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NSAIDs Pharmacology Lecture Notes Tissue Injury & Inflammatory Response Initial vasoconstriction occurs immediately after injury to minimize blood loss (temporary reaction) Chemical mediators released: histamines, kinins, and prostaglandins - crucial for inflammatory response Vasodilation follows - blood vessels widen, increasing blood flow to injured area Classic inflammatory symptoms: redness (erythema), swelling (edema), pain from nerve stimulation, fever/heat NSAIDs Classification & Examples Propionic derivatives: ibuprofen, naproxen Phenomates: mefenamic acid Available OTC: salicylates, propionic acid derivatives Prescription required: COX2 inhibitors, acetic acid derivatives, oxicams, phenomates Mechanism of Action COX enzymes: cyclooxygenase (COX1 & COX2) convert arachidonic acid to prostaglandins COX1: Always active, protects stomach lining, helps platelet aggregation COX2: Activated only during tissue injury, causes inflammation and pain NSAIDs inhibit COX enzymes, preventing prostaglandin production (prostaglandin inhibitors) Primary Effects Antipyretic: reduces fever Analgesic: pain relief Anticoagulant: prevents blood clots (especially aspirin) Specific Drug Categories Salicylates (aspirin): pain, inflammation, fever, anticoagulant effects Propionic acid derivatives: mild to moderate pain (1-6 on pain scale), inflammation, fever Acetic acid derivatives: more effective for inflammation but significant GI side effects COX2 inhibitors: second generation NSAIDs with better safety profile, target COX2 specifically Oxicams: long-term use for osteoarthritis/rheumatoid arthritis, longer half-life (once daily) Phenomates: especially effective for menstrual pain Major Side Effects Gastrointestinal Dyspepsia: heartburn, indigestion, abdominal pain, nausea Long-term risks: stomach lining damage, GI bleeding, perforation (holes in stomach/intestines) Bleeding signs to monitor: dark tarry stools, bleeding gums, petechiae, ecchymosis, purpura Higher risk patients: older adults, smokers, alcohol users, pre-existing ulcers Prevention: proton pump inhibitors or H2 receptor antagonists to reduce stomach acid Kidney Effects Impaired function: reduced urine output, fluid retention, weight gain, edema Monitor: BUN and creatinine levels for kidney function Mechanism: NSAIDs reduce blood flow to kidneys, worsening function and increasing kidney disease risk Cardiovascular Risk Non-aspirin NSAIDs increase heart attack and stroke risk Prescribe at smallest effective dose Special Considerations Menstrual Pain (Dysmenorrhea) Avoid aspirin for painful menstruation with heavy bleeding Use acetaminophen 2 days before and during first 2 days of menstrual period Aspirin-Specific Risks Salicylism/Aspirin toxicity: early symptoms from overdose, can progress to electrolyte imbalances, coma, respiratory depression Serum salicylate levels: >30 mg/dL mild toxicity, >50 mg/dL severe toxicity Treatment: activated charcoal, possible hemodialysis Reye's syndrome: rare but serious condition causing liver/brain swelling in children/adolescents recovering from viral infections (flu, chickenpox) Reye's syndrome symptoms: persistent vomiting, lethargy, confusion → irritability, aggression, disorientation, seizures, loss of consciousness Avoid aspirin in children/adolescents with viral infections Drug Interactions & Precautions Glucocorticoids: amplify stomach bleeding risk Alcohol: increases stomach bleeding - limit/avoid consumption Other NSAIDs: can negate heart protective effects of aspirin - space dosing apart Herbal supplements: garlic and ginseng enhance bleeding risk High-risk populations: older adults, smokers, certain health conditions (H7
Updated 54d ago
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Chapter 7:6 Study Guide NERVOUS SYSTEM P179-187 Nervous System-complex, highly organized system that coordinates all the activities of the body. *The basic structural unit of the nervous system is the neuron, or nerve cell. It consists of a cell body containing:  Nucleus  Nerve fibers called dendrites (carry impulses toward the cell body)  Single nerve fiber called axon (carry impulses away from the cell body) Many axons have a lipid covering called a myelin sheath, which increases the rate of impulse transmission and insulates and maintains the axon. The axon of one neuron lies close to the dendrites of many other neurons. The spaces between them are known as synapses. Special chemicals, called neurotransmitters, located at the end of each axon allow the nerve impulses to pass from one neuron to another. Nerves are a combination of many nerve fibers located outside the brain and spinal cord. Meninges are membranes or protective lining that covers the brain and spinal cord. Afferent, or sensory, nerves carry messages from all parts of the body to the brain and spinal cord. Efferent, or motor, nerves carry messages from the brain and spinal cord to the muscles and glands. Associative, or internuncial, nerves carry both sensory and motor messages. There are two main divisions to the nervous system: 1. 2. Central nervous system: consists of the brain and spinal cord Peripheral nervous system: consists of the nerves. A separate division of the peripheral nervous system is the autonomic nervous system. This system controls involuntary body functions. *Brain-mass of nerve tissue well protected by membranes and the cranium, or skull. The main sections include:  Cerebrum-the largest and highest section of the brain. Responsible for: reasoning, thought, memory, speech, sensation, sight, smell, hearing, and voluntary body movement.  Cerebellum-section below the back of the cerebrum. Responsible for: muscle coordination, balance and posture, muscle tone.  Diencephalon-section between the cerebrum and midbrain. o Thalamus-acts as a relay center and directs sensory impulses to the cerebrum. o Hypothalamus-regulates and controls the autonomic nervous system, temperature, appetite, water balance sleep and blood vessel constriction and dilation. Also involved in emotions such as anger, fear, pleasure, pain and affection.  Midbrain-the section located below the cerebrum at the top of the brain stem. Responsible for conducting impulses between brain parts and for certain eye and auditory reflexes.  Pons-located below the midbrain and in the brain stem. Responsible for conducting messages to other parts of the brain; for certain reflex actions including chewing, tasting, and saliva production; and for assisting with respiration.  Medulla oblongata-the lowest part of the brain stem. Connects with the spinal cord and is responsible for regulating heartbeat, respiration, swallowing, coughing, and blood pressure. The spinal cord continues down from the medulla oblongata and ends at the first or second lumbar vertebrae. *The meninges are three membranes that cover and protect the brain and spinal cord. 1. 2. 3. Dura mater-thick, tough, outer layer Arachnoid membrane-delicate and web like Pia mater-closely attached to the brain and spinal cord and contains blood vessels that nourish the nerve tissue. The brain has four ventricles, hollow spaces that connect with each other and with the space under the arachnoid membrane. The ventricles are filled with a fluid called cerebrospinal fluid. This fluid circulates continually between the ventricles and through the subarachnoid space. It serves as a shock absorber to protect the brain and spinal cord. It also carries nutrients to some parts of the brain and spinal cord and helps remove metabolic products and wastes. After circulating, it is absorbed into the blood vessels of the dura mater and returned to the bloodstream through special structures called the arachnoid villi. The peripheral nervous system consists of the somatic and autonomic nervous systems. The somatic nervous system consists of 12 pairs of cranial nerves and their branches and 31 pairs of spinal nerves and their branches. Some of the cranial nerves are responsible for special senses such as sight, hearing, taste, and smell. The Autonomic nervous system is an important part of the peripheral nervous system. It helps maintain a balance in the involuntary functions of the body and allows the body to react in times of emergency. *There are two divisions to the autonomic nervous system: Sympathetic nervous system: prepares the body in times of emergencies. Prepares the body to act by increasing heart rate, respiration, and blood pressure and slowing activity in the digestive tract. This is known as the fight or flight response. Parasympathetic nervous system: After the emergency, this slows down the heart rate, decreases respirations, lowers blood pressure and increases activity in the digestive tract. Cerebral Palsy is a disturbance in voluntary muscle action and is caused by brain damage. Lack of oxygen to the brain, birth injuries, prenatal rubella, and infections can all cause cerebral palsy. Cerebrovascular Accident or CVA (stroke) occurs when the blood flow to the brain is impaired, resulting in a lack of oxygen and a destruction of brain tissue. CVA includes loss of consciousness; weakness or 1. 2. paralysis on one side of the body (hemiplegia); dizziness; dysphagia (difficulty swallowing); visual disturbances; mental confusion; aphasia (speech and language impairment); and incontinence. When a CVA occurs, immediate care within the first three hours can help prevent brain damage. Treatment with thrombolytic or “clot-busting” drugs such as TPA (tissue plasminogen activator) can dissolve the blood clot and restore blood flow to the brain. Aphasia is a speech or language impairment. There are different types. ALS is amyotrophic lateral sclerosis. Also called Lou Gehrig’s disease. This is a chronic degenerative neuromuscular disease. The cause is unknown. Carpal tunnel syndrome is a progressive, painful condition of the wrist and hand. It occurs when the median nurse is pinched or compressed. Concussions are traumatic brain injuries, usually from a blow to the head by an accident, injury or fall. The brain slides back/forward and forcefully hits against the skull. Think of it like a bruise on the brain. Encephalitis is an inflammation of the brain and is caused by a virus, bacterium, or chemical agent. Epilepsy or seizure syndrome is a brain disorder associated with abnormal electrical impulses in the neurons of the brain. Hydrocephalus is an excessive accumulation of cerebrospinal fluid in the ventricles and, in some cases, the subarachnoid space of the brain. It is usually cause by a congenital (at birth) defect, infection, or tumor that obstructs the flow of cerebrospinal fluid out of the brain. The condition is treated by the surgical implantation of a shunt (tube) between the ventricles and the veins, heart, or abdominal peritoneal cavity to provide for drainage of the excess fluid. Meningitis is an inflammation of the meninges of the brain and/or spinal cord and is caused by a bacterium, virus, fungus, or toxins such as lead and arsenic. Multiple Sclerosis (MS) is a chronic, progressive, disabling condition resulting from a degeneration of the myelin sheath in the central nervous system. Neuralgia is nerve pain. Inflammation, pressure, toxins, and other disease cause it. Paralysis usually results from a brain or spinal cord injury that destroys neurons and results in a loss of function and sensation below the level of injury. Hemiplegia is paralysis on side of the body and is caused by a tumor, injury, or CVA. Paraplegia is paralysis in the lower extremities or lower part of the body and is caused by a spinal cord injury. Quadriplegia is paralysis of t harems, legs, and body below the spinal cord injury. Parkinson’s disease is a chronic, progressive condition involving degeneration of brain cells, usually in persons over 50 years of age
Updated 67d ago
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Perception The process of organizing and interpreting sensory information to give meaning to our environment. Bottom-up processing An approach where perception starts with sensory input and works up to the brain's integration of this information. Top-down processing Information processing guided by higher-level mental processes, drawing on experience and expectations to construct perceptions. Schema A concept or framework that organizes and interprets information. Perceptual set A mental predisposition to perceive one thing and not another. Gestalt psychology Emphasizes that we often perceive the whole rather than the sum of the parts. Closure The perceptual tendency to mentally fill in gaps in a visual image to perceive objects as wholes. Figure and ground The organization of the visual field into objects (figures) that stand out from their surroundings (ground). Proximity The perceptual tendency to group together visual and auditory events that are near each other. Similarity The perceptual tendency to group together elements that seem alike. Attention The focusing of mental resources on select information. Selective attention The focusing of conscious awareness on a particular stimulus. Cocktail party effect The ability to focus auditory attention on a particular stimulus while filtering out other stimuli. Inattentional blindness Failing to see visible objects when attention is directed elsewhere. Change Blindness Failing to notice changes in the environment. Binocular depth cues Depth cues, such as retinal disparity, that depend on the use of two eyes. Retinal disparity A binocular cue for perceiving depth by comparing images from the retinas in the two eyes. Convergence A binocular cue for perceiving depth by the extent to which the eyes converge inward when looking at an object. Monocular depth cues Depth cues, such as interposition and linear perspective, available to either eye alone. Relative clarity A monocular cue for perceiving depth; hazy objects are seen as farther away than sharp, clear objects. Relative size A cue that allows determining the closeness of objects to an object of known size. Texture gradient A gradual change from coarse to fine texture signaling increasing distance. Linear perspective Parallel lines appear to converge with distance. Aptitude tests Tests designed to predict a person's future performance; aptitude is the capacity to learn. Fixed mindset The idea that we have a set amount of an ability that cannot change. Growth mindset The belief that one's skills and qualities can change and improve through effort and dedication. Explicit memory Memory of facts and experiences that one can consciously know and 'declare.' Episodic memory The collection of past personal experiences that occurred at a particular time and place. Semantic memory Memory for factual information. Implicit memory Retention independent of conscious recollection. Procedural memory A type of long-term memory of how to perform different actions and skills. Prospective memory Remembering to perform a planned action or recall a planned intention at some future point in time. Long-term potentiation An increase in a cell's firing potential after brief, rapid stimulation. Believed to be a neural basis for learning and memory. Working memory model A model that suggests that memory involves a series of active, temporary memory stores that manipulate information. Working memory A newer understanding of short-term memory that involves conscious, active processing of incoming auditory and visual-spatial information, and of information retrieved from long-term memory. Central executive The part of working memory that directs attention and processing. Phonological loop The part of working memory that holds and processes verbal and auditory information. Visuospatial sketchpad The part of working memory that holds visual and spatial information. Multi-store model A model of memory that suggests information passes through three stages: sensory memory, short-term memory, and long-term memory. Sensory memory The immediate, very brief recording of sensory information in the memory system. Iconic memory A momentary sensory memory of visual stimuli; a photographic or picture-image memory lasting no more than a few tenths of a second. Echoic memory A momentary sensory memory of auditory stimuli; if attention is elsewhere, sounds and words can still be recalled within 3 or 4 seconds. Short-Term Memory Activated memory that holds a few items briefly before the information is stored or forgotten. Long-Term Memory The relatively permanent and limitless storehouse of the memory system. Includes knowledge, skills, and experiences. Automatic processing Unconscious encoding of incidental information, such as space, time, and frequency, and of well-learned information. Effortful processing Encoding that requires attention and conscious effort. Encoding The processing of information into the memory system—for example, by extracting meaning. Storage The retention of encoded information over time. Retrieval The process of getting information out of memory storage. Levels of processing model The theory that deeper levels of processing result in longer-lasting memory codes. Shallow encoding Processing information based on its surface characteristics. Deep encoding Processing information based on its meaning and the significance of the information. Mnemonic devices Memory aids, especially those techniques that use vivid imagery and organizational devices. Method of loci A mnemonic device that involves imagining placing items around a room or along a route. Chunking-Grouping Organizing items into familiar, manageable units; often occurs automatically. Categories-Grouping Grouping information into categories that share common attributes. Hierarchies-Grouping Organizing items into a hierarchy, starting with general categories and working down to specific examples. Spacing effect The tendency for distributed study or practice to yield better long-term retention than is achieved through massed study or practice. Massed practice Cramming information all at once. It is less effective than spaced practice. Distributed practice Spacing the study of material to be remembered by including breaks between study periods. Serial position effect Our tendency to recall best the last and first items in a list. Primacy effect The tendency to remember information at the beginning of a body of information better than the information that follows. Recency effect The tendency to remember information that is presented last. Maintenance rehearsal Repeating information over and over to keep it active in short-term memory. Elaborative rehearsal A method of transferring information from short-term to long-term memory by making that information meaningful in some way. Memory retention The ability to retain information over time through the storage and retrieval of information. Autobiographical memory The memory for events and facts related to one's personal life story. Retrograde amnesia An inability to retrieve information from one's past. Anterograde amnesia An inability to form new memories. Alzheimer's disease A progressive and irreversible brain disorder characterized by gradual deterioration of memory, reasoning, language, and, finally, physical functioning. Infantile amnesia The inability to retrieve memories from much before age 3. Recall A measure of memory in which the person must retrieve information learned earlier, as on a fill-in-the-blank test. Recognition A measure of memory in which the person need only identify items previously learned, as on a multiple-choice test. Retrieval cues Stimuli that aid the recall or recognition of information stored in memory. Context-dependent memory The theory that information learned in a particular situation or place is better remembered when in that same situation or place. Mood-congruent memory The tendency to recall experiences that are consistent with one's current good or bad mood. State-dependent memory The theory that information learned in a particular state of mind (e.g., drunk, sober) is more easily recalled when in that same state of mind. The forgetting curve A graph showing retention and forgetting over time. Encoding failure The failure to process information into memory. Proactive interference The disruptive effect of prior learning on the recall of new information. Retroactive interference The disruptive effect of new learning on the recall of old information. Tip-of-the-tongue phenomenon The temporary inability to remember something you know, accompanied by a feeling that it's just out of reach. Repression The basic defense mechanism that banishes from consciousness anxiety-arousing thoughts, feelings, and memories. Misinformation effect Incorporating misleading information into one's memory of an event. Source amnesia Attributing to the wrong source an event we have experienced, heard about, read about, or imagined. Constructive memory The process by which memories are influenced by the meaning we give to events. Memory consolidation The neural storage of a long-term memory. Imagination inflation The increased confidence in a false memory of an event following repeated imagination of the event. Health Psychology A branch of psychology that focuses on how physical activities, psychological traits, and social relationships affect overall health and illness. Stress The process by which we perceive and respond to certain events, called stressors, that we appraise as threatening or challenging. Hypertension High blood pressure, often associated with stress, which can increase the risk of heart and kidney diseases and stroke. Immune Suppression Reduction in the effectiveness of the immune system, which can be caused by various forms of stress. Stressors Events or conditions in your surroundings that may trigger stress. Daily Hassles Everyday minor events that cause stress, such as traffic jams or overwhelming chores. Significant Life Changes Major life transitions like moving, leaving a job, or divorcing, which can be stressful. Catastrophes Unpredictable, large-scale events that cause significant stress and alter the lives of many people. Eustress (motivating) Positive stress which results from striving toward a challenging goal. Distress (debilitating) Negative stress that can make a person sick or keep a person from reaching a goal. Adverse Childhood Experiences (ACEs) Potentially traumatic events that occur in childhood and can have negative, lasting effects on health and well-being. General Adaptation Syndrome (GAS) The three-stage process (alarm, resistance, exhaustion) that describes the physiological changes the body goes through when under stress. Alarm Reaction Phase The initial reaction to a stressor, activating the body's defense systems. Resistance Phase The body's response after the initial shock of a stressful event, where the body attempts to return to normal functioning. Flight-Fight-Freeze Response A physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. Exhaustion Phase The third stage of the GAS, during which the body depletes its resources in responding to a prolonged stressor. Tend-and-Befriend Theory A theory that suggests people seek social support and tend to others in times of stress. Problem-focused Coping Strategies aimed at tackling the cause of stress in practical ways which directly tackle the problem causing the stress. Emotion-focused Coping Strategies aimed at relieving or managing the emotional distress associated with stress. Positive Psychology The scientific study of human strengths and virtues that enable individuals and communities to thrive. Subjective Well-being An individual's own assessment of their happiness and satisfaction with life. Resilience The ability to mentally or emotionally cope with a crisis or to return to pre-crisis status quickly. Posttraumatic Growth Positive psychological change experienced as a result of adversity and other challenges in order to rise to a higher level of functioning. Positive Emotions Feelings that engage us, elevate us, and promote growth and well-being. Gratitude A feeling of thankfulness and appreciation, especially in response to someone doing something kind or helpful. Signature Strengths & Virtues Character strengths and virtues that are personally fulfilling, intrinsic to one's identity, and contribute to the collective well-being. Categories of Virtues Broad categories that encompass character strengths, such as wisdom, courage, humanity, justice, temperance, and transcendence. Abnormal Psychology The study of psychological disorders, including their symptoms, etiology (i.e., their causes), and treatment. Clinical Psychology A branch of psychology that studies, assesses, and treats people with psychological disorders. Psychology Student Syndrome A phenomenon where psychology students begin to believe they have the disorders they are studying. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) The updated manual that describes and categorizes mental disorders in order to improve diagnoses, treatment, and research. International Classification of Mental Disorders (ICD) A standard diagnostic tool for epidemiology, health management, and clinical purposes. It is maintained by the World Health Organization (WHO) and covers a broad range of health conditions, including psychological conditions. Deviation In psychology, typically refers to departing from the norm, which can either be statistical, social, or functional in nature. Distress Negative stress that can lead to anxiety, depression, and potentially to physical problems. Dysfunction Abnormal functioning, as opposed to normal functioning, often used to refer to individual behaviors or the functioning of social systems. Eclectic Approach An approach to clinical practice that involves selecting the best treatment techniques from various disciplines based on the client's unique problems, strengths, and preferences. Behavioral Perspective Focuses on how we learn observable responses and how the environment impacts those responses. Psychodynamic Perspective Emphasizes the influence of the unconscious mind on behavior and the importance of childhood experiences. Humanistic Perspective Focuses on the importance of being your true self in order to lead the most fulfilling life. Cognitive Perspective Focuses on how we encode, process, store, and retrieve information. Evolutionary Perspective How the natural selection of traits promotes the perpetuation of one's genes. Sociocultural Perspective Examines how the social environments and cultural upbringing influence an individual's behavior and thoughts. Biological Perspective Explores the links between brain and mind, and how the body and brain enable emotions, memories, and sensory experiences. Biopsychosocial Model An integrated approach that incorporates biological, psychological, and social-cultural levels of analysis to better understand health and illness. Diathesis-Stress Model Suggests that a person may be predisposed for a psychological disorder that remains unexpressed until triggered by stress. Stigma Disapproval or discrimination against a person based on perceivable social characteristics that serve to distinguish them from other members of society. Anxiety Disorders Mental health disorders characterized by significant feelings of anxiety and fear. Specific Phobia An anxiety disorder characterized by irrational and persistent fear of a specific object, situation, or activity. Acrophobia Fear of heights. Arachnophobia Fear of spiders. Agoraphobia Fear of open or crowded spaces. Panic Disorder An anxiety disorder that consists of sudden, overwhelming attacks of terror. Ataque de nervios A cultural syndrome primarily seen in Latin Americans, involving symptoms of intense emotional upset, acute anxiety, fear, or anger. Social Anxiety Disorder A chronic mental health condition in which social interactions cause irrational anxiety. Taijin Kyofusho A Japanese culture-specific syndrome characterized by an intense fear that one's body, body parts, or bodily functions give others a negative impression. Generalized Anxiety Disorder An anxiety disorder in which a person is continually tense, apprehensive, and in a state of autonomic nervous system arousal. Obsessive-Compulsive Disorders Disorders involving intrusive obsessions and compulsions which impede daily life. Obsessions Persistent ideas, thoughts, or impulses that are unwanted and inappropriate and cause marked distress. Compulsions Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession. Hoarding Disorder A disorder characterized by the persistent difficulty discarding or parting with possessions, regardless of their actual value. Trauma and Stressor-Related Disorders Disorders related to the exposure to a traumatic or stressful event. Posttraumatic Stress Disorder A disorder characterized by failure to recover after experiencing or witnessing a terrifying event. Depressive Disorders Disorders that involve the presence of sad, empty, or irritable mood, accompanied by physical and cognitive changes that significantly affect the individual's capacity to function. Major Depressive Disorder A mood disorder causing a persistent feeling of sadness and loss of interest. Persistent Depressive Disorder A form of depression that is less severe than major depressive disorder but more chronic. Bipolar Disorder A disorder associated with episodes of mood swings ranging from depressive lows to manic highs. Bipolar Cycling The process of cycling through episodes of mania and depression in bipolar disorder. Bipolar I Disorder A type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode. Bipolar II Disorder A type of bipolar disorder marked by milder episodes of hypomania that alternate with periods of severe depression. Neurodevelopmental Disorders A group of conditions with onset in the developmental period, often before school age, that are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning. Attention-Deficit/Hyperactivity Disorder (ADHD) A chronic condition including attention difficulty, hyperactivity, and impulsiveness. Autism Spectrum Disorder (ASD) A disorder that affects communication and behavior. Feeding and Eating Disorders Disorders characterized by abnormal or disturbed eating habits, which negatively affect a person's health. Anorexia Nervosa An eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body weight. Bulimia Nervosa An eating disorder characterized by binge eating followed by purging. Schizophrenic Spectrum Disorders A range of disorders that involve psychosis, including schizophrenia. Delusions False beliefs, often of persecution or grandeur, that may accompany psychotic disorders. Delusions of Persecution The belief that others are out to get one. Delusions of Grandeur A false belief that one is more important or influential than they really are. Hallucinations False sensory experiences, such as seeing something in the absence of an external visual stimulus. Disorganized Thinking A symptom of psychosis, manifested as illogical or incoherent thought and speech. Disorganized Speech A style of talking involving incoherence and a lack of typical logical patterns. Word Salad A confused or unintelligible mixture of seemingly random words and phrases. Disorganized Motor Behavior Includes a variety of unusual behaviors including problems with goal-directed behavior leading to difficulties performing activities of daily living. Catatonia A state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate. Flat Affect A lack of emotional responsiveness. Dopamine Hypothesis The theory that schizophrenia results from an excess of dopamine activity. Positive Symptoms Symptoms of schizophrenia that are excesses of behavior or occur in addition to normal behavior; hallucinations, delusions, and disorganized speech. Negative Symptoms Symptoms of schizophrenia that are marked by deficits in functioning, such as apathy, lack of emotion, and slowed speech and movement. Dissociative Disorders Disorders in which conscious awareness becomes separated (dissociated) from previous memories, thoughts, and feelings. Dissociative Amnesia A disorder characterized by the sudden and extensive inability to recall important personal information, usually of a traumatic or stressful nature. Dissociative Fugue A rare dissociative disorder in which a person loses awareness of their identity or other important autobiographical information and also engages in some form of unexpected travel. Dissociative Identity Disorder A disorder characterized by the presence of two or more distinct personality states. Personality Disorders Psychological disorders characterized by inflexible and enduring behavior patterns that impair social functioning. Cluster A Personality Disorders Odd, eccentric thinking or behavior (including paranoid, schizoid, and schizotypal personality disorders). Paranoid Personality Disorder Type of personality disorder characterized by extreme distrust and suspicion of others. Schizoid Personality Disorder A personality disorder characterized by persistent avoidance of social relationships and little expression of emotion. Schizotypal Personality Disorder A personality disorder characterized by severe social anxiety, thought disorder, paranoid ideation, derealization, transient psychosis, and often unconventional beliefs. Cluster B Personality Disorders Dramatic, overly emotional or unpredictable thinking or behavior (including antisocial, borderline, histrionic, and narcissistic personality disorders). Antisocial Personality Disorder A personality disorder characterized by a lack of conscience for wrongdoing, even toward friends and family. Histrionic Personality Disorder A personality disorder characterized by excessive emotionality and attention seeking. Narcissistic Personality Disorder A disorder in which a person has an inflated sense of self-importance. Borderline Personality Disorder A personality disorder characterized by severe instability in emotions and self-image, along with impulsive and reckless behavior. Cluster C Personality Disorders Anxious, fearful thinking or behavior, including avoidant, dependent, and obsessive-compulsive personality disorders. Avoidant Personality Disorder A personality disorder characterized by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent Personality Disorder A personality disorder characterized by psychological dependence on other people. Obsessive-Compulsive Personality Disorder A personality disorder characterized by preoccupation with orderliness, perfection, and control. Deinstitutionalization The release of institutionalized individuals from institutional care to community-based care. Evidence-Based Interventions Treatments based on scientific evidence. Cultural Humility An approach to engagement across cultures emphasizing openness and self-awareness of one's own cultural identities. Therapeutic Alliance The relationship between a healthcare professional and a client. Conformity Adjusting one's behavior or thinking to coincide with a group standard. Normative Social Influence Influence resulting from a person's desire to gain approval or avoid disapproval. Social Norms Expected standards of conduct, which influence behavior. Social Comparison Evaluating one's abilities and opinions by comparing oneself to others. Relative Deprivation The perception that one is worse off relative to those with whom one compares oneself. Upward Social Comparison Comparing oneself with others who are better off. Downward Social Comparison Comparing oneself with others who are worse off. Informational Social Influence Influence resulting from one's willingness to accept others' opinions about reality. Obedience Following the directives of authority. Social Facilitation Improved performance on simple or well-learned tasks in the presence of others. Group Polarization The enhancement of a group's prevailing inclinations through discussion within the group. Groupthink The mode of thinking that occurs when the desire for harmony in a decision-making group overrides a realistic appraisal of alternatives. Bystander Effect The tendency for any given bystander to be less likely to give aid if other bystanders are present. Diffusion of Responsibility Diminished sense of responsibility among group members to act because others are seen as equally responsible. Social Loafing The tendency for people in a group to exert less effort when pooling their efforts toward attaining a common goal than when individually accountable. Deindividuation The loss of self-awareness and self-restraint occurring in group situations that foster arousal and anonymity. Attribution Theory The theory that we explain someone's behavior by crediting either the situation or the person's disposition. Dispositional Attributions Attributing behavior to the person's disposition and traits. Situational Attributions Attributing behavior to the environment. Explanatory Style A person's habitual way of explaining events, typically assessed along three dimensions: internal/external, stable/unstable, and global/specific. Optimistic Explanatory Style Explaining bad events as results of temporary, external causes. Pessimistic Explanatory Style Explaining bad events as results of stable, internal causes. Fundamental Attribution Error The tendency for observers, when analyzing others' behavior, to underestimate the impact of the situation and to overestimate the impact of personal disposition. Actor-Observer Bias The tendency to attribute one's own actions to external causes while attributing other people's behaviors to internal causes. Self-Serving Bias A readiness to perceive oneself favorably. Internal Locus of Control The perception that one controls one's own fate. External Locus of Control The perception that chance or outside forces beyond one's personal control determine one's fate. Altruism Unselfish regard for the welfare of others. Social Responsibility Norm An expectation