Janet E. Johnson, MD, MPHJanet E. Johnson, MD, MPH

Department of PsychiatryDepartment of Psychiatry

The Human Life Cycle:The Human Life Cycle:Development and Development and

DiseaseDisease

ObjectivesObjectives

Be familiar with the major stages of the life Be familiar with the major stages of the life cycle as defined by different theoristscycle as defined by different theoristsBe able to recognize normal stages and Be able to recognize normal stages and psychological reactions across the life cyclepsychological reactions across the life cycleBe able to discuss the “Adverse Childhood Be able to discuss the “Adverse Childhood Experiences” study and its’ implicationsExperiences” study and its’ implicationsBe able to list different types of divorce and Be able to list different types of divorce and consequences of divorceconsequences of divorceBe familiar with attitudes and reactions to Be familiar with attitudes and reactions to death across the life cycledeath across the life cycle

Why Should I Care About Why Should I Care About Development?Development?

Your patients are people firstYour patients are people first

Each of us begins and ends the same Each of us begins and ends the same way:way:

Biological

Psychological

Social

LifeLife

I don’t want to gain immortality through my work; I want to gain immortality through not dying

Woody AllenWoody Allen

1

Class #3.

A general conceptual framework relating health and behavior

a.

Health Outcome

Biological Proximate

Determinants Behavior

Social Influences Community level Political system Healthcare system Cultural system Family/Soc Group Level Socioeconomic status Education of

household head Family income Social networks Peer group norms Individual Level Knowledge Personality

Individual Factors: “Personality”Individual Factors: “Personality”

What determines someone’s personality?What determines someone’s personality?

What forces push development?What forces push development?

Development is exceedingly complexDevelopment is exceedingly complexHumans are biological beings and social Humans are biological beings and social beings…beings…Many theories have been positedMany theories have been posited– Neurological/CognitiveNeurological/Cognitive– PsychosexualPsychosexual– PsychosocialPsychosocial– Separation/individuationSeparation/individuation– OthersOthers

Neurological DevelopmentNeurological Development

Rapid maturation and growth Rapid maturation and growth

Inborn reflexes: Moro, rooting, Babinski, Inborn reflexes: Moro, rooting, Babinski, endogenous smiling, orients to voice endogenous smiling, orients to voice

8 weeks: see shapes and colors 8 weeks: see shapes and colors

16 weeks: stereoscopic vision, holds head 16 weeks: stereoscopic vision, holds head up up

Neurological DevelopmentNeurological Development

40 weeks: sits alone, pulls up to stand 40 weeks: sits alone, pulls up to stand

52 weeks: walks with hand held 52 weeks: walks with hand held

15 months: walks alone, crawls stairs 15 months: walks alone, crawls stairs

Forms foundation for psychological Forms foundation for psychological developmentdevelopment

Cognitive Development Cognitive Development

Pioneered by Jean Piaget (1896-1980) Pioneered by Jean Piaget (1896-1980)

First paper published age 10 on a species First paper published age 10 on a species of sparrow of sparrow

Developmentally precocious by his system Developmentally precocious by his system

Studied his own children in formulating his Studied his own children in formulating his theoriestheories

Piaget’s Theory of Cognitive Piaget’s Theory of Cognitive DevelopmentDevelopment

Provides a framework for understanding Provides a framework for understanding the cognitive capabilities of children, the cognitive capabilities of children, informing effective communication and informing effective communication and treatment treatment Four stage theory Four stage theory Sensori-motor (0-2) Sensori-motor (0-2) Preoperational (2-6) Preoperational (2-6) Concrete Operational (6-11) Concrete Operational (6-11) Formal Operational (11-adult)Formal Operational (11-adult)

Sigmund FreudSigmund Freud

Psychoanalytic theory Psychoanalytic theory of developmentof development– Very complex theory. Very complex theory. – Major forces behind Major forces behind

development were not development were not observable!observable!

– Theory was influenced Theory was influenced strongly by the culture strongly by the culture of the time in which of the time in which Freud practiced.Freud practiced.

