Lecture 2

Who was Harry Stack Sullivan? What school of psychology did he belong to? What were his main ideas and how did they relate to sz/psychosis? (Give the broad strokes)

- Interpersonal psychology • Never published anything - all info gathered from lectures he gave • He Americanized psychoanalysis • 3 Personifications - self-appraisals derived from interpersonal transactions; you become like the ppl you interact with 1. Good me 2. Bad me (inner critic) - Bad Me messages can be believed but aren't taken so seriously because based on communications from family??? (how do these arise?) - person dev ways of minimizing Bad Me experiences (organizing them and adapting to them) 3. Not me (Dissociated self - repression due to sever trauma) - can break into consciousness and overwhelms the indiv with no integrative functions in place • Self or self-system - good me + bad me (not me is dissociated from consciousness • Purpose of the self - to avoid anxiety caused by disapproval and acquire as much approval as possible • Security operations - defensive operations (e.g. selective inattention, dissociation) ○ Target bad me personifications in an effort to avoid anxiety (disowned self). However mistreatment and bad social interactions can lead to indiv dev invalid pics of themselves, causing them to engage in inappropriate and damaging security operations (like dissociation?) • The adolescent chum relationship (know for exam) - the prototype for intimate relationships in adulthood ○ Sullivan believed that all sz indiv lacked chum relationships (how is this an important factor in sz?) • Psychotic episode - failure of the dissociation security operation, causing Not Me aspect of the self to return to consciousness - not me breaks into consciousness when person has not developed defenses (security operations) to keep not me integrated with good and bad me ○ Results in disorganizing panic-like state ○ Not Me would also appear as if it were actually a personification exterior to indiv i.e. auditory hallucinations seeming as though they were "external" • Views all psychotic behav as being a form of Transference ○ Impossible to interact with other and not treat them as someone from their past ○ Should call to mind Freud's 2 theories about sz - for exam i.e. Specific/Deficit and Unitary/Conflict model - how do these relate to transference? ○ Transference is an interpersonal process i.e. lack of ability to navigate interpersonal relationships § Making other responsible for own feelings that don't want to be owned - fragments the self; makes part of self appear as if they are not self

Who was Heinz Kohut? What school of psychology did he belong to? What were his main ideas and how did they relate to sz/psychosis? (Give the broad strokes)

- Self psychology • Categorize him under theorists who thought that feed back from others (interactions with others) is very important in the dev of indiv sense of self - valence (pos vs neg) sense of self from others perception about self • Thought about what makes up indiv sense of self and how much sense of self is tied to their relationship and view of their caregivers and feedback they get about selves from those ppl • Narcissism is a healthy process which can become pathological ○ Relationships are maintained to validate sense of self i.e. must find rel where ppl think "I'm great"

What factors is early onset sz associated with?

1. Being male 2. Poor premorbid functioning 3. Higher incidence of structural brain abnormalities 4. Higher incidence of negative symptoms 5. More cognitive impairment 6. Worse outcome

What factors is a good prognosis associated with?

1. Good premorbid adjustment 2. Acute onset 3. Older at onset 4. Being female 5. Precipitating events 6. Mood disturbance 7. Brief duration of active symptoms 8. Good inter-episode functioning 9. Minimal residual symptoms 10. Family history of mood disorder 11. No family history of sz

What are the major changes between DSM-4 and 5? (Slide 8 - do these only refer to SZ?)

1. No more subtypes 2. Elimination of requirement that only 1 characteristic symptom need be present if it is a bizarre delusion or a Schneiderian first-rank symptom hallucination (so what is the requirement now?) 3. Require the presence of 2 or more of the 5 Criteria A symptoms for a significant portion of the time during a 1-month period (as in DSM-4), with at least one of those symptoms being either delusions, hallucinations, or disorganized speech ○ In DSM-5 SZ has shifted to being a constellation of Criterion A symptoms (i.e. 2 or more) vs. being defined by only one specific type of symptom (i.e. subtypes) 4. Clarification of negative symptoms (form flat affect to restricted affect) ○ Study heterogeneity of SZ? Where/how? (readings - section III - dimensional rating of severity of core symptoms to capture heterogeneity of symptom type and severity across all psychotic disorders)

Name and describe the various stages/phases that characterize the course of sz.