that people will help those needing their help. Stereotype A generalized belief about a group of people. Confirmation Bias The tendency to interpret new evidence as confirmation of one's existing beliefs or theories. Belief Perseverance Clinging to one's initial conceptions after the basis on which they were formed has been discredited. Self-Fulfilling Prophecy A belief that leads to its own fulfillment. Prejudice An unjustifiable and usually negative attitude toward a group and its members. Discrimination Unjustifiable negative behavior toward a group and its members. Implicit Attitudes Attitudes that influence a person's feelings and behavior at an unconscious level. Just-World Phenomenon The tendency for people to believe the world is just and that people therefore get what they deserve. Out-Group Homogeneity Bias Perception of out-group members as more similar to one another than are in-group members. In-Group Bias The tendency to favor one's own group. Mere Exposure Effect The phenomenon that repeated exposure to novel stimuli increases liking of them. Ethnocentrism Evaluating other cultures according to the standards and customs of one's own culture. Collectivism Giving priority to the goals of one's group and defining one's identity accordingly. Multiculturalism The practice of valuing and respecting differences in culture. Superordinate Goals Shared goals that override differences among people and require their cooperation. Social Traps A situation in which conflicting parties, by each rationally pursuing their self-interest, become caught in mutually destructive behavior. Persuasion The process of creating, reinforcing, or changing people's beliefs or actions. Elaboration Likelihood Model A theory of how persuasive messages lead to attitude changes. Central Route of Persuasion Attitude change path in which interested people focus on the arguments and respond with favorable thoughts. Peripheral Route of Persuasion Attitude change path in which people are influenced by incidental cues, such as a speaker's attractiveness. Halo Effect The tendency to draw a general impression about an individual on the basis of a single characteristic. Foot-in-the-Door Technique The tendency for people who have first agreed to a small request to comply later with a larger request. Door-in-the-Face Technique The strategy of getting someone to agree to a modest request by first asking them to agree to a much larger request that they will likely turn down. False Consensus Effect The tendency to overestimate the extent to which others share our beliefs and behaviors. Cognitive Dissonance The theory that we act to reduce the discomfort we feel when two of our thoughts are inconsistent. Industrial-Organizational (I/O) Psychologists Psychologists who apply psychology's principles to the workplace. Instincts A complex behavior that is rigidly patterned throughout a species and is unlearned. Drive-Reduction Theory The idea that a physiological need creates an aroused tension state (a drive) that motivates an organism to satisfy the need. Homeostasis The tendency to maintain a balanced or constant internal state; the regulation of any aspect of body chemistry, such as blood glucose, around a particular level. Ghrelin Hormone secreted by an empty stomach; sends 'I'm hungry' signals to the brain. Leptin Hormone secreted by fat cells; when abundant, causes brain to increase metabolism and decrease hunger. Hypothalamus A neural structure lying below the thalamus; directs several maintenance activities (eating, drinking, body temperature), helps govern the endocrine system via the pituitary gland, and is linked to emotion and reward. Pituitary Gland The endocrine system's most influential gland. Under the influence of the hypothalamus, the pituitary regulates growth and controls other endocrine glands. Belongingness The human emotional need to be an accepted member of a group. Arousal Theory The theory that people are motivated to maintain an optimal level of alertness and physical and mental activation. Yerkes-Dodson Law The principle that performance increases with arousal only up to a point, beyond which performance decreases. Sensation-Seeking Theory The search for experiences and feelings that are varied, novel, complex, and intense. Thrill Seeking Pursuing activities that provide a rush of adrenaline. Adventure Seeking Engaging in unusual and exciting activities. Disinhibition Acting impulsively, without considering the consequences. Boredom Susceptibility Tendency to experience boredom and frustration when not engaged in stimulating activities. Incentive Theory A theory that states that behavior is motivated by a desire for reinforcement or incentives. Extrinsic Motivation A desire to perform a behavior to receive promised rewards or avoid threatened punishment. Self-Determination Theory A theory of motivation that is concerned with the beneficial effects of intrinsic motivation and the harmful effects of extrinsic motivation. Intrinsic Motivation A desire to perform a behavior effectively for its own sake. Lewin's Motivational Conflicts Theory A theory that describes situations in which conflicting motivations produce indecision and difficulty. Approach-Approach Conflicts Conflict that results from having to choose between two attractive alternatives. Avoidance-Avoidance Conflicts Conflict that results from having to choose between two distasteful alternatives. Approach-Avoidance Conflicts Conflict that results when a single action or event has both attractive and unattractive features. Emotion A response of the whole organism, involving (1) physiological arousal, (2) expressive behaviors, and (3) conscious experience. Affect A broad range of feelings that people experience. Facial-Feedback Hypothesis The idea that facial expressions can influence emotions as well as reflect them. Display Rules Culturally determined rules about which nonverbal behaviors are appropriate to display. Elicitors Stimuli that trigger emotional responses. Broaden-and-Build Theory of Emotion Theory proposing that happiness predisposes us to think more openly. Universal Emotions Basic emotions that are expressed by all cultures around the world such as happiness, sadness, fear, disgust, anger, and surprise. Psychodynamic Theory A view that explains personality in terms of conscious and unconscious forces, such as unconscious desires and beliefs. Preconscious Mind The level of consciousness that is not currently in focal awareness. Unconscious Mind A reservoir of mostly unacceptable thoughts, wishes, feelings, and memories. Denial Psychoanalytic defense mechanism by which people refuse to believe or even to perceive painful realities. Displacement Defense mechanism that shifts sexual or aggressive impulses toward a more acceptable or less threatening object or person. Projection Defense mechanism by which people disguise their own threatening impulses by attributing them to others. Rationalization Defense mechanism that offers self-justifying explanations in place of the real, more threatening, unconscious reasons for one's actions. Reaction Formation Defense mechanism by which the ego unconsciously switches unacceptable impulses into their opposites. Regression Defense mechanism in which an individual faced with anxiety retreats to a more infantile psychosexual stage. Repression Defense mechanism by which anxiety-provoking thoughts and feelings are forced to the unconscious. Sublimation Defense mechanism by which people re-channel their unacceptable impulses into socially approved activities. Humanistic Psychology A historically significant perspective that emphasized the growth potential of healthy people. Unconditional Regard An attitude of total acceptance toward another person. Self-Actualizing Tendency The human motive toward realizing our inner potential. Social-Cognitive Theory Views behavior as influenced by the interaction between people's traits (including their thinking) and their social context. Reciprocal Determinism The interacting influences of behavior, internal cognition, and environment. Self-Concept All our thoughts and feelings about ourselves, in answer to the question, 'Who am I?' Self-Efficacy One's sense of competence and effectiveness. Self-Esteem One's feelings of high or low self-worth. Trait Theories Theories that endeavor to describe the characteristics that make up human personality in an effort to predict future behavior. Big Five Theory The theory that there are five basic personality traits: openness, conscientiousness, extraversion, agreeableness, and neuroticism (emotional stability). Personality Inventories A questionnaire (often with true-false or agree-disagree items) on which people respond to items designed to gauge a wide range of feelings and behaviors; used to assess selected personality traits. Factor Analysis A statistical procedure that identifies clusters of related items (called factors) on a test; used to identify different dimensions of performance that underlie one's total score. Openness to Experience One of the five factors; willingness to try new things and be open to new experiences. Conscientiousness One of the five factors; a tendency to show self-discipline, act dutifully, and aim for achievement. Extraversion One of the five factors; energy, positive emotions, and the tendency to seek stimulation and the company of others. Agreeableness One of the five factors; a tendency to be compassionate and cooperative rather than suspicious and antagonistic towards others. Behavioral Perspective Emphasizes learning and behavior in explaining thoughts, feelings, and actions. Associative Learning Making connections between events to learn. Habituation Becoming less responsive to a repeated stimulus. Classical Conditioning Pairing two stimuli to elicit a response. Unconditioned Stimulus (UCS) Naturally triggers a response without learning. Conditioned Stimulus (CS) Initially neutral, triggers a conditioned response. Acquisition Initial learning stage where a response is established. Extinction Diminishing of a conditioned response. Spontaneous Recovery Reappearance of an extinguished response after a pause. Stimulus Discrimination Ability to differentiate between stimuli. Stimulus Generalization Conditioned stimulus evokes similar responses. Higher-Order Conditioning Pairing a conditioned stimulus with a new one. Counterconditioning Uses conditioning to change responses to triggers. Taste Aversion Avoidance of food associated with discomfort. One-Trial Conditioning Learning with only one pairing of stimulus and response. Biological Preparedness Inclination to form associations between stimuli and responses. Operant Conditioning Learning through rewards and punishments. The Law of Effect Behaviors with favorable consequences are repeated. Reinforcement Strengthens behavior it follows. Primary Reinforcers Innately reinforcing stimuli satisfying biological needs. Secondary Reinforcers Gains reinforcing power through association. Punishment Event decreasing behavior it follows. Shaping Positive reinforcement of behavior patterns. Instinctive Drift Tendency to revert to instinctive behaviors. Fine Motor Coordination The ability to make small, precise movements, typically involving the coordination of the hands and fingers with the eyes. Gross Motor Coordination The ability to make large, general movements, such as crawling and walking. Maturation Biological growth processes that enable orderly changes in behavior, relatively uninfluenced by experience. Reflexes Automatic responses to sensory stimuli, like grasping a finger tightly with the hands. Rooting Reflex A baby's tendency, when touched on the cheek, to turn toward the touch, open the mouth, and search for the nipple. Visual Cliff A laboratory device for testing depth perception in infants and young animals. Critical Periods Specific time periods during which an organism must experience stimuli in order to develop normally. Sensitive Periods Times in development when a person is particularly open to certain kinds of experiences. Imprinting The process by which certain animals form strong attachments during early life. Growth Spurt A rapid increase in growth during puberty. Puberty The period of sexual maturation, during which a person becomes capable of reproducing. Primary Sex Characteristics The body structures (ovaries, testes, and external genitalia) that make sexual reproduction possible. Secondary Sex Characteristics Nonreproductive sexual traits, such as female breasts and hips, male voice quality, and body hair. Menarche The first menstrual period. Spermarche The first ejaculation. Menopause The time of natural cessation of menstruation; also refers to the biological changes a woman experiences as her ability to reproduce declines. Sex The biologically influenced characteristics by which people define males and females. Gender The socially influenced characteristics by which people define men and women. Socialization The process by which people learn the norms, rules, and information of a culture or society. Jean Piaget A psychologist known for his study of cognitive development in children. Sensorimotor Stage The first stage in Piaget's theory of cognitive development, from birth to about 2 years of age, during which infants know the world mostly in terms of their sensory impressions and motor activities. Object Permanence The awareness that things continue to exist even when not perceived. Preoperational Stage The second stage in Piaget's theory, from about 2 to 7 years of age, during which a child learns to use language but does not yet comprehend the mental operations of concrete logic. Mental Symbols Internal depictions of information that the mind can manipulate. Chronosystem In Bronfenbrenner's theory, this system encompasses changes over time in child development. Authoritarian Parenting A parenting style characterized by high demands and low responsiveness. Parents with this style have very high expectations of their children, yet provide very little in the way of feedback and nurturance. Authoritative Parenting A parenting style characterized by high demands and high responsiveness. Parents with this style set limits and enforce rules but also listen to their children. Permissive Parenting A parenting style characterized by low demands with high responsiveness. These parents tend to be very loving, yet provide few guidelines and rules. Attachment Styles Patterns of attachment, defined by different ways of interacting and behaving in relationships. Secure Attachment An attachment style characterized by trust, a lack of concern with being abandoned, and the view that one is worthy and well liked. Insecure Attachment Attachment styles characterized by fear of abandonment and the feeling that one's needs might not be met. Avoidant Attachment An attachment style characterized by difficulty in learning to trust others. Anxious Attachment An attachment style where individuals are often anxious about the stability of their relationships. Disorganized Attachment An attachment style characterized by a lack of clear attachment behavior. Temperament A person's characteristic emotional reactivity and intensity. Separation Anxiety Emotional distress seen in many infants when they are separated from people with whom they have formed an attachment. Contact Comfort The physical and emotional comfort that an infant receives from being in physical contact with its mother. Parallel Play Activity in which children play side by side without interacting. Pretend Play Play involving imaginary people and situations; also called fantasy play, dramatic play, or imaginative play. Egocentrism The inability to differentiate between self and other. More specifically, it is the inability to understand that others have different feelings, desires, and perspectives from one's own. Imaginary Audience A concept in adolescent psychology where an individual believes that his or her behavior is the main focus of others' attention and concern. Personal Fable An adolescent's belief that they are unique and protected from harm. Social Clock The culturally preferred timing of social events such as marriage, parenthood, and retirement. Emerging Adulthood A phase of the life span between adolescence and full-fledged adulthood which encompasses late adolescence and early adulthood, generally ages 18 to 25. Stage Theory of Psychosocial Development (Erikson) Erik Erikson's theory that identifies eight stages through which a healthily developing human should pass from infancy to late adulthood. Trust vs. Mistrust The first stage of Erik Erikson's theory of psychosocial development. This stage occurs between birth and approximately 18 months of age. During this stage, the infant learns if they can trust the world to fulfill their needs. Autonomy vs. Shame and Doubt The second stage of Erik Erikson's stages of psychosocial development. This stage occurs between the ages of 18 months to approximately 3 years. The child learns to be independent and confident or experiences shame and doubt about their abilities. Initiative vs. Guilt The third stage of Erik Erikson's stages of psychosocial development. This stage occurs during the preschool years, between the ages of 3 to 5 years. Children begin to assert control and power over their environment. Industry vs. Inferiority The fourth stage of Erik Erikson's stages of psychosocial development. This stage occurs between the ages of 5 and 12 years. Children learn to cope with new social and academic demands, success leads to a sense of competence, while failure results in feelings of inferiority. Identity vs. Role Confusion The fifth stage of Erik Erikson's stages of psychosocial development. This stage occurs during adolescence, from about 12-18 years. During this stage, adolescents explore their independence and develop a sense of self. Intimacy vs. Isolation The sixth stage of Erik Erikson's theory of psychosocial development. This stage occurs during young adulthood between the ages of approximately 19 and 40 years. Young adults need to form intimate, loving relationships with other people. Generativity vs. Stagnation The seventh stage of Erik Erikson's theory of psychosocial development. This stage takes place during middle adulthood between the ages of approximately 40 and 65. Individuals establish careers, settle down within relationships, begin families, and develop a sense of being a part of the bigger picture. Integrity vs. Despair The eighth and final stage of Erik Erikson's stages of psychosocial development. This stage occurs during old age and is focused on reflecting back on life. Adverse Childhood Experiences (ACEs) Potentially traumatic events that occur in childhood (0-17 years), such as experiencing violence, abuse, or neglect, witnessing violence in the home or community, and having a family member attempt or die by suicide. Achievement (adolescent development) In the context of identity development, this term refers to the successful integration of various aspects of self-concept, based on explorations of roles, values, and beliefs. Diffusion (adolescent development) A status of identity development where an individual has not yet experienced a crisis or made any commitments. They are undecided and uninterested in occupational and ideological choices. Foreclosure (adolescent development) A status of identity development where an individual has made a commitment without experiencing a crisis. This occurs when people commit to roles or values without exploring alternatives. Moratorium (adolescent development) A status of identity development where an individual is in the midst of a crisis but whose commitments are either absent or are only vaguely defined. Racial/Ethnic Identity An individual's awareness and experience of being a member of a racial or ethnic group, including the degree to which one's cultural, historical, and social aspects of identity are embraced. Sexual Orientation An inherent or immutable enduring emotional, romantic, or sexual attraction to other people. Religious Identity An individual's sense of belonging to a religious group, along with the importance of this group membership as it pertains to one's sense of self. Occupational Identity How a person identifies themselves based on their job or career choices and how they feel those roles impact their personal identity. Familial Identity The part of an individual's identity that is formed by the relationships they have with their family members. Possible Selves The aspect of oneself that includes all the ideas of what one might become, what one hopes to become, and what one is afraid of becoming. Evolutionary Perspective A way of looking at human behavior that emphasizes the role of natural selection and survival of the fittest in shaping our actions. Natural Selection A process where organisms better adapted to their environment tend to survive and produce more offspring. Nature Refers to the genetic or hereditary influences on behavior and traits. Nurture Refers to the environmental influences that shape behavior and traits after conception. Twin Studies Research that compares the similarities between identical and fraternal twins to understand the influence of genetics versus environment. Adoption Studies Studies that compare adopted children to their adoptive and biological parents to understand genetic and environmental influences. Family Studies Research that examines behavioral patterns or genetic markers across generations within families. Heredity The passing on of physical or mental traits genetically from one generation to another. Genetic Predisposition The increased likelihood of developing a particular disease or behavior based on a person's genetic makeup. Eugenics A controversial historical movement aimed at improving the genetic composition of the human race. Cerebral Cortex The outermost layer of the brain involved in high-level functions such as thought, language, and memory. Association Areas Parts of the brain that integrate different types of information from the senses and link it with stored memories. Lobes of the Brain Regions of the brain differentiated by their functions, including frontal, parietal, occipital, and temporal lobes. Frontal Lobes Areas of the brain involved in complex processes like reasoning, planning, and emotion. Prefrontal Cortex The part of the frontal lobes directly behind the forehead, involved in decision-making and self-control. Executive Functioning Higher-level cognitive processes including thinking, planning, and problem-solving. Motor Cortex The part of the brain that controls voluntary movements. Parietal Lobes Areas of the brain that process sensory information such as touch, temperature, and pain. Somatosensory Cortex A part of the parietal lobes that processes sensory input from various body areas. Occipital Lobes The part of the brain that processes visual information. Temporal Lobes Areas of the brain involved in processing auditory information and encoding memory. Corpus Callosum A large band of neural fibers that connects the left and right cerebral hemispheres and allows communication between them. Brainstem The central trunk of the brain continuing downward to form the spinal cord. Medulla The base of the brainstem that controls vital life-sustaining functions like heartbeat and breathing. Reticular Activating System A network of neurons in the brainstem that plays a role in waking and sleep. Cerebellum A part of the brain at the back of the skull that coordinates and regulates muscular activity. Limbic System A complex system of nerves and networks in the brain, controlling basic emotions and drives. Reward Center Brain regions that regulate the experience of pleasure, particularly related to survival and reward. Thalamus A structure deep within the brain that relays sensory signals to the cerebral cortex. Hypothalamus A small region at the base of the brain that directs several functions, including temperature regulation and energy maintenance. Pituitary Gland A gland at the base of the brain that controls growth and development. Hippocampus A part of the limbic system involved in learning and memory. Amygdala A structure in the limbic system involved in emotion, particularly fear and aggression. Nervous System The network of nerve cells and fibers that transmits nerve impulses between parts of the body. Central Nervous System The part of the nervous system consisting of the brain and spinal cord. Peripheral Nervous System All the nerves that lie outside the brain and spinal cord. Autonomic Nervous System The part of the nervous system responsible for control of the bodily functions not consciously directed, like breathing and the heartbeat. Sympathetic Nervous System The part of the autonomic nervous system that prepares the body for rapid action in emergencies. Parasympathetic Nervous System The part of the autonomic nervous system that calms the body and conserves energy. Somatic Nervous System The part of the peripheral nervous system associated with voluntary control of body movements via skeletal muscles. Neurons The basic working units of the brain, specialized cells that transmit information to other nerve cells, muscle, or gland cells. Glial Cells Cells in the nervous system that support, nourish, and protect neurons. Motor Neurons Neurons that carry outgoing information from the brain and spinal cord to the muscles and glands. Sensory Neurons Neurons that carry incoming information from the sensory receptors to the brain and spinal cord. Interneurons Neurons within the brain and spinal cord that communicate internally and intervene between the sensory inputs and motor outputs. Reflex Arc A neural pathway that controls a reflex action. Neural Transmission The process by which neurons communicate with each other by sending electrical or chemical signals. Threshold The level of stimulation required to trigger a neural impulse. Action Potential A neural impulse; a brief electrical charge that travels down an axon. All-or-Nothing Principle The rule that neurons are either on or off. Depolarization A change in a cell's membrane potential, making it more positive. Refractory Period A period immediately following stimulation during which a nerve or muscle is unresponsive to further stimulation. Resting Potential The state of the neuron when not firing a neural impulse. Reuptake A neurotransmitter's reabsorption by the sending neuron. Multiple Sclerosis (MS) A disease in which the immune system eats away at the protective covering of nerves. Myasthenia Gravis A chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles. Neurotransmitters Chemicals transmitting information across synapses to dendrites of receiving neurons. Excitatory Neurotransmitters Chemical messengers increasing the likelihood of neuron firing an action potential. Glutamate An excitatory neurotransmitter strengthening synaptic connections between neurons. Inhibitory Neurotransmitters Chemical messengers decreasing the likelihood of neuron firing an action potential. GABA A major inhibitory neurotransmitter in the brain. Dopamine A neurotransmitter influencing movement, learning, attention, and emotion. Serotonin A neurotransmitter affecting mood, hunger, sleep, and arousal. Endorphins Neurotransmitters influencing the perception of pain or pleasure. Substance P A neurotransmitter involved in transmitting pain messages to the brain. Acetylcholine A neurotransmitter enabling learning, memory, and triggering muscle contraction. Hormones Chemicals produced by glands regulating activities of different body cells. Ghrelin A hormone stimulating appetite, increasing food intake, and promoting fat storage. Leptin A hormone helping regulate energy balance by inhibiting hunger. Melatonin A hormone regulating sleep-wake cycles. Oxytocin A hormone acting as a neurotransmitter, influencing social behavior and emotion. Adrenaline A hormone released in response to physical or mental stress. Norepinephrine A hormone and neurotransmitter involved in arousal and fight-or-flight response. Plasticity The brain's ability to change and adapt due to experience. Split Brain Research Studies on patients with severed corpus callosum to understand brain hemisphere functions. Contralateral Hemispheric Organization Arrangement where the brain's right hemisphere controls the left side of the body and vice versa. Hemispheric Specialization Control of distinct functions by the brain's right and left hemispheres. Linguistic Processing Brain functions involved in understanding and producing language. Broca's Area Frontal lobe area directing muscle movements involved in speech. Broca's Aphasia Condition from damage to Broca's area causing impaired speaking and writing. Opioids A class of drugs including heroin and prescription pain relievers. Heroin An opioid drug made from morphine, derived from opium poppy plants. Tolerance Diminishing drug effect with regular use, necessitating larger doses. Addiction Compulsive craving for drugs or behaviors despite adverse consequences. Withdrawal Symptoms post cessation of drug intake in addicted individuals. Sensation Reception and representation of stimulus energies by sensory receptors. Transduction Conversion of stimulus energies into neural impulses in sensation. Perception Organization and interpretation of sensory information for object recognition. Absolute Threshold Minimum stimulus energy to detect a stimulus 50% of the time. Just-noticeable Difference Smallest difference in stimulus intensity detectable by a sense. Sensory Adaptation Decrease in sensitivity to constant stimulation levels. Weber's Law Principle that stimuli must differ by a constant proportion for detection. Synesthesia Condition where one sense is perceived as if by additional senses. Retina Light-sensitive eye surface with rods, cones, and neural processing layers. Blind Spot Point where optic nerve exits the eye, lacking receptor cells. Visual Nerve Nerve transmitting neural impulses from the eye to the brain. Lens Transparent eye structure behind the pupil, aiding image focus. Accommodation Process of lens shape change for focusing on near or far objects. Nearsightedness Clear vision for close objects but blurry for distant ones. Farsightedness Clear vision for distant objects but blurry for close ones. Photoreceptors Rods and cones in the retina converting light into neural signals. Rods Photoreceptors detecting black, white, and gray for peripheral vision. Cones Photoreceptors concentrated for daylight vision, color, and detail. Trichromatic Theory Theory of three color receptors in the retina for color perception. Opponent-process Theory Theory of opposing processes in color vision enabling perception. Psychology the scientific study of mental processes and behavior. Mental Processes Thoughts, feelings, and motives that each of us experiences privately but that cannot be directly observed. Behavior Any action that people can observe or measure Confirmation Bias The tendency to favor information that confirms your existing beliefs. Hindsight Bias The feeling after something happens that you knew it was going to happen. Overconfidence Being more confident than correct; overestimating the accuracy of your beliefs. Empirical Evidence Information from experiments or observations rather than theories. Scientific Method A step-by-step method for conducting research. Hypothesis A prediction that you can test through study and experimentation. Falsifiable Something that can be proven wrong through tests. Peer Review The process of having other experts examine your work to check its validity. Replication Repeating a study to see if the same results are obtained. Reliability The consistency of a research study or measuring test. Validity The accuracy of a test or research to measure what it claims to measure. The American Psychological Association (APA) A major organization for psychologists in the United States. Research Design The plan for a research study, determining how to collect and analyze data. Methodology The specific procedures or techniques used to identify, select, process, and analyze information about a topic. Quantitative Data Data that can be counted or measured and given a numerical value. Qualitative Data Data that describes qualities or characteristics. Likert Scales A scale used to represent people's attitudes or feelings; respondents specify their level of agreement to a statement. Structured Interviews Interviews where everyone is asked the same questions in the same way. Survey Technique A method of gathering information by asking questions to people. Wording Effect How the way a question is phrased can influence the answers given. Social Desirability Bias: The tendency of respondents to answer questions in a manner that will be viewed favorably by others. Naturalistic Observation Watching behaviors occur naturally without interfering. Case Study A detailed examination of a single subject or group. Correlational Research A study that investigates the relationship between two variables to determine if they vary together. Third Variable Problem A situation where an unseen variable affects the results of a study. Scatterplot A graph in which the values of two variables are plotted along two axes, the pattern of the resulting points revealing any correlation present. Correlation Coefficient A number between -1 and 1 that describes the strength and direction of a relationship between variables. Positive Correlation A relationship where if one variable increases, the other does too. Negative Correlation A relationship where if one variable increases, the other decreases. Experimental Method: A method where the researcher manipulates one variable to see if it affects another. Independent Variable The variable that is changed or controlled in a scientific experiment. Dependent Variable The variable that is tested and measured in a scientific experiment. Confounding Variable An extra variable that wasn't accounted for that could affect the results of an experiment. Operational Definitions Clearly defining how you will measure your variables in research. Experimental Group The group in an experiment that receives the variable being tested. Control Group The group in an experiment that does not receive the test variable. Random Assignment Assigning participants to experimental and control groups by chance, which helps ensure that any differences observed after the treatment are due to the treatment and not a preexisting difference. Placebo Effect A change in a participant's illness or behavior that results from a belief that the treatment will have an effect, rather than the actual treatment. Experimenter Bias When a researcher's expectations influence the outcome of a study. Single-Blind Study When the participants do not know whether they are receiving the treatment or not. Double-Blind Study When neither the participants nor the researchers know who is receiving a particular treatment. Placebo Condition A condition in which participants receive a placebo instead of the actual treatment. Sample A group of subjects selected from a larger population for study. Representative Sample: A randomly chosen sample of subjects from a larger population that accurately reflects the characteristics of the larger population. Random Sample A sample that fairly represents a population because each member has an equal chance of being included. Sample Bias A sample that does not accurately represent the population from which it was drawn. Generalizability The extent to which research findings can be applied to larger populations. Statistics The science of collecting, analyzing, presenting, and interpreting data. Descriptive Statistics Statistics that summarize data, such as mean or standard deviation Inferential Statistics: Statistics used to infer the properties of a population, based on a sample of data. Measure of Central Tendency: A statistical measure that describes the center of a data set; includes mean, median, and mode. Mean The average of a set of numbers. Median The middle number in a set of numbers arranged in order. Mode The number that appears most frequently in a data set. Range The difference between the highest and lowest values in a data set. Normal Curve A bell-shaped curve that shows data distribution; most scores fall near the middle. Regression to the Mean The phenomenon that extreme values in data tend to be closer to the average on subsequent measurements. Positive Skew When more scores fall on the low side of the scale and tail on the high side. Negative Skew When more scores fall on the high side of the scale and tail on the low side. Standard Deviation A measure of how spread out numbers are around the mean. Percentile Rank The percentage of scores in a distribution that a specific score is greater than. Bimodal Distribution A distribution of data with two modes or peaks. Statistical Significance The likelihood that a result from data collected by an experiment is not due to chance. Effect Sizes A measure of the strength of the relationship between two variables. Meta Analysis A method of combining data from many different research studies. Institutional Review Boards (IRB) Groups of people responsible for reviewing proposed research to ensure that it is ethical. Informed Consent Permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. Informed Assent Agreement by a minor or other not able to give legal consent to participate in the activity. Confidentiality Keeping information given by participants in a research study private. Deception Misleading participants about the true purpose of a study or the events that will transpire. Confederates Actors who take part in a study pretending to be real participants. Debriefing Explaining to participants at the end of a study the true purpose of the study and exactly what transpired.