Sigmund FreudSigmund Freud

Libido Theory Libido Theory Ages Ages Oral phase (0-1 yr) Oral phase (0-1 yr) Anal phase (1-3 yrs) Anal phase (1-3 yrs) Phallic phase (3-6 yrs) Phallic phase (3-6 yrs) Latency (6-puberty)Latency (6-puberty)– Stage of relative inactivity of sexual drive Stage of relative inactivity of sexual drive – Objective is consolidation of sex role identity and sex Objective is consolidation of sex role identity and sex

role behaviors role behaviors – Generally a time when children look outside the family Generally a time when children look outside the family

(teachers, coaches, other adults)(teachers, coaches, other adults)

Erikson: Erikson: Psychosocial TheoryPsychosocial Theory

Trust v Mistrust (0 to ~1 year) Trust v Mistrust (0 to ~1 year)

Autonomy v Shame/Doubt (~1 to 3 years) Autonomy v Shame/Doubt (~1 to 3 years)

Initiative v Guilt (~3 to 5 years) Initiative v Guilt (~3 to 5 years)

Industry v Inferiority (~6 to 11 years) Industry v Inferiority (~6 to 11 years)

Identity v Role Diffusion (~11 to 21 years) Identity v Role Diffusion (~11 to 21 years)

Intimacy v Isolation (~21 to 40 years) Intimacy v Isolation (~21 to 40 years)

Generativity v Stagnation (~40 to 65 years) Generativity v Stagnation (~40 to 65 years)

Integrity v Despair (~65 years and up) Integrity v Despair (~65 years and up)

Ethology-IEthology-I

Ethologists view behavior as being:Ethologists view behavior as being:– Strongly influenced by biology,Strongly influenced by biology,– Tied to evolution, Tied to evolution, – Characterized by critical periods (sensitive Characterized by critical periods (sensitive

periods) in which characteristics develop.periods) in which characteristics develop.

Konrad Lorenz and his geeseKonrad Lorenz and his geese

The Goose Guy*--ImprintingThe Goose Guy*--Imprinting

*Nobel Prize Winner*Nobel Prize Winner

Weaknesses of EthologyWeaknesses of Ethology

Limited evidence for critical periods in Limited evidence for critical periods in humans.humans.

Views biology as key determinant of Views biology as key determinant of behaviorbehavior

Impact of evolutionary forces is difficult to Impact of evolutionary forces is difficult to study experimentally.study experimentally.

Ecology-IEcology-I

Ecologists believe that behavior is:Ecologists believe that behavior is:– Strongly influenced by the environment (the Strongly influenced by the environment (the

context in which the individual lives),context in which the individual lives),– Environment exists in levels or layers of Environment exists in levels or layers of

influence,influence,– Environmental levels may change rapidly, Environmental levels may change rapidly,

such that the timing of when we grow up is such that the timing of when we grow up is important.important.

Weaknesses of EcologyWeaknesses of Ecology

De-emphasizes the role of inherent De-emphasizes the role of inherent (biological/genetic) differences.(biological/genetic) differences.

New evidence that a person’s genetic New evidence that a person’s genetic makeup may shape their environment.makeup may shape their environment.

ECOLOGYETHOLOGY

NATURE NURTURE

BIOLOGY ENVIRONMENT

What are the components of What are the components of BiologyBiology??

Genes, Genes, Genes…Genes, Genes, Genes…

TeratogensTeratogens

PathogensPathogens

DiseaseDisease

What are the components of What are the components of EnvironmentEnvironment??

What isn’t?What isn’t?– Experience!Experience!

CultureCulture

PovertyPoverty

Risk and Protective FactorsRisk and Protective Factors

May be “biological” or “psychosocial.”May be “biological” or “psychosocial.”

Individual risk or protective factors Individual risk or protective factors generally do not predict specific outcomes.generally do not predict specific outcomes.

High total risk index predicts poor High total risk index predicts poor outcomes (often in several areas).outcomes (often in several areas).

Exposure to risk, if overcome, may be Exposure to risk, if overcome, may be protective.protective.

The Adverse Childhood The Adverse Childhood Experiences (ACE) StudyExperiences (ACE) Study

• The largest study of its kind ever done to The largest study of its kind ever done to examine the health and social effects of examine the health and social effects of adverse childhood experiences over the adverse childhood experiences over the lifespan. (~18,000 participants) lifespan. (~18,000 participants)

• Conducted by a group at Kaiser Conducted by a group at Kaiser Permanente— a series of papers published Permanente— a series of papers published in major medical journals over the last 15 in major medical journals over the last 15 yearsyears

Categories of Categories of Adverse Childhood ExperiencesAdverse Childhood Experiences

Abuse by CategoryAbuse by Category

Psychological (by parent)Psychological (by parent)

Physical (by parent)Physical (by parent)