1. Premorbid stage - no overt psychotic symptoms; prodromal symptoms become increasingly evident; social dysfunction evident in retrospect ○ Does not exist until after diagnosis (sz indiv are just weird) 2. Acute phase - onset of psychotic symptoms; acute episode; psychotic symptoms appear ○ Only some make it to this stage; usually involves hospitalization (thorazine injection) 3. Residual phase ○ Partial remission (most ) - some residual psychotic symptoms ○ Full remission (10-20%) - little or no symptoms; no evidence of functional impairment (sz indiv find low stress niche) 4. Prodromal phase (many) - return of prodromal symptoms 5. Relapse phase (many) - person meets full criteria again • Most with sz cycle through these many times

What were the rationales for the changes from DSM-4 to 5? (corresponds numbers on flash card 11.)

1. Restricted affect better describes range of abnormalities in affective experience and expression in SZ than flat affect 2. No unique diagnostic specificity for these characteristic symptoms in comparison to others has been identified (clarify!) 3. SZ is a psychotic disorder and psychosis is defined by reality distortion (delusions and hallucinations) and severe disorganization (disorganization of speech) 4. Limited diagnostic stability; low reliability; poor validity. Also no distinctive treatment response or longitudinal course. (Read up on this in text-book!!)

Who was Heinz Hartmann? What were his main ideas and how did they relate to sz/psychosis? (Give the broad strokes)

1. Threshold function - stimulus barrier i.e. selective attention (frequently damaged in sz): filters out irrelevant info from outside and impulses from inside 2. Integrative function - info that made it through stimulus threshold and woven into a meaningful narrative; ability to integrate and assign meaning to info; how meaning is made from info that is let in - delusions come from faulty integrative function i. Psychosis failure or collapse of one or both functions ii. Applies to Internal/external and present/past stimuli iii. Imagine what it would be like for these functions to be out of place - disorienting iv. Hartmann saw this as primary task of ego - moment to moment basis

How many with sz will attempt suicide?

50% - this is underappreciated

Crow's type I and type II SZ??

??

What types of SZ recovery are there?

???

What are the general (most important) diagnostic criteria of SZ? (According to DSM-5 -- Hint: focus on Criteria A, B, and C)

A. Characteristic symptoms (at least 2 for 1 month) 1. Delusions (do we need to go into detail on these?) 2. Hallucinations 3. Disorganized speech 4. Gross disorganized or catatonic behavior 5. Negative symptoms B. Social/occupational Dysfunction (there must be evidence of interference) 1. Work 2. Interpersonal relationships 3. Self-care C. Duration (6 months) D. Not due to Schizoaffective or Mood disorder E. Not due to a Substance or medical condition F. Can only co-exisit with a Pervasive development disorder if prominent delusions or hallucinations - Present [ILLUSRATES THE HIREARCHAL DIAGOSITIC SCHEME OF THE DSM]

How did Catatonia change between DSM-4 and 5?

Catatonic changed from a SZ sub-type (DSM-4) to a specifier (DSM-5)

What do personality disorders with psychotic features have in common with SZ?

Shared genetics

What outcomes are commonly associated with sz?

• 10 -20% have good outcome • Complete recovery not common = social recovery vs. symptomatic recovery vs. occupational recovery • More than 50% have poor outcome • 20-30% can and do lead relatively normal lives

What's the difference between a disability and a handicap in SZ?

• ???????? • Disability is where impairments meet expectations of society - if expectations cant be met then you are disabled • Ppl are not handicapped until society makes accommodations

What is the substance abuse rate among sz indiv?

• A lot use substances • 80% smoke cigarettes - many positive symptoms decrease with smoking; nicotinic receptors compete with DA

What symptoms are needed for catatonia to qualify as a specifier (DSM-5)?

• Catatonia is defined as the presence of three or more of the following: Catalepsy, waxy flexibility, stupor, agitation, mutism, negativism, posturing, mannerisms, stereotypies, grimacing, echolalia, echopraxia (memorize 3) • Many symptoms implicate basal-ganglia (like PD)

What is the difference btw disease course and prognosis?

• Course = Onset, Duration, and Outcome ○ Onset may be insidious or acute • Prognosis??

How is bizzar defined (as in bizarre delusions)?

• Delusions are Bizarre if they are clearly implausible and not understood by same-culture peers and do not derive from ordinary experience e.g. belief that outside force has replaced organs with those of another, without any scars vs. belief that one is under surveillance by police, despite lacking evidence

What were DSM-4 subtypes specifically replaced by in DSM-5?