Updated 216d ago
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Abate Definition: To reduce in intensity or amount. Adept Definition: Highly skilled or proficient in a particular area. Ambiguous Definition: Open to more than one interpretation; unclear. Apathy Definition: Lack of interest, enthusiasm, or concern. Benevolent Definition: Well-meaning and kindly; charitable. Candid Definition: Truthful and straightforward; frank. Concur Definition: To agree or have the same opinion. Diligent Definition: Showing care and effort in one's work or duties. Elicit Definition: To draw out a response or reaction. Empathy Definition: The ability to understand and share the feelings of another. Fluctuate Definition: To rise and fall irregularly in number or amount. Fortuitous Definition: Happening by accident or chance, often in a positive way. Imminent Definition: About to happen; impending. Juxtapose Definition: To place two or more things side by side for comparison. Mitigate Definition: To make less severe, serious, or painful. Nostalgia Definition: A sentimental longing for the past. Obsolete Definition: No longer produced or used; out of date. Paradox Definition: A statement that seems contradictory but may reveal a truth. Persevere Definition: To continue in a course of action despite difficulties. Prevalent Definition: Widespread in a particular area or at a particular time. Reconcile Definition: To restore friendly relations or settle a disagreement. Sanguine Definition: Optimistic or positive, especially in a difficult situation. Substantiate Definition: To provide evidence to support or prove the truth of something. Tangible Definition: Perceptible by touch; clear and definite. Ubiquitous Definition: Present, appearing, or found everywhere. Vicarious Definition: Experienced through the feelings or actions of another person. Wane Definition: To decrease in size, amount, or intensity. Zealous Definition: Having or showing passion and enthusiasm for a cause. Cognizant Definition: Having knowledge or being aware of. Dissonance Definition: Lack of harmony among musical notes; a tension or clash resulting from the combination of two disharmonious elements
Updated 232d ago
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1. advocate; verb – to support; to be in favor of. Because the candidate may advocate many new social programs, he is being called a big spender. 2. carping; adjective – complaining. His carping criticism of the book was upsetting to the author. 3. demeanor; noun – behavior. When the twins adopted a conciliatory tone, Sal’s demeanor changed abruptly. 4. elusive; adjective – hard to grasp; baffling. The philosopher’s main point was so elusive that we never did fully comprehend it. 5. fledgling; adjective – newly developed; little known. Luckily, the fledgling pilot’s egregious blunder was discovered before the plane departed. 6. gullible; adjective – easily deceived. The con man told a flagrant lie but the gullible investors swallowed it. 7. hyperbole; noun – an exaggerated statement used as a figure of speech for rhetorical effect. Ione uses hyperbole when galvanizing her sales force into a frenzy of selling. 8. imperturbable; adjective – not easily excited or disturbed. We couldn’t believe that Rafael would be that imperturbable in the midst of a riot. 9. laudable; adjective – worthy of praise. The board rewarded Ellen’s laudable achievements by promoting her to chief executive officer. 10. morose; adjective – gloomy; bad-tempered. Joan’s morose nature makes her always expect the worst. 11. overt; adjective – not hidden; open. Most observers took the senator’s speech as an overt bid for his renomination. 12. peerless; adjective – having no equal; better than the rest. Theresa’s peerless beauty was admired by all who saw her. 13. recalcitrant; adjective – refusing to obey or follow orders; unmanageably resistant. The mule is probably the most recalcitrant domesticated animal. 14. salutary; adjective – healthful; useful or helpful; remedial. Upon sagacious reflection, Simon realized that his parents’ rebuke though painful, was salutary. 15. taciturn; adjective – habitually untalkative; laconic; uncommunicative. Silas’s long years of solitude had made him a taciturn, brooding man unused even to the sound of his own voice
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Person, Time, and Conduct in Bali. The Social Nature of Thought Clifford Geertz Human thought is consummately social: social in its origins, social in its functions, social in its forms, social in its applications. At base, thinking is a public activity--its natural habitat is the houseyard, the marketplace, and the town square. The implications of this fact for the anthropological analysis of culture, my concern here, are enormous, subtle, and insufficiently appreciated. I want to draw out some of these implications by means of what might seem at first glance an excessively special, even a somewhat esoteric inquiry: an examination of the cultural apparatus in terms of which the people of Bali define, perceive, and react to--that is, think about--individual persons. Such an investigation is, however, special and esoteric only in the descriptive sense. The facts, as facts, are of little immediate interest beyond the confines of ethnography, and I shall summarize them as briefly as I can. But when seen against the background of a general theoretical aim--to determine what follows for the analysis of culture from the proposition that human thinking is essentially a social activity--the Balinese data take on a peculiar importance. Not only are Balinese ideas in this area unusually well developed, but they are, from a Western perspective, odd enough to bring to light some general relationships between different orders of cultural conceptualization that are hidden from us when we look only at our own all-too-familiar framework for the identification, classification, and handling of human and quasi-human individuals. In particular, they point up some unobvious connections between the way in which a people perceive themselves and others, the way in which they experience time, and the affective tone of their collective life--connections that have an import not just for the understanding of Balinese society but human society generally. The Study of Culture A great deal of recent social scientific theorizing has turned upon an attempt to distinguish and specify two major analytical concepts: culture and social structure.1 The impetus for this effort has sprung from a desire to take account of ideational factors in social processes without succumbing to either the Hegelian or the Marxist forms of reductionism. In order to avoid having to regard ideas, concepts, values, and expressive forms either as shadows cast by the organization of society upon the hard surfaces of history or as the soul of history whose progress is but a working out of their internal dialectic, it has proved necessary to regard them as independent but not self-sufficient forces--as acting and having their impact only within specific social contexts to which they adapt, by which they are stimulated, but upon which they have, to a greater or lesser degree, a determining influence. "Do you really expect," Marc Bloch wrote in his little book on The Historian's Craft, "to know the great merchants of Renaissance Europe, vendors of cloth or spices, monopolists in copper, mercury or alum, bankers of Kings and the Emperor, by knowing their merchandise alone? Bear in mind that they were painted by Holbein, that they read Erasmus and Luther. To understand the attitude of the medieval vassal to his seigneur you must inform yourself about his attitude to his God as well." Both the organization of social activity, its institutional forms, and the systems of ideas which animate it must be understood, as must the nature of the relations obtaining between them. It is to this end that the attempt to clarify the concepts of social structure and of culture has been directed. There is little doubt, however, that within this two-sided development it has been the cultural side which has proved the more refractory and remains the more retarded. In the very nature of the case, ideas are more difficult to handle scientifically than the economic, political, and social relations among individuals and groups which http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 1 of 28 those ideas inform. And this is all the more true when the ideas involved are not the explicit doctrines of a Luther or an Erasmus, or the articulate images of a Holbein, but the half-formed, taken-for-granted, indifferently systematized notions that guide the normal activities of ordinary men in everyday life. If the scientific study of culture has lagged, bogged down most often in mere descriptivism, it has been in large part because its very subject matter is elusive. The initial problem of any science--defining its object of study in such a manner as to render it susceptible of analysis--has here turned out to be unusually hard to solve. It is at this point that the conception of thinking as basically a social act, taking place in the same public world in which other social acts occur, can play its most constructive role. The view that thought does not consist of mysterious processes located in what Gilbert Ryle has called a secret grotto in the head but of a traffic in significant symbols --objects in experience (rituals and tools; graven idols and water holes; gestures, markings, images, and sounds) upon which men have impressed meaning--makes of the study of culture a positive science like any other.2 The meanings that symbols, the material vehicles of thought, embody are often elusive, vague, fluctuating, and convoluted, but they are, in principle, as capable of being discovered through systematic empirical investigation--especially if the people who perceive them will cooperate a little--as the atomic weight of hydrogen or the function of the adrenal glands. It is through culture patterns, ordered clusters of significant symbols, that man makes sense of the events through which he lives. The study of culture, the accumulated totality of such patterns, is thus the study of the machinery individuals and groups of individuals employ to orient themselves in a world otherwise opaque. In any particular society, the number of generally accepted and frequently used culture patterns is extremely large, so that sorting out even the most important ones and tracing whatever relationships they might have to one another is a staggering analytical task. The task is somewhat lightened, however, by the fact that certain sorts of patterns and certain sorts of relationships among patterns recur from society to society, for the simple reason that the orientational requirements they serve are generically human. The problems, being existential, are universal; their solutions, being human, are diverse. It is, however, through the circumstantial understanding of these unique solutions, and in my opinion only in that way, that the nature of the underlying problems to which they are a comparable response can be truly comprehended. Here, as in so many branches of knowledge, the road to the grand abstractions of science winds through a thicket of singular facts. One of these pervasive orientational necessities is surely the characterization of individual human beings. Peoples everywhere have developed symbolic structures in terms of which persons are perceived not baldly as such, as mere unadorned members of the human race, but as representatives of certain distinct categories of persons, specific sorts of individuals. In any given case, there are inevitably a plurality of such structures. Some, for example kinship terminologies, are ego-centered: that is, they define the status of an individual in terms of his relationship to a specific social actor. Others are centered on one or another subsystem or aspect of society and are invariant with respect to the perspectives of individual actors: noble ranks, age-group statuses, occupational categories. Some--personal names and sobriquets--are informal and particularizing; others--bureaucratic titles and caste designations--are formal and standardizing. The everyday world in which the members of any community move, their taken-for-granted field of social action, is populated not by anybodies, faceless men without qualities, but by somebodies, concrete classes of determinate persons positively characterized and appropriately labeled. And the symbol systems which define these classes are not given in the nature of things-- they are historically constructed, socially maintained, and individually applied. Even a reduction of the task of cultural analysis to a concern only with those patterns having something to do with the characterization of individual persons renders it only slightly less formidable, however. This is because there does not yet exist a perfected theoretical framework within which to carry it out. What is called structural analysis in sociology and social anthropology can ferret out the functional implications for a society of a particular system of person-categories, and at times even predict how such a system might change under the impact of certain social processes; but only if the system--the categories, their meanings, and their logical relationships-- http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 2 of 28 can be taken as already known. Personality theory in social-psychology can uncover the motivational dynamics underlying the formation and the use of such systems and can assess their effect upon the character structures of individuals actually employing them; but also only if, in a sense, they are already given, if how the individuals in question see themselves and others has been somehow determined. What is needed is some systematic, rather than merely literary or impressionistic, way to discover what is given, what the conceptual structure embodied in the symbolic forms through which persons are perceived actually is. What we want and do not yet have is a developed method of describing and analyzing the meaningful structure of experience (here, the experience of persons) as it is apprehended by representative members of a particular society at a particular point in time--in a word, a scientific phenomenology of culture. Predecessors, Contemporaries, Consociates, and Successors There have been, however, a few scattered and rather abstract ventures in cultural analysis thus conceived, from the results of which it is possible to draw some useful leads into our more focused inquiry. Among the more interesting of such forays are those which were carried out by the late philosopher-cum-sociologist Alfred Sch¸tz, whose work represents a somewhat heroic, yet not unsuccessful, attempt to fuse influences stemming from Scheler, Weber, and Husserl on the one side with ones stemming from James, Mead, and Dewey on the other.3 Sch¸tz covered a multitude of topics--almost none of them in terms of any extended or systematic consideration of specific social processes--seeking always to uncover the meaningful structure of what he regarded as "the paramount reality" in human experience: the world of daily life as men confront it, act in it, and live through it. For our own purposes, one of his exercises in speculative social phenomenology--the disaggregation of the blanket notion of "fellowmen" into "predecessors," "contemporaries," "consociates," and "successors" --provides an especially valuable starting point. Viewing the cluster of culture patterns Balinese use to characterize individuals in terms of this breakdown brings out, in a most suggestive way, the relationships between conceptions of personal identity, conceptions of temporal order, and conceptions of behavioral style which, as we shall see, are implicit in them. The distinctions themselves are not abstruse, but the fact that the classes they define overlap and interpenetrate makes it difficult to formulate them with the decisive sharpness analytical categories demand. "Consociates" are individuals who actually meet, persons who encounter one another somewhere in the course of daily life. They thus share, however briefly or superficially, not only a community of time but also of space. They are "involved in one another's biography" at least minimally; they "grow older together" at least momentarily, interacting directly and personally as egos, subjects, selves. Lovers, so long as love lasts, are consociates, as are spouses until they separate or friends until they fall out. So also are members of orchestras, players at games, strangers chatting on a train, hagglers in a market, or inhabitants of a village: any set of persons who have an immediate, face-to-face relationship. It is, however, persons having such relations more or less continuously and to some enduring purpose, rather than merely sporadically or incidentally, who form the heart of the category. The others shade over into being the second sort of fellowmen: "contemporaries." Contemporaries are persons who share a community of time but not of space: they live at (more or less) the same period of history and have, often very attenuated, social relationships with one another, but they do not--at least in the normal course of things--meet. They are linked not by direct social interaction but through a generalized set of symbolically formulated (that is, cultural) assumptions about each other's typical modes of behavior. Further, the level of generalization involved is a matter of degree, so that the graduation of personal involvement in consociate relations from lovers through chance acquaintances--relations also culturally governed, of course--here continues until social ties slip off into a thoroughgoing anonymity, standardization, and interchangeability: Thinking of my absent friend A., I form an ideal type of his personality and behavior based on my http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 3 of 28 past experience of A. as my consociate. Putting a letter in a mailbox, I, expect that unknown people, called postmen, will act in a typical way, not quite intelligible to me, with the result that my letter will reach the addressee within typically reasonable time. Without ever having met a Frenchman or a German, I understand "Why France fears the rearmament of Germany." Complying with a rule of English grammar, I follow [in my writings] a socially-approved behavior pattern of contemporary English-speaking fellow-men to which I have to adjust to make myself understandable. And, finally, any artifact or utensil refers to the anonymous fellow-man who produced it to be used by other anonymous fellow-men for attaining typical goals by typical means. These are just a few of the examples but they are arranged according to the degree of increasing anonymity involved and therewith of the construct needed to grasp the Other and his behavior.4 Finally, "predecessors" and "successors" are individuals who do not share even a community of time and so, by definition, cannot interact; and, as such, they form something of a single class over against both consociates and contemporaries, who can and do. But from the point of view of any particular actor they do not have quite the same significance. Predecessors, having already lived, can be known or, more accurately, known about, and their accomplished acts can have an influence upon the lives of those for whom they are predecessors (that is, their successors), though the reverse is, in the nature of the case, not possible. Successors, on the other hand, cannot be known, or even known about, for they are the unborn occupants of an unarrived future; and though their lives can be influenced by the accomplished acts of those whose successors they are (that is, their predecessors), the reverse is again not possible.5 For empirical purposes, however, it is more useful to formulate these distinctions less strictly also, and to emphasize that, like those setting off consociates from contemporaries, they are relative and far from clear-cut in everyday experience. With some exceptions, our older consociates and contemporaries do not drop suddenly into the past, but fade more or less gradually into being our predecessors as they age and die, during which period of apprentice ancestorhood we may have some effect upon them, as children so often shape the closing phases of their parents' lives. And our younger consociates and contemporaries grow gradually into becoming our successors, so that those of us who live long enough often have the dubious privilege of knowing who is to replace us and even occasionally having some glancing influence upon the direction of his growth. "Consociates," "contemporaries," "predecessors," and "successors" are best seen not as pigeonholes into which individuals distribute one another for classificatory purposes, but as indicating certain general and not altogether distinct, matter-of-fact relationships which individuals conceive to obtain between themselves and others. But again, these relationships are not perceived purely as such; they are grasped only through the agency of cultural formulations of them. And, being culturally formulated, their precise character differs from society to society as the inventory of available culture patterns differs; from situation to situation within a single society as different patterns among the plurality of those which are available are deemed appropriate for application; and from actor to actor within similar situations as idiosyncratic habits, preferences, and interpretations come into play. There are, at least beyond infancy, no neat social experiences of any importance in human life. Everything is tinged with imposed significance, and fellowmen, like social groups, moral obligations, political institutions, or ecological conditions are apprehended only through a screen of significant symbols which are the vehicles of their objectification, a screen that is therefore very far from being neutral with respect to their "real" nature. Consociates, contemporaries, predecessors, and successors are as much made as born.6 Balinese Orders of Person-Definition In Bali,7 there are six sorts of labels which one person can apply to another in order to identify him as a unique individual and which I want to consider against this general conceptual background: (1) personal names; (2) birth order names; (3) kinship terms; (4) teknonyms; (5) status titles (usually called "caste names" in the literature on http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 4 of 28 Bali); and (6) public titles, by which I mean quasi-occupational titles borne by chiefs, rulers, priests, and gods. These various labels are not, in most cases, employed simultaneously, but alternatively, depending upon the situation and sometimes the individual. They are not, also, all the sorts of such labels ever used; but they are the only ones which are generally recognized and regularly applied. And as each sort consists not of a mere collection of useful tags but of a distinct and bounded terminological system, I shall refer to them as "symbolic orders of person-definition" and consider them first serially, only later as a more or less coherent cluster. PERSONAL NAMES The symbolic order defined by personal names is the simplest to describe because it is in formal terms the least complex and in social ones the least important. All Balinese have personal names, but they rarely use them, either to refer to themselves or others or in addressing anyone. (With respect to one's forebears, including one's parents, it is in fact sacrilegious to use them.) Children are more often referred to and on occasion even addressed by their personal names. Such names are therefore sometimes called "child" or "little" names, though once they are ritually bestowed 105 days after birth, they are maintained unchanged through the whole course of a man's life. In general, personal names are seldom heard and play very little public role. Yet, despite this social marginality, the personal-naming system has some characteristics which, in a rather left- handed way, are extremely significant for an understanding of Balinese ideas of personhood. First, personal names are, at least among the commoners (some 90 percent of the population), arbitrarily coined nonsense syllables. They are not drawn from any established pool of names which might lend to them any secondary significance as being "common" or "unusual," as reflecting someone's being named "after" someone--an ancestor, a friend of the parents, a famous personage--or as being propitious, suitable, characteristic of a group or region, indicating a kinship relation, and so forth.8 Second, the duplication of personal names within a single community--that is, a politically unified, nucleated settlement--is studiously avoided. Such a settlement (called a bandjar, or "hamlet") is the primary face-to-face group outside the purely domestic realm of the family, and in some respects is even more intimate. Usually highly endogamous and always highly corporate, the hamlet is the Balinese world of consociates par excellence; and, within it, every person possesses, however unstressed on the social level, at least the rudiments of a completely unique cultural identity. Third, personal names are monomials, and so do not indicate familial connections, or in fact membership in any sort of group whatsoever. And, finally, there are (a few rare, and in any case only partial, exceptions aside) no nicknames, no epithets of the "Richard- the-Lion-Hearted" or "Ivan-the-Terrible" sort among the nobility, not even any diminutives for children or pet names for lovers, spouses, and so on. Thus, whatever role the symbolic order of person-definition marked out by the personal-naming system plays in setting Balinese off from one another or in ordering Balinese social relations is essentially residual in nature. One's name is what remains to one when all the other socially much more salient cultural labels attached to one's person are removed. As the virtually religious avoidance of its direct use indicates, a personal name is an intensely private matter. Indeed, toward the end of a man's life, when he is but a step away from being the deity he will become after his death and cremation, only he (or he and a few equally aged friends) may any longer know what in fact it is; when he disappears it disappears with him. In the well-lit world of everyday life, the purely personal part of an individual's cultural definition, that which in the context of the immediate consociate community is most fully and completely his, and his alone, is highly muted. And with it are muted the more idiosyncratic, merely biographical, and, consequently, transient aspects of his existence as a human being (what, in our more egoistic framework, we call his "personality") in favor of some rather more typical, highly conventionalized, and, consequently, enduring ones. BIRTH ORDER NAMES The most elementary of such more standardized labels are those automatically bestowed upon a child, even a http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 5 of 28 stillborn one, at the instant of its birth, according to whether it is the first, second, third, fourth, etc., member of a sibling set. There is some local and status-group variation in usage here, but the most common system is to use Wayan for the first child, Njoman for the second, Made (or Nengah) for the third, and Ktut for the fourth, beginning the cycle over again with Wayan for the fifth, Njoman for the sixth, and so on. These birth order names are the most frequently used terms of both address and reference within the hamlet for children and for young men and women who have not yet produced offspring. Vocatively, they are almost always used simply, that is, without the addition of the personal name: "Wayan, give me the hoe," and so forth. Referentially, they may be supplemented by the personal name, especially when no other way is convenient to get across which of the dozens of Wayans or Njomans in the hamlet is meant: "No, not Wayan Rugrug, Wayan Kepig," and so on. Parents address their own children and childless siblings address one another almost exclusively by these names, rather than by either personal names or kin terms. For persons who have had children, however, they are never used either inside the family or out, teknonyms being employed, as we shall see, instead, so that, in cultural terms, Balinese who grow to maturity without producing children (a small minority) remain themselves children--that is, are symbolically pictured as such--a fact commonly of great shame to them and embarrassment to their consociates, who often attempt to avoid having to use vocatives to them altogether.9 The birth order system of person-definition represents, therefore, a kind of plus Áa change approach to the denomination of individuals. It distinguishes them according to four completely contentless appellations, which neither define genuine classes (for there is no conceptual or social reality whatsoever to the class of all Wayans or all Ktuts in a community), nor express any concrete characteristics of the individuals to whom they are applied (for there is no notion that Wayans have any special psychological or spiritual traits in common against Njomans or Ktuts). These names, which have no literal meaning in themselves (they are not numerals or derivatives of numerals) do not, in fact, even indicate sibling position or rank in any realistic or reliable way.10 A Wayan may be a fifth (or ninth!) child as well as a first; and, given a traditional peasant demographic structure--great fertility plus a high rate of stillbirths and deaths in infancy and childhood--a Made or a Ktut may actually be the oldest of a long string of siblings and a Wayan the youngest. What they do suggest is that, for all procreating couples, births form a circular succession of Wayans, Njomans, Mades, Ktuts, and once again Wayans, an endless four-stage replication of an imperishable form. Physically men come and go as the ephemerae they are, but socially the dramatis personae remain eternally the same as new Wayans and Ktuts emerge from the timeless world of the gods (for infants, too, are but a step away from divinity) to replace those who dissolve once more into it. KINSHIP TERMS Formally, Balinese kinship terminology is quite simple in type, being of the variety known technically as "Hawaiian" or "Generational." In this sort of system, an individual classifies his relatives primarily according to the generation they occupy with respect to his own. That is to say, siblings, half-siblings, and cousins (and their spouses' siblings, and so forth) are grouped together under the same term; all uncles and aunts on either side are terminologically classed with mother and father; all children of brothers, sisters, cousins, and so on (that is, nephews of one sort or another) are identified with own children; and so on, downward through the grandchild, great-grandchild, etc., generations, and upward through the grandparent, great-grandparent, etc., ones. For any given actor, the general picture is a layer-cake arrangement of relatives, each layer consisting of a different generation of kin--that of actor's parents or his children, of his grandparents or his grandchildren, and so on, with his own layer, the one from which the calculations are made, located exactly halfway up the cake.11 Given the existence of this sort of system, the most significant (and rather unusual) fact about the way it operates in Bali is that the terms it contains are almost never used vocatively, but only referentially, and then not very frequently. With rare exceptions, one does not actually call one's father (or uncle) "father," one's child (or nephew/niece) "child," one's brother (or cousin) "brother," and so on. For relatives genealogically junior to http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 6 of 28 oneself vocative forms do not even exist; for relatives senior they exist but, as with personal names, it is felt to demonstrate a lack of respect for one's elders to use them. In fact, even the referential forms are used only when specifically needed to convey some kinship information as such, almost never as general means of identifying people. Kinship terms appear in public discourse only in response to some question, or in describing some event which has taken place or is expected to take place, with respect to which the existence of the kin tie is felt to be a relevant piece of information. ("Are you going to Fatherof-Regreg's tooth-filing?" "Yes, he is my 'brother.'") Thus, too, modes of address and reference within the family are no more (or not much more) intimate or expressive of kin ties in quality than those within the hamlet generally. As soon as a child is old enough to be capable of doing so (say, six years, though this naturally varies) he calls his mother and father by the same term--a teknonym, status group title, or public title--that everyone else who is acquainted with them uses toward them, and is called in turn Wayan, Ktut, or whatever, by them. And, with even more certainty, he will refer to them, whether in their hearing or outside of it, by this popular, extradomestic term as well. In short, the Balinese system of kinship terminology defines individuals in a primarily taxonomic, not a face-to- face idiom, as occupants of regions in a social field, not partners in social interaction. It functions almost entirely as a cultural map upon which certain persons can be located and certain others, not features of the landscape mapped, cannot. Of course, some notions of appropriate interpersonal behavior follow once such determinations are made, once a person's place in the structure is ascertained. But the critical point is that, in concrete practice, kin terminology is employed virtually exclusively in service of ascertainment, not behavior, with respect to whose patterning other symbolic appliances are dominant.12 The social norms associated with kinship, though real enough, are habitually overridden, even within kinship-type groups themselves (families, households, lineages) by culturally better armed norms associated with religion, politics, and, most fundamentally of all, social stratification. Yet in spite of the rather secondary role it plays in shaping the moment-to-moment flow of social intercourse, the system of kinship terminology, like the personal-naming system, contributes importantly, if indirectly, to the Balinese notion of personhood. For, as a system of significant symbols, it too embodies a conceptual structure under whose agency individuals, one's self as well as others, are apprehended; a conceptual structure which is, moreover, in striking congruence with those embodied in the other, differently constructed and variantly oriented, orders of person-definition. Here, also, the leading motif is the immobilization of time through the iteration of form. This iteration is accomplished by a feature of Balinese kin terminology I have yet to mention: in the third generation above and below the actor's own, terms become completely reciprocal. That is to say, the term for "great-grandparent" and "great-grandchild" is the same: kumpi. The two generations, and the individuals who comprise them, are culturally identified. Symbolically, a man is equated upwardly with the most distant ascendant, downwardly with the most distant descendant, he is ever likely to interact with as a living person. Actually, this sort of reciprocal terminology proceeds on through the fourth generation, and even beyond. But as it is only extremely rarely that the lives of a man and his great-great-grandparent (or great-greatgrandchild) overlap, this continuation is of only theoretical interest, and most people don't even know the terms involved. It is the four-generation span (i.e., the actor's own, plus three ascending or descending) which is considered the attainable ideal, the image, like our threescore-and-ten, of a fully completed life, and around which the kumpikumpi terminology puts, as it were, an emphatic cultural parenthesis. This parenthesis is accentuated further by the rituals surrounding death. At a person's funeral, all his relatives who are generationally junior to him must make homage to his lingering spirit in the Hindu palms-to-forehead fashion, both before his bier and, later, at the graveside. But this virtually absolute obligation, the sacramental http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 7 of 28 heart of the funeral ceremony, stops short with the third descending generation, that of his "grandchildren." His "great-grandchildren" are his kumpi, as he is theirs, and so, the Balinese say, they are not really junior to him at all but rather "the same age." As such, they are not only not required to show homage to his spirit, but they are expressly forbidden to do so. A man prays only to the gods and, what is the same thing, his seniors, not to his equals or juniors.13 Balinese kinship terminology thus not only divides human beings into generational layers with respect to a given actor, it bends these layers into a continuous surface which joins the "lowest" with the "highest" so that, rather than a layer-cake image, a cylinder marked off into six parallel bands called "own," "parent," "grandparent," "kumpi," "grandchild," and "child" is perhaps more exact. 