Sexual (anyone)Sexual (anyone)

Household Dysfunction by CategoryHousehold Dysfunction by Category

Substance AbuseSubstance Abuse

Mental IllnessMental Illness

Mother Treated ViolentlyMother Treated Violently

Household Member ImprisonedHousehold Member Imprisoned

Categories of Categories of Adverse Childhood ExperiencesAdverse Childhood Experiences

Abuse by CategoryAbuse by Category Prevalence of positive Prevalence of positive responseresponse

Psychological (by parent)Psychological (by parent) 11%11%

Physical (by parent)Physical (by parent) 11%11%

Sexual (anyone)Sexual (anyone) 22%22%

Household Dysfunction by CategoryHousehold Dysfunction by Category

Substance AbuseSubstance Abuse 26%26%

Mental IllnessMental Illness 19%19%

Mother Treated ViolentlyMother Treated Violently 13%13%

Imprisoned Household MemberImprisoned Household Member 3% 3%

Research QuestionsResearch Questions

How does self-reported exposure to How does self-reported exposure to adverse childhood experiences relate to adverse childhood experiences relate to major health indicators?major health indicators?

All-Star List of Health IndicatorsAll-Star List of Health Indicators

• SmokingSmoking• Severe ObesitySevere Obesity• Physical InactivityPhysical Inactivity• DepressionDepression• Suicide AttemptSuicide Attempt

• AlcoholismAlcoholism• Illicit Drug UseIllicit Drug Use• Injected Drug UseInjected Drug Use• 5+ Sexual Partners5+ Sexual Partners• History of STDsHistory of STDs

Adverse Childhood Experiences &Adverse Childhood Experiences &Risk for ObesityRisk for Obesity

ACEACE

ScoreScore

ObesityObesity

BMI>35BMI>35

No Physical No Physical ActivityActivity

0-10-1 5%5% 19%19%

2-32-3 7%7% 22%22%

4 or more4 or more 9%9% 25%25%

Aversive Childhood Experiences Aversive Childhood Experiences Vs. Adult AlcoholismVs. Adult Alcoholism

2.9

5.7

10.311.3

16.1

0

2

4

6

8

10

12

14

16

18

0 1 2 3 4+

ACE Score

%Alcoholic

Childhood Experiences Underlie Childhood Experiences Underlie Chronic DepressionChronic Depression

0

10

20

30

40

50

60

0 1 2 3 4+

Women

Men

ACE Score

Percent withLifetime History ofDepression

Childhood Experiences Childhood Experiences Underlie SuicideUnderlie Suicide

1.22.5

4.9

10.5

19

02

468

101214

161820

0 1 2 3 4+

ACE Score

%Attempting

Suicide

ACE Study Summary of ACE Study Summary of FindingsFindings

• Adverse Childhood Experiences are very Adverse Childhood Experiences are very common.common.

• ACEs are strong predictors of later health ACEs are strong predictors of later health risks.risks.

• This combination makes ACEs one of the This combination makes ACEs one of the leading , if not leading , if not the leadingthe leading determinant of determinant of the health and social well-being of our the health and social well-being of our nation.nation.

EarlyDeath

Disease & Disability

Adoption of Health Risk Behavior

Social, Emotional, &Cognitive Impairment

Adverse ChildhoodExperiences

Felitti’s General ModelFelitti’s General Model

Social History?Social History?

What percentage of your patients do you What percentage of your patients do you believe will walk into your office and state: believe will walk into your office and state: “You know, doc, I was abused as a kid.”“You know, doc, I was abused as a kid.”

DivorceDivorce

Divorce risk factors:Divorce risk factors:Early marriage Early marriage Different backgrounds Different backgrounds Serious illness or death in an infant (75%) Serious illness or death in an infant (75%) Time, money, work (SES) Time, money, work (SES) Drug abuse and alcoholism Drug abuse and alcoholism Untreated depressive illness!!! Untreated depressive illness!!! Extramarital affairs (60% of men, 40% of women Extramarital affairs (60% of men, 40% of women by middle age)by middle age)

Divorce- typesDivorce- types

Psychic divorce-loss of the love object Psychic divorce-loss of the love object – may take 2 years to recover may take 2 years to recover

Individuation Individuation

Transfer the love to another love object Transfer the love to another love object

