the National Association of Social Workers, the Child Welfare League of America, the North American Council on Adoptable Children, and the Canadian Psychological Association (CPA). The CPA is concerned that some persons and institutions are misinterpreting the findings of psychological research to support their positions, when their positions are more accurately based on other systems of belief or values. The vast majority of families in the United States today are not the "middle-class family with a bread-winning father and a stay-at-home mother, married to each other and raising their biological children" that has been viewed as the norm. Since the end of the 1980s, it has been well established that children and adolescents can adjust just as well in nontraditional settings as in traditional settings. Psychotherapy Most people with a homosexual orientation who seek psychotherapy do so for the same reasons as straight people (stress, relationship difficulties, difficulty adjusting to social or work situations, etc.); their sexual orientation may be of primary, incidental, or no importance to their issues and treatment. Regardless of the issue for which psychotherapy is sought, there is a high risk of anti-gay bias being directed at non-heterosexual clients. Relationship counseling Most relationship issues are shared equally among couples regardless of sexual orientation, but LGBT clients additionally have to deal with homophobia, heterosexism, and other societal oppressions. Individuals may also be at different stages in the coming out process. Often, same-sex couples do not have as many role models for successful relationships as opposite-sex couples. There may be issues with gender-role socialization that does not affect opposite-sex couples. A significant number of men and women experience conflict surrounding homosexual expression within a mixed-orientation marriage. Therapy may include helping the client feel more comfortable and accepting of same-sex feelings and to explore ways of incorporating same-sex and opposite-sex feelings into life patterns. Although a strong homosexual identity was associated with difficulties in marital satisfaction, viewing the same-sex activities as compulsive facilitated commitment to the marriage and to monogamy. Gay affirmative psychotherapy Gay affirmative psychotherapy is a form of psychotherapy for gay, lesbian, and bisexual clients which encourages them to accept their sexual orientation, and does not attempt to change their sexual orientation to heterosexual, or to eliminate or diminish their same-sex desires and behaviors. The American Psychological Association (APA) and the British Psychological Society offer guidelines and materials for gay affirmative psychotherapy. Practitioners of gay affirmative psychotherapy state that homosexuality or bisexuality is not a mental illness, and that embracing and affirming gay identity can be a key component to recovery from other mental illnesses or substance abuse. Some people may find neither gay affirmative therapy nor conversion therapy appropriate, however. Clients whose religious beliefs are inconsistent with homosexual behavior may require some other method of integrating their conflicting religious and sexual selves. Sexual orientation identity exploration The American Psychological Association recommends that if a client wants treatment to change their sexual orientation, the therapist should explore the reasons behind the desire, without favoring any particular outcome. The therapist should neither promote nor reject the idea of celibacy, but help the client come to their own decisions by evaluating the reasons behind the patient's goals. One example of sexual orientation identity exploration is sexual identity therapy. After exploration, a patient may proceed with sexual orientation identity reconstruction, which helps a patient reconstruct sexual orientation identity. Psychotherapy, support groups, and life events can influence identity development; similarly, self-awareness, self-conception, and identity may evolve during treatment. It can change sexual orientation identity (private and public identification, and group belonging), emotional adjustment (self-stigma and shame reduction), and personal beliefs, values and norms (change of religious and moral belief, behavior and motivation). Some therapies include "gender wholeness therapy". The American Psychiatric Association states in their official statement release on the matter: "The potential risks of 'reparative therapy' are great and include depression, anxiety, and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient. Many patients who have undergone 'reparative therapy' relate that they were inaccurately told that homosexuals are lonely, unhappy individuals who never achieve acceptance or satisfaction. The possibility that the person might achieve happiness and satisfying interpersonal relationships as a gay man or lesbian are not presented, nor are alternative approaches to dealing with the effects of societal stigmatization discussed. APA recognizes that in the course of ongoing psychiatric treatment, there may be appropriate clinical indications for attempting to change sexual behaviors." The American Psychological Association aligns with this in a resolution: it "urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientation" and "Therefore be it further resolved that the American Psychological Association opposes portrayals of lesbian, gay, and bisexual youth and adults as mentally ill due to their sexual orientation and supports the dissemination of accurate information about sexual orientation, and mental health, and appropriate interventions in order to counteract bias that is based in ignorance or unfounded beliefs about sexual orientation." The American Academy of Pediatrics advises lesbian, gay, gynandromorphophilic, and bisexual teenagers struggling with their sexuality: "Homosexuality is not a mental disorder. All of the major medical organizations, including The American Psychiatric Association, The American Psychological Association, and the American Academy of Pediatrics agree that homosexuality is not an illness or disorder, but a form of sexual expression. No one knows what causes a person to be gay, bisexual, or straight. There probably are a number of factors. Some may be biological. Others may be psychological. The reasons can vary from one person to another. The fact is, you do not choose to be gay, bisexual, or straight." Developments in individual psychology In contemporary Adlerian thought, homosexuals are not considered within the problematic discourse of the "failures of life". Christopher Shelley, an Adlerian psychotherapist, published a volume of essays in 1998 that feature Freudian, (post)Jungian and Adlerian contributions that demonstrate affirmative shifts in the depth psychologies. These shifts show how depth psychology can be utilized to support rather than pathologize gay and lesbian psychotherapy clients. The Journal of Individual Psychology, the English language flagship publication of Adlerian psychology, released a volume in the summer of 2008 that reviews and corrects Adler's previously held beliefs on the homosexual community. See also Association of Gay and Lesbian Psychiatrists Conversion therapy Disability and LGBT identities Ego-dystonic sexual orientation Homosexuality in DSM Minority stress Timeline of sexual orientation and medicine References External links American Academy of Pediatrics: "Sexual Orientation and Adolescents" British Psychological Society National Mental Health Association: "What Does Gay Mean? How to Talk with Kids about Sexual Orientation and Prejudice" Conversion therapy: Consensus statement Memorandum on Conversion Therapy in the UK Homosexuality LGBTQ studies Sexual orientation and psychology Social problems in medicine