• Dimensional rating of severity of core symptoms (section III) to capture heterogeneity of symptom type and severity across all disorders

What is ego psychology and who were its main proponents?

• Extended analytic theory outward and farther along the life span • The central question: adaptation to the caretaking environment and family unit - Heinz Hartmann - Erik Erikson

What are the population density effects of sz?

• Higher rates of sz for every million or more

Describe the taxonomy of psychotic disorders

• Idiopathic: 2 categories 1. Autonomous phenomena - occurring in the absence of another disorder ○ Schizophrenia (DSM-4 subtypes), schizophreniform, brief psychotic disorder, delusional disorder, Tourette's disorder 2. Associated phenomena - occurring within the context of an organic problem ○ Autoscopic psychosis?, capgrass syndrome? • Situation specific (define?) ○ Shared psychotic disorder, substance induced psychosis, post-partum psychosis (Do we need to know these? How many examples do we need to name?) • Culture-bound (define?) ○ Amok?, Koro?, etc

Who was Margaret Mahler? How did her ideas relate to sz? (Give the broad strokes)

• Imperial research in babies/toddlers - looking at dev mile stones ○ Also contributed to dev model of object relations theory • Ego boundary dev out of rhythmic cuddling and bodily contact btw mother and infant ○ Absence of this exp leads to diff differentiating self from other ○ Conflict arises as wish for return to symbiotic merger vs fear of disintegration • SZ is a wish to return to totally merged state with mother - no separation/distinction btw self and (mom) other

Medical comorbidity?

• Many are undiagnosed ?

What overarching theme describes the history of SZ classification?

• Marked by movement away from schemes based solely on NOSOLOGY (systematic classification) to ones that include other criteria (i.e. no more subtypes - hence, SZ spectrum disorders)

What are the seasonal birth effects of sz?

• More likely to have sz if borne in winter months • Genotype of sz may help babies survive winter months

What were the major milestones and figures in SZ history? (Hint: focus on the two most important ones)

• Morel (1863) - Demence precoce - progressive, familial (What?) • Hecker (1863) - Catatonia • Kalhbaum (1871) - Hebephrenia (What?) • Kareplin - dementia praecox; hebephrenic, catatonic, paranoid (narrow definition of SZ - SZ is like dementia i.e. no recovery and eventual death) ○ believed that dementia praecox was a disease of the frontal lobes and always had a deteriorating course. An endogenous disorder without gross anatomic lesion or toxic factor: pessimistic view - course of SZ is always deteriorating. Very narrow definition. • Bleuler - Broad definition of SZ - less emphasis on course than Kareplin. Emphasized that illness has variety of courses - adopted Freud's view that SZ psychopathology can be understood in psychodynamic terms ○ Very broad definition, including much of what is now believed to be mood disorders. Saw multiple etiologies - organic and functional (what is meant by functional?), and multiple possible outcomes and presentations. Primary symptoms: Negative-associations, Affect, Ambivalence and Autism). (Also disturbances in activity and volition). Secondary or Accessory symptoms: Delusions and hallucinations ○ He thought Kareplin was to pessimistic. ○ Bleuler thought SZ can recover - many of Bleuler's patients were actually manic depressive

What are the three broad definitions of psychosis?

• Narrow - at least delusions or hallucinations • Intermediate - at least hallucinations • Broad - at least one or more positive symptom from SZ

What are the major socio-economic factors of SZ?

• Negative correlation between income-status (SES) and SZ: As income goes down, SZ prevalence goes up ○ Caused by "downward drift" and "social causation" theories of SZ (will come up in future lecture!) • Homelessness: About 1/3 to 2/3 of homeless people are sz (or at least sz spectrum) • More SZ in industrialized (urban) settings than rural areas ○ Less stress in rural settings, better social support, less pollution and other environmental stressors, less environmental conditions in which one could get in trouble with SZ symptoms as opposed to in an urban context i.e. prevalence is observed less because there isn't as much for SZ to rub up against

What theory did Melanie Klein extrapolate? Describe her main ideas. What defenses did she relate to sz? (Give the broad strokes)

