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Extrapulmo- to treatment with an analog of the luteinizing- nary lymphangioleiomyomatosis and lymphangi- hormone- releasing hormone in a patient with omatous cysts in tuberous sclerosis complex cheap 200mg extra super viagra fast delivery. Effect of a tic criteria: tuberous sclerosis complex: report of the gonadotrophin-releasing hormone analogue on Diagnostic Criteria Committee of the National lung function in lymphangioleiomyomatosis discount 200 mg extra super viagra mastercard. Cryptogenic amelioration of clinical symptoms of recurrent organizing pneumonia: a report of 25 cases and a lymphangioleiomyomatosis after living-donor review of the literature order extra super viagra overnight delivery. An sus-host disease and bronchiolitis obliterans orga- unusual radiographic manifestation of bronchiol- nizing pneumonia in recipients of hematopoietic itis obliterans organizing pneumonia extra super viagra 200 mg with mastercard. Bronchiolitis tial lung disease associated with juvenile dermato- obliterans organizing pneumonia syndrome myositis: clinical features and efficacy of cyclosporin primed by radiation therapy to the breast: the A. Bronchiolitis oblit- Idiopathic bronchiolitis obliterans with organizing erans organizing pneumonia: clinicopathologic pneumonia presenting with adult respiratory dis- review of a series of 45 Korean patients including tress syndrome. Although the number of cases in the United States has been decreasing, the proportion of cases in the foreign-born population has increased from 27% in 1992 to 59% in 2008. The development of an be produced by aerosol treatments, sputum induc- immune response, heralded by the development tion, aerosolization during bronchoscopy, manipu- of delayed-type hypersensitivity during the next lation of lesions, or processing of tissue or secretions 4 weeks, leads to granuloma formation with a in the hospital or laboratory. An example would be a per- fit into these categories should be judged to have a son who had an initial false-negative reaction positive reaction with indurations of 15 mm. The dictum now is as treated with rifampin/pyrazinamide have prompted follows: “the decision to tuberculin test is the deci- recommendations that urge a cautious and extremely sion to treat (and complete). The addition of pleural biopsy for ognition of the disease is essential to stop further histologic studies and culture increases the yield transmission; however, no single clinical, radio- to approximately 80%. The most frequent sites sweats, shortness of breath, and occasionally are the apical and posterior segments of the lung, hemoptysis) should be obtained. Healing of the tuberculous lesions cytokine release associated with the inflammatory usually results in a scar, with the loss of lung paren- response by the host to the organism. The risk of progres- although an endobronchial lesion may not be sion is significant, and persons who have nodular associated with a radiographic finding. In areas with 4% isoniazid resistance, the an improvement in clinical status after treatment fourth drug may be omitted from the initial regi- with antituberculous therapy, despite negative men. Once the results reveal susceptibility to microbiological studies and no other etiology isoniazid, rifampin, and pyrazinamide, therapy accounting for the illness. If amide is stopped, and isoniazid and rifampin are culture findings are not negative after 2 months of continued for an additional 4 months for a total of therapy and cavities are present on chest radio- 6 months of treatment (completion is also defined graphs, then treatment should be extended for at by the number of doses administered; Table 5). Although there are no studies that have compared five daily doses with seven daily doses, extensive experience indicates this would be an effective practice. Those who do not have a symptom- shown to be safe for use in pregnant women and atic improvement or whose culture results fail to should be administered. Pyrazinamide, although convert to negative within 2 months of treatment recommended by many authorities, has not been initiation should be evaluated for treatment failure. The need to treat with multiple current medical conditions; and (3) noncompliance drugs for a prolonged period leads to the major with prescribed treatment regimens. The responsibility for Baseline liver function tests should be performed successful treatment has clearly been assigned by for all patients beginning treatment, and monthly current guidelines to the public health program monitoring is recommended for anyone with base- or private provider, not to the patient. The most common reasons for the development of On the basis of more current experience, drug resistance are patient nonadherence to ther- rifabutin, which is a rifamycin derivative with less apy and/or physician mistakes (eg, adding a single effect on the hepatic p450 system but equivalent drug to an ineffective regimen). Outbreaks of such strains have been well for the particular patient (recent recommendations documented, resulting in significant rates of mor- can be found at http://www. These patients may experience patients with confirmed multidrug-resistant dis- the development of new ascites, lymphadenopa- ease, therapy with at least two drugs to which the thy, fever, pleural effusions, or cerebral lesions. It is are returning to their previous residence (in non- assumed that most persons have exposure to these congregate settings), and the health department organisms through the environment. It has since become the most widely used is the likely source of infection in patients with vaccine preparation in the world, despite questions soft-tissue infections. With the The following criteria should be used to estab- introduction of rifamycins, the rate of treatment lish a diagnosis of pulmonary disease caused by failures has decreased. Other etiologies for 18 months), with a minimum of 12 months for the clinical and radiologic findings should be of treatment after culture results