Isolation to facilitate abuse

Isolation (physical, social or emotional) is often used to facilitate power and control over someone for an abusive purpose. This applies in many contexts such as workplace bullying, elder abuse, domestic abuse, child abuse, and cults. Isolation reduces the opportunity of the abused to be rescued or escape from the abuse. It also helps disorient the abused and makes the abused more dependent on the abuser. The degree of power and control over the abused is contingent upon the degree of their physical or emotional isolation. Isolation of the victim from the outside world is an important element of psychological control. Isolation includes controlling a person's social activity: whom they see, whom they talk to, where they go and any other method to limit their access to others. It may also include limiting what material is read. It can include insisting on knowing where they are and requiring permission for medical care. The abuser exhibits hypersensitive and reactive jealousy. Isolation can be aided by: economic abuse thus limiting the victim's actions as they may then lack the necessary resources to resist or escape from the abuse smearing or discrediting the abused amongst their community so the abused does not get help or support from others divide and conquer In cults Various isolation techniques may be used by cults: separating from family and community taking control of the handling of the victim's resources and property undoing (mind control) physical isolation extortion/dependency tactics controlling victim's access to necessities. In workplace bullying Isolation is a common element of workplace bullying. It includes preventing access to opportunities, physical or social isolation, withholding necessary information, keeping the target "out of the loop", ignoring or excluding. Workplace isolation is a defined category in the workplace power and control wheel. References Power (social and political) concepts Control (social and political) Abuse Workplace harassment and bullying Psychological abuse Domestic violence

Societal and cultural aspects of autism

Societal and cultural aspects of autism or sociology of autism come into play with recognition of autism, approaches to its support services and therapies, and how autism affects the definition of personhood. The autistic community is divided primarily into two camps; the autism rights movement and the pathology paradigm. The pathology paradigm advocates for supporting research into therapies, treatments, and/or a cure to help minimize or remove autistic traits, seeing treatment as vital to help individuals with autism, while the neurodiversity movement believes autism should be seen as a different way of being and advocates against a cure and interventions that focus on normalization (but do not oppose interventions that emphasize acceptance, adaptive skills building, or interventions that aim to reduce intrinsically harmful traits, behaviors, or conditions), seeing it as trying to exterminate autistic people and their individuality. Both are controversial in autism communities and advocacy which has led to significant infighting between these two camps. While the dominant paradigm is the pathology paradigm and is followed largely by autism research and scientific communities, the neurodiversity movement is highly popular among most autistic people, within autism advocacy, autism rights organizations, and related neurodiversity approaches have been rapidly growing and applied in the autism research field in the last few years. There are many autism-related events and celebrations; including World Autism Awareness Day, Autism Sunday and Autistic Pride Day, and notable people have spoken about being autistic or are thought to be or have been autistic. Autism is diagnosed more frequently in males than in females. Terminology Although some prefer to use the person-first terminology person with autism, other members of the autistic community prefer identity-first terminology, such as autistic person or autistic in formal English, to stress that autism is a part of their identity rather than a disease they have. In addition, phrases like are objectionable to many people. The autistic community has developed abbreviations for commonly used terms, such as: Aspie – a person with Asperger syndrome. Autie or Autist – an autistic person. It can be contrasted with aspie to refer to those specifically diagnosed with classic autism or another autism spectrum disorder. Autistics and cousins – a cover term including aspies, auties, and their "cousins", i.e. people with some autistic traits but no formal diagnosis. Curebie – a person with the desire to cure autism. This term is highly derogatory. Neurodiversity – tolerance of people regardless of neurological makeup. Neurotypical – a person who does not have any developmental or neurological disorders. Often used to describe an individual who is not on the autism spectrum. Allistic – a person who is not autistic but may or may not be neurodivergent in other ways, for example, a dyslexic person, or someone with ADHD. Originally and commonly, however, it is used satirically to describe those without autism. Autism spectrum disorders; DSM-5; Diagnostic criteria-Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association's classification and diagnostic tool. In the United States, the DSM serves as a universal authority for psychiatric diagnosis. Overview Autistic adults Communication and social problems often cause difficulties in many areas of an autistic adult's life. A 2008 study found that adults with ASD commonly experience difficulty starting social interactions, a longing for greater intimacy, a profound sense of isolation, and effort to develop greater social or self-awareness. A much smaller proportion of adult autistics marry than the general population. It has been hypothesized that autistic people are subject to assortative mating; they tend to pair with each other and raise autistic offspring. This hypothesis has been publicized in the popular press and is supported by empirical evidence. Out of eleven conditions assessed in one study, participants with autism spectrum disorder exhibited the highest rates of assortative mating. British psychologist Simon Baron-Cohen said that an increasingly technological society has opened up niches for people with Asperger syndrome, who may choose fields that are "highly systematised and predictable." People with AS could do well in workplace roles that are "system-centered, and connect with the nitty-gritty detail of the product or the system." Autistic savants An autistic savant is an autistic person with extreme talent in one or more areas of study. Although there is a common association between savant syndrome and autism (an association made popular by the 1988 film Rain Man), most autistic people are not savants and savantism is not unique to autistic people, though there does seem to be some relation. One in ten autistic people may have notable abilities, but prodigious savants like Stephen Wiltshire are very rare; only about 100 such people have been described/identified in the century since savants were first identified, and there are only about 25 living identified prodigious savants worldwide. Gender aspects Autistic women Historically, autism was thought of as a condition mostly affecting males. Some studies found that males were up to four times more likely than females to be diagnosed as autistic and among those with Asperger syndrome or "high-functioning autism", males were up to ten times more likely to be diagnosed. This may be due to the fact that many of the diagnostic tools used to diagnose autism have