PSYCHOLOGY😊

PSYCHOLOGY

• Sigmund Freud coined: Psychoanalysis.

• He is the 'Father of Psychoanalysis'.

Transference and Countertransference

Transference

• Feelings of a patient towards the therapist.

• Can be conscious or unconscious.

• Based on past relationships with a significant figure.

• Can be negative and positive.

• Example Scenarios:
• Negative: 30yo female to 50yo therapist: "you are very rude just like my stepfather."
• Positive: 30yo female to 50yo therapist: "you are very kind just like my father."

• Used in therapy to know unconscious feelings.

Countertransference

• Feelings of a therapist towards the patient.

• Can be conscious and unconscious.

• Can be negative and positive.

• Example Scenarios:
• Therapist missing appointments.
• Therapist sleeping during an interview.

Catharsis vs. Abreaction

Catharsis

• Sharing, ventilation, expressing, processing of emotions by the patient.

Abreaction

• Excessive expression of a repressed emotion.

• Mnemonic: Abnormal reaction

Delivering Bad News – SPIKES Protocol

• S – Setting: Private, safe, comfortable environment.

• P – Perception of the patient.

• I – Invitation for the patient to voice concerns.

• K – Knowledge sharing by the doctor.

• E – Emotions of the patient: Validated.

• S – Summarization / strategizing.

Projective Tests

• Ambiguous stimuli used to tap into the unconscious.
• Rorschach ink blot test
• Thematic Apperception Test (TAT)
• Sentence completion test
• Draw a person test

Rorschach inkblot test

• Developed by Herman Rorschach.

• Most frequently used projective personality test.

• Consists of 10 inkblot cards
• ambiguous,
• symmetrical

• Patient is asked what they see in the cards.

• Projective test:
• Patient projects internal conflicts onto the test.
• Personality is assessed based on answers.

Thematic apperception test (TAT)

• Consists of 20 pictures of individuals in various activities.

• Person is asked to make stories about them.

• Projective personality test.

Minnesota Multiphasic Personality Inventory

• Objective personality test

Grief

Stages of Grief – Kubler Ross

• Denial – Ostrich phenomena

• Anger

• Bargaining

• Depression / Loneliness

• Acceptance

• Note: Can occur in any sequence.

Pathological Grief

Management

• Antidepressants – Short term

• Anxiolytics – Short term

• Grief counselling

Sigmund Freud's Theories

1. Topographical Model of Mind

• Mind divided into three parts:
• Conscious:
• Content is in our awareness.
• Preconscious:
• Content not in awareness.
• Can be brought to conscious awareness by focused attention.
• Unconscious:
• Content kept away from conscious awareness.

• Ways Content Might Cross Repression Barrier:
• Free association:
• Therapist sits near the couch, not visible to the patient.
• Patient speaks uninterrupted.
• Advised to say whatever comes to mind without censoring.
• Outcome: Patient may speak thoughts from the unconscious mind.
• Slip of the tongue (Parapraxis):
• Sigmund Freud: not a simple mistake.
• May be important information about the unconscious mind.

2. Structural Theory of Mind

• Mind divided into three parts:
• Id:
• Immediate gratification
• Consists of instinctive drives.
• Based on pleasure principle.
• Operates under primary process.
• Lacks capacity to delay urges.
• Lies in the unconscious mind.
• Example: Id says, "Let's Go out and Party."
• Ego:
• Executive organ of the mind.
• Works on reality principle.
• Balances id, superego, and the real world.
• Present in unconscious, conscious, and preconscious parts.
• Defence mechanism of ego resides in the unconscious.
• Example: Ego says, "Let's study half a day and then let's go out."
• Superego:
• Moral compass.
• Insists on socially acceptable behaviour.
• Development: 5-6 years (after Oedipus complex resolution).
• Lies in the unconscious part;
• has some conscious components.
• Example: Superego says, "Study for exams."

Maslow’s hierarchy of needs

Défense Mechanisms of Ego

• Tools used by Ego to overcome friction between Id and Ego.

• Help prevent excessive anxiety.

• Important: Most defence mechanisms are in the unconscious mind.

• Important: All mechanisms are unconscious, except suppression.

Projection:

• Person projects his own desires onto someone else.

• Seen in psychosis.

• Example: Mr. P has an affair but is convinced his wife is having one.

Acting out:

• Unconscious wishes enacted in behaviour to avoid awareness.

• Seen in impulse control disorders (ICD).