are negative. Positive culture results from at least two sepa- historically has been frustrating and disappoint- rate expectorated sputum samples (if the results ing. Acces- Crit Care Med 2000; 161:S221−S247 sed May 4, 2009 American Thoracic Society, Centers for Disease Con- Recent recommendations concerning the concomitant trol and Prevention. Interobserver and intraobserver vari- ability may be problematic127; consensus is usually radiolucencies (some cysts are 3 cm in diameter) and hon- eycombing involving both lungs. Recently, a 6-min step dose data in place of chest radiographs would enhance was advocated as another way of assessing exercise the predictive value of such systems. Zones of “old,” relatively acellular collagen bundles interstitial component is lacking and is overshad- are interspersed with aggregates of actively owed by the intra-alveolar component. The pathologic lesion respiratory bronchiolitis was originally described in an autopsy series of young cigarette smokers who died of nonpulmonary causes. At a median follow- lin-eosin) [reproduced with permission from Lynch et al, up of 42 months, 17 patients (61%) had died; J Respir Dis 2000; 21;197–214]. Azathioprine should be used with ments conclude that existing therapies are of caution in patients receiving allopurinol, and the unproven benefit but acknowledge that physi- dose should be reduced by at least 50%. Fur- requiring treatment, the British Thoracic Society ther, treatment is discontinued among patients Committee advocated combining prednisolone experiencing side effects or disease progression. Mycophenolate mofetil and other immuno- mg/kg/d for 4 weeks, with subsequent taper) suppressive agents have been used by some clini- with either oral azathioprine (2 to 3 mg/kg/d) or cians, but these agents have not been evaluated oral cyclophosphamide (2 mg/kg/d). It should prine fails may be switched to mycophenolate be emphasized that these recommendations3,232 mofetil or cyclophosphamide, but published data reflect expert opinion but have not been validated in this regard are lacking. At 48 severe symptoms and a declining course, provided weeks, there were no significant differences in that the pros and cons of therapy are discussed primary end points (physiologic parameters) honestly. We emphasize to patients that no therapy between groups, but trends favoring etanercept has been proven to influence survival or clinically were observed in some secondary end points. Azathioprine does not cause bladder injury or Novel and Future Therapies: Major advances bladder carcinomas and has less oncogenic poten- await the development of novel therapies that tial than cyclophosphamide. The decision as went right-heart catheterization to assess the acute to when to list should be left to the transplant cen- hemodynamic effects of vasodilators. One ous oxygen ameliorates pulmonary vasoconstric- third or more of patients are asymptomatic, with tion and may delay the clinical development of cor incidental findings of bilateral hilar lymphade- pulmonale. Mortality rates at 3 years and 5 years for patients Histopathology with sarcoidosis were 5% and 7%, respectively, compared with 2% and 4% among age- and gender- The histologic hallmark of sarcoidosis is the matched controls without sarcoidosis. Biopsy of extrapulmonary sites may be appropriate when specific lesions or abnormalities are identified (eg, lymphadenopathy, skin lesions, abnormal liver enzymes). These derangements in calcium metabolism reflect enhanced production of 1,2-dihydroxycalciferol by mononuclear phago- specimens from both the upper and lower lobes cytes from sarcoid granulomas. Posteroanterior chest festations or with normal chest radiographs but radiograph demonstrates extensive cystic, bullous, and with clinical suspicion of disease. Patients with exten- alveolar septae or pleural surfaces; traction bron- sive fibrosis, honeycombing, and lung distortion chiectasis; and distortion or displacement of ves- are not likely to respond to therapy with cortico- sels, bronchi, or interlobar tissues. Characteristic patterns of Given the variability of Dlco and the expense uptake have been noted in sarcoidosis (eg, of obtaining lung volumes, spirometry and increased uptake in lacrimal, salivary, and parotid flow-volume loops are the most useful and cost- glands and hilar and mediastinal lymph nodes). Patients may have a limited role in patients with normal with pulmonary symptoms or derangements in chest radiographs and suspected sarcoidosis to pulmonary function require more frequent stud- detect clinically silent extrathoracic sites of 67Ga ies. Because of the potential for spontane- teristic of Löfgren syndrome, yet spontaneous ous resolution and the toxicities associated with remissions occur in 85% of patients in this set- corticosteroid therapy, indications for treatment ting. Although several studies suggested short-term improvement with Pathogenesis corticosteroid therapy, relapses often occurred after the cessation of therapy. The lack of efficacy may The inciting signals responsible for the exuber- reflect the study designs because patients with ant granulomatous response and its subsequent stage I disease, minimal or no symptoms, and progression to fibrosis (or resolution) have not normal lung function were often enrolled into been identified. In most of these studies, high rates mononuclear phagocytes (eg, monocytes and of improvement or stabilization were noted in both macrophages) and activated T-helper/inducer treated and untreated patients. The remaining to be individualized according to clinical response 58 untreated patients with persistent radiographic and presence or absence of adverse effects. A infiltrates after 6 months were randomly assigned 3-month trial of corticosteroids is usually adequate to be administered routine corticosteroids for to judge efficacy. If no objective response has been 18 months (n 27) or selective therapy only (to shown within this time, corticosteroids can be control symptoms or deteriorating pulmonary tapered and discontinued.

