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![Eysenbach G, ]adadAR
Evidence-based Patient Choice
and Consumer heatth
informat/cs in the Internet age
] Med Internet Res 2001,3t2):e19
URL: http://wwwjmit
org/2001/2/e19
DOl: lo.2196/jmir.3.2.e19
PMID: 11720961
PMCID: PMC1761898
5. Doctor-Patient Relationship
Ifyou have come to hetp me
You are wasting your time
But ifyou hove come because
Your tiberation is bound up with mine
Then let us work together
- An Australian Aborigine’s statement to a Doctor
The basis of the unique relationship between doctor and patient is the
capacity of the doctor to appreciate the complexity of human behaviour. A
doctor must be sensitive to the effects of history, culture, and environment
on his patients. At the center of this therapeutic retationship is the trust that
a patient has in the doctor, This trust is built on the unconditionaL positive
regard that the doctor holds for the patient, irrespective of their gender,
social class, caste, colour or creed. The bond that forms in the relationship
can take three forms:
The vertical model, where the doctor completely takes over the
process of care with the patient having virtually no role e.g. when a
patient is unconscious, immobilised or in an altered state of con
scious, or is incapacitated.
The teacher-student model, where the doctor plays a roLe similar to
that of an authority figure (such as a teacher or a parent), who dom
inates, controls and guides the patient e.g. in the case of a patient -
recovering from a surgical intervention.
The mutual participation, horizontal modeL where the doctor and
the participation behave as partners in the process of healing and
care. Each augments and supports the other’s effort. The patient in
this is fully aware and informed and plays an active role in the treat
ment process e.g. a patient of diabetes metlitus who understands
the nature of his/her illness and undertakes lifestyle changes to
manage it with the doctor’s cooperation. is an active partner in the
management process.
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![The orbitofrontal cortex (so called because it represents the area above
the orbits) plays an important role in emotional regulation, specifical
ly anger management. It functions to associate possible outcomes of a
certain behaviour by weighing pros and cons based on reward and pun
ishment and makes a decision. Iii In one study people with more outgoing
personalities were found to have higher volume orbitofrontal cortex, while
more introverted people were found to have a higher volume ventromediat
prefrontal cortex. [2]
A part of the cingulate cortex, the anterior cingulate cortex (ACC) is the area
where the integration of emotional input with attention occurs. It, therefore,
controls emotional arousal and emotional self-controL It is involved in gen
erating empathy and social awareness and becomes active when individu
als indulge in acts of bravery. [41
To summarise, the prefrontal cortex (the smart’ part of the brain), takes into
account the emotions elicited and decides the most logical and rational
action to take in a situation. 171
The limbic system, specifically the amygdala, works to integrate inputs
from the thalamus and frontal cortex with outputs involving the endocrine
and autonomic nervous systems. This results in the expression of emotion.
• The amygdala is the main mediator of the fight, flight or freeze response.
It is invo[ved in the mediation of aggression, fear, sexuaL orientation and
social interaction, including the number and kind of people one is friends
with and interacts with in a social context. It also regulates personal space,
in that it is stimulated when another human being gets “uncomfortably
close.” [81
The right lobe of the amygdala houses negative emotions such as fear and
anxiety. The left lobe, on the other hand, mediates and stores both positive
emotions such as pleasure and happiness and negative emotions such as
fear. In one study, poLitical conservatism was linked to increased volume of
the right amygdala. [9]
Distinct gender differences have been seen in the male and female amyg
data. The mate amygdata has a larger right lobe, while the female amygda
Ia has a larger left lobe. As the right lobe is associated with negative emo
tions and action, men are more likely to react physically in situations that
are emotionally stressful. The left lobe is important in the recall of emotion
ally charged memories and details, leading to more intense thought, which
may explain why women are more likely to not react in physical ways to
emotional stress.
The amygdaLa also mediates the formation of memories that have an emo
tional content. When sensory input is received, it is relayed by the thalamus
to both the frontal cortex and the amygdata. The amygdala then checks
with the hippocampus to see if there is an emotional memory of a similar
experience. If one is found, we tend to react in a similar fashion, if not; the
prefrontal cortex kicks in to make something of the novel experience and
forms a new response. Activity of the amygdala has been linked to clinical
depression, anxiety disorders, and posttraumatic stress disorder. liD]
Despite the tact that the prefrontal cortex is the smart part of the brain, the
amygdala exerts far more control over it than the prefrontal cortex does
over the amygdata This can be understood it the amygdata is equated
with the moon which despite its size may eclipse the sun. This “limbic
eclipse” is th reason that “love is blind” “ghussa akal ko khaajaata hai”](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-115-320.jpg)
![References
i.Kringelbach, M. L. (2005) “The orbitofrontal cortex: Unking reward to he
donic experience. Nature Reviews Neuroscience 6: 691-702.
2. Schoenbaum G, Takahashi Y, Liu T, & McDannatd M (2011). “Does the orbi
tofrontat cortex signal vaLue?” Annals of the New York Academy ofSciences
1239: 87-99
3. Hu, C; Jiang, X (2014). “An emotion regulation role of ventromedial pre
frontal cortex in moratjudgment.” Front. Hum. Neurosci 8: 873. doi:10.3389/
fnhum.2o14.oo873.
4. Nicolle, A. & Goet, V. (2013). What is the role of ventromedial prefrontal
cortex in emotional influences on reason? In I. Btanchette (Ed.), Emotion
and Reasoning. Psychology Press.
5. Schwartz, Carl E., et aL “Structural differences in adult orbital and ventro
medial prefrontal cortex predicted by infant temperament at 4 months of
age.”Archives ofgeneral psychiatry 67.1 (2010): 78-84.
6. Carlson, N. (2012). Physiology of Behaviour filth Ed.). Hartow: Prentice
Hall.
.
Chan, R. C. K., Shum. D., Tou[opoutou, T. & Chen, E. Y. H., R: Shum, D: Tou
lopoulou, I; Chen, E (2008). “Assessment of executive functions: Review of
instruments and identification of critical issues.” Archives of Clinical Neuro
psychology. 2 23 (2): 201-216.
8. Kennedy, Daniel P., et al. “Personal space regulation by the human amyg
data.” Nature neuroscience 12.10 (2009): 1226-1227.
9. Kanai, Ryota, et at “Political orientations are correlated with brain struc
ture in young adults.” Current biology 21.8 (201;): 677-680.
10. Sheune, Yvette I., et at “Increased amygdata response to masked emo
tional faces in depressed subjects resolves with antidepressant treatment:
an fMRI study.” Biological psychiatry 50.9 (2001): 651-658,
ii. Peirson AR, Heuchert JW. Correlations for serotonin levels and measures
of mood in a nonctinica[ sample. Psychot Rep 2000:87:707-16,
12. Flory JD, Manuck SB, Matthews KA. et at. Serotonergic function in the
central nervous system is associated with daily ratings of positive mood.
Psychiatry Res 2004:129:11-9.
13. Muldoon MF, Mackey RH, Williams KV, et at. Low central nervous sys
tem serotonergic responsivity is associated with the metabolic syndrome
and physical inactivity. ] Clin Endocrinol Metab 2004: 89:266-71.
14. Schultz W (2007). “Multiple dopamine functions at different time cours
es.” Annual Review of Neuroscience 30: 259-88.
15. BjOrktund A, Dunnett SB (May 2007). “Dopamine neuron systems in the
brain: an update.” Trends in Neurosciences 30 (5): 194—202.
i6. Lee HJ, Macbeth AH, Pagani JH, Young WS (Jun 2009). “Oxytocin: the
great facilitator of tite.” Progress in Neurobiology 88 (2): 127-51.
17. 01ff, M.. FrUling. J. L., Kubzansky, L. D., Bradley, B., Ettenbogen. M. A., Car
doso, C & van Zuiden, M. (2013). The role of oxytocin in social bonding, stress
regulation and mental heatth: an update on the moderating effects of context and
interindividuat differences. Psychoneuroendocrinotogy, 38(9), 1883-1894.](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-118-320.jpg)
![Motor and Sensory Regions of the Cerebral Cortex
Language
Language forms a quintessential part of what it means to be human.
Human language is unique compared to the communication techniques
used by other animals. Other animats communicate using a finite num
ber of ideas that can be expressed. Human language. on the other hand,
is open-ended and productive meaning. Humans, can, thus produce an
infinite range of expressions from a finite set of elements to create new
words and sentences. [ii
Speaking is the default mode for language in all human cultures. Humans
produce language using control of the lips, tongue and the rest of the vo
cal apparatus. They are able to differentiate spoken sounds white attaching
contextual meaning to the sounds. In other words we can understand what
is being said, and what it means in a certain situation. These abilities are
[inked to a neurological apparatus to acquire and produce language. 12]
While, language is processed in various areas in the human brain, the two
areas that are mainly involved in language processing are Wernicke’s area,
located in the posterior section of the superior temporal gyrus, (temporal
lobe) and the Broca’s area, located in the posterior inferior frontal gyrus
(frontal lobe) of the dominant hemisphere. Wernicke’s area is used for lan
guage comprehension and Broca’s area is responsible for language artic
ulation. Language is the only human behavior that has two controlcentres.
thus the famous idiom pehte tolah phir boto’ (think before you speak).
Primary motor cortex
(precentr& gyms)
Somatic motor association area
(premotor cortex)
Prefrontal cortex
Sri
Broca’s area—
(production of speech)
Primary sensory cortex
(postcentml gyms)
/ Somatic sensory association area
Visual association
//_ area
Visual cortex
Auditory association area / -
--
I Wemicke’s area
Auditory cortex (understand speech)](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-119-320.jpg)
![Memory
Memory is defined as the mental capacity to encode, store, and retrieve
information. [ii
Clinically we are concerned with three, testable periods of memory which
have distinct anatomical correlates: Immediate memory functioning over
a period of seconds: recent memory applicable over a scale of minutes to
days: and remote memory ranging over time periods spanning months to
years.
Immediate memory can be understood as the ability to follow a train of
thought. It is divided into phonological and visuospatial components. The
phonological component is localised in the left hemishphere and the
visuospatial in the right.. Immediate memory is often related with recent
memory using the concept of working memory. Working memory is defined
as the ability to store information for several seconds while other cognitive
operations take place using this information. The dorsolateral prefrontal
cortex is required for working memory along with the certainty with which
the information is known. [2] Some researchers locaUse working memory
predominantly to the left frontal cortex.
Three brain structures are critical to the formation of memories: the medial
temporal lobe, certain diencephalic nuclei, and the basal forebrain.
The hippocompus is part of the medial temporat tobe. Adjacent to the ante
rior end of the hippocampus is the amygdata. The amygdala and the hip
pocampus work in tandem to store emotional experiences. The amygdala
rates the emotional importance of an experience and activates the level of
hippocampal activity. This phenomenon is called the memory enhance
ment effect and is the reason why emotionally intense experiences are
etched in memory. This is why most of us would find it hard to recall what
we had for lunch last Tuesday, but remember in great detail what the menu
for a close family wedding three years ago was or the exact sequence of
events when vie were in a car accident.
The amygdata also plays a role in the formation of long-term memory by
moduLating synaptic plasticity, which helps to retain a memory. It helps to
visuaLise memory as a grassy path, that when used repeatedly becomes a
place of common fare.
Long-term memory for learning events is not formed immediately. These
memories are slowly made over time, through a process called tong term
potentiation These are enhanced and made permanent when they are
potentiated by experiences. This is also why you don’t remember last
minute cramming after a few weeks. It is, therefore, imperative for a medi
cal student to ensure that all forms of knowledge are enriched by seeing a
patient or dealing with a relevant clinical experience in real Life settings of a
hospital. The lesser the gap between studying and clinical experience, the
higher the chance that the knowledge will remain in memory for the long
term.
The association areas are required for the formation of memory for motor
acts. The performance of a new action requires feedback from the sensory
cortex and association areas. Neuroimaging has shown activation of the
large parts of the cortex, during performance of unskilled acts. When per
forming repeated activities initially the medial temporal lobe is activated,
however with time the performance of the act results only in the activation
of the premotor and left parietal cortex. This phenomenon is known as the](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-121-320.jpg)
![There have been attempts to explain different temperaments in humans by
examining variations in a person’s brain stem, Umbic system, and thatamo
cortical arousal system using Electroencephalogram (EEG). [1] Limbic sys
tem activation has been [inked to neuroticism, with high activation showing
high neuroticism.[2] High cortical arousal has been shown to be associated
with introversion. People with high extraversion and low neuroticism have
been shown to have the towest overa[[ levels of internal arousat. Converse
ly people with high extraversion and high neuroticism have been shown to
have the lowest intrinsic thatamocortical excitation.
References
1. Robinson, David (6 November 2000). UH0w brain arousal systems de
termine different temperament types and the major dimensions of per
sonality.” Elsevier. Personality and Individual Differences i: 1233—1259.doi:
10.1016/s0191-8869(oo)0o2;1-7.
2. Robinson, David; Gabriet, Katchan (22 February 1993). Personality and
Second Language Learning(PDF). Personality Individual Differences i6 (1):
143—157.dOi:10,1016/0191-8869(94)90118-x. Retrievedl2 November 2012.
Steep
Steep is a recurring state of altered consciousness, imperative to nor
mal brain and body function. Approximately one third of our lives is spent
asleep. Steep is characterised by decreased awareness and interaction
with surroundings, lowered sensory activity and inhibition of voluntary
muscles.
The awake state is characterised by beta and alpha waves on the electro
encephalogram. Beta waves are commonly seen during active mental con-
centration whereas alpha waves are seen when a person c[oses their eyes
and relaxes.
Each stage of the sleep cycle is characterised by a specific wave form on
EEG. Mapping the transition of sleep from one stage to another is known as
sleep architecture and this changes with age.
The normat sleep cycle is divided into rapid eye movement (REM) steep
and non-rapid eye movement (NREM steep). REM sleep is a period of high
levels of activity in the brain and a level of physiological activity similar to
when the person is awake. During NREM sleep, physiological activity is less
than when an individual is awake. NREM has four stages (1-4).](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-123-320.jpg)
![In our culture, most psychiatric disorders, epilepsy, fits and related chang
es in consciousness, and headache are attributed to supernatural causes
or ‘evil eye’. Heart conditions, diabetes, and hypertension are attributed
to stress, poor dietary habits, and unhealthy lifestyles. Liver and kidney
disease are attributed to eating the ‘wrong food’ ( “garam taseer”). Sexual
diseases are considered a curse of nature, caused by moral depravity.
Cultural views on treatments and interventions are largely diverse and vary
with social class, educational background. urban and rural setting and in-
fluence of prevailing subcultures. Altopathic medication are Largely viewed
as ‘goram’ and dangerous. and essentially lesser of the two evils when
confronted with disease. Pharmacological preparations are called ‘ongrezi
dawayi’ (a reference to the days of the British Pa]). This is to distinguish
it from ‘des! dawa’ (local or medicine of our own heritage). ‘Des! dawn’ is
considered ‘thand/’ and thus, more appropriate in a predominantly hot and
humid temperate setting. Local translations of the words ‘tablet’, ‘injection’
have dangerous connotations e.g. ‘tablet’ is translated as ‘got/which is the
same as ‘bullet’, injections are often just referred to as “su/”fneedle).
The most preferred and the first line of treatment in our culture are house
hold remedies and herbs based on past experience and conventional
wisdom. These are supplemented by prayers to The Almighty by the
individuaL his family, and sometimes the pit, the local faith healer, or the
prayer leader at the local mosque. Alms, sadqo, taweez, and holy water are
also used. It is only after the failure of these convenient, easily accessible,
inexpensive and trustworthy interventions that professional treatments and
interventions are considered an option. Alternative medicine, folk medicine,
healing through spiritualists, omits, sorcerers, shamans, and faith healers
are often reserved for patients with psychiatric disorders and epilepsy.
Often inhumane methods of ‘treatment’ are used by these agents in the
presence of and in connivance with the referring members of the family.
Cuftura[ty Sensitive Clinical Assessment
A culturally sensitive assessment may not he required in all patients and
not always at the start of a treatment plan. It would, however, be urgently
required when a patient is obviously from a different ethnic background
e.g. a patient from rural Sindh, central-Punjab, Balochistan or Northern
Areas being nursed in Lahore, Karachi or Islamabad. It is also important to
consider the concept of heritage consistency. This refers to how closely
an individual is influenced by or practices his/her particular ethnic back
ground. The lifestyle, health belief model, or practices of an individual may
not always be the same as their cultural heritage, In case a patient has a
high heritage consistency, the next step is to note how much of his/her
beliefs are influenced by the cultural background.
The following questions can be asked in a clinicat setting to ensure a
deeper cultural understanding of the patient’s explanatory model of illness
• What do you call your problem? What name does it have?
• What do you think has caused your problem?
• How do you think it started and what course do you think it will take?
A recommended approach for culturally sensitive health professional was
suggested by Fowkes and Berlin in lg8os. This approach can yield not only
invaluable information about the patient and family’s cultural understand
ing of the disease (their health belief model HBM) but also improves](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-143-320.jpg)
![Chapter 5
Psychosocial Aspects of Alternative Medicine
The term alternative medicine refers to atl medicine that has not been
tested using the scientific method, and has no evidence to prove its efficacy.
This includes homeopathy, acupuncture. hikmat and other forms of herb
al medicine. In our culture, alternative medicine is usually the first line of
treatment that a patient adopts when s/he first becomes ilL It is practiced
by anyone and everyone who has ever experienced illness, and alternative
medical advice can be sought from anyone, whether it is a fruit vendor, a
neighbour or your grandmother. The reasons for this are that traditionalLy
a[Lopathic medicine was considered a western invention, harsh’ on the
body and unsuitable for the subcontinentat climate. It was only to be turned
to if and when all else had failed, and the healing properUes of household
remedies had failed. A return to the use of alternative medicine is seen in
patients in situations where allopathic medicine suggests a painful cure, or
does not have one.
White anecdotal evidence states that these alternative methods are ef
fective there is no scientific evidence to back this claim. Homeopathy, in
particutar, according to the NHS UK has been cited as ‘performing no better
than placebos.” The National Institute of Health and Care Excellence (NICE)
guidelines do not recommend the use of homeopathy for the treatment of
any ailment. In a 2013 large scale study conducted by the Nationat Health
and Medical Research Council of Australia, 57 systematic reviews containing
176 individual studies, published between 1997 and 2013 were evaluated by
an independent contractor overseen by a body of homeopaths. The study
found that there is no evidence that homeopathy caused greater health im
provements than placebo. or caused health improvements equal to those
of another treatment. This finding has been repeatedly confirmed by find
ings in various peer reviewed journals. tl][21[3][41
As health professionals it is therefore, unethical to recommend homeo
pathic treatment to any of our patients, even if we have personally feel that
they are effective. Any patients who report that they are using homeopathic
medication must be informed that there is no evidence to support their effi
cacy. They must also be instructed to continue the use of altopathic medi
cine if they insist on using homeopathic or other remedies.
References
1. Fisher, P., & Ernst, E. (2015). Should doctors recommend homeopathy?.
www.bmj.com
2. Australian National Health and Medicat Research CounciL Statement on
homeopathy. 2015.
www.nhmrc.gov.au/_ffles_nhmrc/pubtications/attachments/camo2_nhm-
rc_statement_homeopathy.pdf.
3. Ernst E. A systematic review of systematic reviews of homeopathy. British
journal of clinical
pharmacology. 2002 Dec 1;54(6):577-82.
4. Campbell A. Homeopathy in perspective. Lulu, 2008.
5. Cucherat M, Haugh MC, Gooch M, BoisselJP. Evidence of clinical effica
cy of homeopathy. European Journal of Clinical Pharmacology. 2000 Apr
1:56t1):27-33.
6. Smith K. Against homeopathy—a utilitarian perspective. Bioethics. 2012
Oct 1;26(8):398-409.](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-179-320.jpg)
![Chapter 6
Common Psychiatric Disorders in General
Health Settings
The workings of the human mind have remained mysterious since the
beginning of time. Psychiatry. the medical specialty devoted to the study.
diagnosis, treatment, and prevention of mental illness, is just as Little
understood, despite being the oldest profession known to man. In prehis
toric times, people haunted by ‘evil spirits” were taken to medicine men
to have holes drilled into their skutts to let the spirits escape. The need to
understand the way our minds work coupled with lack of scientific prowess
to investigate the mechanics of the brain led to the perpetuation of these
myths. The first psychiatric facilities were set up in the 8th century in the
Islamic world but methods more humane than exorcisms did not come into
use until the seventeenth and eighteenth centuries. Psychiatry has come
a long way since then but sadly the perceptions surrounding it are very
much prehistoric, especially in our part of the world.
The myths and misconceptions surrounding mental illness, treatments and
mental health professionals themselves are many and manifest. The war
against the stigma of mental illness is one that we alt fight. whether we are
protesting against being called “crazy” or fighting for a loved one to get
help. According to the WHO Mental Health Action Plan 2013-2020 Re
port, “mental, neurological and substance use disorders exact a high toll,
accounting for 13% of the total global burden of disease in the year 2004,
Depression atone accounts for 4.3% of the global burden of disease and is
among the largest single causes of disability worldwide Eli % of all years
lived with disabitity globally], particularty for women. The economic conse
quences of these health losses are equally large: a recent study estimated
that the cumutative global impact of mental disorders in terms of lost eco
nomic output will amount to US$ 16.3 million between 2011 and 2030.”
Some of the most common myths and misconceptions surrounding mentaL
health issues, their treatments and mentat health professionals are being
dealt with here hi:
Myth: Psychiatric Illnesses do not exist or are caused by magic and evit
spirits
Reatity: Psychiatric illnesses are caused by structural and chemical chang
es in various structures of the body, especially the brain, and are just as
much a “curse” as any other illness or adverse life event. The reasons for
this are genetic, biochemical, behavioural and environmentaL According
to a WHO Report, one in every four people in the world wilt be affected by
mental or neurological disorders at some point in their lives. Psychiatric
Illnesses constitute 15% of all diseases incurred in people throughout the
world. 33% of all hospital attendances are for psychiatric diseases.
Myth: Psychological factors do not cause any other diseases
Reality: Psychological factors are acause of the disease for at least 60% of
alt patients with any disease. In fact, mental illnesses such as depression
may predispose one to developing infections, heart disease, diabetes and
even cancer.
•xed!n
istHyaKhan](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-180-320.jpg)
![f Suicide and Detiberate Self harm (DSH)
All patients of depression must be screened for suicide risk as go% of those
committing suicide or deliberate self harm are suffering from a psychiatric
illness. It is one of the top 10 causes of death in all age groups and one of
the top 3 causes in young adults and teenagers. Certain risk factors are
particutarty associated with completed suicide including:
• Gender (elderly white males being at highest risk),
• Psychosis,
• Alcoholism,
• Chronic physical illness, lack of social support and use of generally
lethal methods in the past (e.g. Gun rather than overdose of
medication). (For more, see box)
Medical students and young doctors may be reluctant to explore suicid
al ideation in the mistaken belief that asking about suicide may actually
increase a patient’s risk or give them ideas of suicide.” In fact, the opposite
may be true. Assessment of suicidal tendencies usually reassures patients,
reduces anxiety for both patient and doctor and facilitates partnership
in suicide prevention. The assessment should begin gradually by asking
questions such as Sometimes when people who are going through the
circumstances that you are, they may start to feel like life is not worth tiv
ingr and then asking more specifically about a history of suicidal attempts.
any specific current plans, hopelessness and any specific current inten
tions.
Deliberate self-harm is a term used to describe an act in which an individ
ual deliberately causes injury or harm to themselves, without the intent to
commit suicide. This may be in the form of cutting, or ingesting substances
in non-lethal doses.
Where doctors globally have a lower mortality rate from cancer and heart
disease relative to the general population, they sadly have a significantly
higher risk of dying from suicide [3]. In fact, according to a survey in 2015,
doctors are the most professionals to commit suicide, followed closely by
dentists. The leading cause of this is the prevalence of depression in med
ical students and postgraduate trainees. Completed suicide is also more
prevalent amongst medical professionals partialLy because of availability
and access to lethal means. Medical students and trainees are at particular
risk because they are unlikely to report a history of depression. Sadly. even
when it is reported, it may be neglected. This is due to myth that people
who ctaim to be having suicidal ideas are not likely to commit suicide. The
truth is 67% of individuals who committed suicide had confessed to some
one that they wanted to kill themselves. The famous Urdu saying o garajte
ham wo baraste nahi’ is untrue when it comes to a risk assessment of sui
cide. Any suicidal ideation being reported should, therefore, immediately
be considered as serious and requiring intervention. A detailed suicide risk
assessment must be carried out in all such cases. ‘The biggest risk of sui
cide is a direct statement of intent” [41 . These statements should never be
ignored, or responded to with statements of how the person is just looking
for attention” or ‘doesn’t reatly mean it.”](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-193-320.jpg)
![Protective factors of suicide
Sane. ofconnectadneas
Having Chfl*.n
Good health
flestrictad Access to means
• U&. gender
• Early adufrage
• Psychological/emotional
problems
• P,dcal health problems
•Stranful I wants
• Major Depression
•4polerAfbctlveDbuitler
• Subetanc.abus. plenrd.r
• Antioclal Personality
Dlsord.r
• HLstoryofpsychlattlccare
• Previous 5ulcldai
b.hauiow
•Slngh
• Separated
• Family conflicts
• History oFchUdhood abuse
•Family history ofsuicide .
r
g. DeLirium
Delirium, also referred to as acute confusional state, refers to an acute de
dine in consciousness, cognition and attention. There is an incidence of up
to 55% in medicat and surgical inpatients 12].
Presenting Complaints
Families rather than the patient may request help because the patient is
often in a state of confusion or agitation. Delirium may commonly occur in
patients who are hospitalised for medical conditions, particularly in inten
sive care units and acute surgical units.
Diagnostic Features
Delirium is characterised by its sudden onset of hours or days. Confusion
is often present and patient struggles to understand surroundings. The
following neuropsychiatric symptoms are common:
Individualised Family Related Social Environmental
Risk Factors Risk Factors Risk Factors Risk Factors
• Socioeconomic .. Easy access to methods
disadvantage • cuturaisuppcttersuicisie
• Migrant population M.dio
UflernpbYrneflt Suicide among peers
•Soc
• Clouding of consciousness
• Poor memory,
• Agitation,
• Changi ng/ftuctuating emotions,
• Loss of orientation,](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-194-320.jpg)
![Masturbation
No other form ofsexual activity has been more frequently discussed, more
roundly condemned, and more universally practiced than masturbation.
- Kaplan and Saddock, Synopsis of Psychiatry
Masturbation refers to the physical stimulation of genitalia by oneself for
sexuat pteasure. This is a normal part of psychosexual devetopment. It is
an activity shrouded in shame and mystery despite the fact that nearly
all post-pubescent males and up to three fourths of females indutge in it
(Kinsey).
Children become aware of their genitaliajust as they become aware of
their other body parts. Upon reaching puberty. however, due to the in
crease in sex hormones and development of secondary sexual characteris
tics, masturbation may become a regular activity.
Myths and misconceptions such as “masturbation may result in loss of
sexual prowess and potency” and “masturbation can cause mental illness”
or “masturbation may result in a loss of manhood and mate virility” abound,
especially in our culture. There is no scientific evidence to support these
claims. Masturbation is a symptom of an emotional disturbance (not a
sexual one) only if it results in the individual losing control and
compulsively indulging in it ho].
SexuaL orientation
According to the American Psychological Association, sexual orientation
refers to the sex of those to whom one is sexuatly and romanticatl.y attract-
ed. For the majority of the population (according to census data worldwide)
sexuat orientation is heterosexual i.e. individuals are attracted to the oppo
site sex. Statistics suggest that about 1-5% of the population of the world
has different sexual orientations. This number may be understated, how
ever, given government and religious taws banning homosexuality in most
parts of the world. This may be homosexual, i.e attraction to the same sex,
bisexual, i.e attraction to both genders and asexual, i.e no sexual attrac
tion. Another subset of individuals exists, who feel that sexuality cannot
be labelled. These individuals refer to themselves as “queer” or pansexual
or polysexual. Some research indicates that for some individuals, sexual
orientation may be fluid. This may be especiatly true for women (e.g.. Dia
mond, 2007; Golden, 1987; Peptau & Garnets, 2000),
As of July 2015, 72 countries and five sub-nationaljurisdictions have laws
criminaUzing homosexuality. A majority of these countries, inctuding Paki
stan are in Asia and Africa.
According to Darwin, natural selection dictates that any variations that
occur have to be ‘useful to man’ i.e. they must aid in an organism’s struggle
for survival and procreation. Homosexuality defies laws of natural selection
by preventing procreation due to same-sex sexual behaviour. Despite this,
it remains a stable population level trait in humans and animals, resulting in
a so-catted Darwinian “paradox.” Evolutionary models propose that genes
influencing homosexuality have a reproductive benefit on heterosexual
carriers of the gene 121. This may be the reason that homosexuality
continues to persist.](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-200-320.jpg)
![In 2006, a study found that human sexual preference has a significant ge
netic component. [41. It was also seen that biological and congenital factors
regulate human sexuatity 13]. These findings were corroborated in a study
2015, in which a Large scate genome-wide scan resulted in findings that
support the existence of genes on chromosome 8 and Xq28 influencing the
development of mate sexual orientation. ti] . Another study found linkage
between male sexual orientation and markers on the X chromosome of the
mother in some famities. The study found that the X chromosome played
a role in regutating sexuat orientation in a subgroup of homosexual males
[41. Some studies indicate females with hyperadrenocorticalism are more
likely to be homosexual as welt as bisexual than the general population.
Research in this field has been, for the most part, inconclusive. This may he
due to the tack of definitive samples, the abstract concept of attraction or
the taboo associated with nonheterosexuality. Continued research efforts
are required to enhance understanding of the genetics factors affecting
human sexuality.
Psychiatric morbidity
Research shows that non-heterosexual individuals are more likely to suffer
from poor general health [71. They are also twice as Likely to suffer from
depression, panic disorder, generatised anxiety disorder and have a higher
risk of suicide [51181. This is especially true for younger adults [6]. They also
have significantly higher rates of alcohol dependency and drug abuse Ig].
One factor in this is of course, the societal pressures and religious taboo
associated with non-heterosexuality. Due to this taboo, such individuals
may often present to a health professional with medically unexplained
symptoms, and/or severe depression and anxiety.
Sexuat Disorders
According to the International Classification of Disease, Tenth Edition, sex
ual disorders encompass three categories: sexual dysfunction (not caused
by organic disorders), disorders of sexual preference (paraphilias) and
gender identity disorders (gender dysphoria).
These are of importance due to the higher number of psychiatric morbid
ities associated with them. These individuals are more likely to suffer from
anxiety, depression and somatoform disorders. They also have higher risks
of suicide and deliberate self-harm. Often the clinical presentation may he
that of persistent headache, backache, abdominal discomfort. and gener
alised aches and pains. Low mood and other depressive features,
especially guilt and severe anxiety may he present.