been crafted through the observation of males on the autism spectrum and are therefore more likely to identify men and boys with autism than their female counterparts. To date, the research and support surrounding autistic people has been male-centric; women and non-binary people are seriously underrepresented. For many autistic females the lack of diagnosis or a late diagnosis results in them missing out on supports and interventions that are most valuable when implemented at a younger age. For those females who do receive a diagnosis and are provided with those supports, often have to face the many of them have been created with males in mind and may not acknowledge the physical, psychological and societal differences that females face. Some autistic women find themselves misdiagnosed with personality disorders, such as borderline personality disorder, avoidant personality disorder and schizoid personality disorder. Autistic females are "research orphans" according to Yale's Ami Klin; some drugs used to treat anxiety or hyperactivity that may accompany autism are rarely tested on autistic females. Autism may express differently in the sexes, with many females on the spectrum presenting more subtly than males and may be more adept at developing more sophisticated social masking behaviours, as such females with more prominent difficulties are more likely to be diagnosed than those who present differently. Autistic females are more likely to develop a more sophisticated social camouflage for a variety of reasons. One theory as to why is that women as a whole face more complex social expectations than men, creating a greater need to "prepare more thoroughly for social situations, or risk ostracism". Another theory suggests that women on the spectrum have a more inborn need for social interaction than their male counterparts, leading many women and girls to be more invested in creating social camouflage strategies. These strategies are developed in a variety of ways such as, observing and copying the social interactions of those around them as well as creating strategies to attempt to "go undetected". These coping mechanisms can take an immense amount of time and energy to learn and practice and can as Dr. Shana Nicols states "more often than not lead to exhaustion, withdrawal, anxiety, selective mutism and depression". Females may be more concerned with how they are viewed by peers and the failure to connect with people outside of their immediate family could lead to severe anxiety or clinical depression. Autistic girls who have "normal" intelligence may be more socially disadvantaged than males because of the "rising level of social interaction that comes in middle school," when girls' "friendships often hinge on attention to feelings and lots of rapid and nuanced communication." Autistic girls may suffer additionally by being placed in specialized educational programs, where they will be surrounded by males and further isolated from female social contacts. Females on the autism spectrum often "internalize feelings of frustration and failure" and are believed to have higher rates of certain comorbidities such as anxiety and depression (36 and 34 percent respectively), due in large part to the desire for along with the difficulties in finding social inclusion along with other social and sensory challenges. Lack of diagnosis can also lead autistic females to have higher rates of depression, anxiety and self-esteem issues as they are left without a clear understanding as to why they do not "fit in" with their peers. Females on the spectrum also seem to have higher rates of eating disorders, such as anorexia, than other females. This may be related to social isolation and elevated levels of anxiety along with a need to control their environment more fully, although a complicating factor which is just being explored in the scientific literature is that functional disorders of eating and digestion such as IBS, GERD, food allergies, gastroparesis et al, as well as sensory issues common in autistic people generally, may contribute heavily to "disordered eating" behavior which is physical, sensory, allergic, or pain-related rather than psychological. Although both males and females on the spectrum have a higher risk of experiencing bullying, these experiences often present differently based on gender. Although sample sizes are too small to draw firm conclusions, one study suggests that autistic women are less likely than males over the long term to marry, have families, go to college, have careers and live independently. An intense interest in specific topics plays a significant factor in the lives of those on the autism spectrum of both genders. Females on the spectrum may focus on different topics than their male counterparts; autistic females rarely have interests in numbers or have stores of specialized knowledge, the intense interests of autistic females can be overlooked as they are often seen to be more applicable to a broader section of society. Both males and females with autism deal with the same core symptom, but when those symptoms are mixed with ideas of gender, they can offer very different lived experiences for females than their male counterparts. The profile of autism may change as more is understood about females, whose autism may go undiagnosed. Gender identity and sexual orientation In recent years (as of 2022), research has suggested overlap between people with autism and a non-heterosexual identity (with autistic people more likely to be identified as homosexual, bisexual or asexual) as well as an overlap with a transgender identity. It is currently unclear whether this correlation exists due to any innate characteristic of autism that may also cause unusual discrepancies in sex or gender, or whether it is the result of exposing a group of people who experience difficulty in (or resistance to) abidance with social norms, including those related to gender, to sexism and gender stereotypes. Relationships with animals Temple Grandin, autistic designer of cattle handling systems, said that one reason she can easily figure out how a cow would react is because autistic people can easily "think the way that animals think." According to Grandin, animals do not have "complex emotions such as shame or guilt" and they do not think in language. She says that, although not everything about animals is like an autistic person, the similarity is that they think visually and without language. She says people do not make this connection because the study of autism and the study of animal behavior are parallel disciplines involving different individuals. Despite these similarities, the degree to which autistic individuals can be said to think like animals remains undetermined; non-human animals, as well as humans, have evolved cognitive specializations that may or may not share characteristics with other species. Dawn Prince-Hughes, diagnosed with Asperger's, describes her observations of gorillas in Songs of the Gorilla Nation. Asperger syndrome and interpersonal relationships Individuals with Asperger syndrome (AS) may develop problems in their abilities to engage successfully in interpersonal relationships. Social impact Asperger syndrome may lead to problems in social interaction with peers. These problems can be severe or mild depending on the individual. People with AS are often the target of bullying behavior. Children with AS are often the target of bullying at school due to their idiosyncratic behavior, precise language, unusual interests, and impaired ability to perceive and respond in socially expected ways to nonverbal cues, particularly in interpersonal conflict, which results in them being sought out by classmates and rejected. People with AS may be overly literal