Legal divorce Legal divorce

50-60% of women remarry within 3 years 50-60% of women remarry within 3 years

80% of men remarry within 3 years 80% of men remarry within 3 years

Divorce - typesDivorce - types

Economic divorce Economic divorce – division of property division of property

Failure of a father to comply with court Failure of a father to comply with court ordered child support reveals much about ordered child support reveals much about how that person might respond to medical how that person might respond to medical treatments (compliance etc.) treatments (compliance etc.) Community divorce- loss of friends Community divorce- loss of friends Co-parental divorce- separation from Co-parental divorce- separation from child’s perspectivechild’s perspective

Outcomes for children of divorceOutcomes for children of divorce

Good outcome Good outcome – continued relationship with both parents continued relationship with both parents – Genuine concern by both parents Genuine concern by both parents – removal from abusive parent removal from abusive parent – dissipation of parental frictiondissipation of parental friction

Outcomes for children of divorceOutcomes for children of divorce

Poor outcome Poor outcome – 35% of children 35% of children – rejection by one or both patents rejection by one or both patents – (disinterested custodial parent) (disinterested custodial parent) – infrequent or unreliable visits by infrequent or unreliable visits by – noncustodial parent lonely or depressed or noncustodial parent lonely or depressed or

physically ill mother physically ill mother – Continued parental strife Continued parental strife – impoverished social supportsimpoverished social supports

Other effects on childrenOther effects on children

Depends on age at which divorce occurred Depends on age at which divorce occurred Preschool-regression (fear of Preschool-regression (fear of abandonment) abandonment) Latency age-depression (fear of Latency age-depression (fear of replacement and fantasy of reunion) replacement and fantasy of reunion) Pre-adolescence-(anger at one or both Pre-adolescence-(anger at one or both parents and splitting) parents and splitting) Adolescents-anxiety about becoming an Adolescents-anxiety about becoming an adult adult

Life Span Life Span

The age in which the average individual would The age in which the average individual would die if there were not premature deaths from die if there were not premature deaths from accidents or disease. accidents or disease.

This is approximately 85-95 years and has not This is approximately 85-95 years and has not changed for centuries, and probably millenia. changed for centuries, and probably millenia. Life span, like maximum life potential, is Life span, like maximum life potential, is probably a fixed biological constant for each probably a fixed biological constant for each species.species.

Life Expectancy Life Expectancy

The age of which the average individual The age of which the average individual would die when accidents and disease would die when accidents and disease have been taken into consideration. have been taken into consideration.

Life ExpectancyLife Expectancy

In 2001, life expectancy for women in the In 2001, life expectancy for women in the U.S. A.:U.S. A.: 80.05 years 80.05 years

and for men and for men 74.37 years74.37 years

AgingAging

Variability in Life Expectancy Variability in Life Expectancy WorldwideWorldwide

Life Expectancy at birth (years), 2007██ over 80██ 77.5-80██ 75-77.5██ 72.5-75██ 70-72.5██ 67.5-70██ 65-67.5

██ 60-65██ 55-60██ 50-55██ 45-50██ 40-45██ under 40██ not available

Death and DyingDeath and Dying

Meaning of deathMeaning of death– Reaction/experience of death depends on contextReaction/experience of death depends on context

Timely: one’s expected survival and actual life Timely: one’s expected survival and actual life span are approximately equalspan are approximately equal– Erikson: Integrity versus despairErikson: Integrity versus despair

Untimely: unexpected or premature deathUntimely: unexpected or premature death– Death of a young personDeath of a young person– Sudden deathSudden death– Catastrophic death associated with violence or Catastrophic death associated with violence or

accidentaccident

DefinitionsDefinitions

Thanatology:Thanatology: study of the phenomenon of death and study of the phenomenon of death and the emotional and psychological processes involved in the emotional and psychological processes involved in the reaction to death, including grief, bereavement, and the reaction to death, including grief, bereavement, and mourningmourningGrief:Grief: subjective feelings that are precipitated by the subjective feelings that are precipitated by the death of a loved onedeath of a loved oneBereavement:Bereavement: to be deprived of someone by death and to be deprived of someone by death and refers to being in the state of mourningrefers to being in the state of mourningMourningMourning: process by which grief is resolved; societal : process by which grief is resolved; societal expression of post bereavement behavior and practicesexpression of post bereavement behavior and practicesGrief workGrief work: complex psychological process of : complex psychological process of withdrawal of attachment and working through the pain withdrawal of attachment and working through the pain of bereavementof bereavement