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Other than those those concerns through the procedures matters referred to the Offce of Institu- described in this policy purchase extra super viagra cheap. If the will be referred for disciplinary action under complaint is lodged against a research fel- the appropriate University procedures which low generic 200mg extra super viagra mastercard, the Vice Dean for Education and the are described elsewhere order extra super viagra online now. Other than those matters referred to the Offce of Institutional Equity generic 200 mg extra super viagra with mastercard, Procedures Relating to if based on the written report, those Deans Student Discipline decide that a formal investigation is mer- ited, they will convene an ad hoc commit- The following procedures will govern com- tee to investigate the complaint and will plaints regarding the conduct of a student notify the complainant, the respondent and enrolled in the School of Medicine. The ad Medicine will contain documentation refect- hoc committee will be composed of three ing conduct during the period of enrollment. A faculty members from departments other student will have access to his School record, than those of the complainant or respon- including those documents, if any, refecting dent. The committee will be responsible for conduct, in accordance with the standards set gathering information and interviewing the forth in the Family Educational Rights to Pri- complainant, respondent, and other indi- vacy Act and applicable University policy. Based University’s policy on access to and release upon information gathered and their delib- of student records is published annually and erations, the committee will submit a writ- a copy may be obtained from the Offce of the ten report to the Deans involved within thirty Registrar of the School of Medicine. When information reaches the School indi- will include their fndings and recommenda- cating that a student has engaged in behavior tions for dismissal of the complaint or for unbeftting a physician and/or a medical sci- disciplinary action(s). The senior Deans entist, the student will be requested to confer will then communicate to the complainant with the Associate Dean for Student Affairs. If the committee fnds cannot be resolved to the satisfaction of the against a post-graduate trainee, the fnd- Associate Dean for Student Affairs, or where ings will be communicated to the appropri- the gravity of the acts with which the student ate Department Chair and Program Direc- is charged appears to warrant further atten- tor and sanctions will be determined and tion, the Dean of the Medical Faculty will enforced according to the policy on Pro- appoint an ad hoc committee of the Adviso- bation, Suspension, and Termination of ry Board of the Medical Faculty to hear the Post-Doctoral Fellows published elsewhere charge of misconduct. Suspension for a specifed time or until mittee and may vote when the ad hoc com- explicit* conditions are met. Unconditional Expulsion given written notice of the charges and of the date and time of the Committee hearing. Prior *Explicit conditions are to be unambiguous to the hearing an accused student shall be and as objective as the conditions allow. An accused stu- sion to the Dean of the School of Medicine, dent may request an opportunity to consult or, in the absence of the Dean, appeal may with the Dean, Vice Dean, or an Associate be made to the Vice Dean or an Associate Dean prior to a hearing. A student may be accompanied to the calendar days of the date of the committee hearing by a faculty member or student advi- decision. A student may attend classes pending or the accusing party at the hearing by attor- the proceedings before the ad hoc commit- neys will not be permitted. In the course of the hearing, a student will Vice Dean, or Associate Dean to be a danger be given the opportunity to present evidence to himself or others. A student must seek the and witnesses in his behalf, to question all permission of the Dean, Vice Dean, or Asso- witnesses, and to make statements to the ciate Dean in order to continue the education- Committee. Members of the ad hoc committee may ask questions of the student charged and of wit- nesses appearing before the Committee. A hearing before the ad hoc committee will be closed and persons other than Deans Preclinical Curriculum appearing as witnesses will be asked to Among the goals of the Scientifc Founda- absent themselves before and after their tes- tions of Medicine and the Genes to Society timony. Parents of the accused student will be courses are to develop a sense of profes- permitted to accompany a student throughout sionalism, to promote collegiality, to engage the hearing, and, if they should wish to do so, students in teaching one another, and to give to make a statement. A hearing shall be recorded but the delib- different backgrounds and expertise are rep- erations of the ad hoc committee shall not resented. Following the hearing, the student to be actively engaged, therefore accused student shall be permitted to listen attendance is mandatory at all group learn- to the recording upon request, but all copies ing and teamwork activities including