SexuaL Dysfunction
Sexual dysfunction occurs when there is inability, difficulty or pain involving
sexual intercourse. This includes disorders such as those described in the
table above, The presence of any sexual dysfunction is a difficult situation for
not just the individual but also the sexual partner. In cases where the dys
function is severe enough to not allow for consummation of the marriage or
lead to reproductive problems. the entire family may become involved. This
can be a source for great discomfort for the individual. This is especially true
for males as they are expected to be ‘more informed’ in the sexual act and
all its nuances), even if they have no prior experience. Also in males, sexual
prowess or lack thereof, is closely connected to their self-esteem.](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-201-320.jpg)
![References
1. Sanders AR, Martin ER, Beecham GW, Guo 5, Dawood K, Rieger G, Bad
nerJA, Gershon ES, Krishnappa RS, Kolundza AS, Duan]. Genome-wide
scan demonstrates significant linkage for male sexual orientation.
Psychotogicat medicine. 2015 May 1:45(07):1379-88.
2. Burn A, SpectorT, Rahman Q. Common genetic factors among sexual
orientation, gender nonconformity, and number of sex partners in female
twins: ImpLications for the evolution of homosexuality. The journal of sexual
medicine. 2015 Apr 1;12(4):1004-11.
3. Jannini EA, Burn A, Jern P. and Nove[ti G. Genetics of human sexual be
havior: Where we are, where we are going. Sex Med Rev 2015;3:65-77.
4, Bocktandt S, Horvath 5, Vilain E, Hamer DH. Extreme skewing of X chro
mosome inactivation in mothers of homosexual men. Human Genetics.
2006 Feb 1:118(6):691-4.
5. Prajapati AC, Parikh S, Bala DV. A study of mental heatth status of men
who have sex with men in Ahmedabad city. Indian journal of psychiatry.
2014 Apr:56(2161.
6. Bränström R, Pachankis JE. Hatzenbuehler ML. Sexual orientation differ-
ences in mentaL health morbidity: A population-based longitudinal study.
The European Journal of Public Health. 2015 Oct 1:25(suppl 3):ckVl74-062,
7. Fredriksen-Gotdsen KI, Emlet CA, Kim HJ, Muraco A, Erosheva EA, Gold-
sen J, Hoy-Ellis CP. The physical and mental health of lesbian, gay male,
and bisexuat (LGB) o[der adults: The rote of key health indicators and risk
and protective factors. The Gerontologist. 2013 Aug 1:53(4):664-75.
8. Cochran SD, Sullivan JG, Mays VM. Prevalence of mental disorders,
psychological distress, and mental health services use among lesbian, gay,
and bisexual adults in the United States. Journal of consulting and clinical
psychology. 2003 Feb;71t1):53.
9. Cochran SD, Mays VM. Relation between psychiatric syndromes and
behavioraLly defined sexual orientation in a sample of the US, population.
American Journat of Epidemiology. 2000b;151:516-523. [PMC tree artictel
tPubMedl
io. Kaplan and Saddock Synopsis of Psychiatry, Eleventh Edition, page 570.
V](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-205-320.jpg)
![trauma “esults from anything that disrupts a chitds sense of safety and
security. This can include an unsafe environment, separation from a parent
or a sei Quo iLlness. Developmental trauma is most severe when it involves
betraya or harm at the hands of a cai’egiver. This trauma has a negative
impact on a childs physical, emotional and social development. Children
who have been traumatised see the world as a dangerous and frightening
place. When childhood trauma is i ot resolved, this sense of fear and help
tessness can carry over into adulthood, setting the stage for further trauma.
Normal responses to traumatic events
It is important to distinguish between normal reactions to traumatic events
and symptoms of a more serious and persistent problem Following a
traumatic event, most people experience a variety of emotions, including
shock, fear, anger and reLief to be alive. Often they think or talk of nothing
else except what they went through. Many others feei]umpy, detached or
depressed. Such reactions are neither a sign of weakness nor a positive
indicator of lasting trouble. They represent a normal response to an
abnormal event.
These feelings and symptoms typically last from a few days to a few
months gradually fading as one processes the trauma. Recovering from
trauma takes time and everyone heats at his or her own pace. However if
despite passage of months, the symptoms show no sign of letting up, a
person may be experiencing emotional or psychological trauma.
Professionat help is required if a person has:
Problems at home or work
• Living with persistent fear and anxiety
• Haunted by overwhelming memories or emotions
• Avoiding more and more things that reminds one of trauma
Posttraumatic Stress Disorder
Posttraumatic Stress Disorder tPTSD) is a condition that results from the
most severe kind of trauma. It is characterised by intrusive memories.
flashbacks or nightmares, avoiding things that remind one of the traumatic
event and living in a constant state of red alert, also known as
hyperarousal.
Common reactions to trauma
Guilt and wff-blarne
Mood swings nd lrtftablIftr
Dlstr.sslng memories
Social withdrawal
Feeling sad](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-217-320.jpg)
![Chapter]3
Stress and its Management
Definition
Hans Setye introduced the concept of stress into physiology from phys
ics, where it generally refers to a force acting against some resistance.
He defined stress as “the rate of wear and tear in the body” and “the state
manifested by a specific syndrome which consists of all the non-specifical
ly induced changes within a biological system.” In this General adaptation
syndrome (GAS), glucocotticoids are secreted by the adrenal cortex in re
sponse to adaptation demands placed on the organism by such disparate
stressors as heat, cold, starvation, and other environmental insult. Any such
stimulus to the body results in certain physiological changes in the body
which are cumulatively termed as stress (Lazarus; 1984). Stressors are the
environmental sources of threat to an organism, while stress is what occurs
as a result of this. Richard Lazarus emphasised the potential threat of life
events in causing stress.
Individuals have a personal view of their stress, based on their perception
of the event, past experiences, strengths. biographical assets and social
support. Other factors which influence the outcome of stress upon an
individual include race, gender. age, marital status, socioeconomic sta
tus and early developmental experiences. For example, black people are
more prone to develop hypertension than Caucasians. Females tend to
live tonger and recover quicker from illness than males. They also show
less physiological reactivity to stress as compared to males. The elderly
are more vulnerable to all kinds of stressors. The general observation that
work capacity decreases by 1% every year after 21 years of age, provides
evidence that people.who continue to work with same routines beyond 50
years tend to have higher incidence of coronary heart disease. Marriage
is considered a protective factor against stress and most illnesses in both
genders. Educational and economic attainments provide more resilience
against stress. Early parental loss, quality of love and care received in early
life years and children’s early exposure to socializations shape the re
sponse of people to different types of stress.
Stress is conventionally divided into two types based on the causative
factors:
Physiological stress caused by temperature. noise, hunger, disease, smok
ing, drinking and similar habits are considered generalised life stressors
affecting most people.
Psychosocial stress caused by psychological factors such as low self-es
teem, social factors such as life events (see table), job stability, career satis
faction, economic viability. marriage, children, relationships etc.
Stressors bring about a physiological change in the body of a person.
Some stressors produce impacts in a short span of time; such as loss of
parents orjob. Others, such as distressed relationships or care of a
disabled person in the house, inftuence the person gradually over a period
of time. Individual and situational variables mediate the relationship
between life change and illness.](https://image.slidesharecdn.com/behavioral-sciences-dr-mowadatrana1-240518055311-07f33cb4/85/Behavioral-sciences-dr-mowadat-rana-1-pdf-225-320.jpg)
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- 1. CONTENTS Section A .1 Introduction to Behavioural Sciences 1 Holistic vs. Traditional Allopathic Medicine 2 Health Care Models and their Clinical Applications 3 1. Bio-Psycho-Social (BPS) model of health and disease 3 2. The Integrated ModeL of Health Care: Correlation of Body, Brain, Mind, Spirit and Behavioural Sciences 5 3. The Public Health Care Model g Non-pharmacologicaL Interventions (NPIs) in Clinical Practice 11 1. Communication Skills 11 2 Counselling 14 3. Informational Care (IC) 16 . Handling Difficult Patients and their Families i8 5. Breaking Bad News 20 6. Crisis Intervention and Disaster Management 27 7. Confticl. Resolution 29 Empathy 32 Sample MCQs and Essay Questions 33 Section B 35 Medical Ethics and Professionatism 36 Relevance of Ethics in the Life of a Doctor 37 ;. Scope and Meaning of Medical Ethics 37 2. Guiding Principles of Medical Ethics 38 3. Common Ethical Issues in Medical Practice 39 4. Common Ethical Dilemmas in a Health Professonat’s Life 43 . Doctor-Patient Relationship 48 Rights and Responsibilities of Patients and Doctors 49 a. Rights of the Patient 49 b. Responsibilities of the Patients 50 c. Rights cf the Doctor 50 d. esponsibilities of the Doctor 50
- 2. Psychological Reactions inDoctor-Patient Relationship 52 a. Social bonding 52 b. Dependence 53 c. Transference 53 U. Counter-transference 54 e. Resistance 55 f, Unwell Physician / Burn-out 56 Professionalism in Heatth Care 57 - a. Knowledge 57 b.Skills 57 c. Attitudes 58 Sampte MCQs and Essay Questions 61 Section C 63 Psychotogy in Medicat Practice 63 a. Role of psychologicaL factors in the aetiology of health probLems 63 b. Role of psychological factors in the precipitation (triggering) of iltnesse 63 c. Role of psychological factors in the management of illnesses 64 U. Role of psychological and social factors in diseases causing disability. handicap and stigma 64 e. Role of psychological factors in patients reactions to illness 64 f. Medicat[y Unexplained Physical Symptoms (MUPS) 64 Principles of Psychology 65 1. Learning 65 2. Metacognition 72 3. Memory 74 4. Perception 81 5. Thinking 85 6. Emotions 92 7. Motivation 94 8. Intelligence 97 9. Personality Development 101 NeurobiologicaL Basis of Behaviour 108 Emotion 109 Language 114
- 3. Memory . 116 ArousaL. 117 Sleep 118 Sample MCQs and Essay Questions 123 Section D 125 Socio[ogy and Anthropology 125 Introduction 125 1. Sociology and Health 127 2. Anthropology and Health 135 Sample MCQs and Essay Questions 141 Section E 143 Psychosociat Aspects of Health and Disease 143 Health and NormaLity 143 Defence Mechanisms 145 Psychosocial Assessment in Health Care 14$ ClinicaL Situations Demanding a Comprehensive PsychosociaL Assessmer 148 Psychological reactions to IlLness and Hospitalization 149 Psychosociat Assessment ... 153 Psychosocial Issues in SpeciaL Hospital Settings 157 a. Coronary Care Unit 157 b. Intensive Care Unit 158 c. The Emergency Department 159 d. Psychosocial Aspects of Organ Transplantation 159 e. The Dialysis Unit i6o f. Reproductive Health 161 g. Paediatrics Ward 163 h. Oncology 167 i. Operating Theatre 168 PsychosociaL Peculiarities of Dentistry 170 PsychosociaL Aspects of Atternative Medicine 174 Common Psychiatric Disorders in General Health Settings 175
- 4. a. Mixed Anxietyand Depression in b. Panic Disorder 179 c. Unexplained Somatic Complaints: Persistent Complainers 181 d. Dissociative and Possession States 182 e. Drug Abuse, ALcohol & Tobacco Use 184 f. Suicide and Deliberate SeLf harm (DSH) 188 g. Delirium 189 PsychosociaL Aspects of Gender and SexuaLity 192 Sexual Identity 192 Gender Identity 193 Sexual Behaviour 194 Gender differences in Sexual Behaviour 194 Masturbation 195 Sexual orientation 195 Psychiatric morbidity ig6 SexuaL Disorders 196 SexuaL Dysfunction 196 Disorders of SexuaL Preterence/ Paraphilias 197 Gender Dysphoria (DSM V) or Gender Identity Disorder (lCD io) 198 Management of Gender and Sexuality Issues 199 PsychosociaL Aspects of Pain 201 Psychosocial. Aspects of Aging 207 Psychosocial. Aspects of Death and Dying 210 Psychotrauma 211 Psychosocial Aspects of Terrorism 214 Stress and its Management 220 Job-related Stress & Burnout 222 Response to stress 222 Stress Management 225 Sample MCQs and Essay Questions 228 Appendix 230 Suggested Reading 232
- 5.
- 6. hitroduction to Behavioura’Sciences As the name implies, behavioural sciences deal with the study of human behaviour through an integrated knowledge of psychology. neuroscience, sociology and anthropology. It is now widely recognised that the psychological and social sciences play a role equal to biotogical sciences in determining states of health and disease. Amongst the behavioural sciences, psychology and neuroscience contribute to the study of the human mind and the roLes played by its various functions. They examine the role of functions such as emotions. thoughts, cognitions. motivations, perceptions, and intelligence in maintaining health or causing disease. Psychology also seeks to understand how the development of personality takes place. Another major influence on human behaviour is the role ptayed by the family, the society and the community. The study of sociology helps a doctor understand the influence of society and its various units and institutions on the processes of heaLth and how they can change to cause disease. The role of family. gender issues, social classes, socioeconomic circumstances, housing, employment, social supports and social policies in maintaining health or causing disease is studied in this domain. Medical anthropology is the study of the effects of the evolutionary history of human beings. It highlights their cultural history, racial classification, geographic distribution of human races, and effects on health and signs and symptoms of disease. It also involves the study of cultural methods of deating with diseases and other distressing events of human life. What disease is to be stigmatised, which symptom is to be kept secret, what is to be handed over to the doctors and what is to be dealt with by the faith healers is determined largely by anthropological influences on a culture. Understanding the health belief model, attitudes of a society and the rote culture assigns to a sick person can highlight the importance of anthropology for a health professionaL F ECTIONA èhaviourai Sciences and their Relevance to Healthcare — OUTLINE Introduction to Behavioural Sciences Holistic vs. Traditional Medicine Models of Health Care Non-pharmacological Interventions A The behavioural sciences add to the disciplines of anatomy, physiology, and biochemistry to support the study of holistic medicine.
- 7. t Chapter 1 Holistic vs.Traditional Allopathic Medicine Holistic medicine is inspired from the theory of Holism, which states that reality (including all living matter) is made up of unified wholes that are greater than the sum of their parts. Each sub-part is linked with the other in a dynamic way. Holistic medicine considers mind, body and spirit sub-parts that form the person; a whole that is greater than the sum of its parts. It denies the separation of mind and body advocated in traditional atlopathic medicine. Traditional allopathic medicine works on a biomedical model that aims to treat the diseased part of the human being. Holistic medicine on the other hand is committed to the restoration of health and wellness to the person as a whole, rather than focusing on the diseased part alone. A health professional committed to holistic medicine is expected to understand the following elements of this approach: Person, Environment, Health and Physician. Person: A human being who has the well-integrated etements of mind, body and spirit held in a dynamic balance. Environment: A set of external forces that can inftuence our experience of health and disease such as family, community, culture, socioeconomic resources, access to health care and quality of heaLth care. These external factors help shape our attitudes and health beliefs, Attitudes and beliefs that we learn from our environment have the capacity to either support or disrupt the dynamic balance of our mind, body and spirit. TraditionalADopathic Medicine methodology: Ju5t x the pmbLem Artist Laura Zomhie HeaLth: A dynamic state of well-being achieved through a mind-body-spirit balance that hetps an individual realise their full potential. While the former three teach about the body, psychotogy and neuroscience educate the physician about the mind, sociology and anthropology illustrate the evolution of human spirit and the factors that constantly inftuence it. T I.: Physician: A person who supports health (as defined above) rather than one who merety treats disease. A practitioner of holistic medicine, therefore, believes that health results from a dynamic and interactive reLationship between the person, his environment and the physician. 4
- 8. Holistic medicine demandsthat a physician must be a person who has the following characteristics: • BeLief in the potential of the heating act • Capacity to listen and empathise Respect for the dignity of human beings • Tolerance for difference of opinion 4’ • A gentte spirit • Ability to mix creative thinking and intuition with scientific thought • Will to never give up hope even against heavy odds The knowledge of physical sciences and anatomy, physiology, and biochemistry provide adequate basis for the practice of traditional allopathic medicine. The practice of holistic medicine, however, demands the knowledge of behavioural sciences as welt as natural sciences. Chapter 2 Health Care Models and their Clinical Applications ;. Bio-Psycho-Sociat (BPS) modeL of heatth and disease In 1977, George Enget theorised the importance of integrating the traditional biological (pathophysiological or structural) aspects of medicine with the behavioural sciences (psychology, sociology and anthropology). He put forward the concept of the Bio-Psycho-Sociat (BPS) perspective of health and disease. Engels BPS model was based on three principles: a) Disease is a result of multiple factors that interact to make an individual feel ilL Illness and disease are not a consequence of biologicaL factors alone. b) An individual is composed of a complex, integrated system composed of interacting subsystem elements of mind, body, spirit and social relationships, alt having feedback loops. Any change in one will result to changes in other systems. c) Biological, psychological, and social factors form a triad to interact and serve as determinants of disease. BIOLOGICAL Biopsychosociat Modet
- 9. He proposed thatthe biological, psychological and social systems work together to cause disease. The biological system ensures a structural, biochemical and a molecutar study of a disease. The psychological system provides insight into the role of personality, attitudes, attributes and motivation in the genesis of the illness. The social system emphasises the impact of family, society, social forces and culture on the aetiotogy, presentation and the management of a given illness. The biopsychosocial model stresses that understanding and manipulation of the psychosocial environment of a patient is just as important to recovery as the study of pathophysiological processes and methods of treatment. Engel proposed that death of a significant other, grief, loss of self-esteem, a threat to one’s life, property or integrity, even victories and reunions were events that can trigger a medical, surgical or a psychiatric condition. The biopsychosocial model, therefore, provides a comprehensive clinical approach towards the practice of holistic medicine. This approach lays great emphasis on the doctor-patient relationship. This involves psychosociat assessment, the use of communication skills, infor mational care, counselling crisis intervention and extension of care to the family. One of the significant contributions of the BPS model in health care is the emphasis it assigns to the use of interventions that do not involve surgery or drus: the non-pharmacological interventions. Ctinicat AppLication of BPS Model It is useful for a health professional committed to holistic medicine to approach patients using the BPS model. Research shows that biomedical and behavioural factors come into play in infectious as well as non-infec tious disordets. A patient of dengue fever is suffering at a biological level on account c breakdown of the body’s reticuloendotheLial system. Social issues related to drainage of fresh water, poor disposal of waste, however, are also contributing factors. Psychological and anthropologicalfactors such as risk taking behavior and inappropriate dressing in high risk settings are equally important in the spread of this infectious disease. Sexually transmitted diseases, HIV-AIDS, and hepatitis epidemics may atl occur due to risk taking behavior and poor protection strategies. Non-infectious disorders ar- also affected by biopsychosocial factors. This includes heart disease, di&’• tes mellitus, cancer, and depression. This is because changes n hormones, immune factors, metabolism and neurotransmitters re alt associated with socioeconomic stressors. Occupational hazards, dietary habits, child rearing practices, personality development, exposure to childhood trauma are alt governed by culture and geography. Many metabolic disorders are now called ‘life-style disorders’ due to the socio-cultural and psychological factors that work hand in hand with biological factors. Another example of the BPS model determining disease is seen in road traffic accidents due to drug and alcohol abuse.
- 10. ‘U - college togetherHamid decidedto stayin the hostel ashe belonged to a dtstant village while Hassanpreferred to cometo cottege ftam home eveiy day Soon the stress ofmedical studies started to mount Hatndpraposed that theyshould trysmoking a cigarette to qchieve ‘betterconcent,r%ion white studying Hassan readily agreed and they both started to iridutge ip smoking white studying togetherin the evenings. Hamidsoon developed a cough, but continued to smoke HassdAsparet7tsfound out and discussed the dangerous consequences ofhis habit Hassan opted out ofsmoking, joined a gym andstarted to exercise regularly He consulted his behavioural sciencesteacher to learn some innovative methods oftudyIng and techniques to give up smoking This helped him feel healthier and conceritmte befterin his studies He tned to convince Hamid tojoin him in these newly learnt techniques btHamtd did not Usten Within ayear Hamid went on to startuseofcannabis and a few months laterbecame addicted to a stimuLantMsgiades as welt as his physicat health detenoratedand he failed his annual exams. He started to develop repeated episodes ofchest infections Repeated absence fann classes and poorperfoiwance in the academics ted to his eventuat wfthdrawat from medicat college, while Hassan went on to’continue his medicqt studies enjoying goodfi7ysicathealth. The story of Hamid and Hasan illustrates an interplay of bioLogicaL psychologicaL and social factors resulting in contrasting outcomes on account of the differences between the two friends in these domains. The story highlights how homeostatic mechanisms failed Hamid. On the other hand, restorative and predictive atlostatic behavior (discussed below) such as parental concern, joining a gym and counselling by the behavioural sciences teacher helped Hasan overcome a stress they both shared. The outcome of disease in Hamid and health in Hasan was decided by an integrative interplay of all three domains, Social support and allostatic mechanisms were in place for Hasan, but none of these were avaiLable for Hamid. Hasan managed to effectively turn the stress of studies into eustress, He was, thus, able to achieve a better state of heaLth. a The Integrated ModeL of HeaLth Care: CorreLation of Body, Grain, Mind, Spirit and BehaviouraL Sciences The integrated model of health care is a step ahead of the biopsychosocial modeL It suggests a dynamic functional link between five domains of human beings: biological, cognitive, behavioural, sociocu[tural, and environmental. In this model, health is a state of a harmonious equilibrium between these domains which occurs in response to eustress or distress. This state is achieved through processes called homeostasis and attostasis. ‘1 p Homeostasis is a reactive state that ensures harmony within the body systems through adaptive negative feedback loops. It also uses reactive behavioural adjustments in domains operating outside the body.
- 11. -* BEHAViOURAl. Integrated Modet ofHeatth Care Attostasis is an adaptive mechanism in which the individual makes the adaptations by predicting changes in advance, rather than in reaction. These adaptations are creative and organised multisystem changes made in anticipation of a possible challenge to health. A typical example of homeostasis is the increased intake of fluids and salts while working on a hot summer day. Allostasis on the other hand would be to organise your work schedule in advance to be undertaken at the time of the day when it is Least hot, so that you may not need the extra salt and fluids. In the Integrated Model, an optimum degree of stress called Eustress is considered appropriate and necessary for a person to function and stay healthy. Eustress is seen as moderate, motivating and inspiring. It ensures optimum functioning of homeostatic and atlostatic mechanisms that keep alt five domains (biological, cognitive, behavioural, socioculturat, and environmental) working in synergy. SOCIO- ENVIRON cucll.rnAL MENTAl. Distress is a state in which the homeostatic and atlostatic mechanisms of biological, behavioural, cognitive, environmental and sociocultural domains are challenged by extrinsic or intrinsic factors. Challenge to any one domain influences alL the other domains and sets up a restorative feedback loop. If the systems respond with effective homeostatic and allostatic responses health is restored. If the stressor worsens to result in distress, a failure of homeostatic and allostatic mechanisms resuLts in disease and illness. Clinical Application of Integrated Heatth Care Model Separating Disease from Sickness, Distress and Stress Alt patients who develop symptoms and report to hospitals are not suffering from disease. The body and mind respond to any disturbance in biological, sociaL cognitive, behavioural and environmental domains through unpleasant experiences which can be called symptoms. Most of the time, symptoms serve as a stimulus for adaptive mechanisms and homeostasis is restored through changes in the body, mind, social support and environmental manipulation. Not all individuals reporting to hospitals are, therefore, ‘patients’ in the biomedical sense. They may not require
- 12. Distress: This isthe earliest unpteasant departure from a state of happiness and health. This state appears when homeostatic and allostatic mechanisms in the body and mind are challenged by stress. This sets into motion immediate restorative mechanisms in the body in order to attain a feeling of health through physiologicat means. No structural or psychologicat damage takes place at the level of the body and mind. Changes are visible, however, in the individuaL’s behaviour and social roles as functioning of the individual may be affected. S/he can readity return to normal following the restoration of homeostasis without any biological interventions in the form of medication or surgery. Minor environmental manipulation, mobilisation of social support and adjustments in cognitive and behavioural domains may be all that is required. Distressful states may present with the same symptoms as that of a disease. Common distress symptoms include headache, backache, vague bodily discomforts, feelings of indigestion, heaviness in abdomen, lack of sleep, appetite, lethargy, fatigue. weakness, dizziness and Light headedness. Individuals may also experience an urge to remain silent, avoid responsibility at home or work and have a general feeling of inability to cope. These feelings in a state of distress usually last for a few hours, or a day or two, but never beyond a week in one go. They are self-limiting, and improve with pleasant occurrences such as meeting friends, sharing feelings, indulging in a hobby orjoyful pursuit or even a couple of paracetamot tablets. PERFORMANCE RELAXED A INACTIVE ANGER/FRUSTRATION/ PANIC FATIGUE EXHAUSTION - I. EUSTRESS STRESS BURNOUT OVERLOAD STRESS Stress-Performance (Yerkes-Dodson) curve laboratory and radiological tests or treatment with medication. It is, thus, important to separate disease from distress, sickness and iltness. STRESS UNDERLOAD FAILUREI ‘,, BREAKDOWN Sickness: The state of distress can sometimes give way to or be replaced by a feeting of being sick’ or unwell, or nauseous. This unpleasant state can appear without any disease or any pathological change. On the other hand one may have a disease and not appear to feel sick at all (as in the case of some diseases in early stages, like cancer).
- 13. Sick Rote: Thisis a state that an individual may assume at home or in office settings to show his inability to perform his routine roles or duties. This role may succeed in freeing the individual from their routine duties. S/he is expected to seek medical help and follow the advice of his well-wisher. If they do not do so, they may be seen as a malingerer. Malingering is a derogatory term used to describe a frauduLent sick role that an individual assumes to avoid responsibitity or gain a social or a financial advantage. A competent doctor is hesitant to jump to this ‘diagnosis’ and always seeks a more experienced colleague’s opinion before labelling a patient as a ‘malingerer’. Many patients who are seen initiatly to be feigning an illness have been known to develop the same or some other serious disease, Ittness: is an overall view that an individual, the family and the society take of a person who is feeling sick or unwell. The explanation that each has of the sickness decides the course of actions and health care plan that wilt follow. If the family and the community have no obvious or known explanation of the symptoms experienced by the sick individual, the likelihood of a medical consultation is rare. The patient wilt, instead, be taken to a spiritual healer, an aamil, or a charlatan. This is especially true of patients suffering from psychiatric disorders, epilepsy, and many behavioural disorders. Most patients suffering from anxiety and depressive disorders experience physical symptoms for which they prefer to undergo tab tests and consultations with physicians and neurologists rather than psychiatrists. Disease: The diagnosis of disease is made when the symptoms of an individual are attributed to a cause or aetiology. This can be in the form of injury, an organism, a substance, a pathological or structural change or a defect leading to changes in functioning in biologicat, behavioural, and social spheres. These factors are severe enough to not only challenge but disrupt and even destroy homeostatic and allostatic mechanisms. They have the capacity to change the restorative negative physiological loops in the body so that pathological processes begin to worsen the state of the individual, instead of initiating repair and equilibrium. In a diseased state, it is assumed that a reversaL of the causative pathoLogy would result in heal ing of the disease. Typical examples would be enteric fever, a fracture, or insulin dependent diabetes mellitus, Here, a complete return to health and reversal of disease is guaranteed through a medicat or surgical intervention. It is important for health professionals to note that all of the above states may or may not co-exist in the same patient at a given point in time. A person may feel distressed and sick without any disease. S/he may move around performing routine roles and duties even while harbouring a serious disease. WelL trained health professionals, clear about distress, sickness and disease should not call for unnecessary lab and radiological tests, They should also not prescribe ptacebos in the form of pain killers, muttivitamins, intravenous drips, ‘brain tonics’ and ‘high energy pills’ to individuals who report to hospitals in a state of distress. All medical and surgical interventions are, thus, only to be used once the diagnosis of a disease has been made. I
- 14. I Integrated Model ofHeaLth Care Cilnicat Scenario Mr Xis aiar oLdcterkk the tnxatianoffica HepresenL5 to the physician with increased thirstand appetite toss ofsexualfeetings al?d weightgain. His Ibstiog bLoQd UgatwaSfeufltb3OO mg/dL He has a (omityhistory ofdibete& He is nqsedas Iiawng Type II Diabetes MeUitus The treat ment armsare maintenance ofasgar- dIeL j%xstrng blood glucose levels j or infections He isp1aced on.z gram ofmetlbnntn/day Hers ciskedto have F tyhome ‘. meats waik to his offIce in the mornings andtakea3 km walk with dieirithe averii# Biotogis.trzsulin istc dIstUrbedarbohydratemetaboLisnz encfzctors Magee,tMetfi2rmii7. Thishelped in ave gtheb7sutin ies&dnce andknpxove the carbohrate metqkoffstn 8ebavawoiiPeferencef&h Ca esugarithfaO asedentary tifestyte shssft(jØband unhappy mari&Life. ManngenentAttreversed with a change inea& habits. shaitbursts of pIcaLe’re dLiring working hours andin7pioved interaction with hIs wife dJrinre9uIarevenfrg walks CDislk..frpersonai physiqueand thoughts ofgrowing oLd, overweight and ugly. rnaritatstress anda satIsed maritaLlife Management Information andunderstandingrofhazards ofovereating ond .entanj Lifestyle, and cQmrnitment toa healthierway ofthinking about self future, his fqrnily and his work! in generaL sociocuLturaLjactoxs Clerks in such oie regularly receive sweets and unheatthy food and eat unhealthy high calQrle and carbohydrate nchfood a the office canteen, cuture ofworking long hOurs Enviro)metaLfactois Colleagues wiihsfmllar unhealthyeating hat’its and lifestyles Availability ofunhealthy food at the canteen absence ofopportuni ties for exerciseand tack ofaccess tohealthyfood Minorchonges in lifestyte t work and home reversed the environnentatkl&1ence, Management Mr X’s refusot to accept swAts bip lunch from home,. simple physical exercises during ofñcehours for5 to 10 minutes insteadof constantty sitting on the choir alt helped in improving the culture in the office and other workers soon started to copy Mr. X 3. The PubLic HeaLth Care Modet Treatment at Primary Care Levet, Prevention of ILlness, Promotion and Protection of Health Hospital based health care models work primarily to emphasise treatment of disease, This kind of health care approach is one of damage control Public health care models on the other hand, work not only to treat disease but also to prevent it. The World Health Organisation (WHO), a premier stakeho[der in the field of li .4 heatth care, promotes a public health care approach in addition to hospital
- 15. based care. Thismodel is committed to treatment of common diseas es and basic health issues through primary health care centres. Primary heatth care centres are estabLished at the grassroot level, where the maximum rural, and semi-urban population resides. In Pakistan these are called Basic Health Units (BHU), and Rural Health Centres (RHCs). These Centres work towards prevention of illness and promotion and protection of health by working with the community in the delivery of heaLth care. The strategies in place include immunization campaigns, mother and child health programmes, reproductive health, HIV-AIDS programmes, nationaL programme of mental heaLth, narcotics control, antimaLarial and dengue controL programmes. These run in collaboration with national and international governmental and non-governmentaL organisations. Health legislations on smoking, healthy diets, seat belts, helmets, safe sex, population welfare, and reduction in mentaL health gap are some of the initiatives undertaken to achieve the promotion of health. SUMMARY KnowLedge, skills and attitudes rooted in Behavioural Sciences are an essential component of alt the models of health care currently in practice. A comprehensive understanding of psychology, sociology and anthropology as well as biological determinants of health and disease is cruciaL for the practice of scientiIc medicine. The traditional biomedical model of reversing biological causes of disease has proven to be inadequate. An integrated model of health care in which the psychosocial, cognitive, behaviouraL and environmental stressors are considered as important as biological causes of disease is the future of modern medicine. This approach aims at restoration of homeostasis, and stress reduction to optimise functioning. It also helps attain equilibrium between the internal and external world through allostatic processes. Interventions that go beyond medication and surgery to include non-pharmacological measures heLp achieve health in a far more effective and lasting way. This includes measures such as mobilising social support, influencing existing health belief modeLs, ensuring a healthy and safe environment, providing informational care, conflict resolution and early handling of psychotrauma. A public health approach of primary and secondary prevention which emphasise treatment of disorders and promotion of health as cLose to the community as possible helps to achieve a more global perspective of health.