14 What at first glance seems a very diachronic formulation, stressing the ceaseless progression of generations is, in fact, an assertion of the essential unreality- -or anyway the unimportance--of such a progression. The sense of sequence, of sets of collaterals following one another through time, is an illusion generated by looking at the terminological system as though it were used to formulate the changing quality of face-to-face interactions between a man and his kinsmen as he ages and dies-- as indeed many, if not most such systems are used. When one looks at it, as the Balinese primarily do, as a common-sense taxonomy of the possible types of familial relationships human beings may have, a classification of kinsmen into natural groups, it is clear that what the bands on the cylinder are used to represent is the genealogical order of seniority among living people and nothing more. They depict the spiritual (and what is the same thing, structural) relations among coexisting generations, not the location of successive generations in an unrepeating historical process. TEKNONYMS If personal names are treated as though they were military secrets, birth order names applied mainly to children and young adolescents, and kinship terms invoked at best sporadically, and then only for purposes of secondary specification, how, then, do most Balinese address and refer to one another? For the great mass of the peasantry, the answer is: by teknonyms.15 As soon as a couple's first child is named, people begin to address and refer to them as "Father-of" and "Mother- of" Regreg, Pula, or whatever the child's name happens to be. They will continue to be so called (and to call themselves) until their first grandchild is born, at which time they will begin to be addressed and referred to as "Grandfatherof" and "Grandmother-of" Suda, Lilir, or whomever; and a similar transition occurs if they live to see their first great-grandchild.16 Thus, over the "natural" four-generation kumpi-to-kumpi life span, the term by which an individual is known will change three times, as first he, then at least one of his children, and finally at least one of his grandchildren produce offspring. Of course, many if not most people neither live so long nor prove so fortunate in the fertility of their descendants. Also, a wide variety of other factors enter in to complicate this simplified picture. But, subtleties aside, the point is that we have here a culturally exceptionally well developed and socially exceptionally influential system of teknonymy. What impact does it have upon the individual Balinese's perceptions of himself and his acquaintances? Its first effect is to identify the husband and wife pair, rather as the bride's taking on of her husband's surname does in our society; except that here it is not the act of marriage which brings about the identification but of procreation. Symbolically, the link between husband and wife is expressed in terms of their common relation to their children, grandchildren, or great-grandchildren, not in terms of the wife's incorporation into her husband's "family" (which, as marriage is highly endogamous, she usually belongs to anyway). This husband-wife--or, more accurately, father-mother--pair has very great economic, political, and spiritual importance. It is, in fact, the fundamental social building block. Single men cannot participate in the hamlet http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 8 of 28 council, where seats are awarded by married couple; and, with rare exceptions, only men with children carry any weight there. (In fact, in some hamlets men are not even awarded seats until they have a child.) The same is true for descent groups, voluntary organizations, irrigation societies, temple congregations, and so on. In virtually all local activities, from the religious to the agricultural, the parental couple participates as a unit, the male performing certain tasks, the female certain complementary ones. By linking a man and a wife through an incorporation of the name of one of their direct descendants into their own, teknonymy underscores both the importance of the marital pair in local society and the enormous value which is placed upon procreation.17 This value also appears, in a more explicit way, in the second cultural consequence of the pervasive use of teknonyms: the classification of individuals into what, for want of a better term, may be called procreational strata. From the point of view of any actor, his hamletmates are divided into childless people, called Wayan, Made, and so on; people with children, called "Father (Mother)-of"; people with grandchildren, called "Grandfather (Grandmother)-of"; and people with greatgrandchildren, called "Great-grandparent-of." And to this ranking is attached a general image of the nature of social hierarchy: childless people are dependent minors; fathers-of are active citizens directing community life; grandfathers-of are respected elders giving sage advice from behind the scenes; and great-grandfathers-of are senior dependents, already half-returned to the world of the gods. In any given case, various mechanisms have to be employed to adjust this rather too-schematic formula to practical realities in such a way as to allow it to mark out a workable social ladder. But, with these adjustments, it does, indeed, mark one out, and as a result a man's "procreative status" is a major element in his social identity, both in his own eyes and those of everyone else. In Bali, the stages of human life are not conceived in terms of the processes of biological aging, to which little cultural attention is given, but of those of social regenesis. Thus, it is not sheer reproductive power as such, how many children one can oneself produce, that is critical. A couple with ten children is no more honored than a couple with five; and a couple with but a single child who has in turn but a single child outranks them both. What counts is reproductive continuity, the preservation of the community's ability to perpetuate itself just as it is, a fact which the third result of teknonymy, the designation of procreative chains, brings out most clearly. The way in which Balinese teknonymy outlines such chains can be seen from the model diagram (Figure 1 ). For simplicity, I have shown only the male teknonyms and have used English names for the referent generation. I have also arranged the model so as to stress the fact that teknonymous usage reflects the absolute age not the genealogical order (or the sex) of the eponymous descendants. FIGURE 1 Balinese Teknonymy (not available) NOTE: Mary is older than Don; Joe is older than Mary, Jane, and Don. The relative ages of all other people, save of course as they are ascendants and descendants, are irrelevant so far as teknonymy is concerned. As Figure 1 indicates, teknonymy outlines not only procreative statuses but specific sequences of such statuses, two, three, or four (very, very occasionally, five) generations deep. Which particular sequences are marked out is largely accidental: had Mary been born before Joe, or Don before Mary, the whole alignment would have been altered. But though the particular individuals who are taken as referents, and hence the particular sequences of filiation which receive symbolic recognition, is an arbitrary and not very consequential matter, the fact that such sequences are marked out stresses an important fact about personal identity among the Balinese: an individual is not perceived in the context of who his ancestors were (that, given the cultural veil which slips over the dead, is not even known), but rather in the context of whom he is ancestral to. One is not defined, as in so many societies of the world, in terms of who produced one, some more or less distant, more or less grand founder of http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 9 of 28 one's line, but in terms of whom one has produced, a specific, in most cases still living, half-formed individual who is one's child, grandchild, or great-grandchild, and to whom one traces one's connection through a particular set of procreative links.18 What links "Great-grandfather-of-Joe," "Grandfather-of-Joe," and "Father-of-Joe" is the fact that, in a sense, they have cooperated to produce Joe--that is, to sustain the social metabolism of the Balinese people in general and their hamlet in particular. Again, what looks like a celebration of a temporal process is in fact a celebration of the maintenance of what, borrowing a term from physics, Gregory Bateson has aptly called a "steady state."19 In this sort of teknonymous regime, the entire population is classified in terms of its relation to and representation in that subclass of the population in whose hands social regenesis now most instantly lies--the oncoming cohort of prospective parents. Under its aspect even that most time-saturated of human conditions, great-grandparenthood, appears as but an ingredient in an unperishing present. STATUS TITLES In theory, everyone (or nearly everyone) in Bali bears one or another title--Ida Bagus, Gusti, Pasek, Dauh, and so forth--which places him on a particular rung in an all-Bali status ladder; each title represents a specific degree of cultural superiority or inferiority with respect to each and every other one, so that the whole population is sorted out into a set of uniformly graded castes. In fact, as those who have tried to analyze the system in such terms have discovered, the situation is much more complex. It is not simply that a few low-ranking villagers claim that they (or their parents) have somehow "forgotten" what their titles are; nor that there are marked inconsistencies in the ranking of titles from place to place, at times even from informant to informant; nor that, in spite of their hereditary basis, there are nevertheless ways to change titles. These are but (not uninteresting) details concerning the day-to-day working of the system. What is critical is that status titles are not attached to groups at all, but only to individuals.20 Status in Bali, or at least that sort determined by titles, is a personal characteristic; it is independent of any social structural factors whatsoever. It has, of course, important practical consequences, and those consequences are shaped by and expressed through a wide variety of social arrangements, from kinship groups to governmental institutions. But to be a Dewa, a Pulosari, a Pring, or a Maspadan is at base only to have inherited the right to bear that title and to demand the public tokens of deference associated with it. It is not to play any particular role, to belong to any particular group, or to occupy any particular economic, political, or sacerdotal position. The status title system is a pure prestige system. From a man's title you know, given your own title, exactly what demeanor you ought to display toward him and he toward you in practically every context of public life, irrespective of whatever other social ties obtain between you and whatever you may happen to think of him as a man. Balinese politesse is very highly developed and it rigorously controls the outer surface of social behavior over virtually the entire range of daily life. Speech style, posture, dress, eating, marriage, even house- construction, place of burial, and mode of cremation are patterned in terms of a precise code of manners which grows less out of a passion for social grace as such as out of some rather far-reaching metaphysical considerations. The sort of human inequality embodied in the status title system and the system of etiquette which expresses it is neither moral, nor economic, nor political--it is religious. It is the reflection in everyday interaction of the divine order upon which such interaction, from this point of view a form of ritual, is supposed to be modeled. A man's title does not signal his wealth, his power, or even his moral reputation, it signals his spiritual composition; and the incongruity between this and his secular position may be enormous. Some of the greatest movers and shakers in Bali are the most rudely approached, some of the most delicately handled the least respected. It would be difficult to conceive of anything further from the Balinese spirit than Machiavelli's comment that titles do not reflect honor upon men, but rather men upon their titles. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 10 of 28 In theory, Balinese theory, all titles come from the gods. Each has been passed along, not always without alteration, from father to child, like some sacred heirloom, the difference in prestige value of the different titles being an outcome of the varying degree to which the men who have had care of them have observed the spiritual stipulations embodied in them. To bear a title is to agree, implicitly at least, to meet divine standards of action, or at least approach them, and not all men have been able to do this to the same extent. The result is the existing discrepancy in the rank of titles and of those who bear them. Cultural status, as opposed to social position, is here once again a reflection of distance from divinity. Associated with virtually every title there are one or a series of legendary events, very concrete in nature, involving some spiritually significant misstep by one or another holder of the title. These offenses-one can hardly call them sins--are regarded as specifying the degree to which the title has declined in value, the distance which it has fallen from a fully transcendent status, and thus as fixing, in a general way at least, its position in the overall scale of prestige. Particular (if mythic) geographical migrations, cross--title marriages, military failures, breaches of mourning etiquette, ritual lapses, and the like are regarded as having debased the title to a greater or lesser extent: greater for the lower titles, lesser for the higher. Yet, despite appearances, this uneven deterioration is, in its essence, neither a moral nor an historical phenomenon. It is not moral because the incidents conceived to have occasioned it are not, for the most part, those against which negative ethical judgments would, in Bali any more than elsewhere, ordinarily be brought, while genuine moral faults (cruelty, treachery, dishonesty, profligacy) damage only reputations, which pass from the scene with their owners, not titles which remain. It is not historical because these incidents, disjunct occurrences in a once-upona-time, are not invoked as the causes of present realities but as statements of their nature. The important fact about title-debasing events is not that they happened in the past, or even that they happened at all, but that they are debasing. They are formulations not of the processes which have brought the existing state of affairs into being, nor yet of moral judgments upon it (in neither of which intellectual exercises the Balinese show much interest): they are images of the underlying relationship between the form of human society and the divine pattern of which it is, in the nature of things, an imperfect expression--more imperfect at some points than at others. But if, after all that has been said about the autonomy of the title system, such a relationship between cosmic patterns and social forms is conceived to exist, exactly how is it understood? How is the title system, based solely on religious conceptions, on theories of inherent differences in spiritual worth among individual men, connected up with what, looking at the society from the outside, we would call the "realities" of power, influence, wealth, reputation, and so on, implicit in the social division of labor? How, in short, is the actual order of social command fitted into a system of prestige ranking wholly independent of it so as to account for and, indeed, sustain the loose and general correlation between them which in fact obtains? The answer is: through performing, quite ingeniously, a kind of hat trick, a certain sleight of hand, with a famous cultural institution imported from India and adapted to local tastes--the Varna System. By means of the Varna System the Balinese inform a very disorderly collection of status pigeonholes with a simple shape which is represented as growing naturally out of it but which in fact is arbitrarily imposed upon it. As in India, the Varna System consists of four gross categories--Brahmana, Satria, Wesia, and Sudra--ranked in descending order of prestige, and with the first three (called in Bali, Triwangsa--"the three peoples") defining a spiritual patriciate over against the plebeian fourth. But in Bali the Varna System is not in itself a cultural device for making status discriminations but for correlating those already made by the title system. It summarizes the literally countless fine comparisons implicit in that system in a neat (from some points of view all-too-neat) separation of sheep from goats, and first-quality sheep from second, second from third.21 Men do not perceive one another as Satrias or Sudras but as, say, Dewas or Kebun Tubuhs, merely using the Satria-Sudra distinction to express generally, and for social organizational purposes, the order of contrast which is involved by identifying Dewa as a Satria title and Kebun Tubuh as a Sudra one. Varna categories are labels applied not to men, but to http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 11 of 28 the titles they bear--they formulate the structure of the prestige system; titles, on the other hand, are labels applied to individual men--they place persons within that structure. To the degree that the Varna classification of titles is congruent with the actual distribution of power, wealth, and esteem in the society--that is, with the system of social stratification--the society is considered to be well ordered. The right sort of men are in the right sort of places: spiritual worth and social standing coincide. This difference in function between title and Varna is clear from the way in which the symbolic forms associated with them are actually used. Among the Triwangsa gentry, where, some exceptions aside, teknonymy is not employed, an individual's title is used as his or her main term of address and reference. One calls a man Ida Bagus, Njakan, or Gusi (not Brahmana, Satria, or Wesia) and refers to him by the same terms, sometimes adding a birth order name for more exact specification ( Ida Bagus Made, Njakan Njoman, and so forth). Among the Sudras, titles are used only referentially, never in address, and then mainly with respect to members of other hamlets than one's own, where the person's teknonym may not be known, or, if known, considered to be too familiar in tone to be used for someone not a hamletmate. Within the hamlet, the referential use of Sudra titles occurs only when prestige status information is considered relevant ("Father-of-Joe is a Kedisan, and thus 'lower' than we Pande," and so on), while address is, of course, in terms of teknonyms. Across hamlet lines, where, except between close friends, teknonyms fall aside, the most common term of address is Djero. Literally, this means "inside" or "insider," thus a member of the Triwangsa, who are considered to be "inside," as against the Sudras, who are "outside" (Djaba); but in this context it has the effect of saying, "In order to be polite, I am addressing you as though you were a Triwangsa, which you are not (if you were, I would call you by your proper title), and I expect the same pretense from you in return." As for Varna terms, they are used, by Triwangsa and Sudra alike, only in conceptualizing the overall prestige hierarchy in general terms, a need which usually appears in connection with transhamlet political, sacerdotal, or stratificatory matters: "The kings of Klungkung are Satrias, but those of Tabanan only Wesias," or "There are lots of rich Brahmanas in Sanur, which is why the Sudras there have so little to say about hamlet affairs," and so on. The Varna System thus does two things. It connects up a series of what appear to be ad hoc and arbitrary prestige distinctions, the titles, with Hinduism, or the Balinese version of Hinduism, thus rooting them in a general world view. And it interprets the implications of that world view, and therefore the titles, for social organization: the prestige gradients implicit in the title system ought to be reflected in the actual distribution of wealth, power, and esteem in society, and, in fact, be completely coincident with it. The degree to which this coincidence actually obtains is, of course, moderate at best. But, however many exceptions there may be to the rule--Sudras with enormous power, Satrias working as tenant farmers, Brahmanas neither esteemed nor estimable--it is the rule and not the exceptions that the Balinese regard as truly illuminating the human condition. The Varna System orders the title system in such a way as to make it possible to view social life under the aspect of a general set of cosmological notions: notions in which the diversity of human talent and the workings of historical process are regarded as superficial phenomena when compared with the location of persons in a system of standardized status categories, as blind to individual character as they are immortal. PUBLIC TITLES This final symbolic order of person-definition is, on the surface, the most reminiscent of one of the more prominent of our own ways of identifying and characterizing individuals.22 We, too, often (all too often, perhaps) see people through a screen of occupational categories --as not just practicing this vocation or that, but as almost physically infused with the quality of being a postman, teamster, politician, or salesman. Social function serves as the symbolic vehicle through which personal identity is perceived; men are what they do. The resemblance is only apparent, however. Set amid a different cluster of ideas about what selfhood consists in, placed against a different religio-philosophical conception of what the world consists in, and expressed in terms of a different set of cultural devices--public titles --for portraying it, the Balinese view of the relation http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 12 of 28 between social role and personal identity gives a quite different slant to the ideographic significance of what we call occupation but the Balinese call linggih-"seat," "place," "berth." This notion of "seat" rests on the existence in Balinese thought and practice of an extremely sharp distinction between the civic and domestic sectors of society. The boundary between the public and private domains of life is very clearly drawn both conceptually and institutionally. At every level, from the hamlet to the royal palace, matters of general concern are sharply distinguished and carefully insulated from matters of individual or familial concern, rather than being allowed to interpenetrate as they do in so many other societies. The Balinese sense of the public as a corporate body, having interests and purposes of its own, is very highly developed. To be charged, at any level, with special responsibilities with respect to those interests and purposes is to be set aside from the run of one's fellowmen who are not so charged, and it is this special status that public titles express. At the same time, though the Balinese conceive the public sector of society as bounded and autonomous, they do not look upon it as forming a seamless whole, or even a whole at all. Rather they see it as consisting of a number of separate, discontinuous, and at times even competitive realms, each self-sufficient, self-contained, jealous of its rights, and based on its own principles of organization. The most salient of such realms include: the hamlet as a corporate political community; the local temple as a corporate religious body, a congregation; the irrigation society as a corporate agricultural body; and, above these, the structures of regional--that is, suprahamlet--government and worship, centering on the nobility and the high priesthood. A description of these various public realms or sectors would involve an extensive analysis of Balinese social structure inappropriate in the present context.23 The point to be made here is that, associated with each of them, there are responsible officers--stewards is perhaps a better term--who as a result bear particular titles: Klian, Perbekel, Pekaseh, Pemangku, Anak Agung, Tjakorda, Dewa Agung, Pedanda, and so on up to perhaps a half a hundred or more. And these men (a very small proportion of the total population) are addressed and referred to by these official titles--sometimes in combination with birth order names, status titles, or, in the case of Sudras, teknonyms for purposes of secondary specification.24 The various "village chiefs" and "folk priests" on the Sudra level, and, on the Triwangsa, the host of "kings," "princes," "lords," and "high priests" do not merely occupy a role. They become, in the eyes of themselves and those around them, absorbed into it. They are truly public men, men for whom other aspects of personhood--individual character, birth order, kinship relations, procreative status, and prestige rank take, symbolically at least, a secondary position. We, focusing upon psychological traits as the heart of personal identity, would say they have sacrificed their true selves to their role; they, focusing on social position, say that their role is of the essence of their true selves. Access to these public-title-bearing roles is closely connected with the system of status titles and its organization into Varna categories, a connection effected by what may be called "the doctrine of spiritual eligibility." This doctrine asserts that political and religious "seats" of translocal--regional or Bali-wide--significance are to be manned only by Triwangsas, while those of local significance ought properly to be in the hands of Sudras. At the upper levels the doctrine is strict: only Satrias--that is, men bearing titles deemed of Satria rank--may be kings or paramount princes, only Wesias or Satrias lords or lesser princes, only Brahmanas high priests, and so on. At the lower levels, it is less strict; but the sense that hamlet chiefs, irrigation society heads, and folk priests should be Sudras, that Triwangsas should keep their place, is quite strong. In either case, however, the overwhelming majority of persons bearing status titles of the Varna category or categories theoretically eligible for the stewardship roles to which the public titles are attached do not have such roles and are not likely to get them. On the Triwangsa level, access is largely hereditary, primogenitural even, and a sharp distinction is made between that handful of individuals who "own power" and the vast remainder of the gentry who do not. On the Sudra level, access to public office is more often elective, but the number of men who have the opportunity to serve is still fairly limited. Prestige status decides what sort of public role one can presume to occupy; whether or not one occupies such a role is another question altogether. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 13 of 28 Yet, because of the general correlation between prestige status and public office the doctrine of spiritual eligibility brings about, the order of political and ecclesiastical authority in the society is hooked in with the general notion that social order reflects dimly, and ought to reflect clearly, metaphysical order; and, beyond that, that personal identity is to be defined not in terms of such superficial, because merely human, matters as age, sex, talent, temperament, or achievement--that is, biographically, but in terms of location in a general spiritual hierarchy-that is, typologically. Like all the other symbolic orders of person-definition, that stemming from public titles consists of a formulation, with respect to different social contexts, of an underlying assumption: it is not what a man is as a man (as we would phrase it) that matters, but where he fits in a set of cultural categories which not only do not change but, being transhuman, cannot. And, here too, these categories ascend toward divinity (or with equal accuracy, descend from it), their power to submerge character and nullify time increasing as they go. Not only do the higher level public titles borne by human beings blend gradually into those borne by the gods, becoming at the apex identical with them, but at the level of the gods there is literally nothing left of identity but the title itself. All gods and goddesses are addressed and referred to either as Dewa (f. Dewi) or, for the higher ranking ones, Betara (f. Betari). In a few cases, these general appellations are followed by particularizing ones: Betara Guru, Dewi Sri, and so forth. But even such specifically named divinities are not conceived as possessing distinctive personalities: they are merely thought to be administratively responsible, so to speak, for regulating certain matters of cosmic significance: fertility, power, knowledge, death, and so on. In most cases, Balinese do not know, and do not want to know, which gods and goddesses are those worshipped in their various temples (there is always a pair, one male, one female), but merely call them " Dewa (Dewi) Pura Such-and-Such"--god (goddess) of temple such-and-such. Unlike the ancient Greeks and Romans, the average Balinese shows little interest in the detailed doings of particular gods, nor in their motivations, their personalities, or their individual histories. The same circumspection and propriety is maintained with respect to such matters as is maintained with respect to similar matters concerning elders and superiors generally.25 The world of the gods is, in short, but another public realm, transcending all the others and imbued with an ethos which those others seek, so far as they are able, to embody in themselves. The concerns of this realm lie on the cosmic level rather than the political, the economic, or the ceremonial (that is, the human) and its stewards are men without features, individuals with respect to whom the usual indices of perishing humanity have no significance. The nearly faceless, thoroughly conventionalized, never-changing icons by which nameless gods known only by their public titles are, year after year, represented in the thousands of temple festivals across the island comprise the purest expression of the Balinese concept of personhood. Genuflecting to them (or, more precisely, to the gods for the moment resident in them) the Balinese are not just acknowledging divine power. They are also confronting the image of what they consider themselves at bottom to be; an image which the biological, psychological, and sociological concomitants of being alive, the mere materialities of historical time, tend only to obscure from sight. A Cultural Triangle of Forces There are many ways in which men are made aware, or rather make themselves aware, of the passage of time-- by marking the changing of the seasons, the alterations of the moon, or the progress of plant life; by the measured cycling of rites, or agricultural work, or household activities; by the preparation and scheduling of projected acts and the memory and assessment of accomplished ones; by the preservation of genealogies, the recital of legends, or the framing of prophecies. But surely among the most important is by the recognition in oneself and in one's fellowmen of the process of biological aging, the appearance, maturation, decay, and disappearance of concrete individuals. How one views this process affects, therefore, and affects profoundly, how one experiences time. Between a people's conception of what it is to be a person and their conception of the structure of history there is an unbreakable internal link. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 14 of 28 Now, as I have been stressing, the most striking thing about the culture patterns in which Balinese notions of personal identity are embodied is the degree to which they depict virtually everyone--friends, relatives, neighbors, and strangers; elders and youths; superiors and inferiors; men and women; chiefs, kings, priests, and gods; even the dead and the unborn--as stereotyped contemporaries, abstract and anonymous fellowmen. Each of the symbolic orders of person-definition, from concealed names to flaunted titles, acts to stress and strengthen the standardization, idealization, and generalization implicit in the relation between individuals whose main connection consists in the accident of their being alive at the same time and to mute or gloss over those implicit in the relation between consociates, men intimately involved in one another's biographies, or between predecessors and successors, men who stand to one another as blind testator and unwitting heir. Of course, people in Baliare directly, and sometimes deeply, involved in one another's lives; they do feel their world to have been shaped by the actions of those who came before them and orient their actions toward shaping the world of those who will come after them. But it is not these aspects of their existence as persons--their immediacy and individuality, or their special, never-to-be-repeated, impact upon the stream of historical events--which are culturally played up, symbolically emphasized: it is their social placement, their particular location within a persisting, indeed an eternal, metaphysical order.26 The illuminating paradox of Balinese formulations of personhood is that they are --in our terms anyway--depersonalizing. In this way, the Balinese blunt, though of course they cannot efface, three of the most important sources of a sense of temporality: the apprehension of one's comrades (and thus oneself with them) as perpetually perishing; the awareness of the heaviness with which the completed lives of the dead weigh upon the uncompleted lives of the living; and the appreciation of the potential impact upon the unborn of actions just now being undertaken. Consociates, as they meet, confront and grasp one another in an immediate present, a synoptic "now"; and in so doing they experience the elusiveness and ephemerality of such a now as it slips by in the ongoing stream of face-to-face interaction. "For each partner [in a consociate relationship] the other's body, his gestures, his gait and facial expressions, are immediately observable, not merely as things or events of the outer world but in their physiognomical significance, that is as [expressions! of the other's thoughts. . . . Each partner participates in the onrolling life of the other, can grasp in a vivid present the other's thoughts as they are built up step by step. They may thus share one another's anticipations of the future as plans, or hopes, or anxieties. . . . [They] are mutually involved in one another's biography; they are growing older together. . . ."27 As for predecessors and successors, separated by a material gulf, they perceive one another in terms of origins and outcomes, and in so doing experience the inherent chronologicality of events, the linear progress of standard, transpersonal time--the sort whose passage can be measured with clocks and calendars.28 In minimizing, culturally, all three of these experiences--that of the evanescing present consociate intimacy evokes; that of the determining past contemplation of predecessors evokes; and that of the moldable future anticipation of successors evokes--in favor of the sense of pure simultaneity generated by the anonymized encounter of sheer contemporaries, the Balinese produce yet a second paradox. Linked to their depersonalizing conception of personhood is a detemporalizing (again from our point of view) conception of time. TAXONOMIC CALENDARS AND PUNCTUAL TIME Balinese calendrical notions--their cultural machinery for demarcating temporal units--reflect this clearly; for they are largely used not to measure the elapse of time, nor yet to accent the uniqueness and irrecoverability of the passing moment, but to mark and classify the qualitative modalities in terms of which time manifests itself in human experience. The Balinese calendar (or, rather, calendars; as we shall see there are two of them) cuts time up into bounded units not in order to count and total them but to describe and characterize them, to formulate their differential social, intellectual, and religious significance.29 http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 15 of 28 The two calendars which the Balinese employ are a lunar-solar one and one built around the interaction of independent cycles of daynames, which I shall call "permutational." The permutational calendar is by far the most important. It consists of ten different cycles of daynames. These cycles are of varying lengths. The longest contains ten day-names, following one another in a fixed order, after which the first day-name reappears and the cycle starts over. Similarly, there are nine, eight, seven, six, five, four, three, two, and even--the ultimate of a "contemporized" view of time--one day-name cycles. The names in each cycle are also different, and the cycles run concurrently. That is to say, any given day has, at least in theory, ten different names simultaneously applied to it, one from each of the ten cycles. Of the ten cycles only those containing five, six, and seven day-names are of major cultural significance, however, although the three-name cycle is used to define the market week and plays a role in fixing certain minor rituals, such as the personal-naming ceremony referred to earlier. Now, the interaction of these three main cycles--the five, the six, and the seven--means that a given trinomially designated day (that is, one with a particular combination of names from all three cycles) will appear once in every two hundred and ten days, the simple product of five, six, and seven. Similar interactions between the five- and sevenname cycles produce binomially designated days which turn up every thirty-five days, between the six- and seven-name cycles binomially designated days which occur every forty-two days, and between the fiveand six-name cycles binomially designated days appearing at thirty-day intervals. The conjunctions that each of these four periodicities, supercycles as it were, define (but not the periodicities themselves) are considered not only to be socially significant but to reflect, in one fashion or another, the very structure of reality. The outcome of all this wheels-within-wheels computation is a view of time as consisting of ordered sets of thirty, thirty-five, forty-two, or two hundred and ten quantum units ("days"), each of which units has a particular qualitative significance of some sort indexed by its trinomial or binomial name: rather like our notion of the unluckiness of Friday-the-Thirteenth. To identify a day in the forty-two-day set--and thus assess its practical and/or religious significance--one needs to determine its place, that is, its name, in the six-name cycle (say, Ariang) and in the seven- (say, Boda): the day is Boda-Ariang, and one shapes one's actions accordingly. To identify a day in the thirty-five-day set, one needs its place and name in the five-name cycle (for example, Klion) and in the seven-: for example, Boda-Klion--this is rainan, the day on which one must set out small offerings at various points to "feed" the gods. For the two hundred and ten-day set, unique determination demands names from all three weeks: for example, Boda-Ariang-Klion, which, it so happens, is the day on which the most important Balinese holiday, Galungan, is celebrated.30 Details aside, the nature of time-reckoning this sort of calendar facilitates is clearly not durational but punctual. That is, it is not used (and could only with much awkwardness and the addition of some ancillary devices be used) to measure the rate at which time passes, the amount which has passed since the occurrence of some event, or the amount which remains within which to complete some project: it is adapted to and used for distinguishing and classifying discrete, self-subsistent particles of time--"days." The cycles and supercycles are endless, unanchored, uncountable, and, as their internal order has no significance, without climax. They do not accumulate, they do not build, and they are not consumed. They don't tell you what time it is; they tell you what kind of time it is.31 The uses of the permutational calendar extend to virtually all aspects of Balinese life. In the first instance, it determines (with one exception) all the holidays--that is, general community celebrations--of which Goris lists some thirty-two in all, or on the average about one day out of every seven.32 These do not appear, however, in any discernible overall rhythm. If we begin, arbitrarily, with RaditÈ-Tungleh-Paing as "one," holidays appear on days numbering: 1, 2, 3, 4, 14, 15, 24, 49, 51, 68, 69, 71, 72, 73, 74, 77, 78, 79, 81, 83, 84, 85, 109, 119, 125, 154, 183, 189, 193, 196, 205, 210.33 The result of this sort of spasmodic occurrence of festivals, large and small, is a perception of time --that is, of days--as falling broadly into two very general varieties, "full" and "empty": days http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 16 of 28 on which something of importance goes on and others on which nothing, or at least nothing much, goes on, the former often being called "times" or "junctures" and the latter "holes." All of the other applications of the calendar merely reinforce and refine this general perception. Of these other applications, the most important is the determination of temple celebrations. No one knows how many temples there are on Bali, though Swellengrebel has estimated that there are more than 20,000.34 Each of these temples--family temples, descent-group temples, agricultural temples, death temples, settlement temples, associational temples, "caste" temples, state temples, and so on--has its own day of celebration, called odalan, a term which though commonly, and misleadingly, translated as "birthday" or, worse yet, "anniversary," literally means "coming out," "emergence," "appearance"--that is, not the day on which the temple was built but the day on which it is (and since it has been in existence always has been) "activated," on which the gods come down from the heavens to inhabit it. In between odalans it is quiescent, uninhabited, empty; and, aside from a few offerings prepared by its priest on certain days, nothing happens there. For the great majority of the temples, the odalan is determined according to the permutational calendar (for the remainder, odalans are determined by the lunar-solar calendar, which as we shall see, comes to about the same thing so far as modes of time-perception are concerned), again in terms of the interaction of the five-, six-, and seven-name cycles. What this means is that temple ceremonies--which range from the incredibly elaborate to the almost invisibly simple--are of, to put it mildly, frequent occurrence in Bali, though here too there are certain days on which many such celebrations fall and others on which, for essentially metaphysical reasons, none do.35 Balinese life is thus not only irregularly punctuated by frequent holidays, which everyone celebrates, but by even more frequent temple celebrations which involve only those who are, usually by birth, members of the temple. As most Balinese belong to a half-dozen temples or more, this makes for a fairly busy, not to say frenetic, ritual life, though again one which alternates, unrhythmically, between hyperactivity and quiescence. In addition to these more religious matters of holidays and temple festivals, the permutational calendar invades and secular ones of everyday life as well.36 There are good and bad days on which to build a house, launch a business enterprise, change residence, go on a trip, harvest crops, sharpen cock spurs, hold a puppet show, or (in the old days) start a war, or conclude a peace. The day on which one was born, which again is not a birthday in our sense (when you ask a Balinese when he was born his reply comes to the equivalent of "Thursday, the ninth," which is not of much help in determining his age) but his odalan, is conceived to control or, more accurately, to indicate much of his destiny.37 Men born on this day are liable to suicide, on that to become thieves, on this to be rich, on that to be poor; on this to be well, or long-lived, or happy, on that to be sickly, or short-lived, or unhappy. Temperament is similarly assessed, and so is talent. The diagnosis and treatment of disease is complexly integrated with calendrical determinations, which may involve the odalans of both the patient and the curer, the day on which he fell ill, as well as days metaphysically associated with the symptoms and with the medicine. Before marriages are contracted, the odalans of the individuals are compared to see if their conjunction is auspicious, and if not there will be--at least if the parties, as is almost always the case, are prudent--no marriage. There is a time to bury and a time to cremate, a time to marry and a time to divorce, a time--to shift from the Hebraic to the Balinese idiom--for the mountain top and a time for the market, for social withdrawal and social participation. Meetings of village council, irrigation societies, voluntary associations are all fixed in terms of the permutational (or, more rarely, the lunar-solar) calendar; and so are periods for sitting quietly at home and trying to keep out of trouble. The lunar-solar calendar, though constructed on a different basis, actually embodies the same punctual conception of time as the permutational. Its main distinction and, for certain purposes, advantage is that it is more or less anchored; it does not drift with respect to the seasons. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 17 of 28 This calendar consists of twelve numbered months which run from new moon to new moon.38 These months are then divided into two sorts of (also numbered) days: lunar (tithi) and solar (diwasa). There are always thirty lunar days in a month, but, given the discrepancy between the lunar and solar years, there are sometimes thirty solar days in a month and sometimes twenty-nine. In the latter case, two lunar days are considered to fall on one solar day--that is, one lunar day is skipped. This occurs every sixty-three days; but, although this calculation is astronomically quite accurate, the actual determination is not made on the basis of astronomical observation and theory, for which the Balinese do not have the necessary cultural equipment (to say nothing of the interest); it is determined by the use of the permutational calendar. The calculation was of course originally arrived at astronomically; but it was arrived at by the Hindus from whom the Balinese, in the most distant past, imported the calendar. For the Balinese, the double lunar day-the day on which it is two days at once--is just one more special kind of day thrown up by the workings of the cycles and supercycles of the permutational calendar--a priori, not a posteriori, knowledge. In any case, this correction still leaves a nine-eleven-day deviation from the true solar year, and this is compensated for by the interpolation of a leap-month every thirty months, an operation which though again originally a result of Hindu astronomical observation and calculation is here simply mechanical. Despite the fact that the lunar-solar calendar looks astronomical, and thus seems to be based on some perceptions of natural temporal processes, celestial clocks, this is an illusion arising from attending to its origins rather than its uses. Its uses are as divorced from observation of the heavens--or from any other experience of passing time--as are those of the permutational calendar by which it is so rigorously paced. As with the permutational calendar, it is the system, automatic, particulate, fundamentally not metrical but classificatory, which tells you what day (or what kind of day) it is, not the appearance of the moon, which, as one looks casually up at it, is experienced not as a determinant of the calendar but as a reflex of it. What is "really real" is the name--or, in this case, the (two- place) number--of the day, its place in the transempirical taxonomy of days, not its epiphenomenal reflection in the sky.39 In practice, the lunar-solar calendar is used in the same way for the same sorts of things as the permutational. The fact that it is (loosely) anchored makes it rather more handy in agricultural contexts, so that planting, weeding, harvesting, and the like are usually regulated in terms of it, and some temples having a symbolic connection with agriculture or fertility celebrate their reception of the gods according to it. This means that such receptions appear only about every 355 (in leap years, about 385) rather than 210 days. But otherwise the pattern is unchanged. In addition, there is one major holiday, Njepi ("to make quiet"), which is celebrated according to the lunar-solar calendar. Often called, by Western scholars, "the Balinese New Year," even though it falls at the beginning (that is, the new moon) of not the first but the tenth month and is concerned not with renewal or rededication but with an accentuated fear of demons and an attempt to render one's emotions tranquil. Njepi is observed by an eerie day of silence: no one goes out on the streets, no work is conducted, no light or fire is lit, while conversation even within houseyards is muted. The lunar-solar system is not much used for "fortune telling" purposes, though the new moon and full moon days are considered to have certain qualitative characteristics, sinister in the first case, auspicious in the second. In general, the lunarsolar calendar is more a supplement to the permutational than an alternative to it. It makes possible the employment of a classificatory, fulland-empty, "detemporalized" conception of time in contexts where the fact that natural conditions vary periodically has to be at least minimally acknowledged. CEREMONY, STAGE FRIGHT, AND ABSENCE OF CLIMAX The anonymization of persons and the immobilization of time are thus but two sides of the same cultural process: the symbolic de-emphasis, in the everyday life of the Balinese, of the perception of fellowmen as consociates, successors, or predecessors in favor of the perception of them as contemporaries. As the various http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 18 of 28 symbolic orders of person-definition conceal the biological, psychological, and historical foundation of that changing pattern of gifts and inclinations we call personality behind a dense screen of ready-made identities, iconic selves, so the calendar, or rather the application of the calendar, blunts the sense of dissolving days and evaporating years that those foundations and that pattern inevitably suggest by pulverizing the flow of time into disconnected, dimensionless, motionless particles. A sheer contemporary needs an absolute present in which to live; an absolute present can be inhabited only by a contemporized man. Yet, there is a third side to this same process which transforms it from a pair of complementary prepossessions into a triangle of mutually reinforcing cultural forces: the ceremonialization of social intercourse. To maintain the (relative) anonymization of individuals with whom one is in daily contact, to dampen the intimacy implicit in face-to-face relationships--in a word, to render consociates contemporaries--it is necessary to formalize relations with them to a fairly high degree, to confront them in a sociological middle distance where they are close enough to be identified but not so close as to be grasped: quasi strangers, quasi friends. The ceremoniousness of so much of Balinese daily life, the extent (and the intensity) to which interpersonal relations are controlled by a developed system of conventions and proprieties, is thus a logical correlate of a thoroughgoing attempt to block the more creatural aspects of the human condition--individuality, spontaneity, perishability, emotionality, vulnerability--from sight. This attempt is, like its counterparts, only very partially successful, and the ceremonialization of Balinese social interaction is no closer to being complete than is the anonymization of persons or the immobilization of time. But the degree to which its success is wished for, the degree to which it is an obsessing ideal, accounts for the degree to which the ceremonialization obtains, for the fact that in Bali manners are not a mere matter of practical convenience or incidental decoration but are of deep spiritual concern. Calculated politesse, outward form pure and simple, has there a normative value that we, who regard it as pretentious or comic when we don't regard it as hypocritical, can scarcely, now that Jane Austen is about as far from us as Bali, any longer appreciate. Such an appreciation is rendered even more difficult by the presence within this industrious polishing of the surfaces of social life of a peculiar note, a stylistic nuance, we would not, I think, expect to be there. Being stylistic and being a nuance (though an altogether pervasive one), it is very difficult to communicate to someone who has not himself experienced it. "Playful theatricality" perhaps hits near it, if it is understood that the playfulness is not lighthearted but almost grave and the theatricality not spontaneous but almost forced. Balinese social relations are at once a solemn game and a studied drama. This is most clearly seen in their ritual and (what is the same thing) artistic life, much of which is in fact but a portrait of and a mold for their social life. Daily interaction is so ritualistic and religious activity so civic that it is difficult to tell where the one leaves off and the other begins; and both are but expressions of what is justly Bali's most famous cultural attribute: her artistic genius. The elaborate temple pageants; the grandiloquent operas, equilibristic ballets, and stilted shadow plays; the circuitous speech and apologetic gestures--all these are of a piece. Etiquette is a kind of dance, dance a kind of ritual, and worship a form of etiquette. Art, religion, and politesse all exalt the outward, the contrived, the well-wrought appearance of things. They celebrate the forms; and it is the tireless manipulation of these forms--what they call "playing"--that gives to Balinese life its settled haze of ceremony. The mannered cast of Balinese interpersonal relations, the fusion of rite, craft, and courtesy, thus leads into a recognition of the most fundamental and most distinctive quality of their particular brand of sociality: its radical aestheticism. Social acts, all social acts, are first and foremost designed to please--to please the gods, to please the audience, to please the other, to please the self; but to please as beauty pleases, not as virtue pleases. Like temple offerings or gamelan concerts, acts of courtesy are works of art, and as such they demonstrate, and are meant to demonstrate, not rectitude (or what we would call rectitude) but sensibility. Now, from all this--that daily life is markedly ceremonious; that this ceremoniousness takes the form of an earnest, even sedulous, kind of "playing" with public forms; that religion, art, and etiquette are then but differently http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 19 of 28 directed manifestations of an overall cultural fascination with the worked-up semblance of things; and that morality here is consequently aesthetic at base--it is possible to attain a more exact understanding of two of the most marked (and most remarked) features of the affective tone of Balinese life: the importance of the emotion of what has been (wrongly) called "shame" in interpersonal relations, and the failure of collective activity--religious, artistic, political, economic--to build toward the definable consummations, what has been (acutely) called its "absence of climax."40 One of these themes, the first, leads directly back toward conceptions of personhood, the other, no less directly, toward conceptions of time, so securing the vertices of our metaphorical triangle connecting the Balinese behavioral style with the ideational environment in which it moves. The concept of "shame," together with its moral and emotional cousin "guilt," has been much discussed in the literature, entire cultures sometimes being designated as "shame cultures" because of the presumed prominence in them of an intense concern with "honor," "reputation," and the like, at the expense of a concern, conceived to be dominant in "guilt cultures," with "sin," "inner worth," and so forth.41 The usefulness of such an overall categorization and the complex problems of comparative psychological dynamics involved aside, it has proven difficult in such studies to divest the term "shame" of what is after all its most common meaning in English-- "consciousness of guilt"--and so to disconnect it very completely from guilt as such--"the fact or feeling of having done something reprehensible." Usually, the contrast has been turned upon the fact that "shame" tends to be applied (although, actually, far from exclusively) to situations in which wrongdoing is publicly exposed, and "guilt" (though equally far from exclusively) to situations in which it is not. Shame is the feeling of disgrace and humiliation which follows upon a transgression found out; guilt is the feeling of secret badness attendant upon one not, or not yet, found out. Thus, though shame and guilt are not precisely the same thing in our ethical and psychological vocabulary, they are of the same family; the one is a surfacing of the other, the other a concealment of the one. But Balinese "shame," or what has been translated as such (lek), has nothing to do with transgressions, exposed or unexposed, acknowledged or hidden, merely imagined or actually performed. This is not to say that Balinese feel neither guilt nor shame, are without either conscience or pride, anymore than they are unaware that time passes or that men are unique individuals. It is to say that neither guilt nor shame is of cardinal importance as affective regulators of their interpersonal conduct, and that lek, which is far and away the most important of such regulators, culturally the most intensely emphasized, ought therefore not to be translated as "shame," but rather, to follow out our theatrical image, as "stage fright." It is neither the sense that one has transgressed nor the sense of humiliation that follows upon some uncovered transgression, both rather lightly felt and quickly effaced in Bali, that is the controlling emotion in Balinese face-to-face encounters. It is, on the contrary, a diffuse, usually mild, though in certain situations virtually paralyzing, nervousness before the prospect (and the fact) of social interaction, a chronic, mostly low-grade worry that one will not be able to bring it off with the required finesse.42 Whatever its deeper causes, stage fright consists in a fear that, for want of skill or self-control, or perhaps by mere accident, an aesthetic illusion will not be maintained, that the actor will show through his part and the part thus dissolve into the actor. Aesthetic distance collapses, the audience (and the actor) loses sight of Hamlet and gains it, uncomfortably for all concerned, of bumbling John Smith painfully miscast as the Prince of Denmark. In Bali, the case is the same, if the drama more humble. What is feared--mildly in most cases, intensely in a few--is that the public performance that is etiquette will be botched, that the social distance etiquette maintains will consequently collapse, and that the personality of the individual will then break through to dissolve his standardized public identity. When this occurs, as it sometimes does, our triangle falls apart: ceremony evaporates, the immediacy of the moment is felt with an excruciating intensity, and men become unwilling consociates locked in mutual embarrassment, as though they had inadvertently intruded upon one another's privacy. Lek is at once the awareness of the ever-present possibility of such an interpersonal disaster and, like stage fright, a motivating force toward avoiding it. It is the fear of faux pas--rendered only that much more probable by an elaborated politesse--that keeps social intercourse on its deliberately narrowed rails. It is lek, more than anything else, that protects Balinese concepts of personhood from the individualizing force of face-to- http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 20 of 28 face encounters. "Absence of climax," the other outstanding quality of Balinese social behavior, is so peculiarly distinctive and so distinctively odd that only extended description of concrete events could properly evoke it. It amounts to the fact that social activities do not build, or are not permitted to build, toward definitive consummations. Quarrels appear and disappear, on occasion they even persist, but they hardly ever come to a head. Issues are not sharpened for decision, they are blunted and softened in the hope that the mere evolution of circumstances will resolve them, or better yet, that they will simply evaporate. Daily life consists of self-contained, monadic encounters in which something either happens or does not--an intention is realized or it is not, a task accomplished or not. When the thing doesn't happen--the intention is frustrated, the task unaccomplished--the effort may be made again from the beginning at some other time; or it may simply be abandoned. Artistic performances start, go on (often for very extended periods when one does not attend continually but drifts away and back, chatters for a while, sleeps for a while, watches rapt for a while), and stop; they are as uncentered as a parade, as directionless as a pageant. Ritual often seems, as in the temple celebrations, to consist largely of getting ready and cleaning up. The heart of the ceremony, the obeisance to the gods come down onto their altars, is deliberately muted to the point where it sometimes seems almost an afterthought, a glancing, hesitant confrontation of anonymous persons brought physically very close and kept socially very distant. It is all welcoming and bidding farewell, foretaste and aftertaste, with but the most ceremonially buffered, ritually insulated sort of actual encounter with the sacred presences themselves. Even in such a dramatically more heightened ceremony as the RangdaBarong, fearful witch and foolish dragon combat ends in a state of complete irresolution, a mystical, metaphysical, and moral standoff leaving everything precisely as it was, and the observer--or anyway the foreign observer--with the feeling that something decisive was on the verge of happening but never quite did.43 In short, events happen like holidays. They appear, vanish, and reappear--each discrete, sufficient unto itself, a particular manifestation of the fixed order of things. Social activities are separate performances; they do not march toward some destination, gather toward some denouement. As time is punctual, so life is. Not orderless, but qualitatively ordered, like the days themselves, into a limited number of established kinds. Balinese social life lacks climax because it takes place in a motionless present, a vectorless now. Or, equally true, Balinese time lacks motion because Balinese social life lacks climax. The two imply one another, and both together imply and are implied by the Balinese contemporization of persons. The perception of fellowmen, the experience of history, and the temper of collective life--what has sometimes been called ethos--are hooked together by a definable logic. But the logic is not syllogistic; it is social. Cultural Integration, Cultural Conflict, Cultural Change Referring as it does both to formal principles of reasoning and to rational connections among facts and events, "logic" is a treacherous word; and nowhere more so than in the analysis of culture. When one deals with meaningful forms, the temptation to see the relationship among them as immanent, as consisting of some sort of intrinsic affinity (or disaffinity) they bear for one another, is virtually overwhelming. And so we hear cultural integration spoken of as a harmony of meaning, cultural change as an instability of meaning, and cultural conflict as an incongruity of meaning, with the implication that the harmony, the instability, or the incongruity are properties of meaning itself, as, say, sweetness is a property of sugar or brittleness of glass. Yet, when we try to treat these properties as we would sweetness or brittleness, they fail to behave, "logically," in the expected way. When we look for the constituents of the harmony, the instability, or the incongruity, we are unable to find them resident in that of which they are presumably properties. One cannot run symbolic forms through some sort of cultural assay to discover their harmony content, their stability ratio, or their index of incongruity; one can only look and see if the forms in question are in fact coexisting, changing, or interfering with one another in some way or other, which is like tasting sugar to see if it is sweet or dropping a glass to see if it is http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 21 of 28 brittle, not like investigating the chemical composition of sugar or the physical structure of glass. The reason for this is, of course, that meaning is not intrinsic in the objects, acts, processes, and so on, which bear it, but--as Durkheim, Weber, and so many others have emphasized--imposed upon them; and the explanation of its properties must therefore be sought in that which does the imposing--men living in society. The study of thought is, to borrow a phrase from Joseph Levenson, the study of men thinking;44 and as they think not in some special place of their own, but in the same place--the social world--that they do everything else, the nature of cultural integration, cultural change, or cultural conflict is to be probed for there: in the experiences of individuals and groups of individuals as, under the guidance of symbols, they perceive, feel, reason, judge, and act. To say this is, however, not to yield to psychologism, which along with logicism is the other great saboteur of cultural analysis; for human experience--the actual living through of events--is not mere sentience, but, from the most immediate perception to the most mediated judgment, significant sentience--sentience interpreted, sentience grasped. For human beings, with the possible exception of neonates, who except for their physical structure are human only in posse anyway, all experience is construed experience, and the symbolic forms in terms of which it is construed thus determine--in conjunction with a wide variety of other factors ranging from the cellular geometry of the retina to the endogenous stages of psychological maturation--its intrinsic texture. To abandon the hope of finding the "logic" of cultural organization in some Pythagorean "realm of meaning" is not to abandon the hope of finding it at all. It is to turn our attention toward that which gives symbols their life: their use.45 What binds Balinese symbolic structures for defining persons (names, kin terms, teknonyms, titles, and so on) to their symbolic structures for characterizing time (permutational calendars, and so forth), and both of these to their symbolic structures for ordering interpersonal behavior (art, ritual, politesse, and so on), is the interaction of the effects each of these structures has upon the perceptions of those who use them, the way in which their experiential impacts play into and reinforce one another. A penchant for "contemporizing" fellowmen blunts the sense of biological aging; a blunted sense of biological aging removes one of the main sources of a sense of temporal flow; a reduced sense of temporal flow gives to interpersonal events an episodic quality. Ceremonialized interaction supports standardized perceptions of others; standardized perceptions of others support a "steady-state" conception of society; a steady-state conception of society supports a taxonomic perception of time. And so on: one could begin with conceptions of time and go around, in either direction, the same circle. The circle, though continuous, is not in a strict sense closed, because none of these modes of experience is more than a dominant tendency, a cultural emphasis, and their subdued opposites, equally well- rooted in the general conditions of human existence and not without some cultural expression of their own, coexist with them, and indeed act against them. Yet, they are dominant; they do reinforce one another; and they are persisting. And it is to this state of affairs, neither permanent nor perfect, that the concept "cultural integration" --what Weber called "Sinnzusammenhang" --can be legitimately applied. In this view, cultural integration is no longer taken to be a sui generis phenomenon locked away from the common life of man in a logical world of its own. Perhaps even more important, however, it is also not taken to be an all-embracing, completely pervasive, unbounded one. In the first place, as just noted, patterns counteractive to the primary ones exist as subdominant but nonetheless important themes in, so far as we can tell, any culture. In an ordinary, quite un-Hegelian way, the elements of a culture's own negation are, with greater or lesser force, included within it. With respect to the Balinese, for example, an investigation of their witch beliefs (or, to speak phenomenologically, witch experiences) as inverses of what might be called their person beliefs, or of their trance behavior as an inverse of their etiquette, would be most enlightening in this respect and would add both depth and complexity to the present analysis. Some of the more famous attacks upon received cultural characterizations--revelations of suspicion and factionalism among the "harmony-loving" Pueblans, or of an "amiable side" to the rivalrous Kwakiutl--consist essentially in a pointing out of the existence, and the importance, of such themes.46 http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 22 of 28 But beyond this sort of natural counterpoint there are also simple, unbridged discontinuities between certain major themes themselves. Not everything is connected to everything else with equal directness; not everything plays immediately into or against everything else. At the very least such universal primary interconnection has to be empirically demonstrated, not just, as so often has been the case, axiomatically assumed. Cultural discontinuity, and the social disorganization which, even in highly stable societies, can result from it, is as real as cultural integration. The notion, still quite widespread in anthropology, that culture is a seamless web is no less a petitio principii than the older view that culture is a thing of shreds and patches which, with a certain excess of enthusiasm, it replaced after the Malinowskian revolution of the early thirties. Systems need not be exhaustively interconnected to be systems. They may be densely interconnected or poorly, but which they are- how rightly integrated they are--is an empirical matter. To assert connections among modes of experiencing, as among any variables, it is necessary to find them (and find ways of finding them), not simply assume them. And as there are some rather compelling theoretical reasons for believing that a system which is both complex, as any culture is, and fully joined cannot function, the problem of cultural analysis is as much a matter of determining independencies as interconnections, gulfs as well as bridges.47 The appropriate image, if one must have images, of cultural organization, is neither the spider web nor the pile of sand. It is rather more the octopus, whose tentacles are in large part separately integrated, neurally quite poorly connected with one another and with what in the octopus passes for a brain, and yet who nonetheless manages both to get around and to preserve himself, for a while anyway, as a viable if somewhat ungainly entity. The close and immediate interdependency between conceptions of person, time, and conduct which has been proposed in this essay is, so I would argue, a general phenomenon, even if the particular Balinese form of it is peculiar to a degree, because such an interdependency is inherent in the way in which human experience is organized, a necessary effect of the conditions under which human life is led. But it is only one of a vast and unknown number of such general interdependencies, to some of which it is more or less directly connected, to others only very indirectly, to others for all practical purposes virtually not at all. The analysis of culture comes down therefore not to an heroic "holistic" assault upon "the basic configurations of the culture," an overarching "order of orders" from which more limited configurations can be seen as mere deductions, but to a searching out of significant symbols, clusters of significant symbols, and clusters of clusters of significant symbols--the material vehicles of perception, emotion, and understanding--and the statement of the underlying regularities of human experience implicit in their formation. A workable theory of culture is to be achieved, if it is to be achieved, by building up from directly observable modes of thought, first to determinate families of them and then to more variable, less tightly coherent, but nonetheless ordered "octopoid" systems of them, confluences of partial integrations, partial incongruencies, and partial independencies. Culture moves rather like an octopus too--not all at once in a smoothly coordinated synergy of parts, a massive coaction of the whole, but by disjointed movements of this part, then that, and now the other which somehow cumulate to directional change. Where, leaving cephalopods behind, in any given culture the first impulses toward progression will appear, and how and to what degree they will spread through the system, is, at this stage of our understanding, if not wholly unpredictable, very largely so. Yet that if such impulses appear within some rather closely interconnected and socially consequential part of the system, their driving force will most likely be high, does not appear to be too unreasonable a supposition. Any development which would effectively attack Balinese personperceptions, Balinese experiences of time, or Balinese notions of propriety would seem to be laden with potentialities for transforming the greater part of Balinese culture. These are not the only points at which such revolutionary developments might appear (anything which attacked Balinese notions of prestige and its bases would seem at least equally portentous), but surely they are among the most important. If the Balinese develop a less anonymized view of one another, or a more dynamic sense of time, or a more informal style of social interaction, a very great deal indeed--not everything, http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 23 of 28 but a very great deal--would have to change in Balinese life, if only because any one of these changes would imply, immediately and directly, the others and all three of them play, in different ways and in different contexts, a crucial role in shaping that life. Such cultural changes could, in theory, come from within Balinese society or from without; but considering the fact that Bali is now part of a developing national state whose center of gravity is elsewhere--in the great cities of Java and Sumatra--it would seem most likely to come from without. The emergence for almost the first time in Indonesian history of a political leader who is human, all-too-human, not merely in fact but in appearance would seem to imply something of a challenge to traditional Balinese personhood conceptions. Not only is Sukarno a unique, vivid, and intensely intimate personality in the eyes of the Balinese, he is also, so to speak, aging in public. Despite the fact that they do not engage in face-to-face interaction with him, he is phenomenologically much more their consociate than their contemporary, and his unparalleled success in achieving this kind of relationship--not only in Bali, but in Indonesia quite generally--is the secret of a good deal of his hold on, his fascination for, the population. As with all truly charismatic figures his power comes in great part from the fact that he does not fit traditional cultural categories but bursts them open by celebrating his own distinctiveness. The same is true, in reduced intensity, for the lesser leaders of the New Indonesia, down to those small-frog Sukarnos (with whom the population does have face-to-face relations) now beginning to appear in Bali itself.48 The sort of individualism which Burckhardt saw the Renaissance princes bringing, through sheer force of character, to Italy, and bringing with it the modern Western consciousness, may be in the process of being brought, in rather different form, to Bali by the new populist princes of Indonesia. Similarly, the politics of continuing crisis on which the national state has embarked, a passion for pushing events toward their climaxes rather than away from them, would seem to pose the same sort of challenge to Balinese conceptions of time. And when such politics are placed, as they are increasingly being placed, in the historical framework so characteristic of New Nation nationalism almost everywhere--original greatness, foreign oppression, extended struggle, sacrifice and self-liberation, impending modernization--the whole conception of the relation of what is now happening to what has happened and what is going to happen is altered. And finally, the new informality of urban life and of the pan-Indonesian culture which dominates it--the growth in importance of youth and youth culture with the consequent narrowing, sometimes even the reversal, of the social distance between generations; the sentimental comradeship of fellow revolutionaries; the populist equalitarianism of political ideology, Marxist and non-Marxist alike--appears to contain a similar threat to the third, the ethos or behavioral style, side of the Balinese triangle. All this is admittedly mere speculation (though, given the events of the fifteen years of Independence, not wholly groundless speculation) and when, how, how fast, and in what order Balinese perceptions of person, time, and conduct will change is, if not wholly unpredictable in general, largely so in detail. But as they do change--which seems to me certain, and in fact already to have well begun49 --the sort of analysis here developed of cultural concepts as active forces, of thought as a public phenomenon with effects like other public phenomena, should aid us in discovering its outlines, its dynamics, and, even more important, its social implications. Nor, in other forms and with other results, should it be less useful elsewhere. Notes 1 The most systematic and extensive discussions are to be found in T. Parsons and E. Shils, eds., Toward a General Theory of Action ( Cambridge, Mass., 1959); and T. Parsons, The Social System ( Glencoe, Ill., 1951). Within anthropology, some of the more notable treatments, not all of them in agreement, include: S. F. Nadel , Theory of Social Structure ( Glencoe. Ill., 1957). E. Leach, Political Systems of Highland Burma ( Cambridge, Mass., 1954); E. E. Evans-Pritchard, Social Anthropology ( Glencoe, Ill., 1951); R. Redfield, The Primitive World and Its Transformations ( Ithaca, 1953); C. LÈvi-Strauss, "Social Structure," in his Structural Anthropology ( New York, 1963). pp. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 24 of 28 277-323; R. Firth, Elements of Social Organization ( New York, 1951); and M. Singer, "Culture," in International Encyclopedia of the Social Sciences, vol. 3 ( New York, 1968), p. 527. 2 G. Ryle, The Concept of Mind ( New York, 1949). I have dealt with some of the philosophical issues, here passed over in silence, raised by the "extrinsic theory of thought," above, Chapter 3, pp. 55-61. and need now only re-emphasize that this theory does not involve a commitment to behaviorism, in either its methodological or epistemological forms; nor yet again to any disputation of the brute fact that it is individuals, not collectivities, who think. 3 For an introduction to Schutz work in this field, see his "The Problem of Social Reality", Collected Papers, 1, ed. M. Natanson ( The Hague, 1962). 4 Ibid., pp. 17 - 18. Brackets added, paragraphing altered. 5 Where "ancestor worship" on the one side or "ghost beliefs" on the other are present, successors may be regarded as (ritually) capable of interacting with their predecessors, or predecessors of (mystically) interacting with their successors. But in such cases the "persons" involved are, while the interaction is conceived to be occurring, phenomenologically not predecessors and successors, but contemporaries, or even consociates. It should be kept clearly in mind that, both here and in the discussion to follow, distinctions are formulated from the actor's point of view, not from that of an outside, third-person observer. For the place of actororiented (sometimes miscalled "subjective") constructs in the social sciences, see, T. Parsons, The Structure of Social Action ( Glencoe, Ill., 1937), especially the chapters on Max Weber's methodological writings. 6 It is in this regard that the consociate-contemporary-predecessor-successor formulation differs critically from at least some versions of the umwelt-mitweltvorwelt-vogelwelt formulation from which it derives, for there is no question here of apodictic deliverances of "transcendental subjectivity" ý la Husserl but rather of socio-psychologically developed and historically transmitted "forms of understanding" ý la Weber. For an extended, if somewhat indecisive, discussion of this contrast, see M. Merleau-Ponty, "Phenomenology and the Sciences of Man," in his The Primacy of Perception ( Evanston, 1964), pp. 43 - 55. 