activi- of the recording shall remain in the School’s ties in the Simulation Center and workshops. All parties, witnesses, and representa- that involve patients and/or guests, such as tives shall be excused at the conclusion of clinical correlations. Videofles of large group the hearing and the ad hoc committee shall lectures where attendance is not required deliberate privately. The Committee shall are available online via course management make fndings as to the truth or falsity of the software. Unexcused attendance below 80% the Committee decide that the student’s will affect the student’s performance in the behavior warrants discipline, will include, but course and will be considered a breach of will not necessarily be limited to the following: the standards of professionalism expected by a. Probation for a specifed time period or Group Discussions), attendance at 80% of until explicit* conditions are met. Students Excused absences may be granted in should make every effort to leave as late as cases of illness, religious observance, fam- possible and return as early as possible when ily emergency, presentations at scientifc interviewing to minimize time lost from a core conferences, or required legal activity (e. On 6-9 week clerkships, students will be whenever feasible) with the section director, allowed to miss 3 full days of responsibili- course director, and/or Associate Dean for ties as excused absences for interviews. Students must inform course directors Attendance Policy of any such absences in advance of the The School of Medicine recognizes the pri- beginning of the clerkship when possible. Atten- be considered unexcused and will impact dance rules are governed by the School of on the student’s fnal grade. Students should expect to The holidays which occur during the Clerk- attend required basic clerkship educational ship time generally fall on a Monday or Fri- activities after they have completed the exam. If this occurs, scheduled activities activities may be scheduled on those week- for these other courses take priority over all end days at the discretion of the Clerkship scheduled Clerkship activities. Elective Coursework public or civic events are not considered holi- Under no circumstances will elective course- days for Core Clerkship students. Students will not be excused from Excused & Unexcused Absences required Core Clerkship duties to attend a. This includes elective ensure that students obtain suffcient experi- experiences requiring complex or expensive ence in each of the basic disciplines to meet travel arrangements, such as those con- the objectives of the Hopkins curriculum. Illness or Injury (Personal or Family) Holidays) Illnesses or injuries are handled on a case by Students must notify the Clerkship Director case basis by Clerkship Directors. In almost as early as possible before the start of the all cases, such events cannot be predicted in clerkship regarding any scheduled absence advance. When either occurs, the student’s other than those described above, and should frst responsibility is to their own personal expect that they will need to make up missed safety and the safety and well-being of those time. Once the situation has stabi- absence for religious holidays, academic lized suffciently and it is safe to do so, a stu- events (e. As necessary, remediation plans will be tial impact on the educational experience, the made on a case-by-case basis by the Clerk- general rule is “a day for a day” (i. Students who of the educational experience is missed for must miss a class or an examination because any reason, it is at the Clerkship Director’s of a religious holiday must inform the instruc- discretion to require remediation, reduce the tor as early as possible in order to be excused student’s grade, or remove the student from from class or to make up any work that is the Clerkship that cycle. Weather and Other Related Emergencies Clerkship slot, potentially delaying promotion Within the Baltimore Area or graduation in some circumstances. Weather-related policies are stipulated by Students who fail to attend required activi- the Johns Hopkins University. Clerkship Orientation) without ship students are not considered “Required advance notice and are unable to offer a rea- Attendance Employees” and are excused sonable or appropriate justifcation (as judged from attendance at normally-required Clerk- by the Clerkship Director) may be subject ship activities if affected by circumstances to grade reductions, failure, or disciplinary (e. As necessary, remediation plans Any student who feels unfairly treated with will be made on a case-by-case basis by the regard to attendance or duty hours policy Clerkship Director. If a mutually agreeable deci- Outside the Baltimore Area sion is not reached, the student should con- Students who travel during (e. Once the student’s safety is assured, they In recognition of the primacy of the educa- should immediately notify people related to tional goals for students enrolled the full- the Clerkship, as appropriate (e. Stu- provide guidance to students, faculty, and dents will generally be required to remediate administrators: any time or activities upon safe return or at a 1. Students must be in good academic