- 16. Chapter 3 Non-pharmacological InterventionsfNPIs) in Clinical Practice The use of these interventions is advocated in the BPS model for their established efficacy (as seen by extensive research) in augmenting the impact of drug treatment and surgical procedures. Non-pharmacological interventions (NPIs) enhance patient satisfaction, improve adherence to treatment, and strengthen the bond between the doctor and his patients as well as the community. The NPI5 in particular that a medical or a dental student can use to diagnostic and therapeutic advantage include the following: 1. Communication Skitts While communication seems like the most basic and innate part of being human, effective communication is a vital toot in clinical settings as it forms the basis of the doctor-patient interaction. The doctor and patient undertake a joint voyage, many a times into an unknown territory of disease. Problems may arise when the two travelers 9nd it difficult to communicate or understand each other. While the physician is expected to know the patient’s language, the patient is often unaware of medical jargon. As the service provider, the responsibility for effective communication ties with the physician. The tools that can be employed to make this communication effective and skillful are: i) Attending and listening: Attending is the act of truly focusing on the patient. It involves a conscious effort by the doctor to be aware of what the other person is saying and trying to imply. This may only be possible if the interaction with the patient is done in a setting of exclusivity Standing on a patient’s bedside with fellow students, amidst the traffic in a ward, attending to mobile calls simultaneously. or eating/drinking while talking to the patient may signal that you are not exclusively attending to the patient and/or his family member. A screen next to the bed, or a relatively quiet corner of the ward meant for interaction of patients with the students may provide a setting that allows for more effective communication. ii) Active listening: This is a process that goes beyond merely hearing and making notes of what the patient says. It involves a simultaneous focus on the linguistic and the paralinguistic aspects of speech. The linguistic aspect refers to the words and verbal aspect of the speech Paralinguistics refers to nonverbal features of speech such as timing. votume, pitch, accent, fluency, pauses and ums’ and ‘errs’. These are important as they indicate how the person is feeling beyond just the spoken word. An understanding of body language of the patient is important for a doctor to communicate with the patient. Body language refers to the way a patient expresses himself through the use of non-verbal cues such as facial expressions, proximity to the doctor, use of gestures. body position, movements and eye contact. Li
- 17. Use of minimalprompts Lark of exclusivity Sit squarely in relation to the patient Preoccupied oranoious health professionals Open body position In relation to the patient Uncomfortable seating - - Lack of attention to non-verbal cues Leanmg shghtly towards the chont during active listening Maintaining reasonable eye contact Offensive remarks orjudgmcnt by the health professional Pelaxed attentive health professional Frequent interruptions Listen and respond to feelings Selective iintening - - - Oay dreaming or dosing off during Note all pamlrnguist,c and nonverbal cues the communication It shoutd be borne in mind that body language expressions are only cues and not ‘ctinical signs. These cues should be pointed out to the patient to draw his attention to them, to understand his feelings or their meaning to him, e.g. “I notice that you took angry, how are you feeling at the moment?’, or ‘your eyes filled up with tears when you told me the name of your father.” This is more rational than making the wrong assumption about his gestures or body language. This is essential as methods of non-verbal communication vary in patients and their family members, according to their upbringing, culture and background. Active listening also involves customizing your style and language to match that of your patients or anybody you are listening to. This can be done by using the same language as the patient wherever possible. Another important aspect of active listening is respecting the pauses and silences of the patient. This would mean not immediatety jumping in and talking whenever the patient pauses for breath or reflects silently. iii) Verbat techniques.’ These are pivotal in making the communication effective and thus contribute towards the therapeutic process. These are vital skitls for the doctors and can be mastered through practice. Any verbal communication in a clinical setting involves the following components: Questions: these can be closed or open ended. Ctose ended questions elicit a yes/no or a fixed response e.g. 4What is your name?” “Are you married?” 5Do you get nausea after taking your meals”? These questions are vital at the start of an interaction both, to collect data as well as establish familiarity and comfort with the patient. The open ended questions do not elicit a particular answer. They are intended to encourage patients to talk more about their story or to expand more upon their issues. Questions are usually used for exploration of a particular aspect, for obtaining further information, to clarify any details and to encourage a patient to talk. E.g. “What brings you to the hospital today” or 5Kaisay aana hua?° or even simply 5Jee, kohiye.” Fadorsthatrmptøv. cotrimintcaUon
- 18. It is importantto start an interaction with the patient or his family members with an open ended query, such as What brings you to the hospitaL?” What can I do for you”? This gives the patient a chance to open the conversation, with what s/he considers most significant. Leading questions are those that prompt the patient to answer in a certain way. These lead to skewed information as we tend to give the answer that we feet the person is looking for. These should be avoided as should value laden ones. Some examples of these are e.g. Don’t you think your pain radiates into the left arm?” or “Do you feet ashamed of your short stature?” Moreover ‘why’ questions should be used sparingly e.g. “Why do you think you have developed shortness of breath?” An effective communication therefore revolves around questions starting with what, when, where and how Funneling: This refers to the use of questions to guide the conversation from a broader area to a more specific one. These should follow open ended questions. This technique hetps the interviewer move from general statements by the patient to specific areas of clinical relevance e.g. “Now that you have described your complaint of feeling weak and lethargic. can you describe which specific part of the body you were referring to?” Paraphrasing: It refers to the process of repeating the last few words the patient said and summarising what the patient has communicated so far, in your own words, and then ask him or her to validate if you have understood it correctly, e.g. “you have told me about the weakness in your legs and lethargy that you feel after walking for only few yards. Is that right?” ‘Aap ne bataya k aap kal maiday mal 2 haftay sejatan ho rahi haijo khanoy k baud barhjaati hai, kya also he hal?” Setective reflection: Reflection is a technique to bring out the feelings attached to various symptoms and problems that a patient has stated. It refers to the method of repeating back to the client a part of something s/he said that was emphasised in some way or which seemed emotionally charged. e.g. How does it feel when you start to feel fatigued only walking for a few minutes? You told me earlier, that you were once an athlete who could easily run a mile.” Empathy buitding: This refers to statements made by the doctor that make the patient see that his or her feelings have been well understood. It helps the patient understand that his/her feelings are valid and that the doctor would have felt the same if s/he was in the patient’s place. It is important here to refrain from expressing sympathy instead, which would imply that the doctor feels sorry for the patient’s plight. can imagine how difficult it must be for you to live with your pain for such a long time” is an empathetic statement, which is highly desirable; a statement such as “Poor you, really feel bad hearing your story” is an expression of sympathy which may not have the
- 19. desired therapeutic effectand also undermine the effectiveness of communication. Checking for understanding: From time to time during the session the doctor needs to summarise patients statements or ask the patient to comment on the summary. to ensure if s/he has understood the problem and its associated feelings correctly. An effective communication based on the above principles is bound to form a bond and a relationship between the patient and the doctor in which both feel understood and connected. It is this feeting of mutual understanding that is traditionally described by patients as Hatfmy ittness was retieved after tatking to my doctor. WhiLe the principles of effective communication should be part of all clinical interactions between a doctor and his patient, the best use of these principles is in counselling individuals, couples, family members or groups. 2. Counsetting Counselling is a technique that aims to hetp peopte help themselves by the development of a therapeutic relationship between the counsetlor and the patient or family member, a colleague or anybody who seeks counsel. The process aims at helping a person achieve a greater depth of understanding, and clarification of’ the problem mobilises personal coping abilities. It is not an ordinary every day conversation, in which one person • asks the other for advice and gets the other person’s opinion on what to do. Counselling is a limited supportive activity aimed at developing a person’s ability to decide upon and initiate a constructive change. A doctor or a medical student may come across a variety of situations in clinical settings and professional interactions in which they may require counselling skills. Some of the common scenarios where this skill can become a useful intervention include: breaking bad news to patients or their families, or resolving professional conflicts. These may include announcing that a patient’s biopsy report has revealed a malignancy, or that cardiopulmonary resuscitation has failed to revive the patient. It may be required as part of sharing the news of a baby with congenital malformations or a stillborn baby with the expectant parents, resolving a conflict between a colleague and a nurse in the ward, or handling a relative who feels that his patient is being ignored and denied a particular investigation or intervention. A coun selling session aims to: a) Establish a relationship of mutual trust and care in which patients and/or their families feel secure and able to express themselves in any way or form necessary. b) Give patients or their families a chance to seek clarification and expLanation of terms, issues and misgivings. c) Provide an opportunity to patients or whoever is being counselled to freely express his or her feelings and emotions. d) Provide reassurance.
- 20. e) Achieve adeeper and a clearer understanding of a heatth related issue based on scientific and evidence based data. f) Identify the various choices and options alongside their pros and cons through a process of discussion and dialogue between the counsetlor and the patient. g) Help the person make a decision or reach a solution that is most suitable for him/her. h) Seek support of the counsellor i) Mobilise resources required to implement the solution. j) Learn the necessary skills to cope or deal with the issue. Under no circumstances is the counsellor expected to make decisions on behalf of the patient or the one counselled. The responsibility of the consequences of the proposed solution thus always rests on the shoulders of the patient seeking counsel and never on the counsellor. If a medical student or a doctor opts to take up the role of a counsellor s/he needs to develop and exhibit certain attributes, discussed below. What traits must a counsettor have? Unconditionat positive regard This involves a deep and positive feeling for the patient, being non-judgmental and trusting. Empathic understanding This is the ability to accurately perceive others’ feelings, validating them and communicating this understanding to them effectively. As highlighted above, it is different from sympathy which implies feeling sorry for the person. Warmth and consideration This can be achieved by remaining open-minded and non judgmental. Avoiding over emphasis of your professional role and being consistent in behavior helps convey that you are genuinely there to help. Also by remaining respectful and tactful, the counsel tor would be able to show warmth and consideration to his patient. Clarity The counselling relationship should remain clear and without mystery to the patient. As a counsellor you are required to be clear and explicit. Encourage the person being counselled to be similarly explicit in his requirements. Use of the techniques of paraphrasing and checking for understanding described above can ensure successful communication. Here and now thinhing The distressed patients would like to talk excessively about their past in order to avoid the reality of the present. As counsellor you need to help identify present thoughts and feelings to enhance problem solving attitude on the basis of here and now’, and focus on the present day issue(s).
- 21. Do not askwhy” questions, These imply interogatiorv Does not involve giving direct advice to patients Do not say should ought or icarna chahiye tha. Does not solve people’s problems for them These imply moralisation. Do not blame the patient Does not challenge a patient’s feelings and perceptions t)o not compare the patient’s experiences witi, Does not impose the counsellor’s own views your own, or gite examples from your life onto the patient The patient is a different petson from you and has different life experiences. Does not make people less emotional Do not invalidate the patient’s feelings, Does not work to fulfil the counsellor’s need to make people feel better 3. Informational Care (IC) Memoirs of a patient’s son I took my etderly mother to a targe hospitat in our city when she became sick She was very embarrassed to go to the doctor because she said that he would examine herand cause bepardagi but! convinced her that they have welt trained doctors who are trustworthy and wilt take care ofher without causing her any embarrassment We went to the outdoor department where we were told that she had a breast lump which coutd be °a tumOur.” This was like a bolt of lightning for the whole family as we had heard that nobody survives from cancer I borrowed 5000 rupees from a friend and admttted her in the sUrgery ward in the big hospitaL We were hoping that through these doctors, A(tah would help us through this trial, Ajunior doctor took her medical history and startedsome medicines. I asked him whether my mother woutd be okay, but he said he didn’t knowyet and we needed some tests. He then went away and a nurse gave us a slip to do some tests but nobody told us how much the tests would cost woutd it be painful for my mother how long would the results take, how tong would we need to stay in the hospitat, any precautions we need to take for herrecovery? When the test results came thejunior doctor looked at the results and told us that the senior doctorsahib wilt decide during “the round I thought maybe they wilt tell us when they decide after the round The senior doctor sahib came for the round but he discussedsomething in English with the other doctors and moved on from our bed without telling us anything. Later on, a group ofstudents came to our bed andsaid that they needed to examine my mother’s chest My mother was very ashamed but they sqid that it was necessary for her treatment, and so We had to agree Seven ofthem examined my mothers chest turn by turn and we were constantly worried about how manypeopte might be watching her like this. Later on, I asked for the senior doctorsahib to find out about the treat ment ofmymother and the questions I had in my mind, but the peon said that he was in a meeting. I asked for thejunior doctor who had taken our history but he had left after his duty and would be coming back the next day I asked the nurses too but they did not know anything about my mothers treatment plan. A newjunior doctor came that evening on Ucity and told us that we had to prepare formy mothers surgery two days later, and that we also needed to arrange for3 units ofblood and about 20,000 rupees for the items required in the surgery. We were very confused, as no one had discussed anything with us about this surgery. When I asked thejunior doctor about how much money we needed in 4otat how many days we would need to stay in the hospital caun4Ipon 7 MIsconcptfons about Counselling.
- 22. after thaL andifthere was any otheroption besidesthe surgery he gotangry andsaidthat Don tyou trust the doctors advice2 and you care about mon eymore thanyourmothers health 57 was very hurt andembarrassed bythese comments On the otherhand my motherand sisters were very hopetess as they had heard thatnobodysunuvesfrom 5cancer even afterthesurgery Veiywomedand confused we were totd bya neighbturthat a local pirsa R2LJ We didnotknow what to do All we reallywanted was someone to listen and answersome ofour quenes in this confusion and desperation, a consultation with the pirsahib seemed like our onty ray ofhope So the nextmorning we left the hospital fora meeting with the pirsahTh’_.. Recommendedexercise Read this case scenario once before studying this sectlonr and then a sec ond time after completing the section Discuss whythis chath of events ted to this tonsequence and what actions could have been taken differently by the health care team to avoid such an unfortunate outcome LI H Informational care is defined as provision of information to patients using principles of communication regarding the disease, the drugs and the doctor (the 3 Ds). This helps to fill the gap in the patient’s knowledge and understanding in these areas. In order for the patient to fully achieve this understanding, informational care must be provided using Language that the patient understands. During ill health, the patient and his caregivers feel a desperate need to know what exactly is wrong, how it is being or will be managed, who will deliver the care and how. The amount of information provided, timing, Language and setting in which informational care is imparted has to be tailored according to the individual needs of the patient, This includes considerations such as what stage the illness or recovery is at and what questions bother the patient the most. Seven ESSePtIISIfl iflformatlonal Care: The physician must set aside time within a consultation to give a reasonable level of information to the patient and his family about the disease and treatment. The IC session must take place in the language that the patient can understand. it must start with patient’s knowledge, understanding and expectations. Aap apni bemari kal baray ma) kya Jantay haln The doctor must than remove any myths and misconceptions that the patient mentions in his description. These misconceptions must be clarified and replaced with evidence-based information, The task of giving intormation should be professional, evidence based facts are provided without fear of causing a negative reaction in patient and/or family. It must however be done with compassion, empathy and sensitivity. Vague statements and building false hope should be avoided. Both aspects of the disease and treatment, negative and posItive should be communicated to th, patient, but information overload is to b, avoided, Use of simple figures, diagrams and sketches are often helpful to enhance the patient’s understanding. Most patients or relatives may like to keep the sketches at the end of the session, which consolidates their interest and the titility of the IC etetcise in the therapeutic process. The IC session ends with th. patient briefly summerising his new understanding of the 3 Os. This helps to evaluate how much of the InformatIon has been retained, The doctor finally reassures that any future concerns and clarifications that ar. needed will also be addressed.
- 23. What is wrongwith me (diagnosis)? Why have developed this disease (aetiology)? Is there an effective treatment to my problem? Is the treatment safe? Are there any serious or danoerous side effects (management)? How long iIl I take to recover (prognosis)? Is therea ‘Perhez’ (restrictions)? Is there a risk of illness being spread to those APOUND me or passing It onto my offspring (transmission)? How will the illness and the treatment effect or influence my functioning? (Can I continue to work or rest? What will happen to my sex life, sleep, appetite etc.?) 4. Handling Difficutt Patients and their Families Health professionals find certain types of patients and their families exceedingly difficult to deal with. These include individuals who • have long, meaningless and repetitive discussions with the doctor • waste precious time. • become too dependent and clingy ask for undue favours • make unprofessional demands. • try to manipulate the doctor • become angry when things do not go their way • become rude or behave aggressively. • refuse diagnostic tests and treatment. Other patients who are seen as difficult are those with medically unexplained symptoms (MUS) such as vgue physical complaints, aches and pains, mentat health problems and patients who may be drug users, are obese or mute. Management: It is important to be aware of factors operating in a health professional that can give a false feeling that the patient is behaving in a difficult way. These commonly include having a heavy work load and what time of the day the interaction with the patient occurs, as health professionals tend to become irritable towards the end of the day. Inadequate knowledge and skills to deal with a demanding clinical situations may also cause the health pro fessional to become panicked or overly sensitive. Lack of training in com munication and counselling skills may worsen this situation. Some health professionals trained in a biomedical model feel that addressing patient’s. psychosocial and spiritual issues is not their job. They may, therefore, Seven Questions a Patient NeedsAnSwered man CSessian
- 24. become irritable whena patient brings up these aspects for discussion. Whatever ones views may be, as a heatth professional you are likely to come across at Least one if not all of the aforementioned situations. The following steps may help in dealing with a difficult patient or family effectively: a) Have an understanding of the biopsychosocial model and integrated health care model and believe in the effectiveness of these well researched models. b) Train yourself well in principles of effective communication and counselling. Seek specialised training in handling of difficult patients by trying to form a relationship or bond with difficult patients in the ward. Looking at videos of how seniors ideally handle such patients and discussions with health team members will help educate you. c) Learn relaxation techniques to manage your own anger and feelings of frustration. d) Approach difficult patients with tolerance, patience and use of principles of active listening and unconditional positive regard, keeping your cool. Concentrate on breathing deeply and easily while listening to the angry patient or a family member. e) Do not take remarks being passed as personal insult’ or challenge to your integrity or authority. Consider them a different viewpoint of an individual who is hurt or is uninformed and unguided. f) Allow the patient or family member to express anger and validate it by statements such as “your anger is understandable”, “I can understand your feelings”, “this must be frustrating for you’. “mujhe andaza hal kaiye aap k tiye kitna mushkft waqt hal” g) Offer a chair and a calmer setting to discuss the issue at hand in more detail. Offer an apology or an explanation for any unintended offense but do not appear defensive. Stay calm, maintaining an open body posture, a safe distance and always keep an eye at the emergency exit. Always ask for assistance from colleagues or staff at the earliest signs of aggression or threatening postures by a patient or famity members. h) For difficult pai. its in particular, define the objectives and duration of consultatio ri advance. i) Offer referral to a colleague or a senior consultant, particularly if you are not making any headway. j) Use humour while collecting further data, reassure, undertake detailed physical examination, and a more extensive diagnostic work up. or seek opinion from a mental health professional. k) Involve family members, friends or significant others in the life of the patient for support as well as help in understanding of the patient’s issues.
- 25. 5. Breaking BadNews Any news that adverseLy and seriously affects an individual.’s view of his or her own future is considered bad news. There are many clinical situations where bad news has to be communicated to patients and/or their relatives, e.g. disctosing the diagnosis or relapse of cancer, birth of mal formed baby or death of a loved one. Breaking bad news is an unpLeasant task and can be learned from the senior physicians or through own profes sional experience. Most patients and families expect full disclosure delivered with empathy, kindness and clarity. There are five different schools of thought regarding the provision of information to patients. The biopsychosocial model has the least number of limitations and is therefore strongly recommended for use in health settings. a) Blo-Psycho-Sociat Modet: This model provides clear, crisp, evidence based information on the patient’s condition but tailors the flow and amount of information accord ing to the needs of the patient. A vertical flow of all data on the disease (particularly the parts that the patient or his family have not asked for), is avoided. The bad news is broken using principles of effective communi cation, counselling and informational care discussed earlier. The patient is encouraged to involve his family members, particularly the ones who can provide psychosocial support, during the session as well as in the long run. This model suggests the following steps for a session that aims at breaking bad news: Step 1: Seating and Setting (Environment): Exclusivity The environment where bad news is being broken can have serious repercussions on the outcome of the interview. A patient’s mistrust and antagonism may simply result from a poorly chosen location. It is, therefore, worth trying to find a private room where the doctor and patient can focus on the subject attentively. invoLvement ofsignificant others Some patients like to have family members or friends around them when they receive bad news, while others prefer to hear bad news alone. Ask the patient who they would like to accompany them. If there are more than a few people supporting the patient, ask one person to act as representative. This gives the patient support and alleviates some stress from the doctor in the face of an emotionally charged interview. Seating arrangements It is advisable for the interview to take place with both octor and patient comfortabty and respectfully seated next to each other, preferably at a distance of an arm’s length. The arrangement should never impart an intimidating image of the doctor. It should provide an appropriate setting for discussions and any emotional outbursts or ventilation of feelings that may arise.
- 26. Be attentive andcalm Most doctors feet anxious when breaking bad news and it is worth spending some time to eliminate any signats that may suggest our own anxieties. Maintain eye contact and show your attention. If the patient starts to cry, try shifting your gaze because nobody Likes to be watched while crying. This should however be done with sensitivity and must never send a signal that you do not realty care about the patients feelings. Listening mode SiLence and repetition of last few words that the patient has said. are two communication skills that wiLt send across the message that you are Listening weLl. Avaitabitity If you have appointments to keep, give your patient a cLear indication of your time constraints but make yourself available to the patient for all his queries and doubts for the duration that you are with him or her. Step 2: Patient’s Perception: Ask: What do you know? “Aap apni bemoan kai baray mai kyajantay ham?” The principle involved in this step is “before you tell, ask.” Before you break the bad news to the patient, try to ascertain as accurately as possible the patient’s perception of his or her MEDICAL condition. Obtaining this information depends on your own communication style. As your patient responds to your questions take note of the language and vocabulary that s/he is using and be sure to use the same vocabulary in your sentences. This alignment is very important as it hetps you assess the gap between patient’s expectations and actual medical condition. If the patient is in denial, try not to confront him in the first interview, as denial is an unconscious defense mechanism that facilitates coping. Step : Invitation: Ask: What would you tike to know? “Aap bemari k baray mai kyajanna chahain ge?” Although most patients want to know all about their illness but assumption towards that should be avoided. Obtaining overt permission respects the patient’s right to know or not to know. Some examples to address this are: “Are you the kind of person who likes to know alt the details about what’s going on?”, “How much information would you like me to give you about your diagnosis and treatment?”, “Would you like me to give you details about what is going on or would you prefer I tell you about the treatments I am prescribing to you?.”
- 27. Step : Knowledge: Beforeyou break bad news, give your patient a warning of some sort to help him prepare e.g. “Unfortunately I have some bad news for you Mr. X” or “I am sorry to have to tell you...” When giving your patient bad news, use Language similar to his. Avoid scientific and technical language. Even the most well informed patients find technical terms difficult to comprehend in that state of emotional turmoil. Give information in small bits and clarify whether s/he un derstands what you have said so far, e.g. “Do you see what I mean?” or “Is this making sense so far?” As emotions and reactions arise during the interview, acknowledge them and respond to them. Ask: What have you understood? “Kya mal aap ko baat theek se samjha saka/saki hoon?” Step 5: Empathy: For most doctors responding to our patients’ emotions is one of the most difficult parts of ourjobs. In our effort to alleviate our own discomfort it is tempting to withhold certain information or give a more hopeful picture than actually exists. These tactics may appear to help in the short term but seriously undermine aft your efforts in the long run. It is much more useful and therapeutic to acknowl edge the patient’s emotions as they arise and address them. The technique that is most useful is termed the empathic response. An empathic response involves listening and identifying the emotion or mix of emotions that the patient is experiencing and offer an acknowledgement for them. Identify the source of that particular emotion and then respond by showing that you understand the emotional expression of the patient. Statements such as “mai bhi agar aap ki jagah hon toh aisa he mehsus karoon” reassure the pa tient that you understand the human side of the medical issue and that you have a respect for his feelings. Step 6: Summarise: Before the discussion ends, recapitulate the information in a short summary of all that has been discussed and give your patient an opportunity to voice any major concerns or questions. Step : Ptan of Action: You and your patient should go away from the interview with a clear plan for the next steps that need to be taken and the role you both would play, in the management of the issues. Also allow the patient to have a way of contacting you, through the hospital exchange or after rounds the next morning, in case they have any questions.
- 28. b) Individuatised DisclosureModel: In this model the amount of information disclosed and the rate of its discLosure are tailored to the desires of the individual patient by doctor-patient negotiation. First the doctor and patient work together to clarify what information the patient wants. The doctor then imparts that information in a way that the patient understands. This is an on-going and developing process. It implies a tevel of mutual trust and communication that takes time and effort to develop. The distinguishing features of this model are that it takes time and skills and its assumptions are supported by evidence. It has the capacity to maximise quality of life for the patient. The underlying assumptions in this model are that it takes each individual a different amount of time to absorb and adjust to bad news. A partnership between the doctor and the patient for decision making is. therefore, in the patient’s best interest. Its disadvantages are that it is a time consuming process that might be difficult for a busy physician to undertake. It also tends to drain a health care providers’ emotional resources. The advantages are that the amount of information given and rate of disclosure is taiLored to needs of the individual and a supportive relationship with the doctor is established. c) FuLL Disclosure Model: This model involves giving full information to every patient as soon as it is known. It argues that this promotes doctor-patient trust and communication and facilitates mutual support within the family unit. The underlying assumptions in this model are that the patient has a right to full information about himself and the doctor has an obligation to give it. It assumes that all patients want to know bad news about themselves and that patients themselves should decide what treatment is best for them. The disadvantage of this model is that discussion of options in detail may frighten and confuse some patients. The doctor insisting on providing information may undermine defenses such as deniaL which are otherwise important for the survival of the patient. The provision of full information may, also, have negative emotional consequences for some. The mod el holds some advantages as well, such as promotion of doctor-patient trust, family support and allowing patients time to put affairs in order in case of a poor prognosis. It also helps those patients who cope better with their diagnosis by having the maximum amount of information about their illness. c) PaternaListic Disctosure ModeL: This model implies that information about the patient’s disease is the right of the doctor. The doctor delivers the information to the patient as and when s/he deems appropriate, in a ‘sugar coating’ to minimise the pain and distress of the patient. It also involves the expression of sympa thy and a sharing of emotions on the part of the doctor. This model is no longer recommended for use. d) Non-Disctosure Modet: This model is based on the view that under no circumstance should patients be informed that they have acquired a lethal disease. It states that deception should be used if necessary, on the basis that the patient needs protection from the terrible reality of terminal illness. This model has been traditionally adopted as part of a paternalistic and nurturing
- 29. attitude of doctorstowards their patients. The underLying assumptions in this modet are that it is appropriate for a doctor to decide what is best for the patient; patients do not want to hear bad news and they need to be protected from it. This model has obvious disadvantages such as: denial of the opportunity to adjust to illness, which the patient is ob • viousty experiencing • trust in doctor is undermined opportunities for helpful interventions are lost • patient compliance is less tikely • patients may acquire wrong information that can lead to avoidance, isolation and a perception of rejection • the patient may experience a sense of loss of control in what is hap pening to his own body Advantages of following this model are that it is easier and less time consuming for the doctor and suits those people who prefer not to know their condition. This model s fast fatling out of favour and is now widely rejected by modern day doctors as welt as patients and their families. What expectations do the patient and [amity have when receiving bad news? According to research, the most important factor to the patient and family receiving bad news, is the attitude of the health professional. The heatth professional should, thus, be knowledgeable, empathetic and give hon est and clear answers in simple language. The second most important factor is the setting in which the news is broken. A quiet, private place • where the news is broken in an uninterrupted way is preferred. What are the common reactions that a patient experiences upon receiv ing bad news? The reactions that a person goes through when they hear bad news, can be summarised as the stages of denial, anger, bargaining, depression and acceptance. These stages are rarely clearly delineated, and often patients go through one or more stages at the same time and for each individual the length of time each stage lasts may vary. It is important that the health professional empathise with and provide support for the patient during each stage. What are the common reactions in a heatth professionaL breaking bad news? Delivering bad news can be equally taxing and demanding for the health professional. S/he may experience strong emotions of being a failure, or of not having done enough for the patient. Feelings of helplessness, sad ness and fear that they may harm the patient emotionally by telling them the truth may be experienced. Some may feel shame and disiltusionment with their profession, and others may experience fear of their own death and disability. These feelings are essentially normal reactions to a challenging and a difficult situation. A young health professional is advised to share these feelings with a senior colleague. S/he may even assist in a few situations before undertaking this specialised communication in clinical settings.
- 30. ChaLlenges In Non-pharmacologicalInterventions As health professionals the biggest hurdle we face in the administration of any non-pharmacological intervention is the Lack of time. In busy cLin ics and overcrowded wards where patients go from being humans with names to beds with numbers, it seems impossible to find the time to give someone all they need. It seems to suffice that we are there at alt, that we are doing the bare minimum to keep afloat in the never-ending sea of patients that threatens to drown us. In such a situation we must keep in mind two things: Research shows that by not spending the required amount of time the first time we see a patient, we tend to misunderstand. misdiagnose and mistreat. The inevitable result of this is that not only does a patient not improve, s/he may return to a different doctor in a worsened condition. This means that for the majority of our time, we are redoing work that a colleague has done improperly (due to lack of time) and vice versa. There are millions of patients stuck in this loop, who keep reappearing for consultations, thereby increasing the workload of heatth professionals as a whole. Secondly. it is important to understand that our job is not to mistreat the most number of people in a day, but to actuaLly treat the minimum number of people we can to the best of our abilities. Using non-pharmacological interventions, such as providing informational care and breaking bad news saves us time in the Long term. For example, if we are able to take the time to explain to a patient that the true mea sure of whether their blood glucose levels is normal is fasting btood glu cose, or an HbAic, they will not waste our time (and that of the path lab) by getting random blood glucose Levels done and showing them to us. Breaking bad news is another time-consuming procedure, how ever, one of utmost importance. To inform an individual that s/he may have cancer or AIDS is to inflict a major psychological trauma. People will remember, for the rest of their lives, the details of the occasions when important news was broken. No surgeon would think of operating without booking an operating theatre and setting aside sufficient time to do the job properly. S/he would not ‘skip the anaesthesia” just because it takes time. The procedure for breaking bad news must have a similar importance. A health pro fessional must think for a moment how they would feel if they were to receive such news. There is a world of difference between the doctor who breaks this news in relaxed atmosphere with a support ive attitude and the caLlous consultant who flings bad news at the patient in a public ward. Before teLling people what we think they need to know, we should find out what they already know, or think they know, about the situation and what their priorities are. If they use words like cancer’ or death’, we should check out that these words mean the same to them as they do to us. ‘There are many kinds of cancer, what does the word mean to you?’. ‘Have you seen anyone die? How do you view death?’ will often reveal considerable ignorance and open the door to positive reassurance and explanation. Too often, doctors fail to invite questions and miss the opportunity to help people with the issues that are concerning them most. The patient has a right to know the truth about an illness, but we must respect their right to monitor the amount of new and painful information that s/he can cope with at any given time. It is just as wrong to tell people too much, too soon, as it is to tell them too little, too late.