• Example: Student angry with a friend, throws a book at him (unintentionally).

Regression:

• Return to an earlier developmental stage to avoid anxiety.

• People may act childish/younger.

• Example: Husband, after a stressful day, converses with his wife in baby talk.

Inhibition:

• Unconsciously limiting an aim.

• Accepting partial fulfillment of desire.

• Example: Person fails MBBS entrance, becomes a veterinary doctor.

Intellectualization:

• Excessive use of intellect to escape painful emotions.

• Example: After a metastatic tumor diagnosis, a person discusses its technical aspects.

Isolation of affect:

• Separation of emotions from a stressful event.

• Reality is accepted.

• Example: Man tells his family about his lung cancer without emotion.

Displacement:

• Unconscious shifting of impulses from one object to another.

• Example: Man angry with boss, shouts at wife, who shouts at son, who punches a toy.

Dissociation:

• Separation of mental functions to avoid distress.

• Example: Kidnapped and tortured person says it was like floating on the ceiling watching it.

Undoing:

• An act to nullify a previous act.

• Example: Man sexually provoked by a woman, leaves, and buys flowers for his wife.

Rationalization:

• Giving logical explanations for unacceptable behaviors.

• Seen in Substance Use Disorders.

• Example: Person says he drinks alcohol to kill germs.

Reaction formation:

• Unacceptable impulse transformed into its opposite.

• Example: Boy fascinated by porn organizes an anti-pornography campaign.

Repression:

• Idea/feeling eliminated from consciousness.

• Cannot be accessed.

• You forget, then forget that you forgot.

• Example: A child abused by his mother has no memory of it.

Altruism:

• Constructive service to others to deal with own feelings.

• May be harmful to the person.

• Example: After husband's death from smoking,
• wife starts a 'No smoking' campaign, neglecting her own health.

• Mnemonic: ALternate Service

Suppression:

• Conscious decision to postpone attention to a conflict.

• Example: Student decides to forget an upcoming exam and take a day's break.

Humor:

• Using humor to deal with unpleasant situations.

• Example: Man laughs after being scolded by his boss.

Stages of Psychosexual Development

• Freud proposed 5 stages.

• Fixation:
• Development arrested at a stage,
• leading to psychiatric disorder.

Oral stage

• Age: Birth - 1.5 years.

• Site of pleasure: Oral cavity (biting, sucking, chewing).

• Fixation:
• Schizophrenia,
• Substance dependence.

Anal stage

• Age: 1.5 - 3 years.

• Site of gratification:
• Anal (pleasure through excretion).

• Fixation:
• Obsessive Compulsive Disorder.

Phallic stage

• Age: 3 - 5 years.

• Site of pleasure:
• Genital area (stimulation).

• Fixation:
• Hysteria, Sexual deviations.

• Oedipus complex:
• Attraction towards mother.
• Fear of castration by the father.
• Mnemonic: Mom (m-male child, o-oedipus complex, m-mother).
• Resolved by identification with the father.

• Electra complex:
• Mnemonic: FEM (female, electra, Male)
• Female child → attraction towards father
• Discontent with female genitalia.
• Fantasy of losing a penis.
• Desire to bear a penis.
• Resolved by identification with the mother.

Latent stage

• Age: 5/6 - 11/13 years.

• Relative sexual quiescence (inactivity).

• Oedipus/Electra complex resolved at the start of this stage.

• Superego is formed.

• Mastery of skills (child learns new skills).

• Fixation: Neurotic disorders.

Genital stage

• Age: 11/13 years - Young adulthood.

• Maturation of genital functioning.

• Development of adult sexuality & identity.

• Fixation: Neurotic disorders.

MCQ DISCUSSION

• Q. Patient says 'I am Tom, I am a con, my friend is gone...'.
• A. Tangentiality
• B. Preservation
• C. Loosening of association
• D. Flight of ideas
Explanation:
• Flight of ideas
• Speed is increased in Flight of ideas;
• normal in loosening of association.
• Words like Tom, con, gone show clang associations, seen in Flight of Ideas.

• Q. Resident asks a patient, 'What will he do if he sees his neighbor's house on fire?'.
• A. Test judgement
• B. Insight
• C. Abstract thinking
• D. Social judgment
Explanation:
• A. Test judgement
• Psychiatrist asked a hypothetical question.
• Insight: asking about one's own mental illness.
• Abstract thinking: assessed by proverbs, similarities.
• Social judgment: assessed by social behavior.