and may have difficulty interpreting and responding to sarcasm, banter, or metaphorical speech. Difficulties with social interaction may also manifest in a lack of play with other children. The above problems can even arise in the family; given an unfavorable family environment, the child may be subject to emotional abuse. A child, teen, or adult with AS is often puzzled by this mistreatment, unaware of what has been done incorrectly. Unlike with other pervasive development disorders, most persons with AS want to be social, but fail to socialize successfully, which can lead to later withdrawal and asocial behavior, especially in adolescence. At this stage of life especially, they risk being drawn into unsuitable and inappropriate friendships and social groups. People with AS often interact better with those considerably older or younger than themselves, rather than those within their own age group. Children with AS often display advanced abilities for their age in language, reading, mathematics, spatial skills, or music—sometimes into the "gifted" range—but this may be counterbalanced by considerable delays in other developmental areas, like verbal and nonverbal communication or some lack of motor coordination. This combination of traits can lead to problems with teachers and other authority figures. A child with AS might be regarded by teachers as a "problem child" or a "poor performer". The child's extremely low tolerance for what they perceive to be ordinary and mundane tasks, such as typical homework assignments, can easily become frustrating; a teacher may well consider the child arrogant, spiteful, and insubordinate. Lack of support and understanding, in combination with the child's anxieties, can result in problematic behavior (such as severe tantrums, violent and angry outbursts, and withdrawal). Employment of autistic people may be difficult. The impaired social skills can be likely to interfere with the interview process—and people with often superior skills can be passed over due to these conflicts with interviewers. Once hired, autistic people may continue to have difficulty with interpersonal communications. Homelessness is very common among autistic people. While some researchers have suggested that autistic individuals are less likely to self-enhance their reputation compared to those without autism, others argue that autistic individuals do not have less of a desire for self-enhancement than non-autistic individuals. Difficulties in relationships Two traits sometimes found in AS individuals are mind-blindness (the inability to predict the beliefs and intentions of others) and alexithymia (the inability to identify and interpret emotional signals in oneself or others), which reduce the ability to be empathetically attuned to others. Alexithymia in AS functions as an independent variable relying on different neural networks than those implicated in theory of mind (ToM). In fact, a lack of ToM in AS may be a result of a lack of information available to the mind due to the operation of the alexithymic deficit. A second issue related to alexithymia involves the inability to identify and modulate strong emotions such as sadness or anger, which leaves the individual prone to "sudden affective outbursts such as crying or rage". According to Tony Attwood, the inability to express feelings using words may also predispose the individual to use physical acts to articulate the mood and release the emotional energy. People with AS report a feeling of being detached against their will from the world around them ("on the outside looking in"). They may have difficulty finding a life partner or getting married due to poor social skills. The complexity and inconsistency of the social world can pose an extreme challenge for individuals with AS. In the UK Asperger's is covered by the Disability Discrimination Act; those with AS who get treated badly because of it may have some redress. The first case was Hewett v Motorola 2004 (sometimes referred to as Hewitt) and the second was Isles v Ealing Council. The same applies in the United States with the Americans with Disabilities Act, amended in 2008 to include autism spectrum disorders. The intense focus and tendency to work things out logically often grants people with AS a high level of ability in their field of interest. When these special interests coincide with a materially or socially useful task, the person with AS can lead a profitable career and a fulfilled life. The child obsessed with a specific area may succeed in employment related to that area. According to Elizabeth Fein, the dynamic of role-playing games is especially positive and attractive to people on the autism spectrum. The social information exchanged in these games are explicit, top-down and systematic and they follow a set of shared abstract rules. Baez and Rattazzi showed that interpreting the implicit social information of daily life is difficult for autistics. Despite the fact that AS individuals are commonly known to lack ToM, recent research has suggested that ToM may be not only present in AS individuals but also act differently compared to neurotypicals as suggested in the double empathy problem. Autistic ToM is simply based on the use of rules and logic. It is also suggested that people on the autism spectrum can understand and predict the thoughts and motivations of each other better than neurotypicals can, and autistic interactions may display even greater social signals of shared enjoyment, ease, and rapport when interacting. This means AS individuals present mind-blindness and alexithymia towards neurotypicals and vice versa due to bidirectional differences in communication style as well as a reciprocal lack of understanding since the two neurotypes clash. Autism rights movement The autism rights movement is a social movement within the context of disability rights that emphasizes the concept of neurodiversity, viewing the autism spectrum as a result of natural variations in the human brain rather than a disorder/disease to be cured. The ARM advocates a variety of goals, including greater acceptance of autistic behaviors; therapies that focus on coping skills rather than imitating the behaviors of neurotypical peers; the creation of social networks and events that allow autistic people to socialize on their own terms; and the recognition of the autistic community as a minority group. Autism rights or neurodiversity advocates believe that the autism spectrum is genetic and should be accepted as a natural expression of the human genome. This perspective is distinct from two other likewise distinct views: the medical perspective, that autism is caused by a genetic defect and should be addressed by targeting the autism gene(s), and the fringe theory that autism is caused by environmental factors like vaccines and pollution and could be cured by addressing environmental causes. The movement is controversial. There are a wide variety of both supportive and critical opinions about the movement among people who are autistic or associated with autistic people. A common criticism leveled against autistic activists is that the majority of them are "high-functioning" or have Asperger syndrome and do not represent the views of "low-functioning" autistic people. Autistic pride Autistic pride refers to pride in autism and shifting views of autism from "disease" to "difference." Autistic pride emphasizes the innate potential in all human phenotypic expressions and celebrates the diversity various neurological types express. Autistic pride asserts that autistic people are not impaired or damaged; rather, they have a unique set of characteristics that provide them many rewards and challenges, not unlike their non-autistic peers. Curing autism is a controversial