- 31. • Life-threatening illnesscan undermine our confidence and trust and members of the caring professions can do a great deal to help peopte through these psychosocial transitions. Accurate informa tion is essential to planning. Many patients may react with relief when they are told they have cancer, as without any information they have already imagined the worst. It is easier to cope with a Le gitimate diagnosis than to live in an unplanned state of uncertainty. • Many of the different ways people cope with threats reflect the coping strategies that have been found to minimise stress earty in life. At times of threat, those who tack confidence in their own resources may seek help of others, express clear signals of distress and cling inappropriately. Those who lack trust in others may keep their problems to themselves, bottle up their feelings and blame hea[thcare providers or therapies for their symptoms. Their tack of trust makes it necessary for them to control us rather than be controlled by us. A few, who lack trust in themselves and others. may keep a low profile, turn in on themselves and become anxious and depressed. To those who lack self-esteem the most important thing we have to offer is our esteem for their true worth and poten tial. To those who lack trust in others we can show that we under stand their suspicion and their need to be in control of us. Doctors must act as advisors rather than instructors and show that they accept that trust must be earned: and that ‘it is not our right to be trusted’. SUMMARY The breaking of bad news is a difficult situation for both the health professional and patient and the family members. The task should be undertaken in an exclusive and an uninterrupted setting. The information provided should be based on what the patient and famity wants to know. The information should build on what is already known to them. Opening statement should be on the lines of “I have to share information that may be unpleasant” or “I know it may be tough for you to know.” The contents may be broken into short sentences making sure that the patient gets adequate chance to process the unpleasant data. Accept and respect the emotional reactions that follow the sharing of the information. In the end leave enough time for clarifications and questions. Always schedule a follow up meeting and mobilization of any immediate support that the patient or the family may need after learning the bad news. The session should not end without assessing the risk of the individual harming them selves, and putting in place clear preventive interventions in this regard. Reassurance that you as a health professional stand committed to pro vide support and be with the patient during these trying moments is a source of comfort for the patient and the family. This is a safe note on which to leave. A calm, compassionate. empathetic health profession alwho has adequate knowledge of the patient’s condition can leave a calming effect on the patient and the family. Young health professionals need to be aware of the strong emotional reactions that they themselves may experience before, during or just after breaking the bad news. These feelings are normal and their impact can be reduced significantly by sharing them with a more experienced colleague.
- 32. 6. Crisis Interventionand Disaster Management The word crisis is derived from a Greek word meaning decision makkig. Chinese language has an expression for it in two words; danger and opportunity. A crisis is, therefore, a situation which holds potential for great individual growth provided that the appropriate decisions are taken. People in individual crises or natural disasters find themselves in situations that require deep and insightful decision-making and lead to a permanent change in their lives. Crises are periods of disorganization, characterised by trial and error, disequilibrium, and attempts to reduce feelings of dis comfort. Resotution of a crisis can result in either an increase or decrease in person’s level of functioning or a return to the previous baseline of functioning. Individuals and communities who undergo major disasters may. however, never be the same again. At a psychological tevel, they may become more vulnerable to future crises. They are at a higher risk to become victims of a variety of post traumatic conditions such as post-traumatic stress disorder (PTSD). depression, anxiety and/or dissociative states. They may become resilient and battle-hardened’, and thus, better equipped to deal with challenges of life. This change that foltows major trauma may be the basis of the positive shifts in human be haviour called post-traumatic growth occur in response to stressful periods of human maturation and transition. These inctude childbirth, early child hood, schooling, adolescence, marriage, parenting, divorce, hospitalization, death of a loved one etc. A situational crisis is where a person is faced with a stressful or traumatic event which could be a natural or a manmade disaster e.g. ftoods, earthquakes, rape, terrorist attacks, war, murder etc. Ak. GENERATE AND EXPLORE ALTERNATIVE RESOURCES AND COPING SKILLS EXPLORE FEELINGS AND EMOTIONS (USING ACTIVE LISTENING AND VAUDATION SKILLS) IDENTIFY DIMENSION OF PRESENTING PROBLEMS. INCLUDING CRISIS PRECJPITANTS ESTABLISH RAPPORT AND COLLABORATIVE RELATIONSHIP PLAN AND CONDUCT CRISIS AND BIOPSYCHOSOCIAL ASSESSMENT (INCLUDING LETHALI1’! MEASURES) Roberts’ seven stage modet ofcrisis intervention
- 33. Communication Strategies InCrisis intervention Using silence gives the person time to reflect and become more aware of feelings. Silence can prompt elaboration. Simply being with the person can make them feel supported. Using non-verbal communication- maintaining eye contact, head nodding, caring facial expressions, and occasional “uh-huhs lets the person know that you are in tune with them Paraphrasing, expressing understanding, empathy and interest are conveyed by repeating portions of what the person said. Paraphrasing also checks for accuracy ,clarifies misunderstandings, and lets people know that they have been heard. You could say, “So you are saying that..”, or”Aap k kehne ka matlab ye hai kaL. 1efiecting feelings helps the person identify and articulate emotions. You could say. “You sound angry...” or “You look scared...” Allowing the expression of emotions is an important part of healing. Venting often helps the person work through feelings and helps in problem solving Disaster Management: A crisis involves three main phases: emergency phase, rehabilitation phase, and recovery phase. Each of these phases has its unique characteristics. The common factors for a medical student to remember regarding disasters include: a) The consequent trauma is never surgical and medical atone: nearly all those affected suffer psychosocial changes. b) Most psychosocial consequences of trauma are essentially normal reactions to the overwhelming nature of the disaster. More people dont get PTSD than do get PTSD. c) Groups most vulnerable to deyeloping post traumatic conditions include women, children and the elderly, but young adults and males are not immune to developing psychological reactions. d) Provision of early psychosocial support by trained professionals prevents long term psychiatric morbidity. It also enhances the impact of surgical and medical interventions and promotes early recovery from the physical, psychological and socioeconomic effects of trauma. e) All medical and psychosocial care should be part and parcel of the larger disaster relief in form of food, shelter, clothing and security. Psychosocial and mentat health care should be made an integral part of medical and surgical care. This will help to prevent stigma of mental and psychosocial issues. It also helps to ensure a holistic. biopsychosocial model of health care delivery fl Traumatised individuals and communities best recover through pro viding psychological, social and economic support to each other (rather than relying on outside help alone). An early return to their homes or shelters close to home and active participation in social, educational, economic, and reconstructive activities ensure a quicker rehabilitation.
- 34. g) The useof psychotropics, particularly. the benzodiazepines should be avoided and simple. evidence-based, culturally rooted, non-phar macological interventions are preterabte. Only short-term use of up to two weeks for morbid anxiety and insomnia may be advised. h) Rescue workers and health professionals involved in provision of relief work require psychosocial support. They need adequate rest and recreation as well as constant appreciation and patronage. They should work using the buddy system, which involves individuals teaming up and caring for and monitoring each others psycholog ical and physical wellbeing. Preferably they should remain in touch with their families and friends back home. This prevents early fatigue. burn out and long term psychosocial complications. j) Up to one third of the affected population may develop long term post traumatic conditions characterised by disabling flashbacks of the trauma, autonomic hyper-arousal. avoidance (of cues, settings and circumstances that are [inked in anyway with the traumatic/di saster event), anxiety, depression and dissociative states. A second disaster wave hits soon after the first. This is largely in the form of epidemics, wound infections, malnutrition, death and dis ease due to exposure to extremes of temperature. 7. Conftict Resolution Conflict is a state where two forces oppose each other. Conflicts arise in situations where individuals and groups are not getting what they want or need. This includes marital conflict, conflict amongst colleagues, the attendant of a patient and the nursing staff, medical students on a clini cal rotation in conftict with hospital staff, or the college administration etc. Conflicts are inevitable situations and are usually seen where there is poor communication, power seeking. dissatisfaction with management style. weak leadership. lack of openness and change in leadership. Conflict has the quality to divert attention from the main activity, undermine morale, polarise people and groups, reduce cooperation, sharpen differences and thus Lead to irresponsible or harmful behaviour. It is, therefore, important to understand that at times the individuals involved may be unaware of their needs or wants. Conflicts have the potential to be constructive when they are raised in the spirit to clarify and solve problems. In these circumstances conflict and timely resolution may help relieve tension and pent up emotion as well as help build cooperation through learning more about each other. a) Common Causes of Conflict in Heatthcare Settings: Assumptions are being made e.g. the doctor assumes that the patient knows that his absence from the ward is on account of an unavoidable academic commitment like attending an international conference. The patient instead may not be aware of the activity or may not attach the same importance to it as the doctor. ii) Knowledge is minimal e.g. the family has inadequate information on the indication of biopsy in a patient and may see it as a suspicion of malignancy in the patient. H i) i) ‘St Las/a Zombie
- 35. iv) Knowledge isminimal e.g. the family has inadequate information on the indication of biopsy in a patient and may see it as a suspicion of malignancy in the patient v) Expectations are too high: e.g. the patient believes that a course of chemotherapy should have completely cured him of his lympho ma, when instead s/he develops a complication of the treatment and deteriorates. vi) Personality, race, gender or social class differences exist e.g. a trainee nurse may have a tow frustration tolerance and take offence of an innocent remark by a patient; a visitor or a medical student or the janitorial staff goes on a strike for being poorly paid. vii) Needs and wants are not being met e.g. a patient dissatisfied with food, bedding or facilities in the ward. viii) Values are being tested e.g. a welt-clad female patient reluctant to allow a male student to examine her. ix) Perceptions are being questioned e.g. a confident medical student distressed about not being given a chance by the surgical resident to undertake an incision and drainage procedure independently. b) Methods of Conflict Resotution: The underlying emotion in all conflicts is bottled up anger, frustration and/or an impression of being ignored, or of being ‘taker for granted’. The most common underlying cause is often not a clash of interests but a faulty communication or unfounded concerns. The worst ways of dealing with conflicts is to brush them under the carpet, or to ignore or postpone their resolution. A formalised strategy to resolve conflicts is called Organised Conflict Management (0CM). The following steps of 0CM help resolve most conflicts readily: i) Meet conflicts head on. / CAUSES OF CONFLiCT IN NEALTHCARE SETTINGS HEALTH OUTCOMES PERFORMANCE iii) Assumptions are being made e.g. the doctor assumes that the patient knows that his absence from the ward is on account of an unavoidable academic commitment like attending an international conference. The patient instead may not be aware of the activity or may not attach the same importance to it as the doctor. P.ERK5ANOPPWEXGE qUA#voPuFg V V ii) Show mutual respect by separating the person(s) from the problem. Do not try to corner, attack or undermine the individual(s) involved in the conflict. iii) Set goals that lead to a win-win situation for both the parties in conflict rather than a victory of one party at the expense of the other. iv) Resolve the conflict through free communication. ___________ __ VV._ VV1
- 36. v) Be honestabout concerns and reservations and verbalise them as early as possible. vi) Agree to disagree. as healthy disagreements lead to better decisions. vii) Leave individual egos out of negotiations, and avoid serving or pleasing one individual. Aim at satisfaction of the group, rather than the leader alone. Exploitative and deceptive methods of resolving confticts can succeed temporarily but are Likely to generate bigger issues in future. viii) If you are the one coordinating the dialogue, tet the negotiating team create solutions rather than handing over the solutions - people support what they create. ix) Discuss differences in values openly. x) Undertake a deeper anaLysis of the situation that generated the conflict. Conftict resolution based on a superficial analysis is likely to result in a bigger conflict in future. A conflict arising out of hurt feelings, and emotional reasons is likely to settle on its own with passage of time and an improved communication between the parties. A conflict that arises out of morality issues, religious differences, or cultural differences is unlikely to resolve. Here the two parties can agree for a peaceful co-existence in spite of the conflict. Realistic, fact based conflicts can be best resolved through creative solutions put forth by the parties themselves. The best method of dealing with conflicts is, however, by preventing them. A sound management system in medical colleges. departments, wards and hospitals helps to ensure this. It involves mechanisms of quali ty control, free horizontal interactions and sharing of information. Leader ship should be based on principles of following a middle path rather than extreme measures. Ensuring equity and justice and imparting feelings of security and predictability can prevent the rise of conflicts as welL as ensure their early resolution. Do’s and Dont’s In Crisis Intervention Do Say: Dont Say: These are normal reactions to ft could have been worse an abnormal situation It Is understandable that you i this W8 You can always get another car/house or have another child It was not your fault; you did the best you could It is best if you just stay busy lam sorry that this happened I know just how you feel Things will get batter, and you will I feel better, although things may You need to get on with your life never be the same again I
- 37. Empathy The single threadthat tinks alt the above non-pharmacological interven tions is the demand on the doctor to empathise with the patient and the family. The most important step in building a therapeutic bond is the doc tors ability to experience the feelings of his patients and to gain a deeper understanding of their distress, disease or disability. Most medical students start their career in medical college with a huge capacity to empathise. Alt that they have to learn is to communicate it effectively. The biomedical modeL with its emphasis on the disease, rather than the person experiencing it provides few opportunities to develop and use this skill. Medical students, eager to perform well, are rewarded for their abiLity to memorise anatomical and biochemical facts, causes of diseases and classification systems. Their ability to empathise or relate with patients at a human level is not marked, rewarded or appreciated. As a resu[t of this, slowly but surely they start to focus more on acquiring knowledge, with their skill at treating patients as humans and empathis ing with them fading into the background. The best time to learn how to empathise is in your relationships with each other as medical students. The first step in this direction is to opt to study in a group rather than alone. Once you are part of a group, try and under stand the reactions of a fellow student who is struggling with language. or a concept; who fails in a class test, a sub-stage or a viva. Sitting next to someone who has failed, or is in pain, and thinking of how s/he is feeling is an important exercise by which you can eventually learn to empathise with patients. Let the person you are trying to empathise with, express their feetings. The best technique in this pursuit is to share their silence. Sit quiet. Listen actively: let the person know, that you care and it is ok for them to share feelings with you. This effort on your part to empathise with your colleagues in the first couple of years in medical college will make you comfortable with your own world of emotions. It is this import ant ability in a human to stay in touch and be aware of one’s own feelings that helps them to relate with feelings of others and thus enhances their ability to empathise. During clinical years, try and sit with patients, even after you have taken the history and have completed the clinical exam-. nation. Encourage them to talk about how they feel in reaction to their illness, hospitalisation, and treatments being offered to them. Share their fears, disappointments and sorrow without trying to take sides of the health professionals and hospitaL authorities. Ask questions about the influence of the disease and the treatment on their life at home, at work and in general. These apparently irrelevant” steps will take you ctoser to your patients and thus increase the chances of empathising with them. It is this ability to bond, and eventually feel the way your patients feet, that wilt help you have an insight into how patients think. i
- 38. 1. A patientfrom a vilLage in ChoListan desert presents to a health professionat in Lahore. He appears to be suffering from diabetes mettitus, according to his HbAic and fasting bLood glucose reports. The heaLth professional does not speak or understand his tanguage. The best way to provide informational care would be: a) Drawing pictures b) Using sign language to communicate effectively c) Seeking help from a colleague who partially knows the patient’s language d) Exclude medical jargon from communication and state essentiat facts through an interpreter e) Make an attempt to learn patient’s Language and then communicate effectively 2. During a counseLling session, the most important aspect is: a) Charismatic personality b) Asking why the patient feels the way they do c) Speaking to the patient in their language U) Unconditional positive regard. e) Empathising with the patient’s situation 3. Active Listening is best accomptished by the doctor understanding and using: a) Body language. b) Paralinguistic aspects c) Active prompting d) Adequate eye contact. e) Responses to open ended questions. 4. White deaLing with a patient who is fearfuL about not waking up from anaesthesia for her hysterectomy, an empathic response is: a) I assure you that your concerns are not scientific, everybody wakes up from anaesthesia b) I do understand your concern, in your situation I, too may have felt the way you are feeling c) I know that you are scared but you are a brave person who can face this d) We are experts in the field; we will make sure that nothing happens to you. e) Please relax, everything will be fine SAMPLE MCQ FOR SECTION A
- 39. 5. Effective communicationskills are considered essentially important for a doctor. The most important reason for a doctor to develop effective communication with his patients is: a) It is a vital tooL in clinical settings. b) It forms the basis of the interaction between the doctor and patient. C) It is used in informationat care sessions with the patient and their famiLies. d) Doctors can convey their message on various health topics better. e) Doctors will gain respect and popularity with the public. Sampte Short Essay Question For Section A Qi. Briefly describe the seven questions that need to be answered in an informational care session. Q2. What are the steps invoLved in breaking bad news to a patient? Answers l.a 2.d 3.b 4.b 5.b For answers to short essay questions see Chapter 3, Non-pharmalog ical interventions.
- 40. b ECTION B edical Ethics,Professionalism and Doctor-Patient elationship I sb,ear [‘p scuLapus, Lpgeta. anb anacra. anb 3 take to b%tite%% all tfje gobs, all d gobbeaea, to keep arcorbing to mp aWftp anti nip ubgmeiu, tt (otLobng atfj. to con%iber bear to me aS mp parentS tdm to(io taug me tl.ü art: to Cibe m cmnmmt it im anti if nws%arp to sbare nip goats tnittj m: to took upon his cljilbrcn aS nip aton .—c beatberL to teach tm this art it tfrp so bcsirr k%tfjmd fee or britten omt%e; to Impart to nip sans anb tbe SonS of ttje master [‘ibjo taughi me anti tk bisnptes bfjo babe enrotkb ttjemwetbes anti babe agreeb to tlje rute% of the profeSSion, but to these atont the prtce5 anti tljt instruction. I UnIt prescribe rtgimtns tar the goat of nip patients ,, acarbingtompabititpanbmpiumeiUanbneberboarmloanpcnc r to please no one tofU I prescribe a beatitp brug nor gibe abbece Wijicfj map cause $S tieatlj. lor bsI( I gibe a boman a pessarp to prorure abortion. ut I bitt preSerbe the puritp of nip (itt anti nip art. I bill nof cut tar Slant, tUtu for patients in bhom the tüea%t is manitt%t I bill (taUt tts operation to be performeb [‘p practitioners, sptclat&s arLInebtrpbousebfrrticome)bstt.tronlptrxdgxb at mp patients. keeping mp%elt far tram alt intentional Ilt-boing anti Th altsebwtionanbesptdaltptromtttp(easureso((bstfjbionietior beth men, be the? fret or stabes. Alt that map come to mp knobeebgey tn the exercise of mp profession or In baitp commerce bath mni Wjlcfj ongljnoftobesprtabaheoab,3bittkeepftcrtianbbellntbertebeaL - It I keep (tO oath taithtuttp. map 3 tnwp nip tite anti practice nip .. art. etsptcteb bp alt men anti In alt times; but it I s’wtrbe (rain U I map the reberft be mp tnt.” - -. --— .- 7 Retevance of Ethics in the Life of a Doctor Medical. Ethics Ethical. Omissions in Medical. Practice Ethical. Dil.emmas in a Doctor’s Life Doctor-Patient Rel.ationship Ptofessiona[ism in Heal.th Care
- 41. After ordering ahot cup ofDoodh Patti, the tocat preferred version ofEnglish tea Ahmed, Fazat, Javed and Safdarstarted their evening chat. The topic today was not potitics but the attitude ofdoctors. Ahmed remarked ‘The new Doctor Saheb who has opened his ctinic is very different from Dr Raheem who died tastyear after serving the community as a generat practitioner for thirtyyears. Dr. Khatid has a neon sign ofhis name and qualifications outside the clinic. He runs his clinic more like a ‘health shop He asks his patients to deposit a fixed amount with him prior to the con sultation, irrespective oftheir financial status. The other day Dr Khatid insisted that I shoutd get the Hepatitis vaccine whether I like it or not without giving me a choice to do so.” Safdar quickly added: “Dr. Saheb removed my appendix in surgery, a few weeks ago, after telling me that the appendix would burst ifI did not get it operated there and then.” Javed recalled the differences between the two doctors: “Dr Raheem was a very kind man. He never charged the poor He always discussed matters with his patients.” He cited Dr Raheem’s gesture ofexplaining atl the advantages and disadvantages ofcontraceptives to his wife and then asking her to make a choice, before he put heron the contraception pilL Javed then came to Dr Khalld’s rescue and remarked, “Yaar, everything and everybody has changed, how can doctors be the same?! Dr. Khatid needs a much larger amount of money than Dr Raheem to run his home and family His family sold a large piece ofland to afford his medical education and is still under debt, while Dr Raheem went to a medical college with hardly any expenses involved. He is a fine surgeon and knows much more than us about illness; why should he ask us about medical matters as long as he means well?” Fazal had anotherstory to telL “Dr Khatid gladly accepted a new mobile phone from a female patient so that she could call him for telephonic advice. He also went on a holiday to Bhurban with his family and a friend, with all expenses paid by the pharmaceutical company where lam emptoyed.” Javed again came to Dr Saheb’s rescue, “But then he never charges any fee from the medical students and his colleagues and recently appeared on the television channel and gave free advice on important health matters.” Ahmed concluded the discussion by saying “Dr Khatid is like all ofus; he has his positives and has some negatives too. Hebannot be compared with Dr Raheem as the ethics of the medicat profession may have changed over the last three decades.”Safdar remarked on his way out ofthe tea bar, “Let us wait and watch Dr Khalid’s progress.” Medical Ethics and Professionalism F— -
- 42. ReLevance of Ethicsin the Life of a Doctor The discussion at the tea bar shows how doctors are regularly viewed and critiqued in terms of their vaLue systems and behaviour by the community. It also shows that doctors vary in their practice of ethical and moral issues. This hightights the need for clear guidelines on how doctors are expected to behave to be considered ethicat professionaLs’. The community puts doctors on very high pedestals. They are expected to be kind, caring, and hetpfu[. They are expected to be committed to heaLth provision and keep the interests of their patients above their own. They must never harm anybody, be just and equitable and show character and resilience. They must also be able to communicate effectively, compassionately and fearlessly. They are supposed to respect the laws of confidentiality when it comes to their patients’ data. Alongside these expectations are the set of laws of the state governing medical profession, and the regulations of the Pakistan Medical and Dental Council, that a doctor must adhere to. The behaviour of doctors is called upon to reflect the traditions and values associated with them over centuries of the history of their profession. Doctors face various ditemmas and difficult choices in their daily practice such as taking consent from patients and families with low literacy and inadequate understanding of health issues. They come across controver sies such as abortion, euthanasia, human rights, and gender issues. They atso deal with powerful sections of society while compiling medico-legal reports. Their relationship with their patients, their families, the pharmaceu tical industry, media and the challenges posed by the internet and modern technologies and treatment options all raise ethical concerns. ALL in atl, ethical principles are required for good medical practice and come into play in almost all ctinical decisions that a doctor makes. They remain under scrutiny even in their personat and private life. A good doc tor is one who adheres to ethicat principles, regulations and customs of his profession under all circumstances. S/he must, therefore, have a clear understanding of what medical ethics are and what their scope is. 1. Scope and Meaning of Medicat Ethics MedicaL ethics is the study of moral aspects of a doctor’s professional life The two branches of ethics relevant to a medical professional are: ETHICS I DES IVE Whatwas,isorwllb , What Is at I NORMATIVE Whatought to or shoId happen What Is ideal
- 43. Normative Ethics: Whatheatth professional should do? Normative ethics refers to what actions are right and wrong in principle, i.e what the norms are. It serves to create moral standards that people should foLlow. These provide the theoretical and ideaL framework that can guide a doctor dealing with a practical problem e.g. Should a doctor be required to take consent for surgery from an iLLiterate man, with the fear that the pa- tient may make the wrong choice? (As was the case in the tea bar dialogue, when Dr. Khalid choe to remove Ahmeds appendix without his consent) Should public money be used to treat patients of drug abuse and AIDS? Should the Population Control Division pay the bills of an employee seeking a test-tube baby or in-vitro fertilization (IVF)? Descriptive Ethics: What health professionals actually do? Descriptive ethics are concerned with researching the morals, be[iefs and behaviours people actually have. It is a study of the behaviours of health professionals and what sort of moral values they follow. This involves var ious medical issues and ethical dilemmas e.g. Should Dr. Khalid charge a large consultation fee irrespective of the patients paying capacity? 2. Guiding PrincipLes of MedicaL Ethics The guiding principles of medical ethics in the practice of a health profes sion, also known as the ‘four pillars” are autonomy, beneficence, non-maleficence, and justice. a. Autonomy: This implies that it is the patients right to choose whether or not to undergo a certain treatment. The doctor must give full information such as therapeutic effects, risks, side effects, positives and negatives to the patient. The patient should then be allowed to make a meaningful decision without any external influence or compulsion. In the tea-bar example, Dr. Khalid should have explained the risks and benefits of undergoing an appendectomy to Ahmed. He should have then let him make a choice about undergoing the surgical intervention. The underlying principle of this approach is called informed consent (explained in more detail later in this chapter). b. Beneficence: This calls for all medical professionals to do good for all patients under all circumstances, the same way as ordinary citizens are required to do good for their parents and children alone. Doctors, therefore, have a special relationship with their patients as they demand care from them as a duty and an obligation. (Javed’s objection to Dr. Khalid’s choice of charging the poor was based on the norm of beneficence). c. Non- maleficence: This refers to the obligation a doctor has to do no harm (or minimise it as much as possible) to his patients. It is an exten sion of the principle of beneficence. This requires the doctor to protect his patient against all forms of harm and always act in his best interest. Dr. Khalid’s decision to protect Ahmed from the risks of an inflamed appendix by operating on him even without his consent was an expression of this principle. The three principles listed above are accepted in legal terms as prima fcicie (assumed to be correct until proven otherwise). They form the basis for all other ethical guidelines, but none of those guidelines can be in contradic tion to them.
- 44. 3. Common EthicaLIssues in MedicaL Practice a. Informed Consent and Confidentiatity The two commonest ethical concerns for a physician are consent and confldentiaUty. These are also the two paramount norms that are most often ignored by physicians. Consent is omitted by most doctors on account of two reasons. Firstly. the paternalistic attitude of doctors thinking they know what is best for the patient. Secondly, the common folly of thinking that an illiterate or an ignorant patient may miss out on a cure if ‘crucial” time is wasted” in obtaining their approvaL There is also a fear that the patient may say no’ when data on the risks/hazards of intervention is communicated. Confidentiality of patient is also regutarly compromised when we share the details of the patient’s condition and clinical details with his relatives, friends and ‘well-wishers’, without the patient’s prior permission. The practice of undertaking interventions and heatth decisions without informed consent, as well as sharing a patient’s clinical data with anybody without his or her prior permission, are unethicat. What is Informed Consent? Consent is the agreement by the patient to undergo an examination, procedure, or treatment. It can be given orally, by signing a form or a written statement or simply agreeing by a gesture e.g. offering to pull up the shirt for letting the doctor examine the abdomen. It must always be obtained in advance. In order for the consent to be valid, the patient should be competent, that is. should have the capacity to make a decision (free of a defect of mind or judgment and not be a minor). The patient must give consent freely and voluntarily (without coercion or threat). S/he must also be given options to choose from and not fear rejection or neglect by the doctor in case he or she re fuses to agree. The patient must be offered all the information that a reasonable professional should have (prudent professional standard) and as much as a patient would like to know (prudent patient stan- dard). The minimum information required is, the risks involved, likely success rate, the side effects, and a comparison with other options. In Ahmed’s case, Dr. Khalid should have informed him of the risks of an aesthesia, and abdominal surgery. The doctor must also ensure that the information has been clearly understood. The whote process of seeking informed consent must be made after building a trusting re lationship with a patient. The patient should be able to see the doctor as caring, competent and reliable. Exceptions to the rule of informed consent are patients: brought into emergency and accident departments unconscious and alone requiring life-saving measures, children under 16 years of age (the parents have the right to provide informed consent) with an impaired capacity to give consent. Consent is a reflection of the norm of autonomy highlighted above as the foremost pillar of medical ethics.
- 45. by Peachy KeenBirth Services taceboak.com/Peachyteen6irth Use your B.R.A.I.N.S. When trying to decide if a precedure is right for you and your baby, here ore the questions to ask to make sure you hove cii of the information necessary to make an informed choke. D Benefits — What are the benefits of this procedure? What are we hoping U to achieve? R Risks—What are the risks or side effects? What other interventions will go along with this? Alternatives — What are our other options? I intuition— Doesthe informationyou’rereceiving make sense. Doyou I need additional info, or a second opinion? [%J Nothing — What if we do nothing, or wait a while before deciding? S ‘Scuse Me — Can we please have some time alone to discuss and decide? Informed consent shoutd answer these questions for patients Confidentiatity: How much? When can it be breached? It is the common law duty of a doctor to respect the confidence that a patient has in him, Doctors are expected to preserve absoLute con fidentiality on all that they know about their patient. This applies not only during the treatment but also after it and even after the patients death. This is a means of expressing respect for the patients right to privacy and hetps the patient speak freely to the doctor. Confiden tiality is the foremost part in the traditional Hippocratic Oath that alt doctors are committed to. A doctor’s registration with PMDC can be cancelled and misconduct charges in a court of Law can be pressed if found responsible for an unauthorised breach in confidentiaLity. There are instances, however, in which breaches of confidentiality can be made: • When a patient authorises it in situations such as while seeking medical fitness to gain employment or getting a medical report prepared for a second opinion. Patient has the right to ask for a copy of the medical report. They must always be explained the contents of the report and should always understand what they have consented to. • When information is to be shared within the health care team What you say in here stays in here. Unions: • Someone In honing yons • You want to hurt samson. • You ssant to hmtyosrsatt • You glue nsa pornsi.sionto sCans with a trusted adult Questions for Informed Consent • When the disclosure is in the best interest of the patient, as in the case of physical or sexual abuse, where confidentiality would mean a continuation of a perpetual hazard. In case of a terminally ill patient who does not wish to know the prognosis fully, the doctor may make the family or next of kin aware of the outcome, with the patients consent.
- 46. • When thedisclosure is in public interest and the doctor’s attempt at holding back information may harm members of the society. This includes instances such as reporting the matter to ticensing authorities when a patient is unfit to drive, or has a sexually transmitted disease e.g. is HIV positive and the wife is at risk. In all such circumstances. the patient should first be persuaded and counseLed to report the matter themselves. • In case of a Legislative requirement. This refers to matters of Laws on Public Health and control of diseases such as chotera, small pox, plague or venereal diseases. • For research purposes and case reporting as anonymous data, or if the identity of the patient may be surmised from it, after the patient’s consent. Medicat Students and the Issues of Consent and Confidentiality: Medical students may only be called to observe a clinical interac tion after the permission of the patient has been sought in advance and not after a patient walks into a setting where the students are already seated. A medical student may onty undertake a procedure after an informed consent has been taken. The patient must be briefed about the training level and status of the student. Adequate safeguards should always be put into place in all such settings and the patient duly informed about them. As regards confidenti ality, medical students have the same duty as the treating doctor. They must adhere to the same principles as those outlined for the members of the health team. Medical students may themselves be required to give informed consent if they opt to serve as healthy volunteers in research projects. The Dean/Principal of their medical cotlege must be kept informed in all such matters. b. Decision-Making Capacity Capacity in health ethics refers to the ability of the individual to understand the nature of their illness, the treatment options and the consequences of the decision. All adults are assumed to have the capacity to make decisions about their health and treatment options. This capacity may be impaired in certain conditions. A psychiatric consultation is not necessary to estabUish capacity of every adult. It is incorrect to assume that alt patients with psychiatric disorders lack this capacity at all times. Patients with psychiatric disorders or head injury must be clearly shown to have impaired judgement and inability to weigh options at the time of decision making. Patients with neurological illnesses like dementia do not automatically lack this capacity till late in the progression of their disease. They can make informed decisions in early stages of their illness and should be encouraged to do so by the family and the treating doctor. Next of kin may make decisions about a patient in a coma or veg etative state. The decision of continuation of life support in a brain dead patient, however, needs to be made by the medical authorities in collaboration with (but not necessarily with the consent of) the family of the patient.