• Object relations - how to adapt to the preverbal caretaker enviro (the extension of Object Relations Earlier and Deeper?) - she went further and deeper than Freud by studying kids • She was concerned with what happened before language dev in children • Split between good mom/bad mom - destructive urges to bad mom and good feelings to good mom - cant see both as same person • Gives way to position where infant can see good and bad from same person - grey zone • Results in babies first experience of guilt and ambivalence (good/bad love/hate feelings at once) for having had split feelings • Contending with destructive urges to bad mom and seeing it as part of same figure • Psychoanalytic theorist focused on infant dev - how baby adapts to early care taking enviro/interpersonal relationship with mom • Defenses (arising in first two stages of dev): splitting and projective identification (early primitive coping strategies) 1. Paranoid-schizoid position - splitting: adults can resort to early defensive posture where good/bad aspects of person are split (black and white) - guilt towards mom (superego develops here) 2. Depressive position - projective identification: feeling emo that one cannot tolerate in self is evoked in "other" - indiv projects neg feeling bout self to other and manip them to conf feelings e.g. "I'm not angry but am evoking angry feelings from partner towards me to blame other for own intolerable feelings towards hate/anger" ○ Externalization - form of image management i.e. inner life becomes complex so projected on other • Focus on this: looked at infant caretaker envro, different stages baby goes through (in seeing mother as integrated person), and there are defenses that adults can exhibit later on that originate during this developmental time

What are the major age, culture, and gender (social membership) factors related to development of SZ?

• Onset usually in late teens - mid 30s (they have always been weird but now home structure is gone and symptoms emerge i.e. freshman year of college) • Onset prior to adolescence (due to home structure) and after 50's (symptoms often associated with other sensory deficits/medical disorders - easy to miss-diagnose) rare • Hallucinations less common in children and delusions less differentiated (what does that mean?) • Onset after 45: Higher ratio of women, better occupational history, more likely to have been married, hallucinations and delusions more likely, disorganized and negative symptoms less likely, responsive to antipsychotics • Onset after 60 usually associated with sensory deficits (easy to miss-diagnose) • Diagnosis later in life better for prognosis - because resilience factors that have worked thus far will tend to continue working • Diagnosis earlier in life worse for prognosis (why?) • Men tend to get SZ diagnosis when younger compared to women (why?) • Women more likely to have positive symptoms than men • Women more likely to have mood issues than men

Who was Sandor Rado? What were his main ideas and how did they relate to sz/psychosis? (Give the broad strokes - review slide 54 but don't prioritize as much)

• Organism is a biological system operating under HEDONIC CONTROL ○ Rado's Hedonic self regulation is same as Freud's pleasure principle • Levels of motivation and integration of behav 1. Hedonic level i. Pain - disorganizing, indicates failure, drops self esteem ii. Pleasure - integrative, neutralizes pain, boosts self esteem 2. Emotional level (integrates time dimension i.e. experience thereof) - welfare emos vs emergency emos i. Welfare - anticipate/prep for pleasure ii. Emergency - anticipate/prep for pain 3. Emotional thought (where most of us live) - intellectual expression of underlying feelings and defenses i. Contains much of everyday thinking; justifies and feeds emotional states i.e. fantasies, dreams, illusions, delusions, and hallucinations 4. Unemotional thought (An aspiration more than reality; narrative structure to experience life informed by culture - Piaget's formal operations) - capacity to be neutral and objective i. Freud's reality principle • Schizotypal behav - innate integrative pleasure deficiency + proprioceptive diathesis ("Succo Ergo Sum") - Clarify!? ○ Failure to integrate pleasure - pleasure organizes behav i.e. negotiate enviro for optimal experience of self; if this fails behav will be disorganized and all over the place (sz indiv don't experience pleasure in same way i.e. negative symptoms) ○ Sz is a pleasure deficiency i.e. not attachment or pleasure derived from being connected to others ○ Proprioceptive - sense of physical self and body - find out more!?

What are the physical anomalies of SZ? (High rate of these in SZ, but SZ rates are low!)

• Overly arched palate • Narrow or very wide set eyes • Subtle malformation of the ears

If you were to have a form of SZ, which would be the best to have and why?

• Paranoid SZ, because ppl wont know you have it (why?) - most function well with it (why?)

Give a brief description of the DSM-4 subtypes (many still use subtypes)

• Paranoid schizophrenia ○ Preoccupied with one or more delusion or frequent auditory hallucinations (hallucinations are not mandatory) ○ None of the following are prominent: Disorganized speech, disorganized or catatonic behavior, flat affect, inappropriate affect i.e. paranoid sz doesn't have any of the feature that would make it obvious that someone has sz • Disorganized schizophrenia ○ All of the following are prominent: Disorganized speech, disorganized behavior, flat or inappropriate affect (disinhibition gone wild i.e. subway encounters) ○ The criteria for catatonic behavior not met • Catatonic subtype (no longer common) ○ Clinical picture dominated by at least 2 of the following: Motoric immobility, excessive motor activity, extreme negativism or mutism, peculiarities of voluntary movement, echolalia (meaningless repetition of another person's spoken words) or echopraxia (meaningless repetition or imitation of the movements of others) - mimicking is one of the first strategies kids learn i.e. early dis-inhibitory reflex to learn from environment ○ Always involves reduction of activity ○ Now a specifier (DSM-5)

What were the DSM-4 subtypes for SZ?