and politicized issue. The "autistic community" can be divided into several groups. Some seek a cure for autism—sometimes dubbed as pro-cure—while others consider a cure unnecessary or unethical, or feel that autism conditions are not harmful or detrimental. For example, it may be seen as an evolutionary adaptation to an ecological niche by some environmentalists and the more radical autism rights campaigners. Autistic culture and community With the recent increases in autism recognition and new approaches to educating and socializing autistics, an autistic culture has begun to develop. Autistic culture is based on a belief that autism is a unique way of being and not a disorder to be cured. The Aspie world, as it is sometimes called, contains people with Asperger syndrome (AS) and high functioning autism (HFA), and can be linked to three historical trends: the emergence of AS and HFA as labels, the emergence of the disability rights movement, and the rise of the Internet. Autistic communities exist both online and offline; many people use these for support and communication with others like themselves, as the social limitations of autism sometimes make it difficult to make friends, to establish support within general society, and to construct an identity within society. Because many autistics find it easier to communicate online than in person, a large number of online resources are available. Some autistic individuals learn sign language, participate in online chat rooms, discussion boards, and websites, or use communication devices at autism-community social events such as Autreat. The Internet helps bypass non-verbal cues and emotional sharing that some autistics tend to have difficulty with. It gives autistic individuals a way to communicate and form online communities. Conducting work, conversation and interviews online in chat rooms, rather than via phone calls or personal contact, help level the playing field for many autistics. A New York Times article said "the impact of the Internet on autistics may one day be compared in magnitude to the spread of sign language among the deaf" because it opens new opportunities for communication by filtering out "sensory overload that impedes communication among autistics." Globally Autistic people may be perceived differently from country to country. For example, many Africans have spiritual beliefs about psychiatric disorders, which extends into perceived causes of autism. In one survey of Nigerian pediatric or psychiatric nurses, 40% cited preternatural causes of autism such as ancestral spirits or the action of the devil. Events and public recognition World Autism Day World Autism Day, also called World Autism Awareness Day, is marked on 2 April. It was designated by the United Nations General Assembly at the end of 2007. On 2 April 2009, activists left 150 strollers near Central Park in New York City to raise awareness that one in 150 children is estimated to be autistic. There are many celebration activities all over the world on 2 April—World Autism Day. "Autism knows no geographic boundaries—it affects individuals and families on every continent and in every country," said Suzanne Wright, co-founder of the group Autism Speaks. "The celebration of World Autism Awareness Day is an important way to help the world better understand the scope of this health crisis and the need for compassion and acceptance for those living with autism. This remarkable day—the first of many to come—promises to be a time of great hope and happiness as we work to build a global autism community." Light It Up Blue In 2010, Autism Speaks launched the Light It Up Blue initiative. Light It Up Blue sees prominent buildings across the world—including the Empire State Building in New York City and the CN Tower in Toronto, Ontario, Canada—turn their lights blue to raise awareness for autism and to commemorate World Autism Awareness Day. However, the Autism Speaks group is not well received by most autism rights activists, due to their lack of incorporation of perspectives of actual autistic people in their work, and their focus on searching for a 'cure'. Autism Sunday Autism Sunday is a global Christian event, observed on the second Sunday of February. It is supported by church leaders and organizations around the world. The event started as a small idea in the front room of British autism campaigners, Ivan and Charika Corea. It is now a huge event celebrated in many countries. Autism Sunday was launched in London in 2002 with a historic service at St. Paul's Cathedral. Autism Awareness Year The year 2002 was declared Autism Awareness Year in the United Kingdom—this idea was initiated by Ivan and Charika Corea, parents of an autistic child, Charin. Autism Awareness Year was led by the British Institute of Brain Injured Children, Disabilities Trust, The Shirley Foundation, National Autistic Society, Autism London and 800 organizations in the United Kingdom. It had the personal backing of British Prime Minister Tony Blair. This was the first ever occasion of partnership working on autism on such a huge scale. 2002 Autism Awareness Year helped raise awareness of the serious issues concerning autism and Asperger's Syndrome across the United Kingdom. A major conference, Autism 2002 was held at the King's Fund in London with debates in the House of Commons and the House of Lords in Westminster. Autism awareness ribbons were worn to mark the year. British autism advocates want autistic people acknowledged as a minority rather than as disabled, because they say that "disability discrimination laws don't protect those who are not disabled but who 'still have something that makes them look or act differently from other people.'" But the autism community is split over this issue, and some view this notion as radical. Autistic Pride Day Autistic Pride Day is an Aspies For Freedom initiative celebrated on 18 June each year. It is a day for celebrating the neurodiversity of autistic people. Modeled after gay pride events, they often compare their efforts to the civil rights and LGBT social movements. Autistics Speaking Day Autistics Speaking Day (ASDay), 1 November, is a self-advocacy campaign run by autistic people to raise awareness and challenge negative stereotypes about autism by speaking for themselves and sharing their stories. The first one was held in 2010. According to one of the founders, Corina Becker, the main goal of ASDay is "to acknowledge our difficulties while sharing our strengths, passions, and interests." The idea for the event developed out of opposition to a "Communication Shutdown" fundraising campaign led by Autism Speaks that year, which had asked for participants to "simulate" having autism by staying away from all forms of online communication for one day. Autism Acceptance Project In 2006 the Autism Acceptance Project was founded by Estée Klar, the mother of an autistic child, with help from an autistic advisory and board. The project's mission statement is, "The Autism Acceptance Project is dedicated to promoting acceptance of and accommodations for autistic people in society." The project is primarily supported by autistic people and their supporters. The goal is to create a positive perspective of autism and to accept autism as a part of life with its trials and tribulations. The project is also working to enable autistic people to gain the right to advocate for themselves (along with their supporters) in all policy decision formats from government to a general committee. By providing an abundance of resources, the project is able to reach a multitude of audiences using a Web site along with lectures and exhibitions. Autism Acceptance Day In 2011, the first Autism Acceptance Day celebrations were organized by Paula Durbin Westby, as