- 47. With regards tominors, parents have the right to make decisions on behalf of their children. It may be inappropriate to have the same rute for teenagers. The physician should, however, encourage teen agers to participate in the decision making process and have a say along with their parents. Religious beliefs of an individual cannot be trespassed in informed decision making. All due respect should be shown to a decision of refusal of treatment on the basis of a religious belief. An organ transplant or transfusion may be refused by a patient on the basis of his beliefs. Parents do not, however, automatically have the right to use their belief system in decisions about their children’s health and treatment options. A court can authorise a decision in their place in situations where a conflict arises on this basis. Can an individual make advance directives regarding health-related decisions? The answer is yes. This can be done by making a Living witt. In this the individual makes their own decisions regarding treat ment choices they would or would not want in case their capacity becomes impaired. This option is particularly useful in decisions related to resuscitation, organ transplant, dialysis or organ donation. Patients may Leave specific instructions regarding cardiopulmonary resuscitation as Do Not Resuscitate (DNR), Comfort Care (a general withdrawal of life prolonging care in favour of the patients care), and Palliative Care. This can also be done by proxy, where the individual nominates a person who will decide on his or her behalf once he or she loses capacity to do so. Legally this is referred to asa power of attorney). The ethical dimension to be kept in mind is to give maximum control to the patients during the times when they can make sane, rational, and objective decisions about their life and death. c. Euthanasia Euthanasia is when a physician administers a Lethal drug to a patient, with the patient’s futl consent and voluntary cooperation. Euthanasia must be distinguished from Physician Assisted Suicide. Physician assisted suicide refers to where the physician dispenses (but does not administer) a lethal drug to a patient with intact capacity for the purpose of they themselves bringing an end to their life. Both are considered illegal and unethical in our setting. Certain Western societies have sanctioned voluntary euthanasia with strict controls in ptace. U. Malpractice In order to state that a health professional has indulged in mal practice, it must be established through adequate and sustainable evidence that the physician has wronged a patient and/or harmed them. It must be shown, however, that the physician had known better. It implies that the health professional was negligent and did not meet the required standards of practice. This includes failure to undertake informed consent.
- 48. e. Inclusion ofPatients in CtinicalTriaLs ClinicaL tria[s may only be started after approval of institutional eth ica[ committees. Patients can give informed and written consent to participate in clinical trials after being provided due explanation of details of the triaL Patients must have the option to opt out of the tri al at any stage. It is obtigatory for the principal investigator to predict. be aware of, and inform the patient of any dangerous consequences of the triaL 4. Common Ethical Ditemmas in a Heatth Professional’s Life On account of their unique position in society, doctors have access to the most intimate areas of peopLe’s lives. They are, therefore, likely to come across unusual social situations. The doctor is not expected to respond to these situations like other members of the society and a minor stumble on their part may compromise their position. Some of the common situations where he needs to show prudence and not take the obvious course are discussed below. a. Euthanasia Euthanasia or physician assisted suicide is considered one of the most prevalent problems when dealing with the ethics of patient management. A worldwide debate continues to rage on the subject of the ‘right to die.” Should people have the right to end their own tives when prolonging it will only cause them more pain? Should families who love someone so much that they don’t want to lose them continue to cause them more pain by keeping them alive? From the Greek term for “good death”, euthanasia means com passionately allowing, hastening or causing the death of another. Generally someone resorts to euthanasia to relieve suffering, main tain dignity and shorten the process of dying when death appears inevitable. Euthanasia can be voluntary if the patient has requested it or involuntary if the decision is made without the patient’s consent. Euthanasia can be passive — simply withholding heroic life saving measures or active — deliberately taking a person’s life. Euthanasia assumes that the intent of the physician is to aid and abet the pa tient’s wish to die. Most of the medical, religious and legal groups in both the United States and UK are against euthanasia. The World Medical Associa tion issued the following declaration on euthanasia in October 1987: ‘Euthanasia, that is the act of deliberately ending the life of a patient, even at his own request or at the request of his close relatives, is un ethical. This does not prevent the physician from respecting the wilL of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.” It should be noted that the Pakistan Medical and Dental Council also holds the same view on euthanasia. Practice of euthanasia by a doctor is considered a criminal act.
- 49. b. Accepting giftsfrom patients Sharing of gifts as an expression of gratitude is a common norm in nearly all societies, especially ours. In certain subcultures, in fact, the gift giver may feel insulted if his offerings are not accepted. A clear set of guidelines should therefore be fottowed by health • professionals which may then become a well-known custom of the medical community in the society. Citizens would then also gradually start to follow these customs. A safe recommendation in this regard is to accept a parting gift at the end of a successful treatment, as long as it is in form of a bou quet of flowers, a box of sweets or chocolates. You may accept this graciously. Patients who bring gifts during the treatment may cause problems. It may be an expression of the patients need for “more than usual” attention. They may be interested in developing a per sonal friendship, or being part of your non-professional life. Extrav agant and expensive gifts must never be accepted. This is because they signify that the patient is putting you under a heavy obligation or has elevated you to an extraordinary pedestal. Both scenarios can land the doctor into serious trouble in the long run. If a patient does so it is safe to return the gifts saying “I will not be able to accept this gift, as it is against my professional ethics. I assure you that my care and concern for your health wilt continue to remain the same.” In the scenario discussed previously, the patient who brought a mo bile phone for Dr. Khalid may have an agenda beyond the obvious meaning of taking medical advice readily. Dr. Khalid should have politely refused the gift and reassured the patient of his availability as and when required to provide professional advice, preferably in person. c. SexuaL boundaries violation: sexuat retationships in medicaL setting Doctors operate in odd hours, in close and sometimes intimate settings for long hours and without clearly defined boundaries of age, gender and social class. They work with fellow, senior and junior colleagues, nurses, paramedics, patients and their families, and visitors. They may also become associated with professionals from departments of sociology, social work, psychology, NGO5, the pharmaceutical industry, and other related organizations. Alt forms of liaisons and relationships involving personal intimacy of a sexual nature in hospital settings are considered unethical and illegaL This is to protect the sanctity of the medical profession and the hospital. A sexual liaison between a patient and his or her doctor is prohibited by law and the regulations governing the profession, the world over. At a psychotogical level such a relationship is considered at par with incest. The same rule applies to a medical student or any health pro fessional working with a patient. Patients are vulnerable to develop ing an erotic attachment with their doctor, a medical student or any health professional involved in their care and may even declare their passion. This can be handled by explaining in no uncertain terms that it is impossible for you to continue as their care provider in such a situation. Medical students themselves run the risk of being ex ploited by senior professionals and even teachers in the hospital and college settings. They must always report the matter to the Dean or Principal and to do so with immediate effect,
- 50. without fear andprejudice. It is useful to remember that a predator or exptoiter who threatens dire consequences if you inform a concerned authority is essentially a coward. Never feel fearful or overwhelmed by such an individual or a group. d. Charges and Fee: Patients, CoLleagues, Teachers, Medical Students The medical profession has traditionally been a service with no pri mary commercial interests. With the privatization of health services and involvement of health insurance in some capitaList countries, the delivery of service is nearly always associated with financial transactions, atbeit not always directly at the point of delivery. It is not unethical to charge a fee for a consultation, procedure or an intervention: it is against the customs and norms to base the doc tor-patient relationship on their capacity to pay. The charges should never be extravagant, or vary from one set for the poor and another for the rich. A simpLe ethical rule is to determine a fee structure that does not render a doctor, a procedure or an intervention, beyond the reach of an average citizen. Traditionally, doctors are not expected to charge their coLleagues, teachers, medical students or the extreme- ly poor. e. Retationship with the Pharmaceuticat Industry Doctors and the pharmaceutical industry need to have a congenial but professional relationship. This must be aimed at mutual pooling of resources to promote welfare of health institutions and patients and investment in research. The use of this relationship for personal gains or profiteering is unethicaL. It is unethical for doctors to seek financial assistance from the pharmaceutical industry, for travels abroad, material benefits for themselves or their families. They may, however, seek support in scientifically valid research pursuits provid ed the research is not aimed at promoting a particular product of the sponsor. They may also receive travel grants from the sponsor if they are traveling to present findings of this research on an academic forum. Grants from the pharmaceutical industry towards setting up or improving a health facility, or a service exclusively for the welfare of patients are a[so acceptable. Prudent use of pharmaceutical human and material resources to improve health literacy amongst patients and the community could be an ethical and useful pursuit. The pharmaceutical industry human resource and customised software may be useful in improving treat ment adherence. A doctor in particular and all health professionals in general must always guard against becoming biased by the promotional literature distributed by the pharmaceuticaL representatives. The preferred resource for information regarding a particular drug should always be peer reviewed medical literature. Health professionals must aLso refrain from luncheons, dinners and meetings held at holiday resorts or hotets under the cover of academic activities such as panel discussions’ and lectures etc. Dinner and Lunches with sponsored educational talks, or for the inclusion of patients in clinical triaLs, are not unethical: however a professional needs to use his or her own prudence as regards the reaL agenda of such a sponsorship.
- 51. Medication samples canbe accepted only for the exclusive use of deserving patients on the basic ethics principle ofjustice. These samples are not for the use of physician’s family and friends. Health professionals walk a tight rope in their relationship with the pharmaceutical industry. If used prudently this relationship can en hance the image of the medical profession and bring great advan tages for research and patient welfare. A minor slip on the doctor’s part or an overenthusiastic nonprofessional interaction can, however, cause him great harm. The single driving force for doctors when they prescribe drugs has to be the benefit of their patient. The doc tor under all circumstances must prescribe those drugs and inter ventions that are the most efficacious, cost effective and supported by most evidence-base. f. Media and Medicine The last two decades have witnessed a rapid growth of print and electronic media. This has resulted in our excessive dependence on the media for all kinds of information. Whether it is the latest development in politics or the day’s weather, the addictive nature of media technology keeps most people glued to their TV or computer screens for considerable lengths of time each day. The news media are also an important source of information on health and medical therapies. There is, however, widespread concern that some media coverage of scientific issues may be inaccurate and over-enthusias tic. Journalists and media managers have been criticised by scien tists and physicians for misleading the public over important medi cal issues. A 1997 survey of scientists found that the majority of them believed that reporters do not understand statistics wetl enough to explain new scientific findings, do not understand the nature of science and technology and are more interested in sensationalism than in scientific truth. For instance, sensationa[ised reports on the hazards of calcium channel blockers may have led some patients to stop taking their prescribed antihypertensive medications, while op timistic coverage of stem cell therapy resulted in patients requesting this unproven treatment. Similarly the internet hosts thousands of web pages offering all kinds of medical advice to the vulnerable user. 5Vhere e-medicine and e-consultations have effectively by passed the hurdLe of distance, they still remain vutnerabte to ex ploitation by quacks and impersonators. Despite the controversy, an effective and judicious use of electronic and print media along with internet can be made in regard to prevention of illnesses and promotion of health. The concept of e-Health offers many opportu nities for prevention, choice, home based care, and chronic disease management, and it has the potential to widen access to health care for most patients. Continuous Medical Education fCME) is being effectively imparted to a wide section of medical professionals through authentic medical websites such as ‘Medscape’ and video teleconferencing is an effective tool for sharing information through long distances today. Artist Laura Zomt The use of electronic and print media to improve health literacy is a noble public health pursuit. Such opportunities do, however, run the risk of misinformation. They also have the potential to be used
- 52. ?‘ for personal projectionby hea[th professionals. Patients and their families may expLoit such opportunities for seeking free advice with adverse and dangerous consequences. Health Literacy programmes cannot be used for advertising a particular drug or intervention or for provision of specific advice to viewers or callers on the show. The use of internet and eHealth can be brought to ethical use through organizing health promotion seminars and video conferencing to run CME (contipuous medical education) and CPD (continuous profes sional development) activities. g. E-Consuttations and Tetemedicine E -consultations and telemedicine has become a reality. Telemed icine is currently linking far flung areas and cities like Gilgit and Skardu with Islamabad. The phenomena of telemedicine is being practiced without boundaries around the world, and with video call ing features available in every social media app, it is likely to spread even more. Surgical interventions can now be monitored by experts in the field from a distance through video links, especially in war torn areas. The appearance of doctors on television channels is an important way to promote health Uteracy. It is, however, unethical to attempt to diagnose and treat patients during these interactions. Medicat advice should not be given out to peopte cat[ing in” to television shows. It is also not ethically correct to attempt to diagnose and treat patients on video calls. h. TechnoLogy-assisted Medicat services E -consultations and telemedicine has become a reality. Telemed icine is currently linking far ftung areas and cities like Gilgit and Skardu with Islamabad. The phenomena of telemedicine is being practiced without boundaries around the world and with video call ing features available in every social media app, it is likely to spread even more. Surgical interventions can now be monitored by experts in the field from a distance through video links, especially in war torn areas. The appearance of doctors on television channels is an important way to promote health literacy. It is, however, unethical to attempt to diagnose and treat patients during these interactions. Medical advice should not be given out to peopLe “calling in’ to television shows. This is ethically incorrect. i. Declaration by a Medicat Student or a Trainee Heatth Professional It is mandatory for all medical students and trainee health profes sionals to declare their exact role and identity. It is unethical for medical students to pose as junior doctor’ or doctor on duty’ in front of an ignorant patient or a family member. Trainee psychologists, clinical psychologists and other health professionals working in hospital settings can be mistaken for doctors. They often do not object when addressed by the patients or their families as ‘doctor. This tendency must be curbed, in favour of revealing your exact identity and role in the health team and taking pride in it. Most patients enjoy talking to medical students and trainees from other health disciplines as they have more time for them and are more interested in their condition
- 53. Eysenbach G, ]adadAR Evidence-basedPatient Choice and Consumer heatth informat/cs in the Internet age ] Med Internet Res 2001,3t2):e19 URL: http://wwwjmit org/2001/2/e19 DOl: lo.2196/jmir.3.2.e19 PMID: 11720961 PMCID: PMC1761898 5. Doctor-Patient Relationship Ifyou have come to hetp me You are wasting your time But ifyou hove come because Your tiberation is bound up with mine Then let us work together - An Australian Aborigine’s statement to a Doctor The basis of the unique relationship between doctor and patient is the capacity of the doctor to appreciate the complexity of human behaviour. A doctor must be sensitive to the effects of history, culture, and environment on his patients. At the center of this therapeutic retationship is the trust that a patient has in the doctor, This trust is built on the unconditionaL positive regard that the doctor holds for the patient, irrespective of their gender, social class, caste, colour or creed. The bond that forms in the relationship can take three forms: The vertical model, where the doctor completely takes over the process of care with the patient having virtually no role e.g. when a patient is unconscious, immobilised or in an altered state of con scious, or is incapacitated. The teacher-student model, where the doctor plays a roLe similar to that of an authority figure (such as a teacher or a parent), who dom inates, controls and guides the patient e.g. in the case of a patient - recovering from a surgical intervention. The mutual participation, horizontal modeL where the doctor and the participation behave as partners in the process of healing and care. Each augments and supports the other’s effort. The patient in this is fully aware and informed and plays an active role in the treat ment process e.g. a patient of diabetes metlitus who understands the nature of his/her illness and undertakes lifestyle changes to manage it with the doctor’s cooperation. is an active partner in the management process. C ‘4(1’-” / - j F,b / ZL:Z ; 2 48
- 54. It is importantto note that the relationship between doctor and patient should be based on empathy, not on friendship or affection and love. Such a model is not always unethicaL but may turn the relationship into an unprofessional one with obvious repercussions and dangers. The major dangers in this relationship include: The doctor assuming the role of a savior and fantasizing that only they can reEscue the patient from all the troubles of the world The doctors inability to switch off and leave behind the patients problems when away from the clinical setting. A need to control everything in the patients life and to try and pre vent death, which may not be possible in all cases. A doctor visualising his or her own complexes and difficulties in the patients issues e.g. a doctor having a disturbed relationship with his father, assuming that the patient must also be going through such difficulties or a doctor avoiding discussion of such an issue with their patient even when it is of clinical significance. The doctor becoming judgmental in the relationship with the pa tient and starting to determine what he or she ought and ought not to do. An enthusiastic medical student handing over financial or material help to a patient or seeking them from a patient. Both transactions are against the norms of professionalism. Rights and Responsibilities of Patients and Doctors a. Rights of the Patient It is useful to have a list of rights that medical ethics grant to a patient. Doc tors have a duty to communicate and assist patients in protecting these rights. Patients have the right to: • have informed consent taken from them. This is after they have been educated about the illness and its treatment, alternative treatment options and side-effects involved. Costs of the proposed treatment and any further costs associated with rehabilitation and details of support services must alo be communicated to the patient. withdraw consent at any time. refuse experimental or research treatment. • obtain a second opinion. • confidentiality regarding details of a condition and treatment being maintained by medical and hospital staff.
- 55. be treated withcare, consideration and dignity. • request medical files from the doctor. • obtain legal advice regarding any matter arising from the treatment. • contact friends, relatives, soLicitors, members of the religious/faith group or his or her wards if he or she is the parent or guardian. • ask to stay with a child at all times except where separation is necessary for medical reasons. • inform nursing staff if he or she wants to or does not want to see or speak to a visitor. b. ResponsibiLities of the Patients Besides their rights, patients have certain responsibilities, such as to: • Know their own medical history including medications taken • Keep appointments or advise / inform those concerned if they are unable to do so. • Comply with the treatment advised / supplied. • Inform the doctor if they are receiving treatment from another health professional • Know how their charges of treatment are best covered. • Conduct themselves in a manner which will not interfere with the welt-being or rights of other patients or staff. c. Rights of the Doctor A doctor has the right to refuse to undertake an action, a procedure or an intervention which is against his/her personal ethics or beliefs. S/he also has the right to refuse to treat a certain individual (provided the individual is not in any immediate Life threatening danger). In such an eventuality the physician is under obligation to refer the patient to another professional. d. ResponsibiLities of the Doctor • leave a hospital at any time (except in the cases of infectious disease or certain psychiatric conditions). If the patient leaves against medical advice, however, s/he is liable for any injury or illness caused, or ag gravated by. the action. ‘!L’1’ Z/— Whon 14t WSflI .‘c— cJon, wtflQ,nfl ID rDu. It is a doctor’s responsibility to provide scientific information on disease, diagnostics and treatment options available to the patient. S/he is also re sponsible for addressing a patient’s concerns and taking informed consent for all therapeutic actions. Doctors must respect the patient’s decisions even when they are in disagreement with them. They must uphold the interest of their patient above their own (fiduciary). They must also never use their authority in any cause other than the best interest of the patient.
- 56. Miss X, atwentyyearoldstudent from the local intermediate cottege, was admitted in a long stay medical ward undergoing treatment forpulmonary tubercutosis. Mr K a thirdyear medical student was assigned to take a de tailed medicat history and examination. During the course ofhistory taking, Mr Ynoticed that only after a few minutes ofinteraction, Miss Xsat up in the bed and became cheerfuL Even while describing the details ofher cough, toss ofweight and night sweats she woutd smile. At the end offorty minutes assignectfor taking the aacount, Mls.XinsistecTthdt Mr. Yshould tal?e a bite from the fruit basket or else take a cup oftea with her She mentioned that some ofthe important details ofthe history have not been yet covered and asked the medical student to come in the evening and she wilt be glad to furnish further details. Mr Ywas impressed by the ‘unusuat’friendly attitude of the patient He turned up in the evening, to find that Miss X was waiting for him. She not ontygave a detailed account ofher iltness but also reported ‘feeling much better”since hermorning interaction with Mr Y. She told him how impressedshe was with the ‘kind andpleasant personatity”ofMr Yand that she had never seen such a wonderful ‘doctor.”She asked for Mr Y’s mo bite numberso that she could talk to him when she felt distressed or unwelL Mr Ygtadly agreed. On his way back from the ward, Mr Ywas thinking about the “positive impact” that he had on his patient He decided that he should visit her regularly during his clinical rotation to “assist herfeel better” Next day he bought fruits,juices and chocolates for the patient He did so secretively, so that the ward staff and his batch mates should not ‘make stories’ or ‘get ideas The gesture went down very well with Miss X In a few days, Ywas a regular visitor to Miss X even after his batch moved on to the surgical rotation. Miss X would regularly call on his cell phone to seek advice. She started to share her unhappiness and her arguments with her mother and how much she missed her kind and affectionate father whom she had lost as a child. Yin the meanwhile start ed to advise her on social and domestic issues, how to deal with her “cruel mother” He started to feel like the only ‘saviour’ and ‘friend’ in X’s “miserable” life. When the ward staffbegan to object to his visits, Mr Ystarted to get into arguments with them and insisted that he was doing so to keep the patient happy and healthy. In a few days, Miss X was discharged from the hospitaL One evening Mr Yresponded to a knock at his hostel room’s door to find Miss Xstaning there with a bag in her hand. She told him that she had left the home and her callous mother who wanted to marry her offto a cousin against her wilL She stated that Mr Ywas the only one whom she thought “really understood and cared”forher and could save her from the wrath of her mother Mr Ywas flabbergasted and did not know what to do. He hurried ly made her sit in the WRoom and started to insist that she return home. He categorically stated that he could not really take responsibility ofMiss X Miss Xbroke down into tears initially and then started to shout and cry, accusing Y ofmisguiding her, and saying he was “no different from the rest ofthe unkind world.” Word started to spread in the hostel and the warden arrived. Miss X’s famity was contacted and she was returned home with great difficulty. Mr Y was severely reprimanded and for many weeks became the laughingstock of his class. Miss X was admitted in the psychiatry ward with an attempt at de liberate self-harm as she took an overdose ofher anti TB drugs and slashed her wrists. Mr Ywas called by the treating psychiatrist, where he learned of the psychological reactions that had led to his and Miss X’s ordeaL It took many weeks ofintense psychotherapeutic work for the mental health team to work through the issues. In the course ofMiss X’s treatment and Mr Y’s coun selling sessions, the phenomena oftransference, counter-transference and resistance became clear to Mr K
- 57. Psychological Reactions inDoctor-Patient Relationship The primary expectation of patients from their doctor is that they show empathy, that is, understand their feelings, show kindness, interest, and a non-judgmental approach. They also expect to be considered active partners in care. In Pakistan the doctor is given the status of someone who always makes the better decision for you in matters of health. This leads to either feelings of sympathy (feeling and experiencing the emotions of the patient) and over-identification with the patient, or distancing and isolation from the patient. Both reactions on the part of the physician can make the relationship complicated or take a turn that undermines professionalism. There are a variety of social and psychological reactions in a typical sus tained doctor-patient relationship. These phenomena are most intense in psychotherapeutic interactions but can occur in any helping relationship in a milder or a somewhat modified form. They are: • social bonding • dependence • transference • counter-transference • resistance • physician burn-out These reactions occur in the mind of the patient as well as the doctor without one’s normat awareness. They can help a doctor understand why a certain patient is reacting in a particular way or why they themselves are behaving differently with a certain patient. a. Social bonding Pakistan is a unique mix of urban, rural, semi urban, modern, pagan, east ern and western cultures. Its Islamic heritage and connection with the Arab, Central Asian and Persian tradition further defines the nature and form of its relationships. The modern doctor who practices allopathic medicine is linked with the British Raj. Fotlowing the independence in 1947, the tertiary care hospitals were run by doctors trained in Britain. The traditional rela tionship that the common man has with the doctor is similar to his bond with the ruling elite in the 19th and 20th century. which was heavily under the Western influence. The common man, therefore, has an urge to form a closer social bond with the doctor, who is seen as part of the elite. The doctor in his own need to be part of the elite makes constant efforts to socia[ise with high ranking government officials, miLitary, politicians, and others in power. This arrangement grossly undermines the professional nature of the bond that should ideally exist in an ethical health setting. It results in the so-called VIP culture in hospitals, and grossly undermines the • founding principle ofjustice in medical ethics. The quality and nature of social bonds between doctors and their patients is expected to take a new shape with the advent of social media. All at tempts at forming social bonds that can challenge the professional
- 58. nature of doctorpatient reLationship must be guarded against. This in c[udes befriending patients on sociaL networks or making them privy to doctors personaL Lives. This is because this shifts the focus of the doctor patient reLationship to the doctor, instead of remaining on the patient and their treatment. It also transforms the doctor patient relationship from a therapeutic to a social one. This may also lead to serious issues of trans ference and counter transference. b. Dependence The vertical nature of the existing relationship between doctors and their patients puts health professionals on a higher pedestal, where they are asked to make crucial health decisions concerning the Life of their pa tients. Traditional family physicians even have a say in personal and family decisions of the community that they serve. This unique status gener ates strong psychological dependence of patients on their doctors. If the patient has dependent personality traits, this dependence can become counter therapeutic and lead to negative heaLth outcomes. A dependent patient can start to tax health resources, a doctor’s time and energies. They may, then, translate their dependence into hostility and anger towards the health profession. An ethical doctor ensures earty detection and management of this psychological reaction. If there is a failure to manage this state it is safe to refer the patient to a colleague for further management after briefing them on the issue. c. Transference Transference is when feelings, attitudes and desires originatly linked with a significant figure in a patient’s life (usually childhood) are projected or transferred onto the doctor. Transference may be positive or negative. The significant figure may be a patient’s parents, sibling or someone that the patient was close to. Depending on the nature of the relationship of the patient with that person in childhood, the feelings for the doctor can be positive or negative. In the case mentioned above, Mr. Y, was seen as a kind and compassionate repLacement of the Miss X’s [ate father. CIii1c 114e D€TO Tht TO -::.--J1
- 59. When a patientis seen showing aggression towards a doctor, with no ob vious cause in the present, this may be an expression of negative transfer ence. A doctor unaware of the phenomenon of transference, may find this behaviour threatening and offensive. Similarly, positive transference feelings amongst patients commonly occur on long stay wards for the female nurses attending them. The femate doc tor or nurse may remind them of a mother or a caring elder sister. Patients in such a state may openly express their desire to bond with the nurse or a doctor as a sister, brother, mother, father, uncle or aunt. Due to the patient experiencing this transference, s/he may give the doctor an elevated sta tus, and start to compliment them unduly. It is important for the doctor or other health professional in this situation to reaLise that the patient knows next to nothing about them personally and is merely identifying them with • someone they knew intimately. This may become difficult, as the show of this emotion may be quite flattering, especially if coming from the opposite sex. $ Unresolved and unaddressed transference can tead to prolongation of the patients stay in the ward. Patients may begin to ask for personal phone numbers and home addresses of the carer. They may also begin to invite the doctor or the nurse to meet outside clinical settings (as in the case of Mr. Y and Miss X). The ethical dilemmas that may follow this behaviour call for a constant awareness and understanding of the phenomenon of trans ference. d. Counter-transference If an adult patient in a medical ward wants to be examined by one partic ular doctor, wishes the doctor comes to their bed first and spend longer time in their company, it may be on account of a paternal transference. The doctor, on account of his physical appearance, mannerism, or personal ity, may remind the patient of their father. The feelings for the father that the patient felt as a child and were tong forgotten, may come to the sur face during their admission. This often happens as patients in a ward feel dependent and cared for, the same as children. This behaviour amongst grown-up patients of reverting to child-like behaviour is catted regression. In this state they start to feel a strong bond for the doctor, similar to one they once had with a parent figure as a child. In countertransference the emotional responses of the doctor are directed towards the patient. Similar to transference, countertransference may also be negative or positive. The patient in such situations reminds the doctor of a welt-loved or hated individual from the past. and fulfils an unfulfilled psychological need. In the case of Mr. Y, (mentioned before) his deep Poctor, I had a dfficuIt childhood.
- 60. I seated desire tofeel like a rescuer was fuLfilled by Miss Xs reaction. In another setting, a young doctor during his house job began spending long hours in the care of a 60 year old patient with hemiplegia. He would miss his ward rounds, emergency duties and even his rest hours to be on the bedside of the patient when there was no cLinical need to do so. A deeper took into the situation revealed that the patient’s looks greatly resembled the doctor’s deceased father, who died of stroke many years ago, and who the young doctor had failed to took after. In this case, the doctor experi enced countertransference towards the patient. Unaddressed counter- transference can greatlyjeopardise the professional life of a doctor anci compromise the quality of the doctor-patient relationship. How can transference and countertransference issues be dealt with? The most important measure in all health care settings is to have a con stant awareness of transference and countertransference. A conscious understanding of the feelings, positive or negative, that a doctor or their patient is having can make behaviour clinicat and prudent. Transference or countertransference may become overpowering and adversely affect the doctor’s ctinicatjudgment or progress of the patient. In such a case, care of the patient should be shifted to a more experienced colleague. It may become necessary to report the matter to the consultant or head of department to make alternative arrangements. This is an action that Mr. Y should have undertaken at the very onset of his discovery of the phe nomena of transference and countertransference; Mr. Y instead kept it a secret as he was unaware of the psychological reactions setting in. In case there are repeated episodes of transference and counter-trans ference with a particular doctor, it is appropriate for them to seek psycho therapeutic advice from a mental health professional. It is also important to work towards ensuring the therapeutic relation ship is strictly professionaL Making statements to a patient such as “you remind me of my mother”, or referring to patients as Uncle, Amma or Cha cha is not helpfuL The use of titles such as Mr., Ma’am, or Bibi or Sahab to refer to patients is respectful and culturally appropriate. e. Resistance Some patients may be seen constantly defying a doctor’s instructions in spite of repeated warnings of the serious consequences. An example of this is a patient of coronary artery disease who refuses to give up smok ing, eats red meat regularly, finds evening walks “boring” and makes no attempt to shed weight. This patient is exhibiting what is referred to as resistance in the doctor patient relationship. Resistance is a result of use of unhealthy defense mechanisms such as denial, avoidance, rationaliza tion and suppression (discussed in detail in section E). The patient is often unaware of this and it may be useful to discuss these in a therapeutic interaction. This will help to make the patient conscious of the basis of their faulty behavior and work towards improving it. Resistance can seriously disrupt the doctor patient relationship. A doc tor who is unaware of it may gradually start to withdraw from the care of such a patient or refuse to treat him at alL The patient may become even more resistant to treatment following or develop hostile feelings towards the doctor. Resistance may be a transitory stage in the treatment process.