• Paranoid, disorganized, catatonic, undifferentiated, residual

What is the difference btw positive and negative symptoms?

• Positive - add to experience/behavior i.e. hallucinations and delusions, etc • Negative - take away from experience/behavior i.e. anhedonia (inability to feel pleasure) and apathy

What is the best treatment approach to SZ?

• Ppl more receptive to getting help concerning handicap vs. impairment area because impairment makes them aware of actual symptoms i.e. they have to face the reality of their situation (impairment leads to "label") ○ "lets work on your hallucinations!" "What do you mean, I don't have any hallucinations!" • Treatment is often talked about as working back from handicap to be sensitive to patients situation (patients have very little insight) • Occupational recovery vs. symptomatic recovery i.e. social skill training

What is Attenuated Psychosis Syndrome? Why is it controversial? Where in the DSM-5 can it be found?

• Presumed premorbid presentation of SZ: Psychosis-like symptoms below threshold for full psychotic disorder - Insight relatively intact; skepticism about their reality can still be induced • Controversial because it is used to intervene early i.e. medicate children - psychotic drugs are very harsh • Found in Section III: Appendix - disorders requiring further study

What is the difference between SZ prevalence and incidence rates?

• Prevalence rates haven't changed • Prevalence is higher than incidence because SZ tends to not go away • Google this!!

How did the DSM-4 attempt a dimensional severity rating of schizophrenia? What implications did this have?

• SZ rated on three dimensions - cluster analysis; symptoms tend to cluster across 3 dimensions i.e. if you have one you tend to have the other (first attempt at dimensional approach) 1. Psychotic - degree to which hallucinations and delusions present 2. Disorganized - degree to which speech, behavior, and affect are disorganized 3. Negative - degree to which negative symptoms present • Rated on 0-4 scale i.e. absent, mild, moderate, severe • Abandoned because it didn't hold up across other cultures when larger sample sizes were introduced • But was nevertheless useful: Is your situation getting better or worse? Illness features can be tracked over time and the extent to which it is characterized by varying degrees of each symptom type. Also allows to monitor how illness is affected by medications. Helped go beyond just giving someone a label - diagnosis become more functional • Became foundation for expanded dimensional approach in DSM-5

How does the ICD classification of SZ differ from DSM-5?

• Social and occupational function is not a diagnostic criteria • Required duration of illness is 1 month vs. 6 months • There is no Pervasive Developmental disorder exclusion

What 2 theoretical factors account for negative relationship between SES and SZ? Describe and define them.

• Social causation theory - stress of being poor is schizogenic (causes sickness i.e. SZ) • Social selection theory - Darwinian perspective: Being ill (SZ) makes you unable to "compete" and rise into ranks of high SES

What were Freud's 2 models if sz? Describe them.

• Specific/Deficit model of sz ○ SZ distinct from other neurosis ○ Saw sz as a mental disability - stuck or regressed to oral stage (i.e. autoerotic stages); failed to develop robust challenges of ego to manage demands from ID and superego) ○ Regression precipitated by interaction of structural deficit in brain (and resulting processing deficits) and stressful or frustrating events in environment - regression cannot be seen as a defensive maneuver ○ Because libido is attached to Self (autoerotic stage), social attachments are not possible or very tenuous - explains autistic state often observed in sz; also explains why transference may not be possible with sz in tx • Unitary/Conflict model of sz ○ Assumes a continuum between sz and other psychological disorders such as the neurotic disorders ○ Like neuroses, the regression is a defensive maneuver ○ Like the neuroses, the assumed regression is precipitated by intra-psychic conflict ○ Like neuroses the behavior and symptoms of sz are assumed to be compromise-formations, and thus are meaningful and motivated ○ Withdrawal of the libidinal energy from the external world is not complete - hence transference and social relationships are possible, albeit somewhat disturbed