a response to traditional "Autism Awareness" campaigns which the Autistic community found harmful and insufficient. Autism Acceptance Day is now held every April. "Awareness" focuses on informing others of the existence of autism while "acceptance" pushes towards validating and honoring the autism community. By providing tools and educational material, people are encouraged to embrace the challenges autistic people face and celebrate their strengths. Rather than making autism into a crippling disability, acceptance integrates those on the autistic spectrum into everyday society. Instead of encouraging people to wear blue as Autism Awareness Day does, Autism Acceptance Day encourages people to wear red. Autreat At Autreat—an annual autistic gathering—participants compared their movement to gay rights activists, or the Deaf culture, where sign language is preferred over surgery that might restore hearing. Other local organizations have also arisen: for example, a European counterpart, Autscape, was created around 2005. Twainbow Twainbow is an advocacy organization that provides awareness, education, and support for autistic people who identify as lesbian/gay/bisexual/transgender (LGBT). According to its founder, "Twainbow is a portmanteau of 'twain' (meaning 'two') and 'rainbow.' Those who are both LGBT and autistic live under two rainbows—the rainbow flag and the autism spectrum." The company also introduced an LGBT-autism Gay Pride flag representing the population. History Donald Triplett was the first person diagnosed with autism. He was diagnosed by Kanner after being first examined in 1938, and was labeled as "case 1". Triplett was noted for his savant abilities, particularly being able to name musical notes played on a piano and to mentally multiply numbers. His father, Oliver, described him as socially withdrawn but interested in number patterns, music notes, letters of the alphabet, and U.S. president pictures. By the age of two, he had the ability to recite the 23rd Psalm and memorized 25 questions and answers from the Presbyterian catechism. He was also interested in creating musical chords. Scholarship Autism spectrum disorders received increasing attention from social-science scholars in the early 2000s, with the goals of improving support services and therapies, arguing that autism should be tolerated as a difference not a disorder, and by how autism affects the definition of personhood and identity. Sociological research has also investigated how social institutions, particularly families, cope with the challenges associated with autism. Media portrayals Much of the public perception of autism is based on its portrayals in biographies, movies, novels, and TV series. Many of these portrayals have been inaccurate, and have contributed to a divergence between public perception and the clinical reality of autism. For example, in the movie Mozart and the Whale (2005), the opening scene gives four clues that a leading character has Asperger syndrome, and two of these clues are extraordinary savant skills. The savant skills are not needed in the film, but in the movies savant skills have become a stereotype for the autism spectrum, because of the incorrect assertion that most autistic people are savants. Some works from the 1970s have autistic characters, who are rarely labeled. In contrast, in the BBC2 television miniseries The Politician's Husband (2013), the impact of Noah Hoynes' Aspergers on the boy's behavior and on his family, and steps Noah's loved ones take to accommodate and address it, are prominent plot points in all three episodes. Popular media have depicted special talents of some autistic people, including exceptional abilities as seen in the 1988 movie Rain Man. Such portrayals have been criticized by both scientific studies and media analysts over the years for fostering a pigeonholing image of autism that leads to false expectations about real-life autistic individuals, with Rain Man being singled out for popularizing it. Since the 1970s, fictional portrayals of people with autism spectrum conditions such as Asperger syndrome have become more frequent. Public perception of autism is often based on these fictional portrayals in novels, biographies, movies, and TV series. These depictions of autism in media today are often made in a way that brings pity to the public and their concern of the topic, because their viewpoint is never actually shown, leaving the public without knowledge of autism and its diagnosis. Portrayals in the media of characters with atypical abilities (for example, the ability to multiply large numbers without a calculator) may be misinterpreted by viewers as accurate portrayals of all autistic people and of autism itself. Additionally, the media frequently depicts autism as only affecting children, which promotes the misconception that autism does not affect adults. Notable individuals Some notable figures like American food animal handling systems designer and author Temple Grandin, American Pulitzer Prize-winning music critic and author Tim Page, Australian musician, lead singer and only constant member of rock band the Vines Craig Nicholls, English actor and filmmaker Paddy Considine, CEO of SpaceX and Tesla, Elon Musk, and Swedish environmental activist Greta Thunberg are autistic. Thunberg, who in August 2018 started the "School strike for climate" movement, has explained how the "gift" of living with Asperger syndrome helps her "see things from outside the box" when it comes to climate change. In an interview with presenter Nick Robinson on BBC Radio 4's Today, the then-16-year-old activist said that autism helps her see things in "black and white". She went on to say: Scottish singer Susan Boyle was diagnosed with Aspergers at the age of 51. Boyle was originally believed to have had slight brain damage at birth. Boyle rose to fame after appearing on the talent show Britain's Got Talent in 2009. Her debut album I Dreamed a Dream, released in 2009, became the fastest selling debut by a UK artist of all time. American actress Daryl Hannah, star of movies such as Splash, Steel Magnolias and Wall Street, was diagnosed as being on the autism spectrum as a child. Diagnosed at fifteen, Heather Kuzmich appeared on America's Next Top Model in 2007. Although she did not win the competition, Kuzmich was voted the viewers' favourite eight weeks in a row. She has since been signed to Elite Model Management. New Zealand-born musician Ladyhawke and gold medal-winning British Paralympic swimmer Jessica-Jane Applegate are also autistic. In June 2021, Scottish strongman Tom Stoltman, became the first person with autism to win the World's Strongest Man competition. Welsh actor Anthony Hopkins is the first openly autistic actor to win an Academy Award. Additionally, media speculation of contemporary figures as being on the autism spectrum has become popular in recent times. New York magazine reported some examples, which included that Time magazine suggested that Bill Gates is autistic, and that a biographer of Warren Buffett wrote that his prodigious memory and "fascination with numbers" give him "a vaguely autistic aura." The magazine also reported that on Celebrity Rehab, Dr. Drew Pinsky deemed basketball player Dennis Rodman a candidate for an Asperger's diagnosis, and the UCLA specialist consulted "seemed to concur". Nora Ephron criticized these conclusions, writing that popular speculative diagnoses suggest autism is "an epidemic, or else a wildly over-diagnosed thing that there used to be other words for." The practice of diagnosing autism in these cases is controversial. Some historical personalities are also the subject of speculation about being autistic, e.g. Michelangelo. See also Autism-friendly Autism: The Musical Autistic art Look Me in the Eye, John Elder Robison's memoir about growing up with Asperger syndrome Love on the Spectrum Social model of disability References Further reading Julia Bascom (editor). Loud Hands: Autistic People, Speaking. Washington, DC: Autistic Self Advocacy Network, 2012. Temple Grandin. Thinking in Pictures, Expanded Edition: My Life with Autism, New York, New York: Vintage, 2011. External links John Elder Robison radio interview about life with Asperger's Syndrome Asperger's Syndrome, on Screen and in Life, The New York Times, 3 August 2009 This Podcast Has Autism , a podcast showcasing Autistics and their achievements