stand- tant Deans of Student Affairs to obtain approv- ing in order to be eligible for employment by al for the event. Documentation of this stand- ing will be coordinated by the Offce of Student Financial Aid Affairs. If there is evidence that the student’s academic performance is placing the student Satisfactory Academic at-risk for failing, in addition to the usual sup- ports offered in these situations, the student’s Progress Review employment status will be reviewed by the Federal law and regulations require that all Offce of Student Affairs in collaboration with students receiving federal fnancial assis- the student. This could result in termination of tance must maintain satisfactory academic University employment. The policy applies to all students who Offce of Student Affairs describing the pro- receive federal fnancial aid assistance. This form also requires In determining student’s academic prog- information from the proposed supervisor of ress, the Financial Aid Offce will follow the the employment and an acknowledgement on School of Medicine’s Student Promotion their part of awareness of this policy. Committee academic review policy which is established for all students and meets the 4. Student academic standing and satisfac- However, only six weeks of paid elective credit tory academic progress will be reviewed can count toward the cumulative elective cred- annually by the Financial Aid Offce to deter- it required for graduation. Evaluations will be the Offce of Student Affairs and could result made on both a qualitative and quantitative in disciplinary action or referral to the appropri- basis. Alcohol Policy for Qualitative Review The Financial Aid Offce will follow the rec- Medical Students ommendations of the Committee on Student Promotions for the qualitative review of aca- Intoxication in the workplace is considered demic progress status of the student. Therefore, this The School of Medicine’s Committee on policy shall regulate the use of alcohol at Student Promotions reviews and assesses school sponsored/sanctioned medical stu- the satisfactory academic progress of all dent events on the premises of the Johns medical students at scheduled intervals.

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Early on order extra super viagra on line, Freud published neurological and neuroanatomical works order extra super viagra 200mg free shipping, including a monograph on aphasia that Erwin Stengel (1902-1973) translated into English in 1953 order extra super viagra 200mg amex. Married Martha Bernays order line extra super viagra, studied under Charcot and published, with Josef Breuer (1842-1925: of reflex fame) Studies on Hysteria in 1895. Possibly addicted to cocaine; his colleague, Carl Koller (1857-1944), discovered its local anaesthetic properties. During this period, immortalised in Traumdeutung (1990), Freud corresponded with Wilhelm Fliess, inventor of the concept of a nasal reflex neurosis. Freud analysed himself, so starting a family of analysts, and each member thereafter being analysed by someone who was analysed by someone else. Claims for cures criticised in recent years, with talk of former patients dying in mental hospitals. He provided a framework allowing the conceptualisation of mental processes where there had previously been only demonology and degeneracy. Freud may have got major ideas from the German philosopher Friedrich Nietzsche (1844-1900). Merskey attacked Freud’s idea of ‘repression’, believing that it has been used unethically to produce false memories of sexual abuse in infancy. Suffered from carcinoma of maxilla and palate from 1923 and received repeated surgery and radiotherapy. On September 23, 1939 in London, his physician and friend Max Schur administered an overdose of morphine at Freud’s request. Bertha or Elsa Pappenheim (Anna O)(1859-1936) is the best known patient of Freud and Breuer. Lessons learned during her treatment were used in the writing of Studies on Hysteria. Merskey argues she had a depressive disorder, morphine and chloral hydrate dependence, hysterical conversion, and cyclothymia! Other patients of Freud included Ida Bauer (Dora) and Sergej Pankejeff (Wolf Man). She observed children at play, was analysed by her father, had no medical qualification, and remained a spinster. Carl Gustav Jung, (1875-1961) leader of the school of ‘analytical psychology’, student of Janet, and a pastor’s son, was born in Switzerland and worked with Bleuler at Zurich. Jung was concerned with the inner world of fantasy and with interpreting unconscious material in dreams and artistic production. A ‘complex’ consists of a group of interconnected ideas that arouse feeling and influence action. In reality, many people do not remember much about this phase in their life because it did not cause much upset at the time. Melanie Klein (1882-1960) worked with pre-oedipal children using play analysis and she placed the Oedipus complex in infancy! Objects, for the infant, are good or bad; part is confused with whole: breast is equated with mother. At about six months the baby is biting objects (oral sadistic stage) and fears mother will punish him for this hostility. Klein’s ‘projective identification’ (subject projects part of