Describe the new way of rating sz symptoms in the DSM-5

• Symptoms assessed on 0-4 scale (absent, equivocal, mild, moderate, severe) - severity assessment based on past month ○ Hallucinations, delusions, disorganization, abnormal psychomotor behavior, restricted emotional expression, avolition, impaired cognition, depression, mania • No assumptions about interrelationships between various symptoms • Rated on severity and dimensions because of heterogeneity of sz presentations - sz is multiphasic (above diagram); a diverse disorder to capture when trying to fit ppl into one narrow box

Summarize Freud's major theories

• Topographical model of the mind ○ Conscious (comparatively small and least interesting), pre-conscious (stuff you can pull into consciousness intentionally), unconscious (stuff that is never available to consciousness) • Structural model of the mind (best known among lay ppl) ○ Mind divided into 3 basic forces which continually interact with each other - since each has a different goal, there is often conflict ○ ID (pleasure principle - unconscious reservoir of libidinal energy that doesn't give a shit about morality; just wants to eat, sleep, hunt, and ****), ego (reality principle - job of trying to contain ID; stop it from going to wild and getting killed; and negotiates real-world problem of superego), superego (idolized conception of how one should behave; your conscience; represents standards of your culture, filtered through awareness of your parents; how you should behave in your cultural environment) - Superego is no more rational than the ID - they are both irrational entities - Ego must fool both (ID and superego) just enough to get what it needs to live: Compromised formations □ Symptoms and signs of a disorder are actually compromises i.e. strategies developed by ego to assuage two competing forces (ID and superego) □ Strategies can be the defenses themselves or consequences of those defenses □ Signal Anxiety - anxiety is an innate warning cue triggering defensive and/or coping behaviors in response to a perceived threat □ Defense mechanisms are unconscious - recruited in response to internal threats ® When same mechanisms are used to deal with external threat they are called coping mechanisms □ Coping mechanisms and defenses are typically employed at same time □ Personality disorders can be characterized by the ego defenses used, and the extent to which they are used - Ego must borrow energy from ID via subterfuge • Developmental model of the mind ○ Libidinal energy moves through stages fairly predictably ○ You don't just pop out fully formed ; there is a process of developing psychological functioning - stages are formed via interaction with each other and the world; process leads the movement of life-force from inside to outside, where we become connected with world, all via libidinal forces ○ Stages (where pleasure is located): Oral (mothers breast), anal (can control elimination), phallic/oedipal (discovery of genitals and what they can be used for. "Dad will castrate me if he finds out what I want to do to them - make love to mom: I want to be just like him, and mom is mine;" superego emerges here - kid internalizes representation of dad - want to be just like dad with own girl), latency (phase of quiescence), adolescence (everything goes wild) - If everything goes well you develop healthy sexual relationships with other ppl besides mom • Freud created these models to understand various types of psychopathology; for that he needed a theory of mind (a measure of what's normal?)

Describe how subtypes were used in the DSM-4.

• Undifferentiated subtype? - sz does not meet criteria for paranoid, catatonic, or disorganized • Residual subtype? - Evidence of continuous disturbance marked by: 1) Absence of prominent Category-A symptoms, and 2) negative symptoms or two or more attenuated Category-A symptoms ○ Stupid category; not a subtype; ended up being a phase that all sz go through (reduced symptoms)

What two schools emerged after Freud died?

○ Melanie Klein (object relations) ○ Anna Freud (ego psychology)

Who was Erik Erickson? What were his main ideas and how did they relate to sz/psychosis? (do we need to know his stages, or any stages from slide 50? Do we need to know how these stages relate to each other?) (Give the broad strokes)

○ Relevant skills need to be dev at various ages to deal with stage-specific conflicts/tasks - most are social expectations that need to be negotiated ○ Ego development doesn't stop in childhood, but continues on as diff life stages beg for diff skills - diff ways of managing probs ○ In sz first break is often in late adolescence/early 20's - think about what's going on in terms of Erikson's framework at that time - what might be the challenge that's not navigated well and why? § Often the time when ppl are separating from family of origin, living independently - why might this life stage might be so triggering and how does this relate to the psychodynamic theories so far? § How does adaptation to different cultural and family environments (social context) affect mental illness? - i.e. what is the context of mental illness? □ In adolescence, challenges are unique; identity is not just a result of family expectations anymore - expectations are now broader with society at large □ Psychosis may emerge if these expectations are not met ○ Ego must develop and keep its skills updated over time - skills need to adapt and function well over time; skill demands change over time