Amplified musculoskeletal pain syndrome

Amplified musculoskeletal pain syndrome (AMPS) is an illness characterized by notable pain intensity without an identifiable physical cause. Characteristic symptoms include skin sensitivity to light touch, also known as allodynia. Associated symptoms may include changes associated with disuse including changes in skin texture, color, and temperature, and changes in hair and nail growth. In up to 80% of cases, symptoms are associated with psychological trauma or psychological stress. AMPS may also follow physical injury or illness. Other associations with AMPS include Ehlers-danlos syndrome, myositis, arthritis, and other rheumatologic diseases. Treatment for notable pain intensity without identifiable pathophysiology can include psychotherapy to alleviate psychological stress. Physical therapists, psychologically informed physical therapists in particular, can coach people on exercises they can do everyday at home. Clinicians who use this diagnosis sometimes apply it to children and adolescents. To date, this diagnosis is used more in women. Signs and symptoms Amplified musculoskeletal pain is a syndrome which is a set of characteristic symptoms and signs. Essentially, the syndrome is characterized by diffuse, ongoing, daily pain associated with relatively high levels of incapability and greater care-seeking behavior. The discomfort can be in the skin (allodynia), abdomen, throat (dysphagia), headache, and joints. There can be other somatic symptoms such as, movement issues, dizziness, fatigue, stiffness, shakiness, coordination difficulty, swelling, fast heart rate, skin texture, color, or temperature changes, paresthesia, and changes in nail or hair growth. These symptoms are associated with symptoms of anxiety, depression, psychological trauma, and psychological stress. Examination Findings on examination can include factors associated with disuse including swelling; changes in skin texture, color, and temperature; changes in nail and hair growth, muscle atrophy, and radiographic osteoporosis. Causes It's not possible to discuss causes when there is no objectively verifiable pathophysiology. It's more accurate to describe when patients and clinicians might find this diagnosis appealing. Psychological trauma Psychological trauma is strongly associated with unexplained pain conceptualized as AMPS. Physical injury The combination of physical injury, such as a bone fracture or surgery, and over protectiveness and disuse can be referred to as complex regional pain syndrome, a type of AMPS that is isolated to one region of the body, such as a hand or foot. Risk factors Rationale AMPS is theoretical rather than experimental. The amplified pain is conceptualized as incorrect sympathetic nervous system signals also known as the "fight or flight" nerves. This causes an involuntary response to pain, including vein constriction. This causes increased heart rate, increase in muscle tone, increased respiratory rate, and a reduce of blood flow to the muscles and bone, resulting in an increase in waste products, such as lactic acid. This buildup of waste products, as well as depletion of oxygen, results in the amplified pain associated with AMPS. Classification AMPS is classified into four different types, of which may be divided into multiple sub-types. This includes complex regional pain syndrome, diffuse idiopathic pain, intermittent amplified pain, and localized amplified pain. Complex regional pain syndrome Complex regional pain syndrome is a term for any amount of spontaneous regional pain lasting longer than the expected recovery time of an observed physical trauma, or other injury. This includes two separate types: type I and type II. Type I CRPS, formerly known as reflex sympathetic dystrophy (RSD) or "Sudeck's atrophy", refers to CRPS without any observed nerve damage. Type II, formerly known as causalgia, refers to CRPS with observed nerve damage. This form, similarly to other forms of AMPS, is known to be able to spread from one limb to a new limb. 35% of people effected with CRPS report full-body impacts from the condition. Common symptoms of CRPS include musculoskeletal pain; swelling; changes to the skin texture, color, or temperature; and limited range of motion. Diffuse idiopathic pain This type of AMPS includes full-body pain. It is also known as juvenile fibromyalgia. Intermittent amplified pain This type of AMPS refers to amplified pain that varies in intensity over time. Localized amplified pain This refers to localized amplified pain without other symptoms. This type cannot include symptoms such as swelling; skin texture, color, or temperature changes; or perspiration. Observation of these symptoms implies the diagnosis of complex regional pain syndrome. Diagnosis Because of the little awareness on AMPS, the condition is frequently not diagnosed when symptoms first present, often with multiple diagnoses of physical conditions before the diagnosis of AMPS. The condition is diagnosed through observation of various patient traits. A full overview of the patients medical history, as well as out rule of any potention physical causes, such as a bone fracture. If no physical causes are observed, a diagnosis of AMPS is likely possible. Other common steps that are taken may include bone scans to detect possible signs of reduced blood flow; magnetic resonance imaging (MRI) to detect possible edema, or muscle atrophy; Nerve testing can be used to look for pain or sensitivity issues; and X-rays can detect osteoporosis as the result of AMPS. While all of these tests can detect possible signs of AMPS, better outcomes are usually made with less tests, and immediate treatment of AMPS without looking for possible differential diagnoses. Management As AMPS is not a disease, there is no one specific cure for it. Management of the condition is a process of patients learning to manage the abnormal amplified pain. This can include a combination of treating the cause(s) of the condition, as well as managing the symptoms of the condition. Medication As psychological stress accounts for up to 80% of cases of AMPS, medication often involves typical antidepressants. These are also often prescribed for chronic pain due to the impact they have on serotonin and its impact on muscular pain and control. Many providers also use an injectable medication for treatment of AMPS. Opioid use is not recommended for most AMPS cases, as it can worsen recovery, and in rare cases, make the condition worse. Physical therapy Physical treatment of AMPS is very common and is shown to have long term benefit. This includes physical therapy, massage therapy, and aerobic exercise. Physical therapy involves training the use of the affected limb or training the use of the body. This is for the purpose of retraining muscles after muscle atrophy, and retraining how to use the affected muscles with less amplified pain. Massage therapy is used to desensitize the affected area or body so it can build a tolerance to pain. This can help with symptoms such as allodynia and hyperalgesia in AMPS, as well as indirectly help with other common symptoms by relieving the patient of pain which could have been the cause of psychological stress, depression, anxiety, as well as a number of physiological conditions, including headaches. Psychotherapy See also Allodynia Complex regional pain syndrome Myalgia Pediatrics Rheumatology References Nerve, nerve root and plexus disorders Syndromes of unknown causes Chronic pain syndromes Osteopathies