• Q. 64M, 2nd post-op day after bypass, says irrelevant things, thinks he's home, irritable, tries to remove catheter.
• A. Schizophrenia
• B. Mania
• C. Acute psychosis
• D. Delirium
Explanation:
• D. Delirium
• Impairment of consciousness suggests delirium.
• Keywords: age, surgery, irritable, 'saying irrelevant things' confirm delirium.

• Q. Schizophrenic patient, non-responsive to haloperidol/thioridazine. Started on Drug A. Side effects: sialorrhea, dyslipidemia, hyperglycemia. Requires blood monitoring.
• A. Clozapine
• B. Risperidone
• C. Aripiprazole
• D. Ziprasidone
Explanation:
• A. Clozapine
• Clozapine for treatment-resistant schizophrenia.
• Hypersalivation and metabolic side effects are observed.
• Agranulocytosis is a serious side effect, requires regular blood monitoring.

• Q. Female, 3 weeks post-delivery. Appears fearful, irritable, has suicidal thoughts.
• A. Postpartum blues
• B. Postpartum psychosis
• C. Postpartum depression
• D. Panic disorders
Explanation:
• C. Postpartum depression
• Symptoms started 3 weeks after delivery.
• Suicidal thoughts without psychotic features suggests Postpartum depression.

• Q. Patient has 5-6 episodes/month for 6 months, 30 min each. Symptoms: anxiety, palpitations, sweating, breathlessness, chest pain, feeling of impending doom/heart attack.
• A. Depression
• B. Panic disorder
• C. GAD
• D. Agoraphobia
Explanation:
• B. Panic disorder
• Sudden anxiety symptoms, last <30 mins, fear of heart attack/impending doom is a panic attack.
• Repeated panic attacks constitute a Panic disorder.

• Q. 17yo female eats by arranging food in pieces, takes small bites, spends a lot of time eating.
• A. Anorexia nervosa
• B. Obsessive-compulsive disorder
• C. Panic disorder
• D. Generalized anxiety disorder
Explanation:
• B. Obsessive-compulsive disorder
• Arranging food in pieces, taking small bytes are examples of OCD rituals.
• Question is not related to an eating disorder.

• Q. 3yo child not developing appropriately. Poor eye contact, doesn't play with others, continuously bangs chin against wall, confined to himself.
• A. Social phobia
• B. ADHD
• C. Depression
• D. Autism
Explanation:
• D. Autism
• Deficit in social communication.
• Repetitive behaviors (banging chin).
• These are diagnostic of Autism.

• Q. 40M with tremors, sweating, anxiety for 2 days. History of alcohol use for 13 years, stopped for 2 days for religious reasons. LFTs deranged.
• A. Thiamine
• B. Diazepam + thiamine
• C. Lorazepam + thiamine
• D. Lorazepam
Explanation:
• C. Lorazepam + thiamine
• Symptoms on stopping alcohol indicate withdrawal.
• Since LFT is deranged, Lorazepam (safer in liver dysfunction) with thiamine is used.

• Q. Male with marital conflicts, complains of early ejaculation. Useful non-pharmacological method?
• A. Squeeze technique
• B. CBT
• C. Exposure and response prevention
• D. Relaxation
Explanation:
• A. Squeeze technique
• Squeeze technique and start-stop technique are behavioral therapies for premature ejaculation.

• Q. 21yo female with depression symptoms. Increased body weight. Image shows callus on knuckles.
• A. Obsessive-compulsive disorder
• B. Anorexia nervosa
• C. Bulimia Nervosa
• D. Binge eating disorder
Explanation:
• Russel sign: Callus on knuckles (from self-induced vomiting).
• Can be seen in Anorexia nervosa (binge/purge type), but increased body weight points to Bulimia.
• Bupropion is contraindicated due to seizure risk.

• Q. 25yo female on lithium for bipolar disorder. Which statement is incorrect?
• A. Lithium decreases thyroid function
• B. Thiazides increase lithium toxicity
• C. Lithium is avoided in pregnancy due to its teratogenic effects
• D. Hemodialysis is not useful in lithium toxicity
Explanation:
• D. Hemodialysis is not useful in lithium toxicity
• Hemodialysis is done for severe lithium toxicity.
• Lithium causes hypothyroidism.
• Thiazides reduce lithium clearance, increasing toxicity.
• Causes Ebstein's anomaly; avoided in pregnancy.