7 In the following discussion, I shall be forced to schematize Balinese practices severely and to represent them as being much more homogeneous and rather more consistent than they really are. In particular, categorical statements, of either a positive or negative variety ("All Balinese ..."; "No Balinese ..."), must be read as having attached to them the implicit qualification " ... so far as my knowledge goes," and even sometimes as riding roughshod over exceptions deemed to be "abnormal." Ethnographically fuller presentations of some of the data here summarized can be found in H. and C. Geertz, "Teknonymy in Bali: Parenthood, Age-Grading, and Genealogical Amnesia," Journal of the Royal Anthropological Institute 94 (part 2) ( 1964):94-108; C. Geertz, "Tihingan: A Balinese Village," Bijdragen tot de taal-, land- en volkenkunde, 120 ( 1964):1-33; and C. Geertz, "Form and Variation in Balinese Village Structure," American Anthropologist 61 ( 1959):991-1012. 8 While personal names of commoners are mere inventions, meaningless in themselves, those of the gentry are often drawn from Sanskrit sources and "mean" something, usually something rather high-flown, like "virtuous warrior" or "courageous scholar." But this meaning is ornamental rather than denotative, and in most cases what the meaning of the name is (as opposed to the simple fact that it has one) is not actually known. This contrast between mere babble among the peasantry and empty grandiloquence among the gentry is not without cultural significance, but its significance lies mainly in the area of the expression and perception of social inequality, not of personal identity. 9 This is, of course, not to say that such people are reduced in sociological (much less psychological) terms to playing the role of a child, for they are accepted as adults, if incomplete ones, by their consociates. The failure to have children is, however, a distinct handicap for anyone desiring much local power or prestige, and I have for my part never known a childless man who carried much weight in hamlet councils, or for that matter who was not socially marginal in general. 10 From a merely etymological point of view, they do have a certain aura of meaning, for they derive from obsolete roots indicating "leading," "medial," and "following"; but these gossamery meanings have no genuine everyday currency and are, if at all, but very peripherally perceived. 11 In point of fact, the Balinese system (or, in all probability, any other system) is not purely generational; but the intent here is merely to convey the general form of the system, not its precise structure. For the full terminological system, see H. and C. Geertz, "Teknonymy in Bali." 12 13 14 15 16 For a distinction, similar to the one drawn here, between the "ordering" and the "role-designating" aspects of kin terminologies, see D. Schneider and G. Homans , "Kinship Terminology and the American Kinship System," American Anthropologist 57 ( 1955):1195-1208. Old men of the same generation as the deceased do not pray to him either, of course, for the same reason. It might seem that the continuation of terms beyond the kumpi level would argue against this view. But in fact it supports it. For, in the rare case where a man has a ("real" or "classificatory") great-great-grandchild (kelab) old enough to worship him at his death, the child is, again, forbidden to do so. But here not because he is "the same age" as the deceased but because he is "(a generation) older"--i.e., equivalent to the dead man's "father." Similarly, an old man who lives long enough to have a great-great-grandchild kelab who has passed infancy and then died will worship--alone--at the child's grave, for the child is (one generation) senior to him. In principle, the same pattern holds in more distant generations, when, as the Balinese do not use kin terms to refer to the dead or the unborn, the problem becomes entirely theoretical: "That's what we'd call them and how we would treat them if we had any, which we never do." Personal pronouns are another possibility and might indeed be considered as a separate symbolic order of person-definition. But, in fact, their use also tends to be avoided whenever possible, often at the expense of some awkwardness of expression. This use of a descendant's personal name as part of a teknonym in no way contradicts my earlier statements about the lack of public currency of such names. The "name" here is part of the appellation of the person bearing the teknonym, not, even derivatively, of the eponymous child, whose name is taken purely as a reference point and is without--so far as I can tell--any independent symbolic value at http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 25 of 28 17 18 19 20 21 22 23 24 25 26 27 28 29 30 all. If the child dies, even in infancy, the teknonym is usually maintained unchanged; the eponymous child addresses and refers to his father and mother by the teknonym which includes his own name quite unself-consciously; there is no notion that the child whose name is embraced in his parents', grandparents', or great-grandparents' teknonyms is, on that account, any way different from or privileged over his siblings whose names are not; there is no shifting of teknonyms to include the names of favored or more able offspring, and so on. It also underscores another theme which runs through all the orders of person-definition discussed here: the minimization of the difference between the sexes which are represented as being virtually interchangeable so far as most social roles are concerned. For an intriguing discussion of this theme, see J. Belo, Rangda and Barong (Locust Valley, N.Y., 1949). In this sense, birth order terms could, in a more elegant analysis, be defined as "zero teknonyms" and included in this symbolic order: a person called Wayan, Njoman, etc., is a person who has produced no one, who has, as yet anyway, no descendants. G. Bateson, "Bali: The Value System of a Steady State," in M. Fortes, ed., Social Structure: Studies Presented to Radcliffe-Brown ( New York, 1963), pp. 35 - 53. Bateson was the first to point out, if somewhat obliquely, the peculiar achronic nature of Balinese thought, and my more narrowly focused analysis has been much stimulated by his general views. See also his "An Old Temple and a New Myth," Djawa (Jogjakarta) 17 ( 1937):219-307. [These have now been reprinted in J. Belo, ed., Traditional Balinese Culture ( New York, 1970), pp. 384- 402; 111 - 136.] Neither how many different titles are found in Bali (though there must be well over a hundred) nor how many individuals bear each title is known, for there has never been a census taken in these terms. In four hamlets I studied intensively in southeastern Bali a total of thirty-two different titles were represented, the largest of which was carried by nearly two hundred and fifty individuals, the smallest by one, with the modal figure running around fifty or sixty. See C. Geertz, "Tihingan: A Balinese Village." Varna categories are often subdivided, especially by high-status persons, into three ranked classes--superior (utama), medium (madia), and inferior (nista)--the various titles in the overall category being appropriately subgrouped. A full analysis of the Balinese system of social stratification--as much Polynesian as Indian in type--cannot be given here. The existence of one other order, that having to do with sex markers (Ni for women, I for men) ought at least to be mentioned. In ordinary life, these titles are affixed only to personal names (most of which are themselves sexually neutral) or to personal names plus birth order name, and then only infrequently. As a result, they are, from the point of view of person-definition, of but incidental importance, and I have felt justified in omitting explicit consideration of them. For an essay in this direction, see C. Geertz, "Form and Variation in Balinese Village Structure." Place names associated with the function the title expresses are perhaps even more common as secondary specification: "Klian Pau," "Pau" being the name of the hamlet of which the person is klian (chief, elder); "Anak Agung Kaleran," "Kaleran"--literally "north" or "northern"--being the name (and the location) of the lord's palace. Traditional texts, some of them fairly extensive, relating certain activities of the gods, do exist and fragments of the stories are known. But not only do these myths also reflect the typological view of personhood, the static view of time, and the ceremonialized style of interaction I am seeking to characterize, but the general reticence to discuss or think about the divine means that the stories they relate enter but slightly into Balinese attempts to understand and adapt to "the world." The difference between the Greeks and the Balinese lies not so much in the sort of lives their gods lead, scandalous in both cases, as in their attitude toward those lives. For the Greeks, the private doings of Zeus and his associates were conceived to illuminate the all-too-similar doings of men, and so gossip about them had philosophical import. For the Balinese, the private lives of Betara Guru and his associates are just that, private, and gossip about them is unmannerly-- even, given their place in the prestige hierarchy, impertinent. It is the overall order which is conceived to be fixed, not the individual's location within it, which is movable, though more along certain axes than others. (Along some, e.g., birth order, it is not movable at all.) But the point is that this movement is not, or anyway not primarily, conceived in what we would regard to be temporal terms: when a "father-of" becomes a "grandfather-of," the alteration is perceived as being less one of aging than a change in social (and what is here the same thing, cosmic) coordinates, a directed movement through a particular sort of unchanging attribute, space. Also, within some symbolic orders of person-definition, location is not conceived as an absolute quality because coordinates are origin-dependent: in Bali, as elsewhere, one man's brother is another man's uncle. Sch¸tz, The Problem of Social Reality, pp. 16-17. Brackets added. Ibid., pp. 221 - 222. As a preface to the following, and an appendix to the preceding, discussion, it should be remarked that, just as the Balinese do have consociate relations with one another and do have some sense of the material connection between ancestors and descendants, so too they do have some, as we would put it, "true" calendrical concepts--absolute dates in the so-called Caka system, Hinduistic notions of successive epochs, as well as, indeed, access to the Gregorian calendar. But these are (ca. 1958) unstressed and of distinctly secondary importance in the ordinary course of everyday life; variant patterns applied in restricted contexts for specific purposes by certain sorts of persons on sporadic occasions. A complete analysis of Balinese culture--so far as such a thing is possible--would indeed have to take account of them; and from certain points of view they are not without theoretical significance. The point, here and elsewhere, in this quite incomplete analysis, however, is not that the Balinese are, as the Hungarians are reputed to be, immigrants from another planet entirely unlike ourselves, but merely that the major thrust of their thought concerning certain matters of critical social importance lies, at least for the moment, in a markedly different direction from ours. Because the thirty-seven-name cycles (uku) which make up the two hundred and ten-day supercycle are also named, they can be, and commonly are, used in conjunction with five- and seven-day names, so eliminating the need to invoke names from the six-name cycle. But this is merely a notational matter: the result is exactly the same, though the days of the thirty- and forty-two-day supercycles are thus obscured. Balinese devices--charts, lists, numerical calculation, mnemonics--for making calendrical determinations and assessing their http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 26 of 28 31 32 33 34 35 36 37 38 39 40 41 42 43 meaning are both complex and various, and there are differences in technique and interpretation between individuals, villages, and regions of the island. Printed calendars in Bali (a still not very widespread innovation) contrive to show at once the uku; the day in each of the ten permutating cycles (including the one that never changes!); the day and month in the lunar-solar system; the day, the month, and year in the Gregorian and Islamic calendars; and the day, month, year, and year-name in the Chinese calendar--complete with notations of all the important holidays from Christmas to Galungan these various systems define. For fuller discussions of Balinese calendrical ideas and their socioreligious meaning, see R. Goris, "Holidays and Holy Days," in J. L. Swellengrebel, ed., Bali ( The Hague, 1960), pp. 115 - 129, together with the references cited there. More accurately: the days they define tell you what kind of time it is. Though the cycles and supercycles, being cycles, are recurrent, it is not this fact about them which is attended to or to which significance is attached. The thirty-, thirty-five-, forty-two-, and two hundred and ten-day periodicities, and thus the intervals they demarcate, are not, or are only very peripherally, perceived as such; nor are the intervals implicit in the elementary periodicities, the cycles proper, which generate them--a fact which has sometimes been obscured by calling the former "months" and "years" and the latter "weeks." It is--one cannot stress it too strongly--only the "days" which really matter, and the Balinese sense of time is not much more cyclical than it is durative: it is particulate. Within individual days there is a certain amount of short- range, not very carefully calibrated, durative measurement, by the public beating of slit-gongs at various points (morning, midday, sundown, and so on) of the diurnal cycle, and for certain collective labor tasks where individual contributions have to be roughly balanced, by water- clocks. But even this is of little importance: in contrast to their calendrical apparatus, Balinese horological concepts and devices are very undeveloped. Goris, "Holidays and Holy Days," p. 121. Not all of these holidays are major, of course. Many of them are celebrated simply within the family and quite routinely. What makes them holidays is that they are identical for all Balinese, something not the case for other sorts of celebrations. Ibid. There are, of course, subrhythms resulting from the workings of the cycles: thus every thirty-fifth day is a holiday because it is determined by the interaction of the five- and seven-name cycles, but in terms of the sheer succession of days there is none, though there is some clustering here and there. Goris regards RaditÈ-Tungleh-Paing as the "first day of the . . . Balinese [permutational] year" (and thus those days as the first days of their respective cycles); but though there may (or may not: Goris doesn't say) be some textual basis for this, I could find no evidence that the Balinese in fact so perceive it. In fact, if any day is regarded as something of what we would regard as a temporal milestone it would be Galungan (number seventy-four in the above reckoning). But even this idea is very weakly developed at best; like other holidays, Galungan merely happens. To present the Balinese calendar, even partially, in terms of Western flowof-time ideas is, in my opinion, inevitably to misrender it phenomenologically. Swellengrebel, Bali, p. 12. These temples are of all sizes and degrees of significance, and Swellengrebel notes that the Bureau of Religious Affairs on Bali gave a (suspiciously precise) figure, ca. 1953, of 4,661 "large and important" temples for the island, which, it should be remembered, is, at 2,170 square miles, about the size of Delaware. For a description of a full-blown odalan (most of which last three days rather than just one), see J. Belo, Balinese Temple Festival (Locust Valley, N.Y., 1953). Again, odalans are most commonly computed by the use of the uku rather than the six-name cycle, together with the five and seven-name cycles. See note 30. There are also various metaphysical conceptions associated with days bearing different names--constellations of gods, demons, natural objects (trees, birds, beasts), virtues and vices (love, hate . . .), and so on--which explain "why" it has the character it has--but these need not be pursued here. In this area, as well as in the associated "fortune telling" operations described in the text, theories and interpretations are less standardized and computation is not confined to the five-, six-, and seven-name cycles, but extended to various permutations of the others, a fact which makes the possibilities virtually limitless. With respect to individuals the term applied is more often otonan than odalan, but the root meaning is just the same: "emerging," "appearance," "coming out." The names of the last two months--borrowed from Sanskrit--are not strictly speaking numbers as are those of the other ten; but in terms of Balinese perceptions they "mean" eleventh and twelfth. In fact, as another Indic borrowing, the years are numbered too, but-outside of priestly circles where familiarity with it is more a matter of scholarly prestige, a cultural ornament, than anything else--year enumeration plays virtually no role in the actual use of the calendar, and lunar-solar dates are almost always given without the year, which is, with the rarest of exceptions, neither known nor cared about. Ancient texts and inscriptions sometimes indicate the year, but in the ordinary course of life the Balinese never "date" anything, in our sense of the term, except perhaps to say that some event--a volcanic eruption, a war, and so forth--happened "when I was small," "when the Dutch were here," or, the Balinese illo tempore, "in Madjapahit times," and so on. On the "shame" theme in Balinese culture, see M. Covarrubias, The Island of Bali ( New York, 1956); on "absence of climax," G. Bateson and M. Mead, Balinese Character ( New York, 1942). For a comprehensive critical review, see G. Piers and M. Singer, Shame and Guilt ( Springfield, Ill., 1953). Again, I am concerned here with cultural phenomenology, not psychological dynamics. It is, of course, quite possible, though I do not think the evidence is available either to prove or disprove it, that Balinese "stage fright" is connected with unconscious guilt feelings of some sort or another. My only point is that to translate lek as either "guilt" or "shame" is, given the usual sense of these terms in English, to misrender it, and that our word "stage fright"--"nervousness felt at appearing before an audience," to resort to Webster's again--gives a much better, if still imperfect, idea of what the Balinese are in fact talking about when they speak, as they do almost constantly, of lek. For a description of the Rangda-Barong combat, see J. Belo, Rangda and Barong; for a brilliant evocation of its mood, G. Bateson and M. Mead, Balinese Character. See also above, pp. 114-118. http://hypergeertz.jku.at/GeertzTexts/Person_ Time _ Conduct.htm 2/26/25, 1:39 PM Page 27 of 28 44 45 46 47 48 49 J. Levenson, Modern China and Its Confucian Past ( Garden City, 1964), p. 212. Here, as elsewhere, I use "thinking" to refer not just to deliberate reflection but intelligent activity of any sort, and "meaning" to refer not just to abstract "concepts" but significance of any sort. This is perhaps somewhat arbitrary, and a little loose, but one must have general terms to talk about general subjects, even if what falls under such subjects is very far from being homogeneous. ,"Every sign by itself seems dead. What gives it life?--in use it is alive. Is life breathed into it there?--Or is its use its life?" L. Wittgenstein, Philosophical Investigations ( New York, 1953), p. 128e. Italics in original. Li An-che, "ZuÒi: Some Observations and Queries," American Anthropologist 39 ( 1937):62-76; H. Codere, "The Amiable Side of Kwakiutl Life," American Anthropologist 58 ( 1956):334-351. Which of two antithetical patterns or clusters of patterns, if either, is in fact primary, is of course an empirical problem, but not, particularly if some thought is given to what "primacy" means in this connection, an insoluble one. "It has thus been shown that, for adaptations to accumulate, there must not be channels ... from some variables . . . to others. ... The idea so often implicit in physiological writings that all will be well if only sufficient cross-connections are available is ... quite wrong." W. R. Ashby, Design for a Brain, 2nd ed. rev. ( New York, 1960), p. 155. Italics in original. Of course, the reference here is to direct connections--what Ashby calls "primary joins." Any variable with no relations whatsoever to other variables in the system would simply not be part of it. For a discussion of the nest of theoretical problems involved here, see Ashby, pp. 171-183, 205-218. For an argument that cultural discontinuity may not only be compatible with the effective functioning of the social systems they govern but even supportive of such functioning, see J. W. Fernandez, "Symbolic Consensus in a Fang Reformative Cult." American Anthropologist 67 ( 1965):902-929. It is perhaps suggestive that the only Balinese of much importance in the central Indonesian government during the early years of the Republic--he was foreign minister for a while--was the Satria paramount prince of Gianjar, one of the traditional Balinese kingdoms, who bore the marvellously Balinese "name" of Anak Agung Gde Agung. "Anak Agung" is the public title borne by the members of the ruling house of Gianjar, Gde is a birth order title (the Triwangsa equivalent of Wayan), and Agung though a personal name is in fact just an echo of the public title. As "gde" and "agung" both mean "big," and "anak" means man, the whole name comes to something like "Big, Big, Big Man"--as indeed he was, until he fell from Sukarno's favor. More recent political leaders in Bali have taken to the use of their more individualized personal names in the Sukarno fashion and to the dropping of titles, birth order names, teknonyms, and so on, as "feudal" or "old-fashioned." This was written in early 1965; for the dramatic changes that, in fact, occurred later that year, see pp. 282-283 and Chapter 11. Person, time, and conduct in Bali: an essay in cultural analysis, New-Haven/Ct./USA 1966: Yale University Press; ed. by the Deptartment of Southeast Asia Studies cf. The interpretation of cultures: selected essays, New-York/N.Y./USA etc. 1973: Basic Books, pp. 360-411. online source: http://www.questia.com/PM.qst?a=o&d=52995835 Using this text is also subject to the general HyperGeertz-Copyright-regulations based on Austrian copyright-law (2001), which - in short - allow a personal, nonprofit & educational (all must apply) use of material stored in data bases, including a restricted redistribution of such material, if this is also for nonprofit purposes and restricted to a specific scientific community (both must apply), and if full and accurate attribution to the author, original source and date of publication, web location(s) or originating list(s) is given ("fair-use-restriction"). Any other use transgressing this restriction is subject to a direct agreement between a subsequent user and the holder of the original copyright(s) as indicated by the source(s). 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The American Sleep Disorders Association, in 1990, initiated a 5 year process to develop the widely used International Classification of Sleep Disorders (ICSD). The original ICSD listed 84 sleep disorders, each with descriptive details and specific diagnostic, severity, and duration criteria. The ICSD had 4 major categories: (1) dyssomnias, (2) parasomnias, (3) disorders associated with medical or psychiatric disorders, (4) "proposed" sleep disorders. The ICSD has since been revised twice. The second edition, ICSD-2 was released in 2005 which contains a list of 77 sleep disorders. That new list was broken down into 8 sub-categories: (1) Insomnia; (2) Sleep-related breathing disorder; (3) Hypersomnia not due to a sleep related breathing disorder; (4) Circadian rhythm sleep disorder; (5) Parasomnia; (6) Sleep-related movement disorder; (7) Isolated Symptoms, apparently normal variants, and unresolved issues; and (8) Other sleep disorders. A third edition of the ICSD was released in 2014. The major clinical divisions were unchanged in the third edition from the 2nd version, but there was an addition of variations in the diagnostic criteria for pediatric patients with obstructive sleep apnea, and there was a heading of Developmental Issues added to each section of disorders that have developmentally-specific clinical features in order to aid physicians in diagnosing those patients (specifically 9-CM and 10 CM). Sleep Disorders Categories The ICSD-3 lists about 77 sleep disorders which are divided into the following categories: Insomnia Sleep-related breathing disorder Central Disorders of Hypersomnolence Circadian rhythm sleep disorder Parasomnias Sleep-related movement disorder Some of the above categories have a section for isolated Symptoms, apparently normal variants, and unresolved issues Other sleep disorders There are some other sleep disorders that are divided into two appendices of the ICSD-2 manual. They are as follows: Sleep Related Medical and Neurological Disorders; and ICD-10-CM Coding for Substance-induced Sleep Disorders Study the disorders listed under each of the above categories until you have a good idea of what is included in each. There is a complete list of all the current classified sleep disorders in chapter 27, beginning on page 476 of your Sleep Disorders Medicine, 4th edition textbook. Insomnias Insomnias are disorders that usually produce complaints of not enough sleep, poor quality of sleep. Patient perception can play a role in the complaints. Occasionally, a patient may perceive that they are getting poor quality or not enough sleep even though they may be getting what we think is a normal night’s rest. Insomnias are defined by a repeated difficulty initiating sleep, not sleeping long enough, or poor quality sleep regardless of the amount of sleep time. Primary insomnia would not be due to another sleep disorder. If another sleep disorder such as OSA is causing the insomnia, then we call that secondary insomnia. These disorders may require medical treatment if they are long-lasting. Temporary insomnia due to a stressful situation or life event may correct itself with time. The types of insomnia are covered on pages 476 and 480 of your textbook. Sleep-Related Breathing Disorders These are disorders that involve disordered respiration, or breathing during sleep. These may be obstructive or not. There can be various causes of both. Central apnea syndromes include Cheyenne-Stokes breathing pattern and high-altitude periodic breathing. Cheyenne-Stokes is usually associated with either congestive heart failure or a traumatic brain injury which would actually be called secondary Central Sleep Apnea because it is secondary to another problem. It can also occur due to extreme old age, or a “worn-out” heart (a pacemaker may be needed for this type of patient). You will see patients like this occasionally. Primary Central Sleep Apnea has no apparent cause but still results in an irregular breathing pattern. These patients are not necessarily good candidates for CPAP because their breathing problem may not involve an obstruction. If not, you will likely see an increase in the number or length of central apneas after placing them on CPAP. There are newer PAP technologies that have been developed in recent years that do have some effect on the regulation of these types of patients’ breathing pattern but may show limited success in extending life expectancy. The obstructive type of breathing disorders, on the other hand, do respond well to treatment. These will likely make up the vast majority of patients that you will encounter in the sleep laboratory. Refer to pages 476 and 481 for more detailed examples of these disorders. Central Disorders of Hypersomnolence If you break down the word “hypersomnia” into its root terms as you did in medical terminology, it should be apparent that these disorders involve excessive sleepiness. However, the excessive sleepiness cannot be the result of another class of disorder. If a patient has another such disorder, that disorder must be effectively treated before a diagnosis of hypersomnia not due to a sleep-related breathing disorder can be made. These patients may have nights of uninterrupted sleep, but they still have unintended or unwanted lapses into sleep during the day. There can be many different causes of this; some of which are very interesting. Narcolepsy and Kleine-Levin Syndrome fall into this category along with some neurologic or psychiatric disorders. Circadian Rhythm Sleep Disorder Circadian rhythm sleep disorders are sleep disorders related to the internal clock of the human body resulting in an irregular sleep-wake cycle. Patients with these sleep disorders have circadian rhythms that make it difficult for them to function in society. The three extrinsic circadian rhythm sleep disorders are the time zone change syndrome, shift work sleep disorder, and irregular sleep-wake pattern (secondary circadian rhythm disorders). Three intrinsic circadian rhythm sleep disorders are delayed sleep phase syndrome, advanced sleep phase syndrome, and non-24-hour sleep-wake disorder (primary circadian rhythm disorders). For Circadian Rhythm disorders, refer to page 482 of your textbook. Time Zone Change Syndrome (Jet Lag Syndrome): Jet lag is experienced as a result of eastward or westward jet travel, after crossing several time zones, disrupting synchronization between the body's inner clock and its external cues. Symptoms do not occur after north-south travel. jet lag symptoms consist of difficulty in maintaining sleep, frequent arousals, and excessive daytime somnolence. Delayed Sleep Phase Syndrome: The ICSD-2 defines delayed sleep phase syndrome (DSPS) as a condition in which a patient's major sleep episode is delayed in relation to a desired clock time. This delay causes symptoms of sleep-onset insomnia or difficulty awakening at the desired time. Typically, patients go to sleep late (between 2:00 am and 6:00 am) and awaken during late morning or afternoon hours (between 10:00 am and 2:00 pm). Patients cannot function normally in society due to disturbed sleep schedules. Patients may try hypnotic medications or alcohol in attempts to initiate sleep sooner. DSPS patients may be treated by the use of chronotherapy (intentionally delays sleep onset by 2-3 hours on successive days until the desired bedtime has been achieved) or phototherapy (exposure to bright light on awakening). Advanced Sleep Phase Syndrome: Advanced sleep phase syndrome is characterized by patients going to sleep in the early evening and wake up earlier than desired in the morning (2:00 am-4:00 am). Because the patients have early morning awakenings, they experience sleep disruption and daytime sleepiness if they don't go to sleep at early hours. ASPS is most commonly seen in elderly individuals. Diagnosis is based upon sleep logs and characteristic actigraphic recordings made over several days. Chronotherapy may be used to treat ASPS; however, this therapy is not as successful in ASPS as in DSPS. Bright light exposure in the evening has been successful in delaying sleep onset. Non-24-Hour Sleep-Wake Disorder: Also known as Non-entrained, free running, or hypernychthemeral syndrome, is a disorder characterized by a patient's inability to maintain a regular bedtime and a sleep onset that occurs at irregular hours. Patients display increases in the delay of sleep onset by approximately one hour per sleep-wake cycle, causing an eventual progression of sleep onset through the daytime hours and into the evening. These individuals fail to be entrained or synchronized by usual time cues such as sunlight or social activities. This disorder is extremely rare and is most often associated with blindness. Parasomnia The parasomnias are a class of sleep disorders associated with arousals, partial arousals, and sleep stage transitions. They are dysfunctions (including movements and behaviors) that are associated with sleep, or that occur during sleep. Most parasomnias occur during delta sleep or slow wave sleep, although some can occur during any stage. REM Behavior Disorder, Nightmare Disorder, and Recurrent Isolated Sleep Paralysis are also included in this group although they are all associated with REM sleep. Rem Behavior Disorder (RBD) may involve a very drastic or sometimes violent dream enactment. Approximately 88% of known cases are in males. Elderly patients (over the age of 60) make up a high percentage of known cases (60%). RBD is now considered to be a possible indication of a future neurodegenerative disease such as Parkinson’s. Around 50% of patients with REM parasomnias also have some type of central nervous system disorder, and almost 10% have a psychiatric disorder. The treatment for these disorders is usually limited to securing the environment, but can also include the prescription of clonazepam. Think of parasomnias as things that patients may also do while sleeping, excluding movement disorders (other than RBD) which used to be included in this category as well. Examples would be Night Terrors, Nightmares, Hallucinations, Sleepwalking, or Enuresis (bed-wetting), etc. Parasomnias are covered in your text book on pages 482 - 484. Sleep-Related Movement Disorders Bruxism: Bruxism (teeth grinding) occurs most commonly in individuals between ages 10 and 20 years and is commonly noted in children with mental retardation or cerebral palsy. Bruxism is noted most prominently during NREM stages I and II and REM sleep. Episodes are characterized by stereotypical tooth grinding and are often precipitated by anxiety, stress, and dental disease. Occasionally, familial cases have been described. Usually, no treatment is required, but in extreme cases, dental reconstruction and appliances such as mouth guards may be needed. Periodic Limb Movement Disorder: Periodic limb movement disorder (PLMD, or PLMS for Periodic Limb Movements in Sleep) is a common sleep disorder affecting approximately 34% of people over the age of 60 years. PLMD can be defined as repetitive, involuntary limb movements during sleep. These movements are seen mostly in stage II sleep, and not in REM sleep due to muscle atonia in REM. The criteria for the leg movements to qualify as PLMS, the leg movements must last from 0.5 seconds to 5 seconds in duration each, there must be a gap of 5 to 90 seconds between each one, and there must be a cluster of at least 4 of these movements. Symptoms of PLMS often include frequent EEG arousals, fragmented sleep architecture, daytime sleepiness, and a disturbed bed partner. Treatment of PLMS usually includes medications. However, if the leg movements are related to respiratory events, they usually disappear when the respiratory events are corrected via CPAP, BiPAP, dental appliances, etc. The most common medications used to treat PLMS include Clonazepam, Dopamine Agonists, Anticonvulsants, and Opiates. Restless Legs Syndrome: Restless Legs Syndrome (RLS) is a disorder that causes discomfort in the legs and an irresistible urge to move them. This scenario can occur while the patient is asleep or awake. Patients often describe this discomfort as an itching, crawling, or creeping sensation in their legs. RLS is a common disorder, and affects more than 5% of the total population. Most RLS patients begin having symptoms before the age of 20, and continue to have these symptoms throughout their lives. Most patients with RLS also have PLMS. The most common treatments for these disorders are medications, including benzodiazepines, dopamine, opiates, and alpha-adrenergic blockers. Nocturnal Leg Cramps: Nocturnal leg cramps are intensely painful sensations that are accompanied by muscle tightness occurring during sleep. These spasms usually last for a few seconds but sometimes persist for several minutes. Cramps during sleep are generally associated with awakening. Many normal individuals experience nocturnal leg cramps. Causes remain unknown. Local massage or movement of the limbs usually relieves the cramps. Rhythmic Movement Disorder: Rhythmic movement disorder occurs mostly in infants younger than 18 months of age, is occasionally associated with retardation, and is rarely familial. It is comprised of three characteristic movements: head rolling, headbanging, and body rocking. These episodes are usually not remembered once the person awakens. It affects approximately three times as many males as females. Treatment for rhythmic movement disorder usually includes behavior modification, benzodiazepines, and antidepressants. Rhythmic movement disorder is a benign condition, and usually, the patient outgrows the episodes. Other rhythmic movement disorders can be related to the use of a drug or substance, or to another medical condition. Isolated Symptoms, Apparently Normal Variants, and Unresolved Issues This category includes disorders that are borderline normal or are normal variants. These include such examples as long sleeper, short sleeper, hypnic jerks, and other types of twitching or jerking movements that may only occur at sleep onset or in newborns. You have probably seen someone display a hypnic jerk as they fell asleep, or you may have woken yourself jerking because you felt like you were falling. Things like snoring or sleep-talking could be included in this case if they are not causing symptoms of insomnia or excessive daytime sleepiness but are disturbing to the patient or other people. Other Sleep Disorders A diagnosis in this category gives the physician an option for when the diagnosis may not be clear or too unusual to clearly fit into one of the other categories. This diagnosis may often be used as a temporary diagnosis until the actual cause of the disorder is determined. Environmental Sleep Disorder could be something in the surrounding environment, such as a barking dog, that is disturbing the patient's sleep enough to cause symptoms. Appendix A: Sleep-Related Medical and Neurological Disorders This category includes disorders that sometimes occur unrelated to sleep, but are related to sleep in these cases. Examples are sleep-related epilepsy, headaches, Sleep-related Myocardial Ischemia, or gastroesophageal reflux. Fibromyalgia used to be included in this section. While fibromyalgia is not necessarily a disorder that is only related to sleep, it can cause arousals, or disruptions of the patient's sleep and is a common diagnosis of patients that you will see. Appendix B: Other Psychiatric/Behavioral Disorders Frequently Encountered in the Differential Diagnosis of Sleep Disorders This section includes mood disorders, anxiety disorders, schizophrenia, or any other psychiatric diagnosis that may affect the patient's quality of sleep. Therefore, you will also likely see patients who have been referred by a psychiatrist on occasions. Intrinsic and Extrinsic Sleep Disorders These are terms that were previously used to differentiate between disorders that originated from within the body and those that were caused by something in the outside environment. However, I think that you could still see these terms again, so I think it is a good idea for you to be familiar with this terminology. INTRINSIC DISORDERS Intrinsic disorders include various types of insomnia and restless legs syndrome. Narcolepsy and recurrent hypersomnia are disorders of excessive sleepiness. Hypersomnolence can also be caused by narcolepsy, apnea, sleep disordered breathing, or periodic limb movements in sleep. EXTRINSIC DISORDERS Extrinsic sleep disorders include those that originate or develop from causes outside the body. Some of these dyssomnias found within this category include: conditions