self onto object, then identifies with object or elicits response in object corresponding to qualities of the projection) was further developed by Wilfred Bion (1897-1979). Klein’s first ‘patient’ was her own daughter, Melitta Schmideberg, who later became an analyst working with delinquent adolescents and who resented her own mother’s intrusions so early in life! Alfred Adler (1870-1937) was born in Vienna, had rickets as a child, trained as an eye specialist, converted to Christianity from Judaism, and died at Aberdeen. He later broke with Freud, rejected libido theory, founded ‘individual psychology’, and taught that contemporary environmental factors were more important than sex in determining human behaviour. Harry Stack Sullivan, (1892-1949) stressed interpersonal dynamics and defined personality in terms of relative and enduring patterns of recurring interpersonal behaviour. Sullivan discussed everyday events with his clients and used pointed questions and provocative statements in preference to theory-based interpretations. A homosexual himself, Sullivan believed that patients need a same-sexed therapist. Freud identified dreams , slips of the tongue, and free associations as important windows on the influence of childhood and the present conflicts of the patient. The goal was to elucidate the ‘childhood neurosis’ as presented in the transference neurosis. Therapy focuses on the recovery of early experiences as they appear in the patient-therapist relationship. The transference neurosis, as distinct from transference phenomena, is the sustained appearance of the transference over time. The patient experiences the analyst as he/she once did an earlier significant figure. The analyst avoids gratifying wishes (abstinence – avoids becoming a figure from the past in reality) and does not take sides in the patient’s conflicts (neutrality). Classically, countertransference is the analyst’s response to the client (modern analysts admit that some responses are ‘normal’ or non-neurotic). Resistance (experienced by the analyst) derives 3311 from the client’s defences and may lead to the break down of free association. Interpretations, often given piecemeal, involve the linking together of the patient’s experience of an event with the transference experience of the analyst and the significant figures from childhood. Many analysts wait until material is very close to consciousness (or is a symptom of resistance) before offering interpretations (unless it is ‘trial interpretation’ during an assessment for analysis). Too early interpretation may be make the patient feel that the analyst is lost in his own theoretical world and hadn’t been concentrating on his client. Shorter (focused) psychodynamic treatments necessitate earlier interpretation than is the case for open-ended analysis. Freud’s first instinctual theory opposed sexual and self- 3307 Good and bad aspects of the mother are split. His final instinctual theory opposed the controversial death instincts (Thanatos) which he saw as tending towards destruction of the life instincts (Eros: sexual and self-preservative instincts). Personality development: Freud described child development as passing through psychosexual stages. During the oral stage the erotogenic zones (skin or mucous membranes possess the capacity to sexually arouse3312) are mouth, lips and tongue. This stage lasts until about 18 months when the major source of conflict revolves around feeding, the latter providing a major focus for the relationship between mother and child. Erickson defined a developmental crisis at this stage of basic trust versus mistrust. The anal stage lasts from approximately 1 to 3 years, conflict being focussed on toilet training with major issues over power and control between parent and child (Erickson’s autonomy versus shame and doubt). The phallic stage centres on penis and clitoris (about 3–5 years of age) with the main issue being the Oedipus complex. The boy wishes to possess his mother physically in a manner derived from his observations/intuitions about sexual life and he tries to seduce her by proudly showing her his penis. He imagines that girls once had a penis and lost it as a punishment and worries lest the same will become him as punishment for his desires. As a consequence, castration anxiety3313 and abandonment of oedipal wishes follow and he identifies with his father and wants to be like his father rather than to usurp him. A latency period follows (about 5-12 years) when sexual impulses tend to become repressed (controversial). The final stage is the genital one wherein penis and vagina constitute erotogenic zones (achieved at adulthood). Heterosexual relationships, love, affection, the development of a secure identity and a capacity for intimacy are of major import as is adapting to the values and expectations of society. Fixation develops when excess libido (psychic energy) remains at one of the earlier stages: this may arise from deprivation or over-indulgence, e. Model of mind: Freud divided the mind into conscious, preconscious and unconscious parts. Structural model The primary process, the pleasure principle and wish fulfilment are aspects of the Id.

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