Organic personality disorder

Organic personality disorder (OPD) or secondary personality change, is a condition described in the ICD-10 and ICD-11 respectively. It is characterized by a significant personality change featuring abnormal behavior due to an underlying traumatic brain injury or another pathophysiological medical condition affecting the brain. Abnormal behavior can include but is not limited to apathy, paranoia and disinhibition. In the ICD-10, it is described as a mental disorder and not included in the classification group of personality disorders. In the ICD-11, it is described as a syndrome. The condition has not been described in any edition of the Diagnostic and Statistical Manual of Mental Disorders. Signs and symptoms OPD is associated with a large variety of symptoms, such as deficits in cognitive function, dysfunctional/abnormal behaviour, psychosis, neurosis, higher irritability and altered emotional expression. Those with OPD can experience emotional lability, meaning that their emotional expressions are unstable and fluctuating. In addition, patients may show a reduction in ability of perseverance with goals and they disinhibition, often characterised by inappropriate sexual and antisocial behavior. Those affected can experience cognitive disturbances, suspiciousness and paranoia. Altered language processing in the brain can also occur. Furthermore, patients may show changes in their sexual preference and hyposexuality symptoms. Causes OPD is associated with "personality change due to general medical condition". The OPD is included in a group of personality and behavioural disorders - in the ICD-10 this is "Personality and behavioural disorders due to brain disease, damage and dysfunction", and in the ICD-11 this is "Secondary Mental or Behavioural Syndromes Associated with Disorders or Diseases Classified Elsewhere". This mental health disorder can be caused by disease, brain damages or dysfunctions in specific brain areas in frontal lobe. The most common reason for this profound change in personality is the traumatic brain injury. Children whose brain areas have been injured or damaged, may present with attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder or OPD. OPD is most often caused by lesions in three brain areas of frontal lobe: traumatic brain injuries in orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex. OPD may also be caused by lesions in other circumscribed brain areas. Another common feature of personality of patients with OPD is their dysfunctional and maladaptive behaviour that causes serious problems in these patients, because they face problems with pursuit and achievement of their goals. Patients with OPD express a feeling of unreasonable satisfaction and euphoria. Patients can show aggressive behaviour and these dysfunctions in behaviour can have effects on interpersonal relationships. One explanation of signs of anger and aggression is due to an inability to handle their impulses, this type of aggression being called "impulsive aggression". Diagnosis ICD-11 In the ICD-11, the condition is called secondary personality change rather than organic personality disorder. To meet diagnosis there must be a clinically significant personality disturbance that represents a change from the individual's previous characteristic personality pattern. This personality disturbance must be explainable directly as a result from a pathophysiological health condition affecting the brain. The duration, onset, and remission of the health condition, along with responses to treatment of the underlying health condition, must be consistent with presentations of the personality disturbance. There are seven sub-classifications of secondary personality change based on disturbances of affect, which includes "constricted", "blunted", "flat", "labile" and "inappropriate", along with other specified and unspecified categories. ICD-10 In the ICD-10 there were no specifically listed diagnostic criteria. It is characterized by "a significant alteration of the habitual patterns of behaviour displayed by the subject premorbidly, involving the expression of emotions, needs and impulses." Cognition, thought functions and sexuality are mentioned as potentially altered or affected. Two "organic" and three "syndrome" underlying causes are mentioned respectively: "pseudopsychopathic personality", "pseudoretarded personality", "frontal lobe damage", "limbic epilepsy personality" and post-lobotomy. Differential diagnosis Being an organic disorder, differential diagnosis between mental disorders and OPD is necessary. According to the ICD-11, specific considerations for differential diagnosis include delerium, dementia, personality disorders, impulse control disorder, and addictive behavior syndrome. For differential diagnosis in the ICD-10, along with personality disorders, there are two mentioned conditions in the ICD-10 under the same diagnostic category "F07" for consideration: postencephalitic parkinsonism (called "postencephalitic syndrome" in the ICD-10) and post-concussion syndrome. Patients with OPD may present similar symptoms to Huntington's disease. The symptoms of apathy and irritability are common between these two conditions. OPD is somewhat similar to temporal lobe epilepsy, as patients who have chronic epilepsy may also express aggressive behaviours. Another similar symptom between Temporal lobe epilepsy and OPD is epileptic seizures. The symptom of epileptic seizure has influence on patients' personality that means it causes behavioural alterations. Temporal lobe epilepsy is associated with the hyperexcitability of the medial temporal lobe of patients. Treatment Patients with OPD show a wide variety of sudden behavioural changes and dysfunctions. There is little information about the treatment of OPD. The pharmacological approach is the most common therapy among patients with OPD. However, the choice of drug therapy relies on the seriousness of patient's situation and what symptoms are shown. The choice and administration of specific drugs contribute to the reduction of symptoms of OPD. For this reason, it is crucial for patients' treatment to be assessed by clinical psychologists and psychiatrists before the administration of drugs. The dysfunctions in expression of behaviour of patients with OPD and the development of symptom of irritability, which are caused by aggressive and self-injurious behaviours, can be dealt with the administration of carbamazepine. Moreover, the symptoms of this disorder can be decreased by the administration of valproic acid. Also, emotional irritability and signs of depression can be dealt with the use of nortriptyline and low-dose thioridazine. Except from the symptom of irritability, patients express aggressive behaviours. For effective treatment of anger and aggression, carbamazepine, phenobarbital, benztropine and haloperidol may be used. In addition, the use of propranolol may decrease the frequent behaviours of rage attacks. It is important for patients to take part in psychotherapy during drug therapy. In this way, many of the adverse effects of the medications, both physiological and behavioural, can be lessened or avoided entirely. Clinicians can provide useful and helpful support to patients during these psychotherapy sessions. See also Organic mental disorder References Mental disorders due to brain damage Personality disorders