- 61. gradually receding onits own. It may be resolved with a couple of sessions addressing the issue in a meaningful discussion with the patient. Clinical ty, resistance may present as or non-adherence to treatment on part of the patient. When a patient is repeatedly seen to do so, it is important to consider it a psychological reaction that needs a deeper insight and un derstanding. f. UnweLL Physician / Burn-out With increasing personal and professional demands. there is a proportion- ‘ I . ate rise in stress experienced by health professionals. This increased stress - ‘- may lead to maladaptive methods of dealing with the situation, causing the ,. . ‘ heaLth professional to burn out.” Burnout refers to a form of psychological stress caused by mental and physical exhaustion. It leads to an increase .. in the number of health professionals who develop depression, become suicidal, indulge in drug abuse, alcoholism and other risk taking behav- Arfist Laura Zombie ior patterns. This adversely affects their professional and ethical standing. These health professionals are a risk to themselves, their patients and their own family and community. Early signs of burnout in physicians include the following: • Long working hours without any time for exercise, healthy family life, and interaction with friends • Loss of temper and anger outbursts at work and at home • Chaotic family life • Impaired clinical decision-making and deteriorating performance • Frequent job changes • Un-prescribed use and misuse of painkillers, tranquillisers, smoking, alcohol abuse It is ethical tooffer and provide help to a colleague who is showing early signs of impairment in performance due to burnout. In case they refuse to seek help and continue to see patients, the matter may need to be report ed to PM&DC or the employers.
- 62. Professionalism in HealthCare A healthy doctor-patient relationship is dependent on the professional excellence of a doctor. Professional excellence is based on the knowledge, skills and attitude of the physician, who is expected to treat both the psy che’ (mind) and the ‘soma’ (body). The following attributes of knowledge, skills and attitude are essential for any doctor to be considered a professional. a. KnowLedge i. Distinguish normality from abnormality from a medical. social and psychological perspective ii. Relate biological factors with psychosociaL factors in health and disease iii. Learn the use principles of behavioural sciences in clinical interviews, assessments and management plans iv. Request and justify not only laboratory, radiological, and electrophysiological investigations but also make social and psychological inquiries v. Use pharmacological as well as non-pharmacological interventions. vi. Apply evidence-based research findings to clinical situations b. SkiLLs Written Communication ShiLLs: i. Demonstrate competence in medical writing ii. Write a comprehensive history of the patient iii. Update medical records clearly and accurately iv. Write management plans, discharge/transfer summaries and referral notes VerbaL Communication ShiLls: i. Establish professional relationships with patients and their caregivers to obtain a history, a physical examination and make an appropriate management plan ii. Demonstrate usage of appropriate Language in bedsiçfe sessions, outpatients, E-communication, seminars, iii. Demonstrate the ability to communicate clearly and sensitively with patients, relatives, other health professionals and the public iv. Demonstrate competence in presentation skills v. Provide informational care and counsel patients f. Use principles of effective communication (section A) in all his/her clinical interactions.
- 63. Patient Management Skitts: i.Interpret the history and examination findings and arrive at an appropriate differential diagnosis and final diagnosis ii. Demonstrate competence in cLinical problem identification, analysis and management of the probtem using appropriate resources üi. Prioritise cLinical probtems for interventions iv. Use evidence-based pharmacological and psychosocial interventions v. Independently undertake counselling and informational care sessions Skitts in Research: i. Undertake relevant literature searches and collect evidence based guidelines for use in clinical practice ii. Interpret and use resuLts of peer reviewed and standard articles to improve clinical practice (and learn to not rely on data published by groups with a vested interest) iii. Organise and actively participate in educational, training and research activities c. Attitudes Towards Patients: i. Establish a therapeutic and ethical relationship with all patients ii. Demonstrate commitment to the biopsycho-’social model in the assessment and management of patients iii. Demonstrate sensitivity, empathy and understanding while performing physical and mental state examinations iv. Consistently show consideration towards the interests of the patient and the community and place them above personal interest v. Adhere to principles of medical ethics under all circumstances vi. Exhibit highest standards of professionalism through the practice of integrity, compassion. honour. humanism and respect for patients. colleagues, seniors and juniors, vii. Demonstrate ability to work as a team member as well as a leader Towards SetfDevelopment: i. Demonstrate consistent respect for every human being irrespective of ethnic background. culture. soclo-economic status and religion. ii. Dealwith patients in a non-discriminatory and prejudice free manner. iU. Deal with patients with honesty, equity and compassion. iv. Demonstrate flexibility to adjust appropriately to changing circumstances.
- 64. v. Foster principlesof self-education and reflection in order to constantly update and refresh knowledge and skills vi. Recognise stress in self and others. vii. Deal with stress and support colleagues and allied health workers. viii. Handte criticism by colleagues or patients constructively. ix. Obtain and value a second opinion on clinical matters. x. Demonstrate effectiveness as a member as well as a leader of the health team Towards Society: i. Exhibit sensitivity towards the social, ethical and legal aspects of health care provision ii. Offer cost effective professional services In addition to the above attitudes s/he must demonstrate a commitment towards following measures of professionaL character deveLopment. These measures can be used by the trainers of medical students and post-graduate trainees to measure professionalism for assessment and feedback. ProfessionaL Attire: A medical student or a doctor is expected to dress in serious, non- provoking and non-offending attire. The bearing of the health professional should help patients become comfortable. It should not in any way give an image of self-neglect or non-concern. Respect for time and punctuatity: A doctor is expected to be punctual and prepared for ward rounds, lec tures, and procedures for patients. This attitude affects the morale of patients, colleagues and students as it reflects commitment towards the profession. A lack of this attitude marks lack of discipline, structuring and organizing capabilities of the doctor. Grasp and knowtedge about patients under care: A doctor is expected to have a grasp and knowledge of the patients s/he interviews and should be equipped with basic literature about the patients’ illness. S/he is also expected to present the patient’s history to the consul tant the next day of hospitalisation. An expression of this pattern is viewed as a positive professional attitude. Lack of this indicates poor work ethic and insufficient intellectualstamina. Conscientiousness: Taking responsibility in carrying out clinical assignments reflects interest in learning and efficient patient care. A doctor is expected to have a responsi ble attitude about his/her patients, which profiles them as a conscientious professional. Inconsistency of this attitude indicates health problems, am bivalence towards career, and inability to become a real professional.
- 65. A doctor ora medical student is expected to adhere to the basic human value of understanding detaits of a patient’s clinical findings and reporting them with accuracy, integrity and confidentiality. A failure to acknowledge one’s mistakes and omissions in reference to patient’s clinical information qualifies for serious professional dishonesty and merits dismissal from training. Avaitabitity to the patients: Doctors are expected to be available to their patients on a daily basis through appointments, and/or telephone. When on leave or out of station on duty, they must be available on telephone to the patients they consider need attention. They must inform the patient of this in advance and intro duce them to another doctor who has been briefed about their condition and will care for them in their absence. Relationships: Relationships with patients, hospital staff, fellow students, colleagues and faculty member are expected to be of mutual support. respect, and professional honesty. Difficulties in dealing with or failure to cooperate with any one or more of these people may reflect health problems or serious personality issues. Integrity in reporting patients’ findings: Assessment of Attitudes (Professionalism) Score in Doctors Professional attire!demeanour •1I Iactf9rumeandpuncwky:: -. - 7 3 Grasp and knowledge ofawn patients L Integrity in reporting patient findings Relatbnsblps with colleagues, hospital staff and patients * Score 7-70 -.
- 66. I SAMPLE MCQ FORSECTION B 1. A young man undergoes a three month tong treatment by a femate doctor. Upon his recovery, to show his gratitude he brings her an expensive gift. Themost ethicaL way to respond wouLd be: a) Report the matter to the head of department. b) Ask the patient to leave immediatety, or you will call security. C) Tell the patient you will be right back and send in a male colleague to manage the situation d) Take the gift but tell the patient to never bring you anything ever again e) Politely refuse to take the gift and explain to the patient that it is against medical ethics to do so. 2. A 25 yr old male presents to you in emergency, after a road traffic accident. On examination he is seen to have had profuse blood toss, has low BR and cotd clammy skin and he is drowsy. What is the most appropriate action: a) Try to wake him up so he can give consent to proceed further. b) Wait for the patient’s brother to arrive so he can give consent c) Start Life saving measures immediately as the situation is an emergency and does not require informed consent. d) To refuse treatment without available consent. e) Ask your senior to decide. 3. A patient recently diagnosed with Type II Diabetes mellitus refuses to cut back on the use of sugary drinks and sweets, despite being given informational care by his doctor, and warned of the serious consequences. He is displaying the phenomenon of: a) Transference b) Resistance c) Counter-transference d) Non-compliance e) Emotional instability. 4. You have been asked to taLk to a patient who has refused diaLysis for renal failure. The most appropriate strategy would be to: a) Provide detailed informational care in an exclusive setting b) Listen and empathise with unconditional positive regard c) Explain the pros and cons of her decision and then leave the choice of dialysis to her d) Explain to the patient’s family the importance of dialysis and ask them to convince her e) Take the patient for dialysis without telling her
- 67. 5. A youngman reports to the medicat OPD with swotten tymph gtands, genital uLcers, and chronic fatigue. He is admitted and upon testing is found to be H IV-Positive. According to the principtes of medical ethics, the most suitable action is to: a) Not give any one the information to protect confidentiaLity b) Tell the patients family to tell everyone he has been in contact with C) Inform the patients wife immediately. U) Convince the patient to keep the information quiet, to protect him from the stigma e) Counsel the patient regarding the transmission of HIV, and persuade the patient to tetl his wife himself. Inform him of your responsibility to teLl her yourself, in case he refuses to do so. Sample Short Essay Question For Section B 01. What are the essentiaL principles of medical ethics? HighLight the two most commonly ignored ethical norms in medical practice. 02. Differentiate between transference and counter-transference. Answers i.e 2. c 3. b 4. c 5. e
- 68. ECTION C sychology inMedical Practice OUTLINE • Role of Psychology in Medical Practice Principles of Psychology • Learning • Metacognition Memoty • Perception • Thinking . Emotions • Motivation Intettigence Personatity Neurobiological Basis of Behaviour Chapter 1 Psychology in Medical Practice Human thought, behaviour and interactions follow a set of psychological processes and principles. The role of these principles and factors in the main tenance of health and illness is of crucial importance. Some of the hea[th and disease situations influenced by psychological factors are as follows: a. Rote of psychoLogicaL factors in the aetioLogy of heaLth probLems There are many habituaL patterns of behaviour that can adversely affect one’s health and increase ones susceptibility to illness. There is ample ev idence that chances of developing a heart disease are increased amongst those who smoke, consume a fatty diet and adopt sedentary lifestyles. Obesity, misuse and abuse of tranquillisers, alcohol, street drugs like cannabis, heroin and stimulants, risk-taking, and thrill seeking behaviour, are all known to lead to diseases and consequences that include diabetes meltitus, cirrhosis of liver, psychiatric disorders, and road traffic accidents with obvious morbidity and mortality. Public health interventions to address these unhealthy lifestyLe factors and promote healthy behaviours in the community can decrease the subsequent risk of the illnesses mentioned above. b. Rote of psychotogicat factors in the precipitation (triggering) of iLLnesses Physiological processes in humans are directly affected by psychological stress, e.g. the immune system. the endocrine system, and the sympathet ic and parasympathetic systems in the body etc. There is scientific evidence that traumatic life events (called critical incident stress) and persistent high stress situations (called cumutative stress) can trigger either
- 69. the first episodeor a repeat episode (called recurrence) of a variety of dis eases. Some common examples incLude ischemic heart disease, asthma, allergies, acid peptic disease, migraine etc. c. RoLe of psychotogicat factors in the management of iLLnesses: Even after a disease process has started, psychological and social fac tors ptay an important role in the course of iLlness, both in aggravating it or recovering from the illness. For example, positive behavioural changes are an integral part of the management of diseases like diabetes meWtus, hypertension, and ischemic heart disease. Similarly social support ptays a vital role in the management of serious illnesses like drug dependence and schizophrenia, among many others. d. Rote of psychoLogicaL and sociaL factors in diseases causing disabiLity, handicap and stigma ALL illnesses which resuLt in temporary or permanent disability or handicap give rise to serious psychological reactions in patients and their carers e.g. despair, hopelessness, guilt, anger, frustration, and Loss of motivation etc. Similarly, illnesses associated with social stigma. e.g. HIV/AIDS, are also as sociated with various psychological and social challenges, and addressing these issues is an integral part of the management of such illnesses. e. Rote of psychotogicaL factors in patients’ reactions to iLLness A persons attitude towards his/her illness can play a vital role in determin ing a person’s future health. Poor compliance with the doctor’s prescrip tion continues to beone of the major hurdles towards the success of any treatment. This non-adherence to treatment is often on account of exces sive and inappropriate use of psychological defence mechanisms. Some people develop a liking towards some aspects of their sickness, such as the excessive attention they get from everybody while they are ill and thus develop sick-roles, which can detay their recovery, and return to work. A positive psychological reaction to illness on the other hand can hasten the recovery and the healing process. f. Medicatty UnexpLained Physicat Symptoms (MUPS) MUPS include a wide variety of apparently physical illnesses that have been shown to have a psychological causation. These are seen in most medical and surgical specialties and include disorders Like irritable bowel syndrome, non-utcer dyspepsia, temporo-mandibular joint dysfunction,
- 70. 8. Intelligence 9. Personality Chapter2 Principles of Psychology 1. Learning MasterA, an 8 year old boy, used to wet his bed almost every night He was ashamed of this and was ridiculed by his cousins. His parents became worried and took him to a doctor who referred him to a psychiatrist. A’s therapist decided to teach him to remain dry during the night by using a number ofbasic learning principles. He was given a buzzer which would sound the moment he passed urine in bed at night, thus waking him up. The idea was to associate the stimuli from a full bladder and the urge to urinate with waking up. IfMasterA woke up in time, he could go to the bathroom before he could wet his bed. In addition to this device, A and his mother were explained a behavioural technique by which A had to change the sheets himself with no help when the bed was wet On the other hand when the bed was dry, A was given a chocolate. After 21 consecutive dry nights the buzzer would be removed, but the behavioural method ofrewarding a ‘dry night’ with a chocolate would remain in place. A review after two months of the start of A’s treatment, his buzzer was removed, since he had remained dry for 21 consecutive nights. He wet his bed twice after this but that was all. In the next 18 months, MasterA stopped wetting his bed. How in your view did he overcome his bed wetting problem? writer’s cramp, atypical facial pain, chronic fatigue syndrome etc. Besides the psychological causation, their management also involves various psy chologicl interventions. A list of psychological phenomena that shape human behaviour in health and disease, therefore, needs to be analysed. A study of these processes of normal human psyche can help a medical student to enhance under standing of their own behaviour as well as assist in developing a deeper insight into t[e behaviour of cotleague, other professionals and most importantly, patients and the individuals around them. These include: 1. Learning 2. Metacognition 3. Memory 4. Perception 5. Thinking 6. Emotions 7. Motivation The psychological principle, that formed the basis of Master A’s treatment, is called the Learning theory. Learning is the process by which new be haviour patterns are acquired, This is a key process in human behaviour. It plays a central role in our language, customs, personality traits and even our perceptions. Humans have instinctual patterns similar to those of an imals but their complex behaviour patterns are a result of their advanced learning capacity. Learning is a relatively permanent change in behaviour, for better or worse.
- 71. a. Operant Conditioning Learningtheory implies that learning new behaviours or changes in behaviour occur on the basis of the environmental conditions or responses to it. This is known as operant conditioning or instrumentaL conditioning. Operant conditioning was established by the work of BE Skinner. Operant conditioning occurs when a behaviour that is not a part of persons naturaL responses is learned (or unlearned) by consequenc es in the form of reward and punishment. Operant conditioning explains the learning of voluntary behaviour, such as motor actions. The famous Skinner Box demonstrated operant conditioning by placing a rat in a box in which the pressing of a small lever produc es food. Skinner showed that the rat eventually learns to press the bar regu[arty to obtain food (reward). If, however, the rat pressed the [ever and received an electric shock or nothing at aLl, (punishment or [ack of reinforcement) it stopped pressing the lever. Skinners work showed that operant conditioning works on the princi ples of reinforcement. Reinforcement refers to any event that increas es the chance that a response will occur again or a behaviour will be repeated. There are three types of reinforcement: Positive reinforce ment (reward), negative reinforcement and punishment. Positive reinforcement is when one receives a reward for a behaviour, which results in the behaviour being reinforced, and thus, repeated. This reward may be in the form of attention, praise, success, a mate- nat gain. An example is a child who consistently gets a praise or hug for picking up his toys. after playing with them will learn to be neat and orderly. Operant Conditioning Reinforcement Punishment Increase Behavior Decrease Behavior I I I Positive Negative Positive Negative A.d appetatrve stimulus nordous stimuli gggg appetative stimulus following correct behavior following behavior following behavior Gn,,,g hrdwus rxioog Escape Active Avoidance Bcmv noxious stimuli Behavior avoids noxious following correct behavior stimulus .,., ,*,,,, dorr xywn,.., vwwco6,d,* ,frw .,,no.6Avn Postive presence of a stimulus Negative absense of a stimulus Reinforcement increases behavior Punixhment decreases behavior Escape removes a stimulus Avoidance prevents a stimulus
- 72. Punishment is whena behaviour is followed by a painfuL stimulus, resutting in the behaviour being stopped, and not repeated. If a child puts her finger into an electric socket and gets electrocuted (punish ment), she is not likely to do this again. Negative reinforcement is not the same as punishment. Negative re inforcement is when a negative stimulus is stopped only when a de sired behaviour occurs. This is experienced commonly as a person in the car behind you constantly pressing the horn until you move your car out of the way. In this case the noise of the loud horn is the nega tive stimulus. The desired behaviour is moving the car. The lever bbx experiment by Skinner mentioned above proved that a behaviour will occur more frequently if given positive reinforcements and witl decrease in frequency by punishment. Master A, described in the beginning of the section was instrumentally conditioned to re main dry by the use of the buzzer. The reward that he got in the form of a chocolate was a positive reinforcement whereas the act of get ting up and washing his clothes was a negative reinforcement. The various types of reinforcement and punishments are summarised in the table below. An important consideration in changing and manipuLating behaviour is the relative effectiveness of the various types of reinforcement. Positive reinforcement is the most effective method in changing be haviour, while punishment is the worst. This is why you may notice that a person has to be punished many times before his/her unde sired behaviour is stopped. Another factor to keep in mind with children is their need for attention which acts as -positive reinforcement, even if the attention involves being yelled at or punished. A child who is repeatedly scolded for nail biting, or thumb-sucking may persist with these habits beyond chitdhood. Feature Effect on behaviour Example Comments Positive Behaviour is increased Child increases his Reward or reinforcement Reinforcement by reward kind behaviour increases desired behaviour. towards his younger Master A got chocolate brother to get praise whenever he succeeded in keeping dry at night - VV VV - -. - V. . - ,Chlnc,ees*hte t1veavoIdanceofan P.inem.ntt.t or escape kind beheviour stimulus increases - towsids hbyouj áed beha6ourThect brtoavd%w.ehinghIsclothes E Punishment Behaviourisdecreased Childdecreaseahis D.ilve,yofanaversive by suppression hitting behaviour stimulus decreases after his mother unwanted behaviour rapidly scolds him but not permanently.The buzzer was th. aversive stimulus in A’s case V - V•_V VV•V VV_VV_ - V_VVVV VV_VV_ liminated C Iopehlg kxtInctlefl I. meN cement V - Iviau’ ,h5iIlIhm.nt - Vii rnothe# V V V mwanted b.hevloUt. V V S.V;VV!V VV V Conditioning Principles in reot tile ‘iSt Hijab Zainab ,nish,nent or Negative Hi if ‘i
- 73. Shaping and Mode[ting Shapingand modelling are also theories of learning derived from the aforementioned principtes. Shaping involves rewarding closer and closer approximations of the wanted behaviour until the correct behaviour is achieved. An example of this is when a child learning to write, starts with writing on a paper with straight lines and is rewarded with a star’ for doing so. He then learns to write in straight lines on a plain paper, or a medical student who starts to learn stitching of wounds, makes mistakes and then at tains perfection by shaping’. Modelling is a type of observational [earning. This is what occurs when a student starts to talk, dress and behave in a manner similar to that of an inspiring teacher; ivhen someone gets a haircut to took the same as their favourite film star or a medical student decides to be a surgeon, after doing a rotation with an excellent surgical specialist. b. Ctassical Conditioning Classicat conditioning is another principle of the learning theory. It involves three factors: A neutral stimulus, a stimulus that causes a biological response, and the biological response itself. It is a form of learning that occurs when these two stimuli are paired. The neu tral stimulus is known as the conditioned stimulus. This is usually a neutral object such as a bell, a picture or a smell. The other stim ulus is known as the unconditioned stimulus. The unconditioned stimulus is one that is inherently capable of producing a biological response such as food or increased room temperature. The biolog ical response is known as the unconditioned response. Salivation, piloerection, sweating and autonomic arousal are types of biological responses. When a biological response is elicited with a stimulus that causes it, such as food causing salivation, this is known as an unconditioned response. When a biological response is coupled with a stimulus that would not normalty cause it, such as a belt causing salivation, this is known as a conditioned response. Classical conditioning Operant Conditioning Developed lntheUsbysldnner V ne.. Classical conditionin Unconditioned stimulus: light butt Conditioned stimutus: cheese Biologicot response: seen in the mous Stimulus is provided before reflex Stimulus is provided after reflex Deve’oped in luuia by Pavlov Relies on association between stimulus and response lnvolufltaiy, automtlc A Relies on reinforcement Voluntaty,opemtes on environment Passive learning Active learning
- 74. — -,-t-. -,. -/.-.—.... Ivan Pavlov,a Russian physiologist in the 1890’s established many of the basic principles of classical conditioning. He designed an appa ratus that coutd measure the amount of saliva being produced in a dog’s mouth in response to food (unconditioned response). Pavlov noted dogs salivated when presented with food. He also saw that dogs did not do this when he rang a bell. He then trained the dog by sounding the bell and shortly afterwards presenting food. After the sound of bell had been paired” with food a few times, he tested the effects of training by measuring the amounts of saliva when he rang the bell but did not present food. He discovered that some saliva was produced in response to the sound of the bell (conditioned stimulus) alone. This is a conditioned response. Similarly, people in many parts of the world have learnt to associate the golden letter M of McDonald’s with tasty fast food and have developed a con ditioned response (of salivation or the smell of the ‘Big Mac’, to the mere sight of the large golden arches). Extinction is the process by which conditioned responses decreases if the conditioned stimulus is never again paired with the uncondi tioned stimulus. For example if only the bell is rung but no food is presented, the salivation in response to the ringing of the bell will eventually stop, i.e. become extinct. r. Learning principLes in Clinical Settings Use of Operant Conditioning against bad habits How can we use learning principles to discontinue bad habits? The following techniques derived from the above mentioned principles of the learning theory could offer some hetpful possibitities: 1. Try to discover what is reinforcing a bad habit, and remove, avoid or delay the reinforcement Exampte: Asif is a medical student who developed the habit of taking longer and longer breaks when studying. He realised that the breaks were usually lengthened by watching TV. The pleasure of watching TV was also reinforcing more frequent breaks. Solution: To improve his study habits, Asif should either resolve to stay out of the TV room untilwork is done (avoid reinforce ment), or else complete 2 hours of study for half an hour of TV watching (delay reinforcement). Example: Farah, another medical student, has a different prob lem. When she reads in the evening, her periods of concentra tion, last only about 15 minutes. They are usually followed by a trip to the kitchen for a snack. In addition to falling behind in her studies, she is gaining weight. Solution: Taking snacks are rewarding her impulse to avoid read ing. Firstly she should do her reading at school or at a library, so that there is a delay between the impulse to eat and the reward of snacking. At home she should only keep foods that require preparation, so that a separate trip to the market is required for the snack. Requiring a walk to the market will also help her in weight control.
- 75. 2. Avoid ornarrow down cues that elicit the bad habit. Exampte: Mr Javed is not ready to give up smoking but would like to reduce it. He has taken many smoking cues out of his daily routine by removing ashtrays, matches and extra cigarettes from his house, car and office. He has also been making an effort to stay away from smokers, take a walk after meals (leaving his cigarettes at home) and put chewing gum in his mouth whenever he feels nervous. Solution: To further improve his controt of smoking MrJaved should try narrowing cues. He could begin by smoking only inside the building, never outside or in his car. He could then limit his smoking to his home and then to only one room at home and then to one chair in that room. If he succeeds in getting this far, he may want to limit his smoking to one uninteresting place such as a bathroom, basement or garage. 3. Make an incompatible response in the presence ofstimuti that usuatty precede the bad habit. ExampLe: Maryam bites her nails so much, that they are painful and unsightly to look at. She has identified several situations in which she is most likely to bite her naiLs and would Like to break the connection between these and her habit. Solution: Maryam should make a list of incompatible behaviours she can engage in, when she has the urge to bite her nails. These can include putting her hands in her pockets, taking notes in her class, sketching pictures, crossing her arms, chewing gum or combing her hair. 4. Use negative practice to associate a bad habit with discomfort. Exampte: Hassan has a facial tic that appears when he is nervous or tired. The tic, which looks like a wink with his right eye often leads to social embarrassment. SoLution: In negative practice a response is repeated until it becomes boring, painful or produces fatigue. This increases the awareness of the habit and tends to discourage its recurrence. Hassan could stand in front of a mirror and repeat the tic until the muscles used become quite uncomfortable. He could also wear a rubber band on his wrist and stretch it to rebound on to the skin causing a mild pain each time he winks. Similarly if you have a habit of saying “you know” or”muttab hai” “uh” or “like” too often when speaking, set aside 15 minutes a day and repeat the error over and over while thinking “I hate the way this sounds. 5. Utitise feedback to change bad habits. Atmost any habit wiLl benefit from simply keeping a score. Keep track of the number of times daily that you arrive late to class, smoke a cigarette, waste time during studying, bite your finger nails. swear or whatever other response you are interested in changing. This will serve as a ‘feedback’. You will soon find the frequency of these bad habits, going down.
- 76. Uses of ClassicalConditioning in CLinical Settings Since much of medical practice involves behaviour and changing behaviour, the principles outlined above can be seen in clinical settings. A few examples will be discussed here. i. Acquisition offear and anxiety about hospitats Children, as well as many adults have a great dislike of doc tors and hospitals. Children, in particular, are known to cry and scream at the sight of the doctor’s white coat and at the smell of the antiseptic, after they have received injections or intrave nous drips in hospital settings. It is quite likely that they associ ate (pair”) neutral stimuli such as white coats with nasty, painful events (injections, drips), It is for this reason that many paediatri clans these days do not wear the traditional ‘uniform’ associated with the medical profession. so that the “paired” response may not take place. After a few visits to such a doctor the classical conditioning that occurred between the white coat and injections witl undergo ‘extinction’. The child will discover that the uncon ditioned stimulus and the conditioned stimulus are not “paired anymore. ii. Chemotherapy for treating cancer Chemotherapy for treating cancer is a highly unpleasant expe rience for patients. It usually involves a series of weekly injec tions of powerful cytotoxic drugs that have marked side effects. The patient’s hair falls out, they feel nauseous and sick, and are unable to eat. It is a common observation that conditioned anticipatory nausea and vomiting occurs in these patients simply at the sight of the medical staff and smell of the hospital setting. Recently, attempts to use the principles of classical condition ing have been tried to help children overcome specific dislikes of food which have been induced by cancer chemotherapy. Frequently children have been found to associate feelings of being sick with the last food they ate before their treatment and so were refusing it afterwards. The children were given a strong tasting sweet after their last meal but before the chemotherapy. The investigators found that children given the sweet ate more of proper nutritionally good food afterwards than children given no such intervention. iü. Treatment of Phobias A phobia is defined as an intense, irrational fear of an on object, animal, or a situation, leading to its avoidance in fLiture. It is per fectly reasonable to feel intense fear at the sight of a poisonous snake. It is unreasonable, however, to feel intense fear of ele vators, lizards, heights, thunder etc. A form of therapy known as Systematic Desensitization based on classical conditioning can be beneficial in treating patients whose lives have become dysfunctionat and miserable because of their phobia. The method involves firstly getting the patient to relax fully, through the use of specific relaxation techniques.
- 77. After that, thepatient is asked to imagine a picture only remote ty associated with the feared object, or situation, In the case of someone frightened of dogs, for example. the patient wilt imag ine a simple outLine drawing of the dog. Whenever the patient feeLs any sign of anxiety, he is asked to signal it by raising a little finger. When that happens. s/he is instructed again to fully relax using relaxation methods. Eventually, the images are brought closer and closer to the real phobic stimulus and continue into real life so that finally s/he is able to maintain a relaxed state of mind firstly in imagination and lafer in the presence of a dog in real tife. The principle invotved is to associate a calm, relaxed state of mind with something which once instilled terror, and irrational fear. 2. Metacognition Metacognition is defined as thinking about how we think. It refers to knowl edge people have about their own thought processes. It is not uncommon for many medical students to take notes of only those aspects of a lecture that they consider difficult. Sirnitarty, often while studying we notice that we are having trouble learning a certain chapter but are able to learn another chapter by mistake. This understanding of our own learning processes is V metacognition. The examples illustrate a student’s awareness of their cog- V V V nition and hints at a strategy for managing learning based on this aware- :“ V - ness. VVV2 Metacognitive awareness is not seen in children as it develops later in life. V It may compensate for tower levels of ability. It enables students to coordi nate the use of extensive knowledge and develop many separate strate- Metocnition-HitingA gies to accomplish complex learning goals. Medical students are expected to learn complex concepts and a rote learning of these is neither possible, nor required Metacognitive techniques can help achieve this task. Efficient learners are highly aware of their own thinking and memory and use this V information to regulate their learning. Their knowLedge includes the how, why and when of learning. The degree of metacognitive ability varies from person to person and some basic level of automaticity comes only through regular practice. One way to practice is to use monitoring checklists in which students can check off component steps in monitoring their learning. Metacognitive strategies for medical students tive reading Involves you In a process of actively questioning the matedaIu read. Befor.you n address the questions of is It any good? and “what does It meanr you must understand whatycu are reading. Here are acme helpful tipw 1. Quickly read the title page prefuce or abstract to get an Idea ofthe topic ofthe article or book and cetego rize It In your mind. Is It really a report of research findings or Is It an anecdotal account of somebody’s Isolat edexperlencei Z. Study the table of contents or the headings In the.ardcle to get a sense of Its stmcture.Thls alerts you In advance about what to expect 3. Read any boldface excerpts or boxed summaries (like this one) to ascertain the maIn points or Ideas. 4. Leaf through the whole article dipping Inhere and there to follow the logic. 5. FInd the Important and unfamiliar words and use racoure like a glossary or dictionary to determine their meaning. 6. HIghlight key points or conclusions by underlining or puWng notes In the margins. 7. Be able to say with certainty that you understand what you have read before you crltidze It 8. Compare what you have read in one study with whatyotW have read cwnulatlveiyon a topic.
- 78. There ate threemain phases in Learning: 1. PLanning 2. Monitoring 3. EvaLuation 1. PLanning phase This is the phase in which the Learner is preparing to tackle what is to be Learnt. In the planning phase, Learners may ask themseLves the folLowing questions: • Why do I need to know this? Write down Learning outcomes of the chapter to be read or the task assigned. • What do I know aLready about this topic? Before reading the chapter, write down a few facts or concepts that you aLready know about it. • How wiLL I Learn it? Use Learning strategies such as mnemonics. watch a video reLated to the subject or reLate the disorder being described in the chapter to a patient you have recently seen. 2. Monitoring phase WhiLe going through the materiaL to be Learnt, Learners can monitor their Learning by asking the foLlowing questions: • How am I doing in grasping these concepts? Do I understand what am I studying? Think or repeat the important points in the mind after reading a few paragraphs. 3. Evatuating phase During this phase, after completing what was to be Learnt, [earners can ask themseLves the foLlowing: • How weLL did I do Learning this? • Is there anything I do not understand? • How shouLd correct my errors? • Were there any distractions or behaviours that were Limiting my concentration while studying? • Have I accomplished the goals I set for myself? Assess yourself on the basis of the objectives that you listed at the start. • Is there a practicaL appLication for what I have learnt?