of inadequate sleep hygiene, altitude insomnia, food allergy insomnia, nocturnal eating, limit-setting sleep disorder, and sleep-onset association disorder. Sleep apnea is a disorder that commonly afflicts more than 12 million people in the United States. The word apnea is of Greek origin and means "without breath." Patients diagnosed with sleep apnea will literally stop breathing numerous times while they are asleep. The apneas on average can last from ten seconds to longer than a minute. These events can occur hundreds of times during a single night of sleep. Obstructive sleep apnea (OSA) is the most common type of apnea found within the category of sleep disordered breathing. OSA is caused by a complete obstruction of the airway, while partial closure is referred to as a hypopnea. The hypopnea is characterized by slow, shallow breathing. There are three types of apneas: obstructive, central, and mixed. So, sleep disordered breathing may be due to an airway obstruction (OSA), an abnormality in the part of the brain that controls respiration (central sleep apnea), or a combination of both ( mixed sleep apnea). This lesson will concentrate on obstructive sleep apnea. OSA occurs in approximately two percent of women and four percent of men over the age of 35. Check out this video for a good example of an OSA patient: Sleep Apnea - Hard to Watch... (Links open in a new window. Right click on link and choose "open in a new window") Obstructive Sleep Apnea sufferers are not always the ones that you would expect. Check out this video of an Asian woman, especially near the end: Sleep Apnea Causes of Obstructive Sleep Apnea The exact cause of OSA is difficult to pinpoint. The site of obstruction in most patients is the soft palate, extending to the region at the base of the tongue. There are no rigid structures, such as cartilage or bone, in this area to hold the airway open. When a patient is awake, muscles in the region keep the passage open. However, a patient who tests positive for OSA will experience a collapsing of the airway when they are asleep. Thus, the obstruction occurs, and the patient awakens to open the airway. The arousal from sleep lasts only a few seconds, but brief arousals disrupt continuous sleep. When the sleep architecture is fragmented, the patient will be prevented from obtaining SWS and REM sleep ( these stages of sleep are needed by the body to replenish its strength ). Once normal breathing is restored, the person falls asleep only to repeat the cycle throughout the night. Typically, the frequency of waking episodes is somewhere between 10 and 60. A patient with severe OSA may have more than 100 waking episodes in a night of sleep. Often, the OSA patient will complain of nonrestorative sleep and excessive daytime sleepiness. Risk Factors The primary risk factor for OSA is excessive weight gain. The accumulation of fat on the sides of the upper airway causes it to become narrow and predisposed to closure when the muscles relax. Age is another prominent risk factor. Loss of muscle mass is a common occurrence associated with the aging process. If muscle mass decreases in the airway, it may be replaced with fat, leaving the airway narrow and soft. Men have a greater risk for OSA. Male hormones can cause structural changes in the upper airway. Below are other common predisposing factors associated with OSA: Anatomic abnormalities, such as a receding chin Enlarged tonsils and adenoids ( the main causes of OSA in children) Family history of OSA ( However, there has been no medically documented facts stating a generic inheritance pattern ) Use of alcohol and sedative drugs, which relax the musculature in the surrounding upper airway Smoking, which can cause inflammation, swelling, and narrowing of the upper airway Hypothyroidism, acromegaly, amyloidosis, vocal cord paralysis, post-polio syndrome, neuromuscular disorders, Marfan's syndrome, and Down syndrome Nasal and sinus congestion or problems Symptoms of OSA The nightly disruption and fragmentation of normal sleep architecture will cause the patient to experience the feeling of nonrestorative sleep. The most common complaint from someone who suffers from OSA is excessive daytime sleepiness (EDS) . The numerous disruptions and arousals will prevent the patient from obtaining a continuous deep sleep. Thus, the individual could also be prone to automobile accidents, personality changes, decreased memory, impotence, and depression. Patients are rarely aware or recall the frequent awakenings that occur following the obstructive episodes. EDS may be mild, moderate, or severe. Some patients will complain of falling asleep in a non stimulating environment, such as reading a book or a newspaper in a quiet room. Severe OSA patients may complain of falling asleep in a stimulating environment, such as during business meetings, eating, or casual conversation. One of the most dangerous scenarios is patients who suffer from OSA can fall asleep behind the wheel. Patients will often complain of feeling like they have not slept at all no matter of the length of time in bed. The same holds true for napping. Other indicators or symptoms of possible OSA include morning headaches and frequent urination during the night. Physical signs that coincides with characteristics of OSA patients include snoring, witnessed apneic episodes, and obesity. Not every individual who snores will test positive for OSA, but most patients who have OSA will snore with moderate to loud levels. Hypertension is prevalent in patients with OSA, although the exact relationship is unclear. It has been medically proven that treating OSA can significantly lower blood pressure. Complications The most prevalent complication for patients who suffer from OSA is a diminished quality of life due to chronic sleep deprivation and previous described symptoms. Coronary artery disease, cerebral vascular accidents (strokes), and congestive heart failure are being evaluated to define the exact nature of their connection to OSA. Still, it has documented that there is a relation between these complications and OSA. Obstructive sleep apnea aggravates congestive heart failure (CHF) by placing stress on the heart during sleep. Statistics show there is a high prevalence of OSA in patients with CHF. Central sleep apnea may be prominent in patients with CHF. Diagnosis The most universal method for diagnosing OSA is to have the patient undergo a sleep study. The technical name for the procedure is nocturnal polysomnograph. The first priority with any procedure is patient safety. A thorough analysis of the information gathered prior to beginning the test will give the technician an opportunity to determine the reason for testing, to verify all necessary monitoring parameters, and to determine the possible need for ancillary equipment. The technician must be aware of any precautions or special patient needs during testing. An understanding and knowledge of the signs, symptoms, and findings of a variety of sleep disorders and sleep related breathing disorders is necessary to ensure patient safety and recording requirements during polysomnography testing. Various medical problems will be encountered with the patients undergoing a sleep study. Examples of these complications include: asthma, COPD, cardiac arrhythmias, carbon dioxide narcosis, and abnormal breathing. Numerous cardiac arrhythmias may occur and they include: asystole, ventricular tachycardia or fibrillation, bigeminy, trigeminy, multi-focal PVC's, heart blocks, atrial fibrillation, bradycardia, or tachycardia associated with sleep apnea. Some of these cardiac arrhythmias are life threatening and require technician intervention. Others are relatively benign and require only that the technician watch the patient closely. Thus, all polysomnography technicians will be required to be certified in Basic Life Support. The polysomnography testing will include recording of multiple physiological parameters in sleep. These parameters usually include EEG, EKG, eye movements, respiration, muscle tone, body position, body movements, and oxygen saturation. The electroencephalogram (EEG) measures brain electrical activity. The brain activity during different stages of sleep as compared to wake is distinctly different. The electrooculogram (EOG) monitors eye movements and allows the examiner to determine REM sleep and wake. The electromyogram (EMG) monitors muscle tone, and the EMG helps to differentiate REM sleep from wake because the muscles relax to a state of paralysis in REM sleep. The electrocardiogram (EKG or ECG) monitors heart rate and graphs the electrical signal as it is conducted through the heart. Respiratory effort belts are placed around the patient's chest and abdomen to detect and record the rising and falling movements associated with respiration. A pulse oximeter is attached to the finger to record oxygen saturation levels in the blood. Leg leads or electrodes are attached to record leg movements which may determine the patient has periodic limb movement disorder. A thermistor is used to monitor breathing. Obstructive sleep apnea is diagnosed if the patient has an apnea/hypopnea index (AHI) of 5 or greater an hour. The respiratory disturbance index (RDI) is sometimes used in place of the AHI and essentially refers to the same data. However, in the recent past, RDI was an index that also included the number of respiratory effort related arousals(RERAS) per hour in addition to the hypopneas and apneas. Some sleep centers may still do this, but most are currently not scoring the RERAS due to non-coverage of insurance. An RDI from five to ten per hour would be a positive finding for OSA as well. Clinically speaking, an obstructive apnea is defined as a complete cessation of airflow for 10 seconds or more with persistent respiratory effort. An obstructive hypopnea is defined as a partial reduction in airflow of at least 30 percent followed by a drop in SaO2 of at least 3% or an arousal from sleep, or an alternate definition of 50 percent reduction in nasal pressure airflow signal followed by at least a 4% drop in SaO2(desaturation). Medicare still requires the 4% drop in SaO2 for their patients, but the first definition is recommended by the American Academy of Sleep currently. SaO2 refers to the amount of Oxygen in the blood being carried by the red blood cells. This will always drop when a patient stops breathing. The many physiological measurements taken usually enable the physician to diagnose or reasonably exclude OSA. Certain scenarios may prove a more difficult diagnosis. Such as, a patient who may have mild OSA at home, or only after using certain medications or alcohol but does not experience any episodes during the sleep study. Thus, the sleep study results must be interpreted with the entire clinical picture in mind. Another condition, called upper airway resistance syndrome, cannot be seen on polysomnography. This syndrome is characterized by repetitive arousals from sleep that probably result from increasing respiratory effort during narrowing of the upper airway. These patients suffer the same sleep disruption and deprivation as other sleep apnea patients. In such cases, the only alarming indicator that is recorded is the recurrent arousals. Ultimately, patients suffering from upper airway resistance syndrome may not test positive for OSA with standard polysomnography testing. Treatment A patient suffering from OSA has several treatment options that include: weight reduction, positional therapy, positive pressure therapy, surgical options, and oral appliances. Significant weight loss has shown tremendous improvement and possible elimination of OSA. The amount of weight a patient needs to lose to achieve noticeable benefits varies. However, one will not need to achieve "ideal body weight" to see improvement. Positional therapy is a method of treatment used to treat patients whose OSA is related to body positioning during sleep. A OSA patient who sleeps flat on their back, or in supine position, will experience worse symptoms in general. This type of therapy has its limits, but some patients have experienced benefits. Some of the strategic methods include: a sock filled with tennis balls is sewn into their shirt to make it uncomfortable for the sleeper to lie on their back, and positional pillows to assist in sleeping on their side. Positive pressure therapy is one of the most if not the best methods of treatment for obstructive sleep apnea. There are three different types of devices: continuous positive airway pressure (CPAP), autotitration, and bi-level positive airway pressure. CPAP, the more common of the three therapy modes, is the most prescribed method of treatment for OSA. A facial or nasal mask is worn by the patient while they sleep. The mask is connected to the CPAP machine with tubing. Positive air pressure is delivered from the machine to the mask and continues to the upper airways establishing a "pneumatic splint" that prevents collapsing of the airways. Autotitration devices are designed to provide the minimum necessary pressure at any given time and change that pressure as the needs of the patient change. Bi-level positive airway pressure differs from the CPAP by reducing the level of positive pressure upon exhalation. Oral appliances are another avenue a patient can try as a therapeutic device. Generally, there are two categories, mandibular advance devices and tongue-retaining devices. Mandibular advance devices are similar to athletic mouth guards. They differ in the mold for the lower teeth is advanced further forward than the mold for the upper teeth. This will cause the jawbone to remain forward and prevent the collapse of the airway. It is effective in mild cases of OSA, particularly if the patient's OSA is positional. Tongue-retaining devices also resemble an athletic mouth guard. It acts as a suction cup and is placed between the upper and lower teeth. The tongue is positioned forward and obstructions caused by the tongue should be minimized. First described in 1981, CPAP therapy has become the most preferred treatment for patients with OSA. CPAP flow generators or machines maintain a constant, controllable pressure to prevent blockage of the upper airway. The positive air pressure travels through the nostrils by a nasal or facial mask. This airflow holds the soft tissue of the uvula, palate, and pharyngeal tissue in the upper airway in position so the airway remains open while the patient progresses into deeper stages of sleep and REM sleep. The CPAP device can be described as a "pneumatic splint." Variations to the CPAP machine are available to help with compliance. BPAP, Bi-PAP or bi-level positive airway pressure is another option for treatment. Those three are one and the same. They are just different ways that you might see this term. The AASM guidelines uses "BPAP" in their protocol publications. BiPAP is a trademarked term by a company named Respironics. Anyway, most of the problems patients experience with CPAP are caused by having to exhale against a high airway pressure. Because the air pressure required to prevent respiratory obstruction is typically less on expiration than on inspiration, Bi-PAP machines are designed to detect when the patient is inhaling and exhaling and to reduce the pressure to a preset level on exhalation. Patients with severe OSA may require maximum levels of pressure to eliminate the obstructive apnea. Bi-PAP may be the chosen method of treatment with this scenario, and Bi-PAP may be used when the patient has more than one respiratory disorder. Regardless of the mechanism used, the goal of the technician should always be to titrate the machine to the lowest possible pressure to eradicate the sleep apnea. Each individual patient with OSA will present a different scenario for the attending polysomnography technician. The sleep study with positive airway pressure titration will need to achieve the optimal pressure for the specific patient. The sleep study with CPAP/Bi-PAP will show not only when the respiratory events have ceased, but also when the arousals from the respiratory events occur. The ultimate goal for the technician during a titration process is to achieve the minimal optimum pressure to eliminate all obstructive events and snoring during all stages of sleep and all body positions while sleeping. Compliance Mask fitting is an essential element of a patient's success with positive airway pressure therapy since it affects compliance and effectiveness of treatment. The higher pressures used during CPAP/Bi-PAP therapy can cause a significant air leak with the mask. The leak can also emerge from the patient's mouth if they are using a mask that doesn't cover the mouth. This can startle a new CPAP user. The leak can wake the patient from sleep. Thus, the mask stability is tested with higher pressures. Higher pressures may also require tighter head gear to maintain an adequate seal. Adversely, this will contribute to the discomfort from wearing the mask. When selecting a CPAP mask the following factors should be considered: comfort quality of air seal convenience quietness air venting CPAP/Bi-PAP machines are also available with humidity. Nasal congestion and dryness are very common complaints with positive airway pressure therapy. Humidification can also be heated. These features have proven to help with patient compliance. Ultimately, the biggest obstacle with compliance is getting patients to comply with their own treatment. Without the patient's willingness to use it, CPAP will not provide effective therapy. Studies have shown that CPAP compliance varies from approximately 65% to 85%. The bottom line for the patient to experience the benefits and relief of complaints is they must use the machine on a nightly basis. Information regarding the degree to which a patient is compliant with CPAP is essential for assessment of therapeutic impact. If problems persist after implementation of CPAP, the causes could include: delivery of insufficient pressure to maintain upper airway patency during sleep misdiagnosis of the etiology of the individual's symptoms failure to use the device for a sufficient duration on a regular basis Possible Side Effects The principal side effects with CPAP/Bi-PAP use include: contact dermatitis nasal congestion rhinorrhea dry eyes mouth leaks nose bleeds (rare) tympanic membrane rupture (very rare) chest pain aerophagia (the excessive swallowing of air, often resulting in belching) pneumoencephalitis (air in the brain, which is extremely rare, reported in a patient with a chronic cerebral spinal fluid leak) claustrophobia smothering sensation Actions can be taken to counteract some of the side effects. Nasal congestion or dryness often can be reduced or eliminated with nasal sprays or humidification. Rhinorrhea can be eliminated with nasal steroid sprays or ipratropium bromide nasal sprays. Epistaxis (nose bleeds) is usually due to dry mucosa and can be treated with humidification. Skin irritation can be combated with different mask materials. Dry eyes are usually caused by mask leaks and can be eliminated by changing to a better fitting mask. Attempts to reduce claustrophobic complaints have resulted in the patient using nasal pillows or prongs as opposed to the nasal or facial mask. Mouth leaks can be reduced or eliminated by using a chin strap. A small number of patients complain of chest pain or discomfort with CPAP use. This can probably be attributed to increased end-expiratory pressure and the consequent elevation of resting lung volume, which stretches wall muscles and cartilaginous structures. The resulting sensation that is created is due to chest wall pressure that persists through the hours of wakefulness. Any complaints of chest pain should always be taken seriously. However, if the complaint by the patient on CPAP proves to be nondiagnostic, Bi-PAP therapy may prove to be an option since expiratory pressure can be reduced. Sometimes it pays for the technologist to develop some psychological skills in order to convince the patient to use the device. I have found that a patient who doesn't seem to believe they need CPAP tends to change her/his mind when they see the data that shows him not breathing. Keep in mind that your patients can't see themselves sleep. They may also not be aware of all the possible complications of OSA down the road. Another area of concern for OSA patients using CPAP/BPAP devices is the negative effects on arterial blood gases and oxyhemoglobin saturation. Studies have reported severe oxyhemoglobin desaturation during nasal CPAP therapy in a hypercapnic (elevated levels of carbon dioxide in the blood) sleep apnea patients. Studies have also shown significant oxygen desaturations with CPAP administration with supplemental oxygen. The exact cause has yet to be determined. This occurrence may be due to the following factors: worsening hypoventilation related to the added mechanical impedance to ventilation associated with exhalation against increased pressure increased dead-space ventilation a decrease in venous return and cardiac output due to increased intrathoracic pressure during CPAP administration in patients with impaired right or left ventricular function and inadequate filling pressure One more possibility is when the optimal pressure setting has not been reached yet. Therefore, a ten second apnea may have turned into a 90 second hypopnea. The patient may not arouse from sleep as quickly to get a breath since the airway is not completely closing off as it was without therapy. This should improve once enough pressure is added, however. Despite the above scenarios and problematic experiences, CPAP/Bi-PAP administration has been reported to improve awake arterial blood gases in OSA patients with hypercapnia and cor pulmonale. Traditional and Evolving Methods of Initiating CPAP/BPAP Different methods have been established for implementation of positive airway pressure therapy. Traditionally, patients have undergone a technician attended PSG-monitored trial of CPAP. Split-night studies are now conducted more frequently. Home CPAP trials is another avenue that is being investigated. Use of predictive formulas to estimate or establish optimal level for CPAP therapy has been investigated. Each scenario has advantages and disadvantages. CPAP Therapy of Nonapneic SDB There are numerous documentations of patients with congestive heart failure (CHF) suffering from sleep-disordered breathing (SDB). Most often the respiratory events will be central in nature (no effort, brain not sending signal to breathe) resembling Cheyne-Stokes respiration (CSR). CSR is defined as a breathing pattern characterized by regular "crescendo-decrescendo" fluctuations in respiratory rate and tidal volume. The presence of SDB was associated with sleep-fragmentation and increased nocturnal hypoxemia. The conclusions from the findings are stated below: There is a high prevalence of daytime sleepiness in patients with CSR in conjunction with CHF. Patients with CHF who also have CSR have a higher mortality than patients who have CHF without CSR. CSR, AHI (apnea/hypopnea index), and the frequency of arousals were correlated with mortality. Furthermore, research has found CPAP has been noteworthy and effective on breathing in patients with CHF and CSR. The results of several studies showed an increase in cardiac output and stroke volume and a reduction in left ventricular wall tension during application of CPAP. The improvements seen in CHF patients with CSR regarding cardiac function during sleep is believed to carry over to wakefulness. Possible factors contributing to the improvements seen include: sleep-related reduction of left ventricular transmural pressure improved oxygenation during sleep reduced sympathetic nervous system activation during sleep CPAP machines have become a lot more sophisticated during the past decade. One of these updates is the ability of some machines to generate an algorithm that can predict the next breath of these central sleep apnea patients. These machines will adjust how much air is delivered during each breath based on this prediction. This has the effect of making the breathing pattern more consistent. You may see this denoted as Auto-SV, or servo-ventilation. We will talk about this more later, but I just wanted you to be aware that there are more sophisticated machines for patients with CHF and irregular breathing patterns that are not due to obstructions. Effects of Altitude Changes and Alcohol Consumption Older CPAP machines will not adjust to changes in altitude. As altitude increases, the older CPAP devices will deliver progressively lower than prescribed pressure. The more modern devices will detect altitude changes and make the appropriate adjustments. The polysomnography technician would benefit from information regarding a patient relocating from a high altitude location to lower altitude or vice versa if there are complaints of the CPAP therapy being nontherapeutic. Alcohol consumption can present further complications for a patient suffering from OSA. Alcohol suppresses the arousal response. The patient may experience a greater frequency and duration of apneas and hypopneas and increased snoring. Excessive alcohol use also increases sleep fragmentation. Taking a sedative can cause these effects to be imitated or exacerbated. Still, there are reports stating moderate alcohol consumption did not significantly alter the level of pressure required to eliminate the obstructive events. Nonetheless, OSA patients should avoid alcohol
Updated 302d ago
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Primary adrenal insufficiency = problem at level of adrenal glands Causes? Addison’s disease Pathophys? Autoimmune destruction of the adrenal glands Associated with hyperpigmentation POMC is precursor to both ACTH and MSH PAI → lack of negative feedback → high ACTH Lab findings? ACTH high Aldosterone low Destruction of zona glomerulosa Renin high Hypotension → RAAS activation Electrolytes Na+ low, K+ high CBC Eosinophils high Pathophys? Glucocorticoids → eosinophil apoptosis. Lack of glucocorticoids cause eosinophilia. Dx? Cosyntropin testing → no rise in cortisol Adrenal glands aren’t working, so no response to ACTH. Tx? prednisone/hydrocortisone/dexamethasone + fludrocortisone (mineralocorticoid) Stress-dose steroids for surgery, serious illness, etc. Secondary adrenal insufficiency = problem at level of pituitary, reduced ACTH release Causes? MC is prolonged steroid use → ACTH suppression Sheehan’s syndrome (infarction of pituitary) pregnancy Pituitary tumors (ACTH-producing tumor) Lab findings? ACTH low Anterior pituitary is being inhibited Aldosterone normal Zona glomerulosa under control of RAAS system Renin normal Electrolytes Na+ & K+ unaffected (Aldosterone levels are normal) CBC Neutrophilia due to demargination (if pt was recently taking steroids) Dx? Cosyntropin testing → rise in cortisol Adrenal gland is functional Tx? Glucocorticoids Do not need to replace mineralocorticoids since adrenals are functional and aldosterone is under RAAS control Stress-dose steroids for surgery, serious illness, etc. AI with a history of nuchal rigidity and purpuric skin lesions → Waterhouse-Friedrichson syndrome Pathophys? AI 2/2 hemorrhagic infarction of the adrenal glands in the context of Neisseria meningitidis infection Adrenal synthesis enzymes If the enzyme starts with 1 → HTN (high mineralocorticoids) and hypokalemia If the second # is 1 → virilization (high androgens) E.g. 11-beta hydroxylase deficiency → HTN & virilization E.g. 21 hydroxylase deficiency → virilization only E.g. 17-alpha hydroxylase deficiency → HTN only B12 deficiency Where does B12 come from? Animal products VS folic from plants Physiology R factor in saliva binds to B12 and protects it from acidity in the stomach. R factor protector -B12 travels to the duodenum. Parietal cells produce intrinsic factor, which travels to the duodenum. Pancreatic enzymes cleave B12 from R factor and B12 then binds IF. B12-IF complex is reabsorbed in the terminal ileum Reabsorption where? Terminal ileum Causes of B12 deficiency Extreme vegan Pernicious anemia Pancreatic enzyme deficiency Cystic Fibrosis Can’t cleave B12 from R factor Crohn’s Affects terminal ileum Lab markers Homocysteine HIGH MethlyManoicAcid HIGH Presentation? Megaloblastic anemia Subacute combined degeneration (of dorsal columns + lateral corticospinal tract) Peripheral neuropathy Dx of pernicious anemia? anti-IF Ab Folate deficiency Where does folate come from? Leafy things Causes of folate deficiency Poor diet (e.g. alcoholics, elderly) Phenytoin Lab markers Homocysteine HIGH MMA normal Presentation? Megaloblastic anemia Prophylaxis in HIV+ patients CD4 < 200 → PCP TMP-SMX, inhaled pentamidine, dapsone, atovaquone CD4 < 100 → Toxoplasm Treat: TMP-SMX CD4 < 50 → MAC Treat: Azithromycin If live in endemic area, CD4 < 250 → Coccidioides Immitis E.g. Arizona, Nevada, Texas, California Treat: Itraconazole If live in endemic area, CD4 < 150 → Histoplasma Capsulatum E.g. Kentucky, Ohio, Missouri Treat: Itraconazole Diabetes insipidus Dx? Water deprivation test Measure serum osmolality & urine osmolality Deprive pt of water Remeasure serum osmolality & urine osmolality If urine osmolality doesn’t go up → suspect DI Central DI → deficiency of ADH Pathophys? Supraoptic nucleus not making enough ADH Dx? Give desmopressin → urine osmolality increases significantly Nephrogenic DI → kidneys are not responding to ADH Dx? Give desmopressin → urine osmolality doesn’t change much Tx? Hydrochlorothiazide Unless 2/2 lithium, use amiloride or triametere Causes? Lithium SSRIs Carbamazepine Demeclocycline Tx of normovolemic hypernatremia? D5W to correct free water deficit Divine says NS, but most other resources I found said correct free water deficit Tx of hypovolemic hypernatremia? Give NS first until normal volume, then give D5W Consequence of correcting hypernatremia too rapidly? Cerebral edema Osteoarthritis Presentation? Old person with joint pain that gets worse throughout the day Risk Factr? Obesity vs decreases osteoporosis Imaging findings? Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes Arthrocentesis findings? <2000 cells Tx? 1st line acetaminophen 2nd line NSAID (e.g. naproxen) 3rd line joint replacement surgery Returned from a business conference 1 week ago + Fever + Nonproductive cough + Abdominal pain + Hyponatremia → Legionella Dx? Urine antigen Tx? FQ or macrolide MaCroLide mnemonic = Mycoplasma, Chlamydia, Legionella What are the common causes of atypical PNA? Mycoplasma, Legionella, Chlamydia MC cause? Mycoplasma CXR findings? Interstitial infiltrates HY associations C. Psittaci → birds C. Burnetii → cows, goats, sheet Mycoplasma → college student w/ walking pneumonia Midsystolic click heard best at the apex. → mitral valve prolapse “Stenosnap & Proclick” Risk Factor? Connective tissue disease Marfarn Ehlers-Danlos ADPKD bilateral renal masses Classic demographic? Young woman psychiatric Pathophys? Myxomatous degeneration MVP vs aortic dissection: cystic medial necrosis Exam maneuvers Anything that increase amount of blood in LV → murmur softer Increase preload Increase afterload Anything that decreases amount of blood in LV → murmur louder Dx? Echo Scaly, itchy skin with yellowish crusting in the winter. → seborrheic dermatitis Tx? Topical antifungals e.g. ketoconazole or selenium sulfide shampoo Classic disease distribution? Hair → e.g. cradle cap Eyebrows Episodic/intermittent HTN + HA → pheochromocytoma Genetic disease associations MEN2A MEN2B VHL in brain (hemangioma) NF-1 growth in skin Pathophys? Catecholamine-secreting tumor Location? Adrenal medulla Posterior mediastinum Organ of Zuckerkandl (chromaffin cells along the aorta) Dx? 1st step: urine metanephrines If elevated → CT abdomen If nothing found on CT → MIBG scan Tx? Alpha blocker (e.g. phenoxybenzamine, phenotaline) THEN beta blocker Most common cause of a Lower GI Bleed in the elderly → diverticulosis Dx? Colonoscopy or barium enema Recall that you acutely do a CT scan for diverticulitis, then 6 weeks later colonoscopy to r/o cancer Ppx? Eat fiber Megaloblastic anemias Blood smear findings? Hypersegmented neutrophils MCV > 100 Classic patient demographic with folate deficiency? Alcoholics Elderly person with poor nutrition Folate synthesis inhibitors Pt with molar pregnancy → methotrexate Pulmonary issue? Pulmonary fibrosis HIV+ pt with ring-enhancing lesions → pyrimethamine-sulfadiazine Pyrimethamine inhibits DHFR AIDS pt on ppx for toxo → TMP-SMX TMP inhibits DHFR Use of leucovorin? Rescue bone marrow in setting of methotrexate toxicity Mechanism? Folinic acid analog CMV presentations Esophagitis → linear ulcers Colitis → post-transplant pt Retinitis → HIV pt with CD4 < 50 Congenital CMV → periventricular calcifications + hearing loss calcifications elsewhere → toxo Histology? Owl’s eye intranuclear inclusions Tx? Gancicyclovir Resistance? UL97 kinase mutation Tx for resistance? foscarnet CD4 < 200 + severe peripheral edema + frothy urine. → FSGS in HIV pt Variant classic in HIV+ pts? Collapsing variant Tx? Steroids + cyclophosphamide + ACE-I Indinavir AE? Kidney stones triad of fever, rash, and eosinophiluria → acute interstitial nephritis Drugs cause? Penicillins Tx? Stop the drug! Can add steroids if severe Vitamin D metabolism Liver converts Vit D to calcidiol (25OH-Vit D). Calcidiol goes to kidney. Alpha-1 hydroxylase converts calcidiol to calcitriol (1,25-OH Vit D). Common causes of Vitamin D deficiency CKD → 1-alpha hydroxyalse deficiency Liver disease → can’t make calcidiol CF → malabsorption Crohn’s → malabsorption Osteomalacia vs Rickets Osteomalacia in adults Rickets in kids Tx? Calcium + vit D Lab findings? Ca++ low Phos low Low in liver disease High in kidney disease (kidneys can’t get rid of phos) PTH high (2ary hyperpara) vs liver dx PTH low Alk phos Aspiration pneumonia Risk Factor? Alcoholism Dementia Neuromuscular problems (e.g. MG, ALS) Bugs? Anaerobes foul smelling Bacteroides FUsobacterium Peptostreptococcus Klebsiella → currant jelly sputum alcoholic Tx? Clindamycin CURB-65 criteria Purpose? Who to admit Cutoff? 2+ → hospitalize C = confusion U = uremia (BUN > 20) R = RR > 30 B = BP < 90/60 Age > 65 Drugs commonly used in PNA treatment Ceftriaxone Levofloxacin fluoroquinolone Macrolides - great for atypical PNA Pharmacological management of pulmonary arterial HTN Endothelin antagonists Bosentan ambrisentan PDE-5 inhibitors Sildenafil Tadalafil Prostacyclin analogs Iloprost Epoprostenol Treprostinil Causes? Young female → idiopathic PAH Mutation? BMPR2 55 yo F presents with a 5 week history of a rash on her forehead. PE reveals scaly macules with a sandpaper texture. → actinic keratosis Risk Factor? Sun exposure Tx? Topical 5-FU Possible dangerous sequelae? Squamous cell carcinoma Most likely disease sequelae? Resolution 1ary hyperparathyroidism 2ary hyperparathyroidism 3ary hyperparathyroidism Autonomous PTH production Causes? Adenoma Parathyroid hyperplasia PTH high Ca++ high Phos low Low Ca++ → PTH production Causes? CKD PTH high Ca++ low Phos high PTH production despite normalized of Ca++ levels Causes? CKD s/p transplant PTH high Ca++ high Phos low Tx? Parathyroidectomy (remove 3.5 glands) Cinacalcet (CSR modulator) Hypercalcemia Presentation? bones, stones, groans, psychic overtones Tx? 1st step: Normal Saline Hypercalcemia of malignancy → bisphosphonates EKG finding? Shortened QT Periumbilical pain that migrates to the right lower quadrant. → appendicitis PE findings? McBurney’s point tenderness Psoas sign (flex hip pain) Obturator sign (pain with internal rotation of hip) Rovsing’s sign (palpation of LLQ → pain in RLQ) Dx? CT scan Pregnant → US Kid → US Tx? Surgery Classic drug and viral causes of aplastic anemia. Drugs? Carbamazepine Chloramphenicol Viral? Parvovirus B19 (single stranded DNA virus) Fanconi anemia Pathophys? Problems with DNA repair Fanconi anemia vs Fanconi syndrome Fanconi anemia → cytopenias + thumb anomalies + short stature + cafe-au-lait spots Fanconi syndrome → type 2 RTA (proximal) CD4 count of 94 + MRI revealing ring enhancing lesions in the cortex → toxoplasmosis Tx? Pyrimethamine-sulfadiazine Rescue agent for pt who becomes leukopenic with treatment? leucovorin Who should get steroids? Increased ICP For PCP pneumonia: O2 sat < 92 PaO2 < 70 A-a gradient > 35 Ppx? TMP-SMX for CD4 < 100 Congenital toxo Hydrocephalus Chorioretinitis Intracranial calcifications Classic methods of transmission? handling cat litter Lupus nephritis Associated autoantibody? anti-dsDNA Classic “immunologic” description? “Full house” pattern Tx? Steroids + cyclophosphamide Osteoporosis Screening population? women > 65 Screening modality? DEXA scan Dx? T-score < -2.5 Risk Factor? Postmenopauseal Low BMI Smoking Alcohol Preventive strategies? Weight bearing exercise Smoking cessation Reduce alcohol consumption Tx? 1st line: bisphosphonates + Ca/Vit D supplementation Raloxifene (SERM) Agonist in bone Blocker Antagonist in breast Classic locations of osteoporotic fractures Vertebral compression fracture Hip fracture Name the PNA Red currant jelly sputum. → Klebsiella Rust colored sputum. → Strep pneumo PNA in an alcoholic. → Klebsiella Post viral PNA with a cavitary CXR lesion. → Staph aureus PNA in a patient that has chronically been on a ventilator. → Pseudomonas MC cause of Community Acquired Pneumonia. → Strep pneumo Pharmacological management of MRSA. Vancomycin Clindamycin Linezolid Ceftaroline (5th gen cephalosporin) Tigecycline, tertracycline Pharmacological management of Pseudomonas. Ceftazidime (only 3rd gen cephalosporin) Cefepime (4th gen cephalosporin) Pip-tazo Fluoroquinolones Carbapenems Aztreonam Aminoglycosides JVD and exercise intolerance in a patient with a recent history of an URI. → dilated cardiomyopathy 2/2 viral myocarditis MC cause? Coxsackie B VS Coxsackie A: Hand foot mouth dx Drug causes myocarditis Clozapine Anthracyclines Prevention? Dexrazoxane (iron chelator) Trastuzumab reversible tx for breast cancer Classic cause in a patient with recent history of travel to S. America? Chagas T. Cruzi Potential sequelae? Achalasia Dilated cardiomyopathy Megacolon (2/2 degeneration of myenteric plexus) Massive skin sloughing (45% BSA) in a patient that was recently started on a gout medication? TEN Dx? <10% BSA → SJS >30% BSA → TEN Tx? STOP the drug IVF Topical abx to prevention infection Tetany and a prolonged QT interval in a patient with recent surgical treatment of follicular thyroid carcinoma. → hypocalcemia due to removal of parathyroids Recurrent viral infections + QT prolongation + tetany → DiGeorge syndrome Pathophys? Failure of development of 3rd/4th pharyngeal pouches Trousseau and Chvostek signs. Trousseau → inflation of BP cuff causes carpopedal spasm Chvostek → taping on cheek causes facial muscle spasm Hypocalcemia that is refractory to repletion → consider hypomagnesemia Electrolyte/drug causes of prolonged QT intervals Electrolytes? Hypocalcemia Hypomagnesemia Hypokalemia Drugs? Macrolides FloroQunlones Haloperidol Ondensatron Methadone Hypoalbuminemia and Ca balance Hypoalbumenia → decrease in total body Ca++, no change in ionized Ca++ Drop of 1 in albumin → add 0.8 to Ca++ Abdominal pain radiating to the back → acute pancreatitis Causes? #1 = Gallstones #2 = Alcohol Hypertriglyceridemia Hypercalcemia Scorpion sting Handlebar injuries Lab markers? Lipase - most sensitive Amylase Physical exam signs in pancreatitis. Cullen’s sign = periumbilical ecchymosis Grey Turner sign = flank ecchymosis Tx? NPO + IVF + pain control Meperidine is a good agent because it doesn’t cause sphincter of Oddi spasms Management of gallstone pancreatitis Dx? US then ERCP Tx? DELAYED cholecystectomy What if the patient becomes severely hypoxic with a CXR revealing a “white out” lung? ARDS noncardiogenic pulm edema PCWP? <18 mmHg NORMAL 20 yo M with red urine in the morning + hepatic vein thrombosis + CBC findings of hemolytic anemia. → paroxysmal nocturnal hemoglobinuria Pathophys? Defect in GPI anchors, which attach CD55 and CD59 to cell (they prevent complement from destroying RBC) Sleep → hypoventilation → mild respiratory acidosis → activation of complement cascade Gene mutation? PIGA Dx? Flow cytometry Tx? Eculizumab (terminal complement inhibitor) Vaccine required? pnemococal Neisseria meningitidis Chronic diarrhea and malabsorption in a HIV+ patient + detection of acid fast oocysts in stool. → cryptosporidium parvum Acid-fast organisms Cryptosporidium TB MAC Nocardia Dx? Stool O&P Tx? Nitazoxanide Route of transmission? Contaminated water Muddy brown casts on urinalysis in a patient with recent CT contrast administration (or Gentamicin administration for a life threatening gram -ve infection) → Acute Tubular Necrosis Woman with morning joint stiffness > 1 hr → Rhematoid Arthritis. Antibodies? Rheum Factor (IgM against IgG) anti-CCP - more specific HLA? DR4 Pathophys? IgM constant region activates complement → inflammation → formation of pannus (hypertrophied synovium) → damage to cartilage and bone Caplan syndrome = RA + pneumoconiosis Felty syndrome = RA + neutropenia + splenomegaly (“RANS”) Classic hand/finger findings/distribution? MCP & PIP joints of hands (DIP joints spared) Imaging findings? Symmetric joint space narrowing Tx? Methotrexate (DMARDs) If no response → TNF alpha inhibitor (e.g. infliximab) Required testing prior to starting methotrexate? PFTs Required testing prior to starting infliximab? TB Hep B/Hep C Differentiating Strep pharyngitis from Infectious Mononucleosis LND distribution Anterior cervical → Strep Posterior cervical → Mono Disease onset Acute → Strep Over weeks → Mono Organ involvement Splenomegaly → Mono Pt with sore throat takes amoxicillin and gets rash → mono NOT allergic rxn! CENTOR criteria C = absence of Cough E = tonsillar Exudates N = nodes/anterior cervical lymphadenopathy T = temp (fever) OR <15 → +1 >=45 → -1 Using CENTOR score 0/1 → don’t test, don’t treat 2/3 → rapid antigen test Positive → treat Negative → throat culture 4/5 → treat empirically Tx of Strep pharyngitis? Amoxillcin If PCN allergic → azithromycin Potential sequelae of Strep pharyngitis RF - preventable with abx PSGN Endocarditis MC cause of endocarditis? IVDU Bug? Staph aureus Valve? tricuspid Prosthetic valve endocarditis Bug? Staph epidermidis Endocarditis after dental procedure? Viridans group streptococci Strep viridans, Strep mitis, Strep mutans, Strep sanguineous Patient with malar rash and echo showing vegetations on both sides of the mitral valve → Libman-Sacks endocarditis Presentation? Fever + night sweats + new murmur Splinter hemorrhages Roth spots (retinal hemorrhages) Painless Janeway lesions + painful Osler nodes (immune phenomenon) Dx? 1st step: blood cultures TEE Tx? Abx that include Staph aureus coverage (e.g. vancomycin) for WEEKS Bugs implicated in culture negative endocarditis HACEK H = haemophilus A = actinobacillus C = cardiobacterium E = eikenella K = kingella Coxiella burnetii Blood cultures in a patient with endocarditis reveal S. Bovis (or S. Gallolyticus bacteremia). NBS? Colonoscopy Who needs antibiotic prophylaxis? Hx endocarditis Prosthetic valve Unrepaired cyanotic congenital dz Heart transplant with valve dysfunction Erythematous salmon colored patch with silvery scale on the elbows and knees. → psoriasis Tx? Topical steroids If this patient presents with joint pain (especially in the fingers)? Psoriatic arthritis Imaging? Pencil-and-cup deformity Tx? NSAIDs T of 104 + tachycardia + new onset Afib in a patient with a history of Graves disease. → thyroid storm Lab findings? TSH low T3/T4 high Tx? 1st step: propranolol 2nd step: PTU Then: Prednisone Potassium iodide (Lugul’s solution) Wolff-Chaikoff effect → large amounts of iodine inhibit thyroid hormone synthesis Biopsy revealing tennis racket shaped structures in cells of immune origin. → Langerhans cell histiocytosis Electron microscopy? Birbeck granules (tennis rackets) Marker? S100 Small bowel obstruction in a HIV patient with purple macules on the face, arms, and lower extremities. → Kaposi’s sarcoma Bug? HHV8 Tx? HAART Pathophys of vascular lesions? Overexpression of VEGF Fever + rash + eosinophiluria 10 days after a patient started an antistaphylococcal penicillin. → acute interstitial nephritis Tx? STOP drug + steroids SLE SOAP BRAIN MD S = serositis O = oral ulcers A = arthritis P = photosensitivity B = blood disorders (cytopenias) R = renal A = ANA/anti-dsDNA I = immunologic N = neurologic findings M = malar rash D = discoid rash Type 2 vs 3 HSRs in lupus Type 2 → cytopenias Type 3 → all other manifestations Lupus Ab? ANA anti-dsDNA anti-Smith Lupus nephritis → full house pattern on IF Antiphospholipid antibody syndrome → recurrent pregnancy losses Pathophys? Thrombosis of the uteroplacental arteries. MC cause of death in lupus patients? What I’ve read recently: CV disease Per Divine: Treated → infection Untreated → renal dz Also 40x risk MI Endocarditis in lupus pt? Libman-Sacks endocarditis Neonatal 3rd degree heart block → neonatal lupus Maternal autoimmune dz? Sjogren’s SLE Ab? anti-SSA/anti-Ro anti-SSB/anti-La Tx? Steroids Cyclophosphamide Hydroxychloroquine → good for skin lesions Pulmonary abscesses Bugs? Staph Anaerobes Klebsiella RF? Alcoholism Elderly Post-viral pneumonia MC location of aspiration pneumonia? Superior segment of RLL Chest pain worsened by deep inspiration and relieved by sitting up in a patient with a recent MI or elevated creatinine or URI or RA/SLE. → pericarditis EKG findings? Diffuse ST elevations + PR depression PE finding? Friction rub (“scratchy sound on auscultation”) A few days after MI → fibrinous pericarditis Weeks after MI → Dressler’s Tx? NSAIDS Consider adding on colchicine Cardiac tamponade Beck’s triad = hypotension + JVD + muffled heart sounds EKG findings? Electrical alternans Type of shock? Obstructive cardiogenic (Amboss) CO low SVR high PCWP high Tx? Pericardiocentesis or pericardial Pearly lesion with telangiectasias on the ear in a farmer. → Basal Cell Carcinoma MC type skin cancer Location? Upper lip Dx? Biopsy Tx? Mohs surgery Cold intolerance in a 35 yo white F → hypothyroidism MC cause? Hashimoto’s Histology? lymphoid follicles w/ active germinal centers Lab findings? TSH high T3/T4 low Ab? anti-TPO Anti-thyroglobulin HLA? DR3/DR5 Tx? Levothyroxine Future complication? thyroid lymphoma Massive hematemesis in a patient with a history of chronic liver disease. → ruptured varices Pathophys? L gastric vein has anastomosis with azygos veins. Increased portal pressure → backward flow from L gastric veins to azygous vein (which empties into SVC). Acute tx? IVF + octreotide + ceftriaxone/cipro + EGD w/ ligation/banding Do NOT give a beta blocker for acute tx Prophalaxsis? Beta blocker + spironolactone Other manifestations of elevated portal pressures Caput medusa Internal hemorrhoids Tx for cirrhotic coagulopathies? FFP If uremia → give desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Hemophilia A Pathophys? deficiency of factor 8 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH b/c clotting problem PT normal Hemophilia B Pathophys? deficiency of factor 9 Inheritance? XLR Coag labs? Bleeding time normal PTT HIGH PT normal Hemophilia C Pathophys? deficiency of factor 11 Inheritance? AR Coag labs? Bleeding time normal PTT HIGH PT normal Bernard Soulier Syndrome Pathophys? Deficiency of GpIb Coag labs? Bleeding time HIGH PTT normal PT normal Glanzmann Thrombasthenia Pathophys? Deficiency of GpIIbIIIa Coag labs? Bleeding time HIGH PTT normal PT normal Von Willebrand’s disease Pathophys? Deficiency of vWF Inheritance? AD Coag labs? Bleeding time HIGH PTT HIGH vWF is a protecting group for factor 8 PT normal ITP Pathophys? Ab against GpIIbIIIa Classic pt? Pt with SLE Tx? Observation Steroids IVIG Splenectomy TTP Pathophys? Deficiency in ADAMTS13 enzyme → cannot cleave vWF multimers → activation of platelets → thrombosis → thrombocytopenia Presentation? microangiopathic hemolytic anemia + thrombocytopenia + renal failure + fever + neurologic problems Tx? Plasma exchange transfusion****** HUS Bugs? Shigella or E. coli O157:H7 Presentation? Fever+ microangiopathic hemolytic anemia + thrombocytopenia + renal failure + neurologic Platelet deficiency vs coagulation factor bleeds Platelet deficiency → mucosal bleeds, petechiae, heavy menses Coag factor deficiency bleeds → hemarthrosis Why do patients with CKD develop coagulopathy? Uremia → platelet dysfunction Tx? Desmopressin Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH Exercising caution with transfusion in patients with Bernard Soulier syndrome Do NOT give transfusion that includes platelets They can have an anaphylactic rxn to GpIb (since they don’t have GpIb) Oropharyngeal candidiasis. RF? HIV Chronic ICS use TNF inhibitor Micro finding? Germ tubes at 37 C Tx oral candidiasis? Nystatin swish-and-swallow Tx invasive candidiasis? Amphotericin B Prevention of Amphotericin B toxicity? Liposomal formulation Pleural effusions Light’s criteria (must meet all 3 to be considered transudative!) LDH < 2/3 ULN LOW Pleural LDH/serum LDH < 0.6 LOW Pleural protein/serum protein < 0.5 LOW Causes of transudative effusion CHF Cirrhosis Nephrotic syndrome Note: Per UW 2021: Mechanism of transudate effusion? Decreased pulmonary artery oncotic pressure, e.g. hypoalbuminemia in nephrotic syndrome Increased pulmonary capillary hydrostatic pressure, e.g. volume overload in heart failure Causes of exudative effusion Malignancy Cancer Parapneumonic effusion Tb Note: Per UW 2021: Mechanism of exudate effusion? Inflammatory increased in vascular permeability of membrane (increased flow of interstitial edema into pleural space) Unique cause of both transudative & exudative effusions? PE Classic Pleural Effusion findings? Decreased breath sounds Dullness to percussion Decreased tactile fremitus Tx? Chest tube Chylothorax = lymph in the pleural space Pathophys? Obstruction of thoracic duct or injury to the thoracic duct Pleural fluid findings? High Triglycerides Holosystolic murmur heard best at the apex with radiation to the axilla in a patient with a recent MI. → mitral regurg 2/2 papillary muscle rupture Dx? Echo Why widely split S2? Aortic valve is closing earlier (LV is emptying into both aorta & LA) Maneuvers that increase intensity Increase preload (putting more blood in that can be regurgitated) Increase afterload Decubitus ulcers RF? Elderly Paraplegic Fecal/urinary incontinence Poor nutrition Staging Stage 1 = non-blanchable erythema Tx? Repositioning q2hrs Stage 2 = loss of epidermis + partial loss of dermis Tx? Occlusive dressing superficial Stage 3 = involves entire dermis, extending to subQ fat Does NOT extend past fascia Tx? Surgical debridement Stage 4 = muscle/tendon/bose exposed Tx? Surgical debridement General tx strategies? Repositioning + good nutritional support Marjolin’s ulcer = non-healing wound that is actually squamous cell carcinoma T1DM Pathophys? Autoimmune destruction of pancreas Ab? anti-GAD 65 (glutamic acid decarboxylase) anti-IA2 (islet tyrosine phosphatase 2) Islet cell autoantibodies Insulin autoantibodies Dx? A1c > 6.5% (twice) Fasting BG >= 126 (twice) Oral glucose tolerance test >= 200 (twice) Sxs of DM + random glucose > 200 Tx? Long-acting insulin + mealtime insulin Long-acting Glargine Detemir Rapid-acting Lispro Aspart Glulisine 3 HY complications Nephropathy Retinopathy & cataracts Neuropathy Chronic DM care A1c q3 months Foot exam annually Eye exam annually Microalbumin:Cr ratio annually Nephroprotection in DM? ACE-I GI bleed algorithm 1st step: ABCs + 2 large-bore IVs + IVFs 2nd step: NG lavage Clear fluid → go deeper Blood → UGIB → upper endoscopy Bilious fluid → have ruled out UGIB → proceed to colonoscopy See source → intervene as needed See nothing → CT angiography for large bleed Tagged RBC scan for smaller bleed Antiplatelet Pharmacology Aspirin Mechanism? Irreversibly inhibits COX-1 and COX-2 Clopidogrel/ticlopidine = P2Y12 (ADP receptor) blockers Mechanism? Inhibit platelet activation Abciximab/eptifibatide/tirofiban = GpIIbIIIa receptor blockers Mechanism? Inhibit platelet aggregation Ristocetin cofactor assay Issues with adhesion step → abnormal result Abnormal ristocetin cofactor assays: Von Willebrand disease Bernard Soulier disease Normal ristocetin cofactor assay: Glanzmann Thrombasthenia Von Willebrand disease effects on PTT? Increased Pathophys? vWF is a protecting group for Factor 8. Treatment of VWD? Desmopressin Mechanism? Increases release of vWF from Weibel-Palade bodies of endothelial cells Note: Desmopressin = ADH analog → so, it can cause AE of hyponatremia 2/2 SIADH HSV1 vs HSV2. Oral herpes → HSV1 Genital herpes → HSV2 Dx? PCR (most up-to-date) Tzanck smear (outdated, not very sensitive, nonspecific) → intranuclear inclusions Brain area affected by HSV encephalitis? Temporal lobes CSF findings in HSV encephalitis? RBCs******* Tx herpes encephalitis? Acyclovir AE? Crystal nephropathy Can’t see, can’t pee, can’t climb a tree. → reactive arthritis HLA? B27 Classic bug? Chlamydia Tx? steroids Need abx? Only if ongoing infection Can’t see, can’t pee, can’t hear a bee → Alport syndrome Inheritance? X-linked dominant Tx of NG & CT NG → treat empirically for both → ceftriaxone + azithro/doxy CT → azithro/doxy Hypovolemic Septic Neurogenic Cardiogenic CO low PCWP low SVR high*** CO high PCWP normal SVR low Tx? norepi CO low SVR low CO low PCWP high*** SVR high*** Tx anaphylactic shock? epinephrine Melanomas ABCDE A = asymmetry B = irregular borders C = color variation D = diameter > 6 mm E = evolving Dx? Full-thickness biopsy Excisional for small lesions Punch for larger lesions Most important prognostic factor → Breslow depth DM pharmacology Lactic acidosis → metformin Decreases hepatic gluconeogenesis → metformin Hold before CT w/ contrast → metformin Weight gain → sulfonylureas & TZDs (-glitizones) Diarrhea → acarbose & migliton Inhibits disaccharidases (can’t reabsorb disaccharides) Recurrent UTIs → SGLT-2 inhibitors Weight loss → GLP-1 agonists (e.g. liraglutide, exenatide) & DPP4 inhibitors (-gliptins) Contraindicated in pt with HF → TZDs PPAR-gamma receptor found in kidney → water retention Contraindication in pt with MTC → GLP-1 agonists Biggest risk of hypoglycemia? Sulfonylureas RF esophageal adenocarcinoma Barrett’s esophagus RF esophageal squamous cell carcinoma Smoking Drinking Achalasia Location esophageal adenocarcinoma? Lower 1/3 Location esophageal squamous cell carcinoma? Upper 2/3 MC US? Adenocarcinoma MC worldwide? Squamous cell carcinoma Presentation? Dysphagia to solids → dysphagia to liquids Dx? EGD Staging? CT scan or esophageal US Factor V Leiden Pathophys? Resistance to protein C Dx? Activated Protein C resistance assay Patient needs super large doses of heparin to record any changes in PTT → AT-III deficiency Recall that heparin is a AT-III activator 35 yo with a hypercoagulable disorder that does not correct with mixing studies. → antiphospholipid antibody disorder Anaphylaxis in a patient with a long history of Hemophilia A → Ab against factor 8 that cause type 1 HSR with transfusion Hx of hemophilia, diagnosed 5 years ago. Before you would give them factor 8 concentrate and PTT would normalize. Now they’re requirizing larger doses of factor 8 to normalize PTT. → inhibitor formation (antibodies against clotting factors) Skin necrosis with Warfarin → protein C/S deficiency Prothrombin G20210 mutation → overproduction of factor II Rash in dermatomal distribution → VZV infection Contraindications to VZV vaccination? Pregnant woman Kid < 1 year Severe immunosuppression (e.g. HIV with CD4 < 200) Tx? Acyclovir If resistant, foscarnet Tzanck smear findings? Intranuclear inclusions Shingles vaccination guidelines? Adults over 60 #1 cause of ESRD in the US → DM nephropathy Histology? Kimmelsteil-Wilson nodules #2 cause of ESRD in the US → hypertensive nephropathy Pt with BP 240/150. How fast should you lower BP? 25% in first 24 hrs Drugs for hypertensive emergencies? Nicardipine Clevidipine Nitroprusside AE? Cyanide poisoning Tx? Amyl nitrate + thiosulfate OR hydroxocobalamin Labelol Renal protective medications in patients with DKD or hypertensive nephropathy? ACE-I Anemia + Cranial Nerve deficits + Thick bones + Carbonic Anhydrase 2 deficiency + Increased TRAP + Increased Alkaline Phosphatase. → osteopetrosis Pathophys? Carbonic anhydrase is defective → osteoclasts cannot produce acid to resorb bone Tx? IFN-gamma Osteoclasts are a specialized macrophage IFN-gamma is an activator of macrophages Clinical diagnostic criteria for Chronic Bronchitis Diagnostic criteria? 2 years 3 months/year of chronic cough PFT findings FEV1 low FEV1/FVC ratio low RV high TLC high Which PFT market can differentiate CB from emphysema? DLCO DLCO normal → CB DLCO low → emphysema ****** Tx acute exacerbation? Abx + bronchodilators + corticosteroids (“ABCs”) Prevention? Stop smoking! Afib #1 RF? Mitral stenosis #1 RF MS? Rheumatic fever #1 RF CAD and AAA: smoking #1 RF stroke and aortic dissection: HTN MC arrhythmia in hyperthyroidism → Afib MC site of ectopic foci in Afib → pulmonary veins EKG findings? “Irregularly irregular” + no P waves Location of emboli formation? LA appendage Who should be cardioverted back to sinus rhythm? New onset (<48 hrs) Afib Anticoagulated for 3 weeks + TEE negative for clot Afib that’s refractory to medical therapy Afib & HDUS Q on T phenomenon? Depolarization during T wave (repolarization) can cause QT prolongation → Torsades → death Prevention? SYNCHRONIZED cardioversion Tx? Rate control Beta blockers ND-CCB (e.g. verapamil, diltiazem) Rhythmic control Amiodarone Reducing stroke risk in Afib? Anticoagulation for CHA2DS2VASc score >= 2 Anticoagulation options Valvular cause (e.g. MS) → warfarin Any other cause → warfarin or NOAC (apixiban) Reversal of AC Warfarin → Vit K, four-factor PCC Heparin → protamine sulfate Dabigatran → idarucizumab Crusty, scaly, ulcerating lesion with heaped up borders → squamous cell carcinoma Classic location? Below Lower lip Precursor lesion? Actinic keratosis What if it arises in a scar or chronic wound? Marjolin ulcer Hypothermia + hypercapnia + non pitting edema + hyponatremia + HR of 35 + hypotension in a patient with a history of papillary thyroid cancer → myxedema coma Tx? Levothyroxine + steroids Lab findings? TSH high T3/T4 low LDL high Acute onset “dermatologic” breakout in a patient with a recent history of weight loss and epigastric pain. → Leser–Trélat sign associated with visceral malignancy pancreatic cancer Lymph node associations Supraclavicular → Virchow’s node Periumbilical → Sister Mary Joseph What are mets to the ovaries called? Kruckenberg tumor Classic bug associated with gastric cancer? H. pylori (MALToma) Classic histological finding in the diffuse type of gastric cancer? Signet ring cells RBCs without central pallor + elevated MCHC + anemia. → hereditary spherocytosis Inheritance? AD Pathophys? Deficiency of spectrin, ankyrin, or band 3.2 Intravascular or extravascular hemolysis? Extravascular (RBCs bound by IgG, attacked by splenic macrophages) Dx? Osmotic fragility test Eosin-5-maleimide Acidified glycerol lysis test Tx? Splenectomy Post-splenectomy preventative care? Strep pneumo Hinflue vaccine Neisseria Septic shock Hemodynamic parameters CO high SVR low PCWP normal MvO2 high Tx? IVF + norepi + broad-spectrum abx (cover MRSA + Pseudomonas) E.g. vanc + pip-tazo E.g
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XX. Physical and Cognitive Changes 1. early adulthood: (18-30) a. reach physical peak: strongest, healthiest, and quickest reflexes b. physical decline is slow and gradual (usually unnoticed until late 20s) 1. possible explanations a. cells lose ability to repair themselves b. cells have preset biological clocks (limit ability to divide and multiply) 2. middle age (30-65) a. changes in appearance: grey and thinning hair, wrinkles b. sight difficulties (seeing in the distance) 3. old age (66+) a. muscles and fat begin to break down; lose weight and become shorter b. gradual or sudden loss of hearing c. reaction time slows Health Problems 1. some changes are natural others develop from disease, or lifestyle a. sensible eating, exercising, avoiding tobacco, drugs and alcohol will look and feel younger b. cancer, heart disease, and cirrhosis of the liver (encouraged by lifestyle) Marriage and Divorce 1. 90% of population will marry; 40-60% of new marriages end in divorce a. marriage success: how couples resolve conflicts & how often they share intimate and happy moments 1. arguments are constructive 2. arranged marriages are surprisingly successful Menopause and Sexual Behavior 1. menopause: the biological event in which a woman’s production of hormones is sharply reduced (usually between age of 45 & 50) a. woman stops ovulating and menstruating: conceiving children is no longer possible b. irritability and depression can develop (psychological origin) c. many women enjoy this stage (more confident, calmer, and freer) 2. sexual activity doesn’t decline with age Cognitive Changes 1. mid 20s: learning new skills and information, solving problems, and shifting problem solving strategies improves dramatically 2. 40s: peak of creativity and productivity 3. 50s-60s: peak in humanities (history, foreign languages, and literature) a person’s character and personality remain stable through the years A. Daniel Levinson’s Theory of Male Development (structures and transitions) 1. Early Adult Transition: 17-22 2. Entering the Adult World: 22-28 a. desire to explore the options of the adult world conflict with need to establish a stable life Age 30 transition: 28-33 a. reexamining life structure: occupation, marriage partner, life goals 4. Settling down: 33-40 a. “making it” & “becoming one’s own man” 5. Midlife transition: 40-45 a. “midlife crisis” Entering middle adulthood: 45-50 a. stability if transition was satisfactory 7. Midlife transition: 50-55 a. generativity: the desire, in middle age, to use one’s accumulated wisdom to guide future generations b. stagnation: a discontinuation of development and a desire to recapture the past Culmination of middle adulthood: 55-60 9. Late adult transition: 60-65 10. Late adulthood: 65-70 Female Development 1. women often face the same challenges as males a. 58% of adult women work outside the home 2. women generally don’t have a midlife crisis a. some women see period as a challenge after starting a family first 3. last child leaving home a. usually only traumatic if paired with an unstable marriage 4. depression is common among middle-aged women a. loss of role as mother, daughter, and wife Changes that Come with Aging 1. decremental model of aging: idea that progressive physical and mental decline are inevitable with age a. view is unrealistic b. ageism: prejudice or discrimination against the elderly Misconceptions a. the elderly rarely suffer from poor health, rarely live in poverty, and are rarely victims of crime b. the elderly rarely withdraw from life c. the elderly are rarely inflexible or senile Changes in Health 1. good health in adulthood carries over into old age 2. 80% of elderly have at least one chronic disease a. heart disease, stroke, cancer, diabetes, and arthritis 3. 65-74 year olds: 80% believe health is good 4. 75+: 72% believe health is good 5. quality of care is inferior to that of the general population a. 4% of elderly population live in nursing homes Changes in Life Situation 1. transitions in late adulthood a. 41% of women and 13% of men 65+ are widowed b. 60% of women and 22% of men 75+ are without a spouse 2. more elderly are spending time learning and developing new skills C. Changes in Sexual Activity 1. the best predictor of future behavior is past behavior Adjusting to Old Age 1. a negative self-concept results from: a. changes in health, recognition in the community, rare visits from family and friends, respect of privacy, leisure and work activities b. loss of physical control 2. assertive personalities cope better 3. AARP: speak out about social issues that affect the elderly there is much less decline in intelligence and memory than assumed 2. crystalized intelligence: the ability to use accumulated knowledge and learning in appropriate situations (increases with age) 3. fluid intelligence: the ability to solve abstract relational problems and to generate new hypotheses (decreases as nervous system declines) Dementia: decreases in mental abilities, which can be experienced by some people in old age 1. memory loss, forgetfulness, disorientation of time and place, decline in ability to think, impaired attention, altered personality 2. is not a normal part of normal development Alzheimer’s Disease: a condition that destroys a person’s ability to think, remember, relate to others, and care for herself or himself 1. 4.5 million have disease in U.S. 2. 6th leading cause of death among U.S. adults 3. most often leads to a weakened state that leads to fatal problems 4. causes are not completely understood and there is currently no cure Approaching Death 1. death is a culturally and emotionally confusing and complex process A. Stages of Dying 1. thanatology: the study of dying and death Elisabeth Kubler-Ross: studied how the terminally ill react to their impending death a. denial: “no it can’t be happening to me” 1. often leads to individuals avoiding treatment b. anger: “Why me?” 1. often alienate themselves from others c. bargaining: changing of attitudes combined with bargaining d. depression: begin contemplating the losses that are coming e. acceptance: often experience a sense of calm Making Adjustments 1. Camille Wortman theorized that Kubler-Ross’s stages were just the five most common styles of dealing with death 2. how should we deal with the impending death of others a. provide opportunities for the dying to have respect, dignity and self-confidence b. open communication about dying process and legal and financial issues c. avoid judgments concerning grieving of others the contemporary population is mostly insulated from death 2. life expectancy is much longer today and most people no longer die at home A. Hospice Care 1. hospice: a facility designed to care for the special needs of the dying a. goal is to create the most home-like environment where pain management can be provided b. home-based hospice care is now more frequently used than inpatient Dealing with Grief 1. John Bowlby: grief-based attachment research a. shock and numbness 1. can last several hours or weeks b. yearning and searching 1. grievers often isolate themselves 2. guilt and anger can manifest in this stage 3. may last for several months John Bowbly: disorientation and disorganization 1. depression can manifest 2. new reality becomes very confusing d. reorganization and resolution 1. griever overcomes feeling of isolation Pavlov’s Dogs 1. classical conditioning: a learning procedure in which associations are made between a neutral stimulus and an unconditioned stimulus a. attaching an old prompt or stimulus to a new prompt or stimulus 2. neutral stimulus (N): a stimulus that does not initially elicit any part of an unconditioned response a. sound of tuning fork (Pavlov’s experiment) 3. unconditioned stimulus (US): an event that elicits a certain predictable response typically without previous training a. food (Pavlov’s experiment) 4. unconditioned response (UR): an organism’s automatic (or natural) reaction to a stimulus a. salivation (Pavlov’s experiment) 5. conditioned stimulus (CS): a once-neutral event that elicits a given response after a period of training in which it has been paired with an unconditioned stimulus 6. conditioned response (CR): the learned reaction to a conditioned stimulus A. Acquisition 1. gradually occurs every time a N/US is paired with a UR/CR 2. best timing is when the N is presented just before an US (.5 seconds) B. Generalization and Discrimination 1. generalization: responding similarly to a range of similar stimuli a. Pavlov taught dog to respond to a circle; dog would respond to other figures 2. discrimination: the ability to respond differently to similar but distinct stimuli a. Pavlov proved by never pairing the food with the oval Extinction and Spontaneous Recovery 1. extinction: the gradual disappearance of a conditioned response when the conditioned stimulus is repeatedly presented without the unconditioned stimulus a. Pavlov stopped giving food after sound of tuning fork 2. spontaneous recovery: when a CR reappears when a CS occurs without a US John Watson & Rosalie Rayner: the case of Little Albert a. explored the relationship between classical conditioning and emotional responses b. trained 11-month old Albert to fear lab rat c. Rat (NS) + loud sound (US) => fear (UR) Hobart & Mollie Mowrer 1938 study a. developed a bed-wetting alarm to awaken children as they begin to wet bed b. Full bladder (NS) + Alarm (UCS) => Awaken (UCR) Taste Aversions 1. develop after illness follows dining experience a. usually connected to new food even when other food was eaten John Garcia & R.A. Koelling 1. Rats (A) shocked after drinking flavored water paired with flashing lights and clicking sounds a. rats developed an aversion to the lights/sounds 2. Rats (B) injected with drug activated by drinking water (led to upset stomach) a. rats developed an aversion to the taste of the water c. used to condition coyotes to hate the taste of sheep Behaviorism 1. classical conditioning is a great example of behaviorist theory a. behaviorist study behaviors that can be observed and measured; not unobservable mental activity Reinforcement 1. operant conditioning: learning in which a certain action is reinforced or punished, resulting in corresponding increases or decreases in occurrence a. participant must be actively involved 1. classically conditioned organisms are passive participants Positive and Negative Reinforcement 1. B.F. Skinner: trained rats to respond to lights and sounds (Skinner Box) 2. reinforcement: stimulus or event that follows a response and increases the likelihood that the response will be repeated positive reinforcement: adding something desirable after a behavior occurs 1. food (Skinner Box), social approval, money, extra privileges b. negative reinforcement: removal of something undesirable after a behavior occurs 1. changing a smoke alarm battery, buckling seatbelt, use of an umbrella Primary and Secondary Reinforcers 1. primary reinforcer: stimulus that is naturally rewarding, such as food or water 2. secondary reinforcer: stimulus such as money that becomes rewarding through its link with a primary reinforcer a. Wolfe experiment 1936 (Chimpanzees) b. money is best example Schedules of Reinforcement 1. continuous schedule: reinforcing behavior every time it occurs 2. partial schedule: positive reinforcement occurs sporadically a. acquired behaviors are more slowly established but are more persistent 1. discovered when the Skinner Box kept breaking down ratio schedules: reinforcement based on the number of responses 1. fixed-ratio: reinforcement depends on specified quantity of responses a. most consumer loyalty punch cards 2. variable-ratio: reinforcement after varying number of responses a. slot machines, door to door sales, telemarketing 1. very resistant to extinction interval schedules: reinforcement occurs after an amount of time elapses 1. fixed-interval: reinforcement of first response after a fixed amount of time has passed a. salaries, cramming for tests 2. variable-interval: reinforcement of the first response after varying amounts of time a. fishing, pop quizzes 1. very resistant to extinction shaping: technique in which the desired behavior is “molded” by first rewarding any act similar to that behavior and then requiring ever-closer approximations to the desired behavior before giving the reward 1. flag-raising rat a. reinforce rat for approaching flagpole b. reinforce after rat raises paw while near flagpole c. reinforce after rat gets on hind legs while near flagpole d. reinforce after rat nibbles at cord while on hind legs Combining Responses: Chaining 1. response chains: learned reactions that follow one another in sequence, each reaction producing the signal for the next a. complex skill of swimming involves organizing large response chains 1. arm stroke chain, breathing chain, leg kick chain Aversive Control: process of influencing behavior by means of unpleasant stimuli completed through use of negative reinforcers or punishers A. Negative Reinforcement: increasing the strength of a given response by removing or preventing a painful stimulus when the response occurs 1. escape conditioning: training of an organism to remove or terminate an unpleasant stimulus a. parents removing an unpleasant meal when child whines and gags while eating avoidance conditioning: training of an organism to respond so as to prevent the occurrence of an unpleasant stimulus a. parents deciding against presenting an unpleasant circumstance because child whines at the possibility Punishment 1. leads to the removal or reduction of behavior 2. must be unpleasant to work a. some reprimands may actually serve as reinforcers 3. positive punishment: adding unpleasant circumstances 4. negative punishment: removal of pleasant circumstances Disadvantages of Punishment 1. can produce rage, aggression, and fear in children 2. spanking can lead to increased aggression toward other children 3. can lead to children avoiding person who punishes 4. fails to teach appropriate and acceptable behavior Cognitive Learning 1. social learning: process of altering behavior by observing and imitating the behavior of others a. learning goes beyond mechanical responses to stimuli or reinforcement 2. cognitive learning: form of altering behavior that involves mental processes and may result from observation or imitation Latent Learning and Cognitive Maps 1. Wolfgang Kohler: chimpanzee study on insight 2. Edward Tolman: rat study on cognitive maps and latent learning a. cognitive map: a mental picture of spatial relationships or relationships between events b. latent learning: alteration of a behavioral tendency that is not demonstrated by an immediate, observable change in behavior Learned Helplessness: condition in which repeated attempts to control a situation fail, resulting in the belief that the situation is uncontrollable 1. college students/noise study 2. Martin Seligman Theory a. stop trying b. lower self-esteem c. depression ensues Modeling: learning by imitating others; copying behavior mimicry: performing old, established responses that we might not be using at the time. 2. observational learning: learning to perform a behavior after watching others perform it a. Albert Bandura: Bobo doll experiment 3. disinhibition: the increased likelihood a behavior will be repeated when observed behavior is not punished a. often used to alleviate phobias the systematic application of learning principles to change people’s actions or feelings A. Computer-Assisted Instruction 1. S.L. Pressey (1933) & B.F. Skinner (1950s) a. program that uses reinforcement (new information, choices, or point rewards) each time a student shows they learned something new b. program builds on information student has already mastered Token Economics 1. token economy: conditioning in which desirable behavior is reinforced with valueless objects, which can be accumulated and exchanged for valued rewards a. used in schools, prisons, mental hospitals, and halfway houses Self-Control 1. having people set up personal systems of rewards and punishments to shape their own thoughts and actions a. define the problem b. track the behavior c. set up a behavioral contract Improving Your Study Habits 1. progressively increase study quotas (successive approximations) a. remove conditioned aversive stimuli adjust to change or alter in order to fit or conform adapt A changing to fit new conditions menopause the biological event in which a woman's production of sex hormones is sharply reduced generativity the desire, in middle age, to use one's accumulated wisdom to guide future generations stagnation a discontinuation of development and a desire to recapture the past function the ability to achieve his or her goals within him or her self and the external environment. It includes an individual's behavior, emotion, social skills, and overall mental health assumed accepted as real or true without proof decremental model of aging idea that progressive physical and mental decline are inevitable with age ageism prejudice or discrimination against the elderly dementia decreases in mental abilities, which can be experienced by some people in old age Alzheimer's disease a condition that destroys a person's ability to think, remember, relate to others, and care for herself or himself component A part or element of a larger whole. isolating causing one to feel alone thanatology the study of death and dying hospice a facility designed to care for the special needs of the dying classical conditioning a learning procedure in which associations are made between a neutral stimulus and an unconditioned stimulus neural stimulus a stimulus that does not initially elicit any part of an unconditioned response unconditioned stimulus an event that elicits a certain predictable response typically without previous training unconditioned response an organism's automatic (or natural) reaction to a stimulus conditioned stimulus a once-neutral event that elicits a given response after a period of training in which it has been paired with an unconditioned stimulus conditioned response the learned reaction to a conditioned stimulus generalization responding similarly to a range of similar stimuli discrimination the ability to respond differently to similar but distinct stimuli extinction the gradual disappearance of a conditioned response when the conditioned stimulus is repeatedly presented without the unconditioned stimulus operant conditioning learning in which a certain action is reinforced or punished, resulting in corresponding increases or decreases in occurrence reinforcement stimulus or event that follows a response and increases the likelihood that the response will be repeated secondary reinforcer stimulus such as money that becomes rewarding through its link with a primary reinforce primary reinforcer stimulus that is naturally rewarding, such as food or water shaping technique in which the desired behavior is "molded" by first rewarding any act similar to that behavior and then requiring ever-closer approximations to the desired behavior before giving the reward response chain learned reactions that follow one another in sequence, each reaction producing the signal for the next aversive control process of influencing behavior by means of unpleasant stimuli negative reinforcement increasing the strength of a given response by removing or preventing a painful stimulus when the response occurs escape conditioning training of an organism to remove or terminate an unpleasant stimulus avoidance conditioning training of an organism to respond so as to prevent the occurrence of an unpleasant stimulus social learning process of altering behavior by observing and imitating the behavior of others cognitive learning form of altering behavior that involves mental processes and may result from observation or imitation cognitive map a mental picture of spatial relationships or relationships between events latent learning alteration of a behavioral tendency that is not demonstrated by an immediate, observable change in behavior learned helplessness condition in which repeated attempts to control a situation fail, resulting in the belief that the situation is uncontrollable modeling learning by imitating others; copying behavior token economy conditioning in which desirable behavior is reinforced with valueless objects, which can be accumulated and exchanged for valued rewards
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