DefinitionsDefinitions

Intentional Intentional – SuicideSuicide

UnintentionalUnintentional– Trauma, diseaseTrauma, disease

Sub-intentionalSub-intentional– Substance abuse, cigarette smokingSubstance abuse, cigarette smoking

Sudden death of psychogenic originSudden death of psychogenic origin– Emotional factors alone Emotional factors alone

MI after sudden psychological stressMI after sudden psychological stressVoodoo deathVoodoo death

Elisabeth Kubler-RossElisabeth Kubler-Ross

StagesStages

Do not necessarily go in orderDo not necessarily go in orderCan alternate between stagesCan alternate between stagesNot all patients will experience each stageNot all patients will experience each stageDo not always get to final stageDo not always get to final stageStage I: Denial and Isolation; ShockStage I: Denial and Isolation; Shock– Can be adaptive or maladaptiveCan be adaptive or maladaptive– Depends on whether patient continues to Depends on whether patient continues to

obtain treatment, even while denying obtain treatment, even while denying diagnosis and prognosisdiagnosis and prognosis

StagesStages

Stage II: AngerStage II: Anger– May be directed at God, fate, family, friends, medical May be directed at God, fate, family, friends, medical

staff, other caregiversstaff, other caregivers– Why me?Why me?– Patients are difficult to help while in this stagePatients are difficult to help while in this stage

Stage III: BargainingStage III: Bargaining– Attempts to negotiate with doctors, friends, God, etcAttempts to negotiate with doctors, friends, God, etc– In return for a cure, patient will fulfill certain promisesIn return for a cure, patient will fulfill certain promises– By being “good”/compliant, doctors and other health By being “good”/compliant, doctors and other health

care providers will cure themcare providers will cure them

StagesStages

Stage IV: DepressionStage IV: Depression– Withdrawal, psychomotor retardation, sleep Withdrawal, psychomotor retardation, sleep

disturbance, hopelessness, possible SIdisturbance, hopelessness, possible SI– May be reaction to effects of illness on their livesMay be reaction to effects of illness on their lives– May be in anticipation of the loss of life that will occurMay be in anticipation of the loss of life that will occur– Treatment will meds or ECT may be indicatedTreatment will meds or ECT may be indicated

Stage V: AcceptanceStage V: Acceptance– Realize death is inevitable; accept universality of the Realize death is inevitable; accept universality of the

experienceexperience

Attitudes toward Death across the Attitudes toward Death across the Life CycleLife Cycle

Children < 5 yearsChildren < 5 years– Animistic Animistic everything, even inaminate objects, is everything, even inaminate objects, is

alive. Death is a separation similar to sleep.alive. Death is a separation similar to sleep.

5-10 years (concrete operations)5-10 years (concrete operations)– Fear parents will die and they will be abandonedFear parents will die and they will be abandoned

9-12 years 9-12 years – Death conceptualized as something that can happen Death conceptualized as something that can happen

to the child, as well as the parentsto the child, as well as the parentsPuberty and abovePuberty and above

– Universal, irreversible and inevitable Universal, irreversible and inevitable – Same as adult viewSame as adult view

Specific ConcernsSpecific Concerns

Children: creates major emotional stresses on Children: creates major emotional stresses on caregiverscaregivers

Adolescents: need for independence and controlAdolescents: need for independence and controlYoung adults: (intimacy versus isolation)Young adults: (intimacy versus isolation)

– May focus on never getting married, having kidsMay focus on never getting married, having kids

Middle age adults: (generativity vs. stagnation)Middle age adults: (generativity vs. stagnation)– May feel frustrated in plans to enjoy hard-earned May feel frustrated in plans to enjoy hard-earned

pleasurespleasures

Elderly: (integrity versus despair)Elderly: (integrity versus despair)

SuccessSuccess

To laugh often and much; to win the respect To laugh often and much; to win the respect of intelligent people and affection of children, of intelligent people and affection of children, to earn the appreciation of honest critics and to earn the appreciation of honest critics and endure the betrayal of false friends. To endure the betrayal of false friends. To appreciate beauty, to find the best in others, appreciate beauty, to find the best in others, to leave the world a bit better, whether by a to leave the world a bit better, whether by a healthy child, a garden patch, a redeemed healthy child, a garden patch, a redeemed social condition; to know even one life has social condition; to know even one life has breathed easier because you have lived. This breathed easier because you have lived. This is to have succeeded.is to have succeeded.

Ralph Waldo EmersonRalph Waldo Emerson