- 79. 3. Memory Zahra wasconsidered one ofthe brightest students in her ctass. Herpeers were envious ofthe ease with which she managed to remember every sin- gte detait by quickLy skimming through her textbooks. Now, as a doctor her performance is phenomenat as she knows the name ofeverypatient and their family member and is able to recall their medical histories with ease. Her friends often commented that her memory was “photographic” and that “her mind works like a computer.” Memory is one of the extraordinary phenomena of the natural world. Our sensory experiences, perceptions and actions change us continuously and determine what we are later abte to perceive, remember, understand, and become. Human memory is unique in its characteristic ability to store visual recordings. aLong with associated emotions and feelings. A subsequent re call of various memories includes reliving the associated emotions. It is this quality that makes our memories pleasant and unpleasant. Higher mental functions such as speech, thinking, perceptions, moods, psychomotor skills and consciousness of surroundings are based on memory. Without memory there can be no mind. (For details on the neurobiological basis of memory, refer to Chapter 7) a. Stages in Memory Human memory resembLes a computer, consists of an information pro cessing system in three separate stages: i. Encoding: Sensory information is received and coded or trans formed into neural impulses that can be processed further or stored for later use. Just as a computer changes keyboard entries into binary digits that can be stored on a disk, sensory information is transduced, so that it can be used and stored by the brain. Apart from transduction a great deat of encoding process appears to be devoted to rehearsing or repeating the input. ii. Storage: Like a computer program, the encoded information must be stored in the memory system. Atthough some bits of information are stored briefly or used only once, and then discarded, others, like certain telephone numbers, are used frequently, and are therefore stored on a more permanent basis. iii. Retrieval: Once a file has been named and stored on a computer, we can call it up by its name and use it again. Human memory works in much the same way. When we recall or bring a memory into consciousness, we have retrieved it. This recall process is known as memory retrieval.
- 80. Sensory Memory (1sec) Episodic Memory (events.experiences) Human Memory Short-term Memory tVrkIng Memory) t1 miii) Procedural Memory (skIlls. tasis) b. Types of Memory I. Sensory Memory: Sensory memory is a memory or storage of sensory events such as sights, sounds and tastes with no further processing or interpreta tion. Sensory memory provides us with a very brief image of all the stimuti that were present at a particular moment and therefore has the potential to be quiet large. Sensory memory appears to Last only briefly, about one half to one second, depending on which senso ry system is involved. For instance if you see an object, an image persists for about one-half second afterwards. Similarly information you hear is held as a brief echo in sensory memory for up to two seconds. ii. Short-term Memory fSTM): Not everything seen or heard is kept in memory. Lets say a TV com mercial is running in the background as your friend reads you his notes on pharmacology. Do you remember the words of the TV ad? Probably not, because selective attention determines what informa tion moves on to short- term memory. Short term memories are also brief, but longer than sensory memories. Attending to your friend’s narration will place his technicaljargon in your short-term memory (while allowing you to ignore the voice on TV saying ‘talk shawk”). Short-term memories can be stored as images, but more often they are stored as sounds, especiatly in recalling words and letters. Short- term memory acts as a temporary storehouse for small amounts of information. Unless the information is important, it is quickly dumped from STM and is lost forever. Short-term memory prevents our minds from collecting useless names, dates, telephone num bers and other trivia. At the same time it provides a working memory where we do much of our thinking, dialling a phone number, doing mental arithmetic and remembering a shopping list. iii. Long-term Memory (LTM): nformation that is meaningful and important is transferred to the third memory system called long- term memory. In contrast to SIM, long-term memory ([TM) acts as a permanent storehouse for infor mation. [TM contains everything you know about the world and yet there appears to be no danger of running out of room in LTM, Long-term Memory IL ft Explicit Memory (.i)flsCiOU( implicit Memory (unconsdousl Declarative Memory (facts, even(s) I Semantic Memory (fads. concepts)
- 81. Type Description Examples Implicit!Memories used In making responses Remembering how to dissect Procedural and skilled actions. pass a nasogastrlc tube, play tennis or drive a car. Semantic Our store of general and specific Vt.r balls at 700 C, Paklstanl knowledge fri Asia, and heart leon the left, . ‘ motorco.kInthemedlel frontal lobe Episodic Memories of personal events. Your first day of college, birthday, your patient’s clinIcal state which is considered to have a Limitless storage capacity. Information in the LTM is stored on the basis ofmeaning and importance and not by sound or image. When new information enters STM, it is related to knowledge stored in LTM. This gives the new information mean ing and makes it easier to store it in LTM. It is therefore important to buiLd new information on what you atready know (stored in your LTM). The hippocampus is of particular importance in LTM. Recent research in human memory has revealed that there is more than one type of LTM. The type of information being processed influences the nature of the stored memory. Three major categories of LTM have been proposed, as iLlustrated in the above table. iv. Rehearsal.: The process of rehearsal consists of keeping items of information in the centre of attention, by repeating them silently or aLoud. The amount of rehearsal given to items is important in the transfer of information from short term memory to tong term memory. Ex periments have indicated that the sheer amount of rehearsal may be tess important than the ways in which information is rehearsed. Just going over and over what is to be remembered (maintenance rehearsal) does not necessarily succeed in transferring it to tong term memory. What reatly works is eLaborative rehearsaL which is an active process involving giving the material organization and mean ing as it is being rehearsed. hiomIng Information SensoTy Memoly + Forgotten Forgotten t4r’ti niy is thougnt to invotve at least three steps. Incoming intormation is first hetd far a second or t&o by sensory memory. Information selected by attention is then transferred to short term memory. If new information is not rapidly encoded, or rehearsed, it is forgotten. If it is transferred to tang term memory, it becomes retativety permanent, althaugh retrieving it may be a problem.
- 82. Forgetting: Forgetting is theinability to recall information. This means that much of what we think as forgotten is not reatly forgotten because it was never encoded and stored in the first ptace. The information, due to tack of attention, may not have reached short term memory from the sensory register. Alternatively due to inadequate encoding and rehearsaL the information may not have been transferred from the short term memory to the tong term memory. How much of the information is forgotten depends on the following factors: • Interference: Experimental evidence as well as everyday experi ence indicates that learning new things interferes with our mem ories of what we learned earlier and prior learning interferes with our memory of things learned later. • Retrieval problems: Finding information in the organised long term memory store is aided by retrieval cues, or reminders which direct the memory search to the appropriate part of the tong term memory Ubrary. Without the retrievat cues, the sought for item stored in LIM may not be found and seem forgotten. While we often cannot recall something while actively searching for it, we may later recall the sought for information, when we have given up the search and are doing something else. The new activity in which we are engaged gives us another set of appropriate re minders or retrieval cues. Perhaps the new situation leads us to search through portions of our LTM store not examined before. It is therefore a good idea to ask the examiner to go to the next question in viva voce, rather than continuing to retrieve an answer. It will come to you in a while, when you are answering another question. Motivated forgetting: The theory of motivated forgetting was in troduced by Sigmund Freud when he described a key concept of psychoanalysis viz, repression. Repression refers to the tenden cy of people to have difficulty in retrieving anxiety- provoking or threatening information. This helps to explain why people gener ally remember pleasant events more often than they do unpleas ant ones: the unpleasant memories have been repressed. This aspect should encourage to make ones learning a lot of fun, en joying your studies and clinical work rather than making it painful and a burden. This will happen if you will leave your exam prepa ration to the few days before the exam. c. The Anatomy and Biochemistry of Memory The study of organic memory disorders has ted researchers to identify brain structures that appear to mediate short term and long term memory processes. Two of the key parts of the limbic system, the hippocampus and the amygdata embedded under the temporal lobes are essential in receiving new information and storing it. The diencephalon also contains a number of structures, the most important for memory being the mam mitlary bodies, thalamus and hypothatamus. Lesions to these structures generally result in problems with encoding of new information. Although
- 83. CyIic-Anp lIly UodiflUonof (mk,pl pu’ DNAnter.tn—.. Undtory Ue.,on, Nw pt.n fo.mtion F,,,tjo,of NewSynpti IrVb Connoton FormaUon of Long Term Memory no-one has yet found the exact physical changes in a cell that accounts for a memory, many new discoveries have been made about the physiologicat basis of learning and memory. One of these findings is the role that Long term potentiation fLTP) may play in memory formation. Studies reveal that repeated electrical stimulation of nerve cells in the brain can lead to a sig nificant increase in the likelihood that a celt will respond strongly to a future stimulation. This effect can tast for a long time and may be a key mech anism in the formation of memories. Studies also indicate that a specific type of receptor viz. NMDA receptor is extremely active in Long term poten tiation as is the role of catcium. An important part of memory formation is an increase in the sensitivity of certain nerve cells to acetytchotine. U. Methods to Improve Memory • The example of Zahra given in the beginning of the section clearLy indi cates that some individuals have specific techniques through which they facilitate there memory and learning of new information. Some of these are as follows: • Know[edge of resuLts: Learning occurs most effectively when feed back or knowledge of resuttsãLtows you to check and see if you are teaming. Feedback also helps you identify material that needs extra practice, and it can be rewarding to know that you have answered or remembered correctly. • Attention: A setting that enhances your focus while studying, and ensures minimal distraction will turn your attention to the memory job at hand. • Recitation and rehearsat: This means repeating to yourself what you have Learned. If you are going to remember something, eventually you will have to retrieve it. Recitation forces you to practice retrieving information as you are learning. When you are reading a textbook, you should stop frequently and try to remember what you have just read by summarizing it aloud. - Organise: Assume that you must memorise the following tist of words; north, man, red, spring, woman, east, autumn, yellow, sum mer, boy, blue, west, winter, girl. green, south. This rather difficult list could be organised into chunks as follows: north-east-south- west, spring-summer-autumn-winter, red- yellow-green-blue, man-worn an-boy-girl. Similarly by making up stories using tong list of words to be memorised makes remembering the list much easier.
- 84. • Selection: TheDutch scholar Erasmus said that a good memory is like a fisherman’s net. It should keep all the big fish and let the little ones escape. If you boil down the paragraphs in your textbooks to one or two important terms or ideas, you will find memorizing more manageable. Practice careful and setective marking in your text books and marginal notes to further summarise ideas. Most students mark their texts too much instead of too little. If everything is under lined, you haven’t been selective. Seriat position: Whenever you must learn something, be aware of the serial position effect. This is the tendency to make most errors in remembering the middle of a list. If you are introduced to a long line of people, the names you are likely to forget will be those in the middle, so you should make an extra effort to attend to them. The middle of a list, poem or speech should therefore be given special attention and extra practice. • Mnemonics: A mnemonic is any kind of memory system or aid. People demonstrating extraordinary feats with their memories are actually using mnemonics to perform this. Mnemonic techniques rely on the linking or association of to-be-remembered material with a systematic and organised set of images or words that are already firmly established in long term memory and can therefore serve as retrieval cues. Similarly medical students often invent mnemonics for memorizing the names of cranial nerves; amino acids etc. and can remember these lists for lengthy periods. The basic principles in the formation of mnemonics are: - Use mental pictures - Make things meaningful - Make information familiar - Form bizarre, unusual or exaggerated mental associations. Attach emotions, feelings or link up with an event. We hardly ever forget what is emotionally significant in our lives. Senior citizens continue to recall events of emotional significance even when their short-term memory is grossly impaired. • Using mental pictures or visuaL imagery to enhance retention. One way is to simply imagine an unusual scene that includes the various elements you want to remember, For instance on your way home, you have to shop for a newspaper, notebook, pen and shaving cream. To remember this list of items, you have to make up a men tal image of something funny and bizarre such as you, opening up the front page of a newspaper to find a picture of a person reading a notebook with one hand and using a pen to wipe off the shaving cream on his face with the other hand. • Overtearning: Many studies indicate that memory is greatly im proved when study is continued beyond bare mastery. In other words after you have learned material well enough to remember it without error, you should continue to study the material. Overlearn ing is your best insurance against going blank on a test because of anxiety.
- 85. Spaced practice: Spacedpractice generally is superior to massed practice. Three 20 minutes study sessions can produce more learn ing than one hour of continuous study. • Whote versus part learning: Generally it is better to practice learn ing whole packages of information rather than smaller parts. Try to study the largest meaningful amount of information possible at one time. This means, reading a textbook is better than reading con densed notes. The only notes that will benefit you will be the ones that you make yourself based on steps listed above (selection). • Steep: Sleeping after study is helpful and reduces the interference. Similarty breaks and free times in a schedule are as important as the study periods. Staying awake the whole night before your exams is not the smart thing to do • Review: Reviewing shortly before an examination is helpfuL though one should avoid the tendency to memorise new information at that point. This review should take about an hour not the whole night prior to the exam e. Pathological Changes in Memory Codu Normal Brain Brain with Alzheimer’s ‘I-
- 86. Before considering thepathological basis of memory toss, it is important to run simple tests of a person’s cognitive functions such as attention, con centration. registration and motivation (see table of MMSE on next page). In case of an impairment of one or more of these higher mental functions, the function of memory does not come into play. People with tow mood, poor motivation and consequent Lack of attention and concentration my there fore complain of Loss of memory.” This state is catted pseudodementia. Another situation, in which people sometimes experience a significant al teration in their memory or identity, occurs on account of loss of integrative function of the brain due to an emotional challenge or a stress that could be sociaL psychological or structurat. Such stress can interrupt learning new information, recalling old information, or change the ability to think and process information. This results in disruption of memory and identity. These alterations in memory (and or of identity. or consciousness) some times lack a clear physical cause and are called dissociative disorders. The principle symptom in such situations is an inabitity to recall important personal events and information of personal significance. Disturbances in memory and identity that have clear physical causes inctude amnestic disorders and dementias. Amnestic disorders affect a person’s memory exclusively, either for events before an amnesia inducing trauma or for information learned after it or both. They are caused by med ical conditions, such as thiamine deficiency, hypothyroidism, hypogtycae mia, chronic alcohot or substance abuse, head injury or other problems that can adversely affect the physical functioning of the brain. Dementias involve mote than just memory ate characterised by deficits in other areas of cognitive functioning. such as reasoning and problem solving. These kinds of dementia are caused primarily by degenerative diseases that af fect specific areas of the brain. The most common amongst them is Alzhei mer’s disease. 4. Perception I never woutd hove dreamed that ye/tow is.. soyettow. I don’t have the words, I’m amazed byyettow. But red is my favourite colour Ijust can’t believe red. I can’t wait to get up each day to see what I can see. And at night I took at the stars in the sky and the flashing tights. You coutd never know how wonderfut everything is. Isaw some bees the other day, and they were magnificent. Isaw a truck drive in the rain and throw a spray in the air It was marvellous. And did I mention. i saw a fatting teafjust drifting through the air” Bob Eden, who had his sight restored after being btind for four decades. Perception is the process of making sense of the stimuli in our environ ment. To activate a particular receptor. a specific type of energy must be present: light waves for vision, movement of air molecules for hearing. molecules in a liquid solution for taste, and so forth. You cannot shine a flashlight in your ear and expect to have a visual response since there are no light-sensitive receptors there. Neurons operate on the basis of changes in their electrical charge and the release of neurotransmitters. Physical energies of light. sound, odour and
- 87. taste molecules mustbe changed into etectrochemical forms that the nervous system can process. This conversion of stimuli from the recep tors into etectrochemical energy that can be used by the nervous system, is catted transduction. Continued presentation of the same stimutus can cause receptors to become tess sensitive to that particular stimulus. This process, known as adaptation, occurs very rapidLy when odours and tastes are involved. To understand perceptual processes, we focus on visual per ception. Many of the processes we wilt discuss also apply to other senses. a. Motivation and Perception: We do not perceive everything in our environment. Our motives, needs, drives, and even prejudices may distort or determine what we perceive. A thirsty traveller lost in a desert is bound to experi ence a mirage, a false perception of water, influenced by his motiva tion to search for a water body. A patient in a ward waiting for visitors in the evening, would from a distance misperceive a stranger as a relative. A medical student may hear his name called (erroneously) while waiting for his turn for the viva voce. Similarly. certain stimuli are more likely to attract our attention than others.ing is your best insurance against going blank on a test because of anxiety. b. Attention and Perception: We cannot possibly attend to and process all the stimuli that our sensory systems receive at any one moment; some of them must be filtered out. A good example of the need to filter information is a typical healthcare situation in our settings. You might be running a busy medical OPD with many patients surrounding you, white you desperately try to focus on the information being given by the pa tient you are examining. If you try to listen to the shouting and crying of the patient waiting for the turn and one in front, you will probably find yourself switching your attention back and forth between them and becoming quite confused. This is why it is important to not have more than one patient by your desk or examination table. Having pa tients wait outside the room will help to limit the amount of sensory input and focus your attention better. c. Basic Perpetual Abitities: i. Patterns and Constancies: We perceive objects in our environ ment as having features such as pattern, constancy, depth. and movement. Our perception of these objects and their features is so automatic that we often take them for granted. They are, how ever, crucial components of perception. ii. Pattern Perception: Among the most basic perceptual abilities is the ability to perceive patterns. To survive in modern society, we must be able to perceive a staggering numbor of shapes and fig ures. A few of the patterns we perceive everyday are the letters of the alphabet, traffic signs, friends facial features, food items in the grocery store. the buildings in an apartment complex, and cars in a parking lot. The ability to discriminate among different shapes and figures is known as pattern perception. iii. Perceptuat Constancies: Once you have identified an object, you continue to recognise it even if it changes its location and distance
- 88. r and, therefore, castsa different image on your retina. A change in the retinal image does not signal a change in the object. This ten dency to perceive objects as relatively stable is called perceptual constancy. The importance of perceptual constancies should be obvious; they allow us to deal with our environment as relatively stable and unchanging. We do not have to treat every perceptual change as if our environment had changed completely different positions. iv. Shape Constancy: Shape constancy means that your perception of the shape ofan object does not change even though the image projected on your retina does. In other words, the shape of an ob ject is perceived independently of the image it casts on the retina. This phenomenon is easy to demonstrate. Look at this book from a number of angles. You see nothing but a book being held in dif ferent positions. The same coutd be said for the opening and clos ing of a door or the image of a car making a left turn in front of you. The image on your retina changes drastically, yet the object you perceive does not. Almost any moving object displays the prin ciple of shape constancy. For the perception of shape constancy to occur, however, the object must be famitiar and must be seen in an identifiable context. If there is no context or background to whfr-h the object can be related, it appears to float in space. and you cannot judge its correct orientation. Shape constancy. thus, disappears. v. Size Constancy: Size constancy also helps us maintain consis tency in our perceptual environment. As objects move toward us, their retinal images enlarge; as they move farther away, their reti nal images diminish. We do not perceive those objects as chang ing their size, we perceive them as moving toward or away from us. Size constancy depends on the familiarity of the object and the ability to judge distance, When we are dealing with familiar objects and can easilyjudge distances, we are more likely to per ceive the objects as having a constant size. When we are dealing with unfamiliar objects and our ability to estimate distance is poor. the objects may appear to change size. Size and shape constan cy may seem rather simple because they are automatic process es, but these constancies involve a great deal of processing. We use familiar background objects for purposes of comparison (size constancy) and to anchor our perceptions (shape constancy). Au ditory constancies are another important aspect of perception. We perceive words as the same when they are spoken by various individuals with different voices. Similarly a melody is recogniz able even when it is played on different instruments and in differ ent keys. vi. Depth Perception: In addition to a world of constancies, we ex perience a third dimension: depth perception. The surface of the retina is two-dimensional (top to bottom, side to side). yet we are able to judge distances and locate objects in space (three-di mensionalty) quite well. Two main types of cues, binocular and monocular, are used to create our perception of depth. Binocular cues involve the use of both eyes, whereas monocular cues are processed by only one eye.
- 89. viii. Monocular Cues:Monocular cues, which can be perceived by ei ther eye, also help determine depth. For example, when the cii lary musctes change the shape of the lens in accommodation, the muscle adjustments are sensed and used to help determine distance. Artists use numerous monocular cues, including super position (the fact that neat objects partialty obscure mote distant objects), texture gradient (that the texture of a surface becomes smoother with increasing distance), linear perspective (that paral lel lines appear to converge as they recede into the distance), and relative brightness (that brighter objects appear closer) to create the illusion of depth. These cues also operate in our day-to-day environment. * ix. Perception of Movement: We often come across messages on electronic signs that has letters and words that appear to move across it. Our perception of separate words is created because of the proximity of the letters that make up each group (word) and the spaces between successive groups of letters. Unlike the let- ters you are reading in this text, the letters on the electronic sign are made up of separate, unconnected points we complete them using closure. This sign adds another dimension to our consider ation of perception: although the words do not really move across the sign, they appear to do so. Apparent motion is the illusion of movement created by turning the lights on and off in a particular sequence. The same phenomenon is seen in movies, television, and videocassettes. All of these forms of entertainment rely on the brain’s ability to create the perception of motion from a series of still pictures. L vii. Binocular Cues: Among the most important binocular cues are adjustments of the eye muscles and binocular disparity. The mus cles that move the eyeball to get the best possible view provide feedback for judging distance. When objects are near, the eyes rotate toward a centre point. You can feel the muscle tension when you look at objects that are very close. To experience this sensation, focus on this sentence and move the book closer to your eyes. The closer the book gets, the more eye muscle strain you feel; the farther away the object is, the less eye muscle strain you experience. It is important for a medical student who spends long hours reading to place the book at a distance which causes minimal or no strain on the eyes. D .) d. AbnormaLities of Perception i. Illusions: An illusion is a misperception of a real external stimulus. Percep tion involves the brain’s attempt to interpret and make sense of the stimuli we receive from our environment. Most of the time our perceptual hypotheses are quite accurate, but sometimes they can be wrong. For example, how often could you have sworn that your professor had said an exam was next Thursday, not next Tuesday? Have you ever been absolutely sure that a traffic light was green. not red? It is easy to trick our senses into developing an incorrect perceptual hypothesis. Such incorrect perceptual hy potheses form the basis for perceptual illusions. These illusions are misperceptions or interpretations of stimuli that do not follow r F i i ‘4:: I Artist: Hj/ab ZaTha The influence of mThd-.cet on perceptio Who do you see in these pictures? Th Ilustrates how a pat vnt a doctor and family member may peicewe the sam problem dit’erentt
- 90. atiucinations tist Lam Zombie Thinking:The talking of the soul with itself the sensations received by the eye. Illusions are often seen in pa tients in Intensive Care Units, such as those in a toxic confusional state or delirium, as well as people under the effect of alcohol and drugs such as LSD. ii. Hattucinations: Hallucinations are perceptions without any stimulus. They can be in any of the five senses but the most common hallucinations are of auditory and visual type. They are seen most commonly in pa tients with serious mentat illnesses such as schizophrenia. These patients may hear voices talking about them or doing a running commentary on their actions. These abnormal perceptions are real to the patient, which is why s/he can be seen to be in con versation with the imaginary voices. The most common cause of visual hallucinations is delirium tremens. e. Extrasensory Perception (ESP): This refers to the occurrence of experiences or behaviours in the absence of an adequate stimulus. Such occurrences are considered to be paranormal or beyond our normal sensory abilities and are studied in parapsychology. ESP includes the phenomena of: • Clairvoyance: The ability to perceive events or gain information in ways that appear unaffected by distance or normal physical barriers. • Tetepathy: Extrasensory perception of another person’s thoughts or in other words the abitity to read someone’s mind. • Precognition: The ability to perceive or accurately predict future events. Thus prophecies and prophetic dreams about the future are included in precognitions. • Telekinesis: This phenomenon studied by parapsychologists is basically the ability to exert influence over inanimate objects. In other words “mind over matter.” To date there is little scientific evidence to prove the existence of extrasensory perceptions. 5. Thinking During most of our waking hours, and even when we are asleep and dreaming, we think. Thinking is a mental process invotving the manipula tion of both information from the environment and the symbols stored in tong term memory. Thinking is evident when we solve a problem or make a decision. Thinking can take the form of images or concepts. Visuat imagery. the experience of seeing even though the event or object is not actually viewed, can activate brain areas responsible for visual perception, such as the occipital lobe. Imagery does not have to be visual, however; it can be auditory or olfactory. Visual images allow us to scan information stored in memory, answer questions and help us plan a course of action. Suppose we need to describe the size of an acre. How might we convey this infor mation? We could say that there are 43,560 square feet in an acre. Would
- 91. that hetp youunderstand how large an acre is? Perhaps not. If we used a visual image, however, and said that an acre is about the size of a football field, this woutd probably make it much more meaningful. Similarly, a consultant listening to a house officer describe a patient on the telephone would rely on her capacity to build visual images of the clinical picture, before she can give some urgent instructions. a. Concepts What would life be like if we had to deal separately with each indi vidual animal, event, object, and person in our environment? How could we learn the names of all of them? We avoid such problems by using concepts or mental representations of a class (students, nurses, chairs, politicians). A concept is a symbolic construction rep resenting some common and general feature of objects or events. Concepts lighten the load on memory and enhance our ability to communicate. They also allow us to make predictions about ani mals, events, objects, and people. Much of what we learn in school, especially primary school, involves concepts such as colours, letters, species of living organisms, whole numbers and fractions, time, and distance. The use of such concepts makes communicating a great deal of information possible with relative ease. Concepts are, therefore, an important class of language symbols used in thinking. b. Problem Sotving Every day we encounter a variety of minor problems; occasionally we face major ones. You may find that your computer has fallen prey to a virus, your shirt button has fallen off, or your motorbike won’t budge. Some problems are easy to solve, others require great effort, and some may be unsolvable. The problems we must solve can differ along several dimensions. One way problems differ is that some of them are well defined and others are ill defined. Well-de fined problems have all their components specified. as in algebraic equations; the goal of the problem is quite clear. Ill-defined prob lems have a degree of uncertainty about the starting point, needed operations and final product. A well-defined problem. for example. might take the form of How should I use the word processor to fit a 500-word essay on two pages%’ An ill-defined question might take the form of How can I write the type of paper that will get me a higher percentage of marks?” Problem-Solving Methods: When you recognise that a problem ex • ists, you can remember whether you faced a similar problem in the past. If so, you can retrieve the solution from memory and appLy it to the current problem. If the problem is new and there is no solution in long-term memory tLTM), you can use several strategies to attack the problem. Computers have provided scientists with a model that can be used to understand human thinking. However, to use the computer as a model of human thought, researchers need to know what human beings do when they solve problems. We use two gen eral approaches to solving problems and these can be programmed into a computer: algorithms and heuristics.
- 92. i. Algorithms: Analgorithm is a recipe or rule for solving a problem that guarantees a solution if there is one. A simple example of an algorithm is the mathematical formula used to determine the area enclosed by a rectangle: length multiplied by width gives the answer, Algorithms cannot, however, provide answers when the probleni is not clearly specified. There are no procedures that can be set up in advance to guarantee a solution for sLich problems. Moreover, some problems are so vast that algorithms are simpty out of the question. For example, chess players could not rely on algorithms because it would take centuries to examine all possi ble arrangements of the chess pieces, even if the players could evaluate them at a rate of several million per second. Computers playing chess are, however, capable of doing so. ii. Heuristics: Heuristics are educated guesses or rules of thumb that are used to solve a problem. The use of heuristics does not guarantee a solution but it makes more efficient use of time than algorithms. For instance, a doctor looking to obtain informed con sent prior to a surgicat intervention may heuristically solve this problem. There exists no international standard for information disclosure for a medical or psychiatric situation but as a rule of thumb, five areas of information are generally provided: diagnosis, treatment, consequences, alternatives and prognosis. Obstacles and Aids to Probtem Sotving Researchers comparing the problem solving techniques of experts and novices and found that experts have more information that they can use to solve problems. Experts know how to collect and orga nise information and are better at recognizing patterns in the infor mation they gather. As health professionals we often come across situations that challenge us and expose the limits of our clinical experience. Such situations merit a consultation from our senior colleagues, and are considered a norm in medical practice. At times the strategies used to solve problems may become obstacles in problem solving. Some examples of this are: • Functional fixedness or rigidity • Mental set • Assumptions • Misleading information • Transfer Mentat set According to Sternberg and Sternberg (2012), a mental set consists of a frame of mind involving an existing model for representing a problem, a problem context, or a procedure for problem solving.” In most cases, it is helpful in problem solving to use a solution that has worked before. It may, however, become a problem if you insist on using a particular strategy to solve a problem (even if it does not work) and cannot think of any other way to do it because this was a strategy that had worked in the past. Mental sets can make it difficult for a doctor to determine the cause of an illness.
- 93. Functionat fixedness Functionat fixednessis a particular kind of mental set that only allows objects to have a fixed functionality. This refers to the ten dency to try and solve problems only in one particular way. It occurs when we are unable to recognise that an object or thinking tool may be used for something other than its intended use. This prevents us from creatively solving a problem. A clothes hanger, for example, is an object intended to hang clothes in a cupboard. Functional fixed- ness is the mental block that dictates this is its only use. This would prevent one, for example, from using the hanger to unlock a car door when the keys have been left inside. Misteading information In a complicated problem there may be large amounts of data avail able, which may distract from the information required to arrive real solution. This may occur, for example when we are unabLe to arrive at a diagnosis for a patient with pyrexia of unknown origin, C PUO) be cause s/he has been tested for everything under the sun, with some reports having positive findings but none seemingly indicating the cause of the infection. It is important, therefore, to be able to sepa rate information with respect to relevance when solving a problem. This is especially the case with admitted patients who have under gone many investigations. Assumptions We may at times be unable to solve a problem because we may he assuming that certain obstacles to the solution exist when this is not the case. Transfer Transfer refers to “the extent to which knowledge and skills acquired in one situation affect a person’s learning or performance in a subse quent situation. (Ormrod, 2014) This is obviously an important prob lem solving technique, but can cause obstacles as welL Negative transfer occurs when one attempts to solve a second problem with the same strategy as the first one. An example of negative transfer is when one switches from driving a manual transmission car to an automatic one and keeps trying to switch gears.
- 94. Problems Involving Transfer,a method of problem solving The Radiation Problem imagine you are a doctor treating a patient with a malignant stomach tumor. You cannot operate on the patient because of the severity of the cancer. But unless you destroy the tumour somehow, the patient will die. You could use high-intensity X-rays to destroy the tumour. Unfortunately. the intensity of X-rays needed to destroy the tumour will also destroy healthy tissue through which the rays must pass. X-rays of lesser intensity will spare the healthy tissue but they will be insufficiently powerful to destroy the tumour. What kind of procedure could you employ that will destroy the tumour without also destroying the healthy tissue surrounding the tumour? The Military Problem A general wishes to capture a fortress located at the centre of a country. All of them are minefleldi Although small groups of men can pass over the road sally. any large armyofsoldiers will detonate the mines. A futl-scale direct attack is, therefore, Impossible. What should the general do? Think about this: What are the commonaifties between the two problems. and what is an elemental strategy that can be derived by comparing the two problems? Correspondence between the Radiation and the Military Problems What are the commonalities between the two problems, and what is an elemental strategy that can be derived by compared the two problems? (After Gick & Holyoak 1983) Military Problem Radiation Problem Initial State Coal: Use army to capture fortress Resources: Sufficiently large army Constraint: Unable to send entire army along one road Solution Plan: Send small groups doing multiple toads simultaneously Outcome: Fortress captured by army Initial State Goal: Use X-raysto destroytumour Resources: Sufficiently powerful rays Constraint: Unable to admInister high-intensity rays from one direction only Solution Plan mister) densftyraysfrom piedirectionssimultaneousty Outcome: Tumour destrcted by rays initial State Goal: Use force to overcome a central target Resources: Sufficiently great force Constraint: Unable to apply full force along one path alone Solution: Apply weak forces along multiple paths simultaneously Outcome: Central target overcome by force M.L Cick and K. 3 Holyoak fl983), schema induction and Analogical Transfer’ Cognitive Psychology. Vol l5pp 7-38. Convergence Schema I
- 95. A c.ction/d.clsion COflsqLeficei achofrr A I The Seven Step Decision Making Process c. Decision making Each day we make dozens, perhaps hundreds, of decisions on every aspect of Life: what to wear, eat, say, do. Some decision making involves choosing among proposed solutions to a problem. Some of these decisions are easy: others are not. How do we make such decisions? The human brain’s prefrontaL cortex, through its vast connectivity with the rest of the brain, enables us to process vast amounts of information quickty and accurately. Heuristics is one method of doing so. Decision making is a seven step process, as seen in the diagram above. d. Creative Thinking As a medical student, you may have noticed that a few of your peers or teachers deal with probLems in a unique and extraordinary way. They are able to visuaLise and understand difficult and boring sub jects in a fresh and new way. Perhaps you are one of those peopLe who think and act creatively. The creative thinker whether artist, stu dent or scientist is trying to create something new. Creative thinking involves a new and unique way of conceptuaLising the worLd around us. Creativity ProfiLe Creative people possess the following qualities: • Unusual awareness of people. events and problems. • High degree of verbal fluency. • Ftexibility with numbers and concepts • Flexibility in social situations. • OriginaLity of ideas and expression. • Sense of humour. • Ability to abstract, organise and synthesise. • High energy and activity Level. • Persistence in tasks of interest. • Lmpatience with routine or repetitive tasks. Willingness to take risks, • Vivid and spontaneous imagination in childhood.
- 96. A - , Verification A Illumination -Incubation Preparation Orientation Five step procs of crcitit’e thinking Stages of creative thinking Creative thinking is a five stage process: i. Orientation: The problem must be defined and important dimensions identified. ii. Preparation: In this stage creative thinkers saturate themselves with as much information related to the problem as possible. iii. Incubation: Most major probLems produce a period when all attempted solutions appear futile. At this point problem solving may proceed on a sub-conscious tevel for some time. iv. Illumination: The stage of incubation is often followed by a wave of insight and produces the Aha!’ or eureka” experience. v. Verification: The final step is to test and critically evaluate the solution obtained during the stage of illumination. Common barriers to creative thinking There are three types of barriers that impede creative thinking and problem solving: Emotional, cultural and perceptual barriers. Emotional barriers: O Inhibitions ‘Fear of failure. Inability to tolerate, ‘Ambiguity • Excessive self-criticism. Cultural barriers: • Value systems that consider fantasy and imagination a waste of time. • Being taught that playfulness is an exclusive domain of children. • Categorisation tat home and as a society) of reason and logic as good but feelings, intuition, pleasure and humour as bad Perceptual barriers include habits leading to a failure to identify important etements of a problem.
- 97. 6. Emotions Being thefirst in his pharmacotogy class to detiver a presentation, Shahid was feeling terrified on the podium with the microphone in his hand. Though the lecture hail was nicely air conditioned, he felt hot As he began to speak, he could feel a strange sense ofhaving a lump in his throat and a feeling ofdiscomfort in his stomach. He tried to clear his throat but his dry mouth and trembling hands were making the task too difficult “Is this the same tecture hall where I have been attending classes every day and had fun with my friends: he thought The growing restlessness and sarcastic expressions on the audiences faces was not a real threat but Shahid felt as ifit was. His heart was now beating at the rate of140 bpm and his ctothes were drenched with sweat The rationat part ofhis mind totd him that his imagination was running wild but he remained unable to shake the fear and dread that had taken over the control ofhis body. Life would be dull and colourless without emotions. Feelings and emo tions add pleasure and excitement to our lives. Have you ever waited untit someone was in a good mood to ask for a favour? If so, you are aware that emotions have a powerful influence on everyday behaviour. It is a common observation that it is easier to make decisions when you are in a good mood, People who are happy are more likely to help others in need. Similarly we are all aware of the importance of love, optimism, acceptance and joy in human relationships. However emotions also have their negative effects as we saw in Shahid’s case. Definition The word emotion is derived from the Latin word which means “to move” and emotions do indeed move us. An emotion is a feeling with its dis tinctive thoughts, psychobiological states, and range of propensities to behave. Human emotions can be disruptive (as in Shahid’s case who was experiencing “stage fright) but often they aid survival. This seems to be why emotional reactions were retained in evoLution. For details on the neurobiology of emotions, refer to Chapter 3, The Neurobiological Basis of Behaviour. a. Types of Emotions There are two types of emotions: innate (primary) emotions and mixed (secondary) emotions. Innate or primary emotions: The concept of primary emotions was first given by Robert Plutchik (ig8o) who believed that there were eight primary or innate emotions: fear, surprise, sadness, disgust, an ger, anticipation,joy and acceptance. A baby by the end of first year can express most of the primary emotions. Secondary or mixed emotions: Primary emotions can be mixed to give rise to the secondary or mixed emotions. For instance the emo tion of love results from a combination ofjoy and acceptance. The mixture of disgust and sadness gives rise to the secondary emotion of remorse. Jealousy can be considered as a mixture of love, anger and feat. Most secondary emotions are acquired. Greed, lust, preju dice, paranoia, hatred, and shame are some examples of acquired emotions.
- 98. b. Expression ofEmotions Facial expressions appear to be central to the expression of emo tions and have been retained through the evolutionary process. Body gesture and movements (body Language) also express feel ings, mainly by communicating emotionaL tone rather than specific messages. While the language we use to express ourseLves verbaLly may vary with race and geography, body language and faciaL ex pressions are Largely universaL C. PhysioLogicat Differences amongst Emotions U. e. It is usually difficult to differentiate one emotion from the other on the basis of physiological changes but some differences provide important cues. For example. people cry when they are sad, some times even when they are happy, but almost never when they are angry or disgusted. Establishing the physiological specificity of emotions does not require that every emotion have a unique phys iological signature, only that some emotions differ from others in consistent ways. Finding such evidence has not been easy because emotions are generally short lived, tasting for only a short white. Over the years, research suggests that there are several reliable differences amongst various emotions. One of the most consistent findings is the tendency for anger to be associated with cardiovascu lar changes. The heart rate increases with anger, fear, and sadness, it decreases with disgust. Compared to anger. fear is associated with lower blood pressure. cooler surface temperature and less blood ftow to the periphery of the body. Our language reflects some of these physiological differences. We use phrases such as “blood boil ing” when we talk about anger but not when talking about disgust. happiness or sadness. The description “white with fear” reflects the cooler skin temperature associated with the emotions EmotionaL Intettigence Most people may find it difficult to identify what emotion they are experiencing and when. For instance, if a student has failed a sub stage. he may be feeling a myriad of different emotions: shame, em barrassment, hopelessness, fear of the future. Now if his best friend topped this exam, this may complicate his feelings even further. In this entire scenario, however, if asked, how he is feeling, he may only respond with: “bad.” Recognizing what particular emotions we are feeling is a key element of the concept of ‘emotional inteLLigence’. The abitity of an individuat to recognise their own and other’s emotions, reason through them and use them to their advantage is referred to as emotionat intelligence. This is measured as emotional intettigence quotient or EQ. This will be further discussed in the section on ‘Inteltigence. Lack of Emotions Not all of us possess the capacity to express our emotions to the same degree. Some individuals feet a great difficulty in expressing their emotions and understanding those of others. This may, inevi tably. lead to a difficulty in maintaining relationships. This emotional difficulty is called alexithymia. People with alexithymia are not aware of their own feelings and may even lack the words needed to
- 99. .4,:. communicate their emotions.A common example in clinical practice is that of patients who are unable to express their distress, depres sion or anxiety. They describe these feetings in terms of physical symptoms such as headache, gas or ‘gala’. These patients more often than not are silent sufferers of atexithymia. presenting with a somatoform disorder. 7. Motivation We alt seek different goals, some more vigorously than others, The same goat may be pursued for different reasons. While alt of us may want to be good doctors, our motivation for this may differ. Some may want this because they would like to treat their patients welL Others may be inter ested in getting famous and stilt others are concerned with becoming rich. Our behaviour is driven and pulled towards goats. The driving force which results in persistent behaviour directed towards particular goats is called ‘motivation’. Motives cannot be observed directly and are in fact inferred by us after we have observed people working towards certain goals. n other words, motives are inferences from behaviour. They are powerful tools for the explanation of behaviour and allow us to make predictions about future behaviour. BiologicaL motivation: The biological motives are rooted in the physiologi cal state of the body. There are many such motives including hunger, thirst, sexuat desire, temperature regutation, steep, pain-avoidance and a need for oxygen. As regards the biological motives, the body tends to maintain a state of equilibrium called homeostasis. Sexual motivation: This depends to a large degree on sex hormones. These hormones organise the brain and body of developing humans so that they have male or female characteristics. The activation of sexual motivation in humans, however, seems to be controlled more by external stimuli and learning than by sex hormones. SociaL motivation: Social motives are learned motives that involve other people. Examples of social motives include the need for achievement, need for approval and need to attain power. Power motivation is when the goal is to influence, control, persuade, lead and charm others and enhance one’s own reputation in the eyes of other people. A special form of power motivation with negative objectives is termed Machiavettianism. It is char acteristic of people who express their motivation to become powerful by exploiting others in a deceptive and unscrupulous fashion. Self-actuaLization motivation: This was first described by Abraham Maslow, who spent most of his life studying healthy people. Self-actualiza tion refers to an individual’s need to do what he or she is capable of doing. Setf-actuatisers’ are people who make the most use of their capabilities, and are able to maximise their potentiaL The goals may vary from per son to person. According to Maslow, self-actualization is considered the topmost in a hierarchy of needs or motives in life. Esteem needs include the need for prestige, success and self-respect. Betongingness and love includes the need for affection, affiliation and identification. Safety needs include the need for security, stability and order. The basic physiological needs include hunger, thirst and sex. The order in which these are listed are important since the physiotogical needs must be
- 100. White the provisionof food, drugs, bedding and a comfortable ward setting by the paramedics in the hospital caters for the basic physiotogicat needs, hospitat administrators provide for the second tier of needs i.e. security The need for betongingness and tove isjeopardised once the patient is so lated from home, famity and significant others. The nursing staff is uniquely placed to fulfil this need. They can provide a surrogate environment that gives unconditional regard and respect. so the patient does not feet aban doned with respect to this third tier of needs. Addressing the patient by their preferred name, rather than bed number 12 or 13 (which undermines the sense of belongingness and need for bonding). greeting patients with a smite, staying by their side when they are in distress or pain, and com forting them are aLl gestures that a sensitive nursing staff ensures in their interaction with patients. A patient’s illness, its correlates and consequent disabilities, undermines their self-respect and setf-esteem. The steps of making him/her wear a patient’s uniform, taking away alt tiberties of movement, food, and choices, confinement to a bed or a room and frequent examinations of body parts (by medicaL students, trainees, residents and consultants) conducted in groups can be embarrassing for the patient. This take away the fourth tier of needs of esteem and recognition, as described by Maslow. As leader of the health team, the doctor should take charge of this most vital need. A healthy doctor-patient relationship based on mutual participation and in formed consent can enhance the self-esteem of the patient. A doctor who greets his/her patients on arrivat; addresses the patient with his/her pre ferred name and adds sahib’ or ‘soft/ba’ (or culturally appropriate phrase of respect); seats them respectfully; takes permission before undertaking an examination or a procedure and looks after them using the bio-psychoso ciat model of health care, not only adequately provides for the self-esteem needs of the patient but also enhances adherence to treatment, and the chances of recovery from itlness. Mastows Hierarchy of Needs in HospitaL satisfied before any of the others can be met A starving man is preoccu pied with the search for food. He is not bothered about what happens to morrow as only today’s meat counts. Once he is assured of eating today, he can begin to worry about his safety needs and thus climb up the hierarchy by one step. Most of us do not make it to the top of the pyramid partly be cause of the state of the society in which we live. It is only when our basic needs are met, that energy is available to strive for greater understanding of ourselves and our surroundings. The patient in a hospital environment in the grip of an illness, experiences a fall to the baseline step of Maslow’s hierarchy of needs. S/he is concerned solely with fulfilling their basic physiological needs and restoring physical or mental health. A comprehensive health care plan should, therefore, not only focus on the management of the disease but also make an attempt to facilitate the patient’s upward ascent on the hierarchy of needs. The diseased state, amongst other influences, also limits a person’s social and occupational functioning. The need to setf-actuatise and realise one’s full potential is, thus, also obstructed by illness and hospitalisation. The ideal health system caters for social and occupational rehabilitation of pa tients during hospitalisation as well as following discharge. The concept of tertiary care and rehabilitation following injury and disease augments the process of self-actualisation. Adding psychological and spiritual
- 101. dimensions to thecare plan can enhance it further. This goat is only possi ble through the implementation of the bio-psycho-social model of health care. It is the responsibility of health policy makers and pubtic heatth pro fessionals to develop and implement a health system that ensures fulfiL ment of unique potentials of the citizens and helps them become self-actualisers. Profite of a setf-actualiser • A doctor has the unique opportunity to achieve his/her own self-actual ization as well as make a contribution towards the achievement of self-ac tualization in others. Maslow found that self-actualisers shared a number of characteristics irrespective of whether they were rich or poor. famous or unknown, academically distinguished or uneducated. These are: • Efficient perceptions of reality: Most of Maslows subjects could judge situations correctly and honestly. • Comfortable acceptance of self, others and nature: SeIf-actuatisers were able to accept their own shortcomings as well as those of others. • Spontaneity: Maslow’s subjects extended their creativity into everyday activities. They tended to be unusually energetic. engaged and spontaneous. • Task-centring: Most subjects had a mission in life that they vigorously pursued. • Autonomy: Subjects were free from dependence on external authority and tended to be resourceful and independent. ../ ( Maslow’s hierarchy ofneeds • Fellowship with humanity: SeIf-actuatisers felt a deep identification with others and the human situation in general. • Profound interpersonal relationships. They were able to form meaningful and sustained mutually beneficial interpersonal relationships.
- 102. • Non-hostile senseof humour: Self actuatisers have a wonderful capacity to laugh at oneself. • Peak experiences: AtI of Mastow’s subjects reported the frequent occurrence of peak experiences. These are experiences that are marked by feelings of euphoria, harmony and deep meaning. 8. Intettigence Intelligence is hard to define. It can, generally, be described as the glob al capacity of the individual to act purposefully, think rationatly, and deal effectively with the environment. In essence, intelligence is the prob tem-sotving ability of an individuaL The Wechs[er Adult InteLligence Scale (WAISR) and the Wechster Intelli gence Scale for Children-Ill IWISC-llI) are the two most common methods of assessing the IQ of adults and chitdren, respectively. Assessment of IC includes the assessment of mathematical, verbal, spatial, and mechanical proficiency. The measure of intelligence is the Intelligence Quotient CIQ) which is ob tained by dividing a child’s mental age with his/her chronological age and multiplying it with 100. IQ mental age/chronological age x 100. Extremes of Intelligence Individuals who enter the medical profession have been found to harbour an IQ score higher than the average 10 of the population which ranges from go to 110. Scores below 70 or above 130 occur in only about 5 per cent of the popuLation. Individuals with such statistically rare scores are considered exceptionaL Those with scores below 70 may be diagnosed as mentally handicapped if they also exhibit significant deficits in adaptive behaviour such as self-care, sociaL skills, or communication. The diagnosis of a mental handicap also requires that the condition begin before age 18. In many cases, deficits that occur after age 18 are the result of brain dam age from traumatic injury to the head and brain. Individuals with 10 scores about 140 and above may be identified as gifted. Savant Syndrome: In 1887, J. Langdon Down described a group of mental ly handicapped children who exhibited speciaL abiLities. Down eventually became known for his description of Down syndrome but in a book enti tled Qn Some of the MentatAffections of Childhood and Youth, he offered a description of Savant syndrome. Savant syndrome occurs in individuaLs who are severely handicapped in overaLt intelligence yet demonstrate exceptional ability in a specific area such as aft, memory, or music. These individuals are often atso gifted with extraordinary memories. For example. despite very Low scores on tests of inteLligence, one of Down’s patients had memorised a large number of historicaL facts.
- 103. Emotionat IntelLigence Emotional intelligenceis defined as the capacity to identify, understand and control the expression of emotions. Emotional intelligence abilities can be divided into four areas: i. The capacity to accurately identify emotions. ii. The capacity to use emotions to facilitate thinking. iii. The capacity to understand emotional meanings. iv. The capacity to manage emotions. To be emotionally intelligent is to have interpersonal skills that characterise a rich and balanced personality. Emotional intelligence includes, as Aris totle put it. the rare ability “to be angry with the right person, to the right degree, at the right time, for the right purpose, and in the right way.” The measure of emotional intelligence is known as Emotionat quotient (EQ.) Components of Emotional Intelligence One commonly used version of Peter Salovey and John Mayer’s 1990 defi nition of emotional intelligence includes abilities in five main areas: i. Self-awareness: Recognizing one’s own feelings as they occur is the crux of emotional intelligence. The ability to monitor feelings from moment to moment is key to insight and understanding one’s own self. Being aware of one’s emotions makes one more confident when making important life decisions such as what career path to follow, or whom to marry. ii. Managing emotions: Having appropriate emotional reactions is a capacity that builds on self-awareness. The ability to modulate negative expressions of emotions such as anxiety, anger, and depression is a crucial emotional skill. Emotional resilience helps one to prevail over life’s inevitable setbacks. Those who lack emotionat self-regulation are continualLy overcome by feelings of distress. iii. Motivating oneself: Being able to focus on a goal is essential for a range of accomplishments. Emotional self-control such as delaying gratification or controlling impulsivity is crucial in working towards such life goats. Individuals who can harness their emotions, and maintain hope and optimism despite frustrations, are generally more productive and effective. iv. Recognizing emotions in others: Empathy, another skill based in emotionat self-awareness, is fundamental to interpersonal effectiveness. Those who are well attuned to subtle social cues that indicate what others feel are more successful in personal and professional settings. v. Handling relationships: The art of relationships requires skill in managing others’ emotions. Social competence underlies popularity. leadership, and interpersonal effectiveness.
- 104. EQ EQ Measures emoIion Intetigence: abtrryto manage emotions Flexible skiT can be learned and Improved Umbic stem Street smort Manages, resolves conflict Effeciiie dung times of stress EmotionaL InteLligence and I.Q. In a sense the human brain contains two minds and two different kinds of intelligence: rationaL and emotionaL. These two fundamentally different modes of consciousness interact to constitute our mental life. The emo tional and rational minds are semi-independent faculties, each reflecting the operation of distinct, but interconnected, circuitry in the brain. The complementary relationship and working of limbic system and neocortex, particutarly of the amygdala and prefrontal lobes, means each is a full partner in mental life. The emotionaL and rational minds operate in tandem for the most part. Emotions contribute to and inform the operations of the rational mind, and the rational mind refines and sometimes vetoes the input of the emotions. When these partners interact welt, both emotional intelligence and intellectual ability are enhanced. There is, at best, a slight correlation between 1.0. and certain facets of emotional intelligence, small enough to make it ctear that these are large ty independent entities. When people with high 1.0. struggle in life, and those with modest I.Q. do surprisingly wett, the difference often may be attributable to emotional intelligence. Those with an extremely high 1.0. but low emotional intelligence-or low 1.0. and extremely high emotionat Intel Ugence are relatively rare. Unlike the familiar tests for 1.0. there is as yet no corresponding test that measures emotional intelligence, although there is ample research on each of its components. Some aspects of emotional intelligence are best tested by studying an individual’s ability at the task. Empathy can be evaluated, for example, by testing an individual’s accuracy at interpreting another’s feelings from their facial expressions. Measures conttlv1ntece; ability to problem soIre1ea,Mm 10gb Permanent, fixed at birth Neocortex — Confronts threats head on
- 105. How to ImproveEmotional InteLligence While I.Q is targely under genetic inftuence, emotional intelligence is a set of skills that can be learnt and enhanced. just like any other skills. Below are a few guidelines to help a person get started with improving their emotional intelligence: Observe how you react to people. Do you rush to judgment before you know all of the facts? Do you stereotype? Look honestly at how you think and interact with other people. Try to put yourself in their place, and be more open and accepting of their perspectives and needs. Look at your work environment. Do you seek attention for your accomplishments? Humility can be a wonderful quality, and it doesn’t mean that you’re shy or lack self-confidence. When you practice humility, you say that you know what you did, and you can be quietly confident about it. Give others a chance to shine - put the focus on them, and don’t worry too much about getting praise for yourself. Do a setf-evatuation. What are your weaknesses? Are you willing to accept that you’re not perfect and that you could work on some areas to make yourself a better person? Have the courage to look at your self honestly - it could change your Life. • Examine how you react to stressful situations. Do you become upset every time there’s a delay or something doesn’t happen the way you want? Do you blame others or become angry at them, even when it’s not their fault? The ability to stay calm and in control in difficult situations is highly valued in alL professional and non-professional settings. Keep your emotions under control when things go wrong. • Take responsibility for your actions. If you hurt someone’s feelings. apologise directly — don’t ignore what you .did or avoid the person. People are usually more willing to forgive and forget if you make an honest attempt to make things right. • Examine how your actions will affect others - before you take those actions. If your decision will impact others, put yourself in their place. How will they feel if you do this? Would you want that experience? If you must take the action, how can you help others deal with the effects?
- 106. i. Sensorimotor stage(0-2 years): The child’s inteLtectua[ development is targety nonverbal in this stage and is mainly concerned with [earn ing to coordinate purposeful movements (such as neck holding. crawling and walking) with sensory input, After the age of 18 months the concept of object permanence begins to emerge. This refers to the child’s ability to recognise the permanence of objects. For instance ifs/he is playing with a ball and it rolls under the sofa, they would not Look for it as they think it no longer exists. For the very young child out of sight can literally mean out of mind,” This is why playing peekaboo (“taa) amuses infants, as they think that if you are hidden, you do not exist and when you reappear. they ate surprised. The development of object permanence, therefore, is the under standing that the ball stilt exists and now the child will search for it. I NW@, 9. Personatity DeveLopment Personality The word personality originates from the Latin persona”, which means mask. Personatity can be defined as the deeply ingrained and relativety enduring patterns of characteristics, behaviour, motives, beliefs, attitudes and cognitions that an individual possesses. Awareness of our personality and our ability to recognise ourselves separately from the environment is the only thing that separates us from artificial intelligence. While the exact nature of personality is a topic of intense academic de bate, general consensus states that aspects of personality start to devetop during childhood and are then strengthened and moulded tilt adulthood. This chapter sheds light on multiple theories of personality development. As alt chiLdren develop differentty and each has their own complex cog nitions and characteristics, no single theory can account for it. Thus, it is helpful to have a broader appreciation of personality development than any one theory. a. Piaget’s Theory of Cognitivó Development The Swiss psychologist, Jean Piaget believed that alt children pass through a series of distinct stages in intellectual development. He believed children construct knowledge for themselves as ‘little scientists’. His theory hypothesised that children advance through four stages of cognitive development with each stage building on the previous one. ü. Preoperational stage (2-7 years): During this stage the child devel ops the ability to think symbolically and use language. The use of language is not sophisticated, however, and they tend to confuse words with the object they represent. The child is also egocentric (they feel everything is about “Me!”) and unable to take the point of view of other people. During this stage chiLdren also make conserva tion errors. where they believe that simply changing the appearance of objects can change their quantity. iii. Concrete Operational stage (7-11 years): An important development during this stage is mastery of the concept of conservation as well the ability to reason logicalLy. Children have learned that pouring liquid from a talL narrow glass into a shallow dish does not reduce
- 107. the amount offluid. During this stage, a child’s thought starts to grasp the concept of time, space and numbers. The child starts using categories and principles. iv. Format Operationat stage (12 years onwards): After the age of ii. the child begins to break away from concrete objects and specific examples. Thinking is based more on abstract ideas and the child becomes tess egocentric. This stage represents the attainment of full adult intellectual ability. The older adoLescent is capable of reasoning and can conceptualise mathematics, physics, and phi losophy. Piaget argued that attainment of this stage is not universal and may depend on quality of education, the environment and the society that the adolescent is living in. b. Freud’s Psychoanatyticat Theory of Personality Devetopment Sigmund Freud proposed that an individual’s personatity develops through a series of five stages stretching from infancy to adulthood. These stages are called psychosexual stages because each is characterised by efforts to obtain pleasure centred on one of several parts of the body catted erogenous zones. According to Freud, the five stages of psychosexual development are the oral, anal, phallic, latency, and genital stages. I Oral Stage: Pleasure-seeking behaviour in the oral stage focuses on the baby’s mouth. Young children can often be seen biting, sucking. or placing objects in their mouths. Freud hypothesised that if oral needs such as the need for food are delayed, the child’s personality may become arrested or fixated. An individual whose development is arrested at this stage will disptay behaviours as an adult that are associated with the time of life during which the fixation occurred. For example, fixation at the oral stage may manifest in behaviours such as chewing on pencils, smoking or overeating and in person ality characteristics such as excessive dependency, optimism, and gullibility. ii. Anal Stage: From about 18 months until about 3 years of age, the child is in the anal stage. As the child gains muscular control, the erogenous zone shifts to the anus, and the child derives pleasure from the retention and expulsion of faeces. The key to this stage is toilet training. The way parents approach toilet training can have lasting effects on their children. If the parents are strict and demand ing, the chitd may rebel, and the result will be fixation at this stage. Individuals who are fixated at this stage may be overly rigid, obses sional and orderly as adults and are referred to as anat-retentive. People who have obsessional traits in personality tend to be per fectionists. These people can become easily distressed and anxious when their orderliness or time tables are disturbed. iii. Phattic Stage: The phallic stage, which begins at about age 4 to 5. is ushered in by another shift in the erogenous zone and the child’s pleasure - seeking behaviour, During this stage, children derive pleasure from fondling their own genitals. Children also begin to differentiate between males and females. It is during this stage that children begin to identify with the same sex parent and compete with them for the other parent’s attention. This is also the stage
- 108. where boys devetopa feeling of wanting to possess the mother and the desire to replace the father — what Freud called the Oedipus complex. Conversely girls develop a simitar set of feelings but for the father in what is referred to as the Etectra complex. A disturbed phallic stage is seen in adults in the form of disturbed relationships with either the opposite gender or both. iv. Latency and Genitat Stages: At about age 6, children enter a peri od when their sexual interests are suppressed. This period, which lasts until the beginning of adotescence, is called the latency stage. Sexual interests are reawakened at puberty and become stronger during the genital stage. In this stage, sexual pleasure is derived from heterosexual relationships. At the beginning of the genital stage, most adolescents have difflculty developing true affection and caring for others: they still experience the narcissistic qualities of earlier stages of development. As they mature, they develop greater ability to establish such relationships, thus setting the foundation for adult relationships. Although Freud’s psychosexual stage theory of personality development was fascinating and audacious given the conservative era of its concep tion, it was based upon case studies and hence lacked repeatability and reliability. The theory was based predominantly on male development and there was little mention of the psychosexual development of females. It can also not be verified through empirical research, as constructs utilised in the theory cannot be measured. c. Erikson’s Stages of Psychosociat Development Erik Erikson added to Freud’s theory by concentrating on human develop ment beyond puberty. He concluded that human personality is determined not only by childhood experiences, but also those of adulthood. denlity nerfi’iky INFANT IDD([R PR[- cUIOUI..- AllcttJ YOUNG MI[[ WR (WOOt[A A[R A11T A[ Afl GvIt tnf€iatil https//sites.googte.com/site/hool?appsychotogy;a/
- 109. He described 8stages of the life cycle fsee table below) I. Infancy. The first of Erikson’s stages is “trust versus mistrust” and occurs from birth to 1 year. The child devises either a trusting or mis trusting relationship with the world around it based on whether its immediate needs are met. These needs are generally concerned with physical cravings (food, sleep, and comfort) and feelings of attachment. ii. Early Childhood: The second stage of development Erikson is “autonomy versus shame and doubt” which occurs between 1 to 3 years of age. During this stage children learn to be independent but only if they are sufficiently encouraged to explore their world and given freedom to do so. Children with overly restrictive or anxious parents who restrict their children’s creativity and independent exploration of their environment, start to self-doubt and become tess confident. iii. Late Childhood: From the age of three to six, children pass through the stage Erikson refers to as “initiative versus guitt.” During this period of development, children take the initiative to further explore their environment and gain new experiences. The aspect of guilt comes about when there are unforeseen consequences involved in these explorations. iv. Shool Age. The final stage of childhood development is called “industry versus inferiority,” and it lasts from age six to 12. In this stage children learn to read and write and learn specific skills. Children seek to win approval by demonstrating skills that are valued by the society and develop a sense of accomplishment. Mastery in these skills, with adequate support from parents, teachers and peers, brings about a sense of overall competence. Failure brings about a sense of inferiority in the child. v. Adolescence. During the years of 12 to 18, the stage of identity versus rote confusion occurs as the vital transition from childhood to adulthood takes place. This is the time when the child evaluates his/her identity and decides the role he wiLl occupy as an adult. Erikson claimed that some uneasiness would be felt as the adult tries to feel comfortable in their changing body and success during this stage wilt lead to fidelity. This is because the individual will only be able to accept others who may be ideologically different once s/he becomes comfortable with whom they are themselves. vi. Occurring in young adulthood (ages i8 to 40 yrs.), in this stage of intimacy versus isolation” individuals become more intimate with each other and explore retationships that lead to long term commitments with people who are not family members. Success during this stage leads to a sense of commitment and healthy relationships whereas resistance to intimacy may lead to isolation. vii. During mid adult years (40-85) individuals reach the stage of “generativity versus stagnation.” They become established in society and their careers as well s give back to their society by educating their children and working. Failure in this stage by not playing an accommodating role in society can tead to stagnation and feelings of worthlessness.
- 110. Child begins toview his/her Overprotective self as an individual In their parenting can lead own right apart from their to selFdoubt in parents but still dependant the chIld. on them, Toilet training and Conditions that I controlling temper lead to the child tantrums begIns feeling inadequate or learning skills like walking or talking are S hazard In this stage Oaedy strict Phallic stage disdplinv bythO 3-6 years parents can PISxJrB suppress the become child’s pleasure zones. Gender identity forms. Oedipus. Electra complex occurs viii. The last and final stage of integrity versus despair” occurs after 65 years of age where productivity deteriorates and individuals reflect on their roles in life and their accomplishments. Erikson believed that people who do not feel satisfied with what they have achieved through their role in society have a tendency to become depressed and feet helpless. Although one of the most influential theories of development. Eriksons work was rather vague in the description of factors that may affect each stage and of the behaviours that would lead to successfuL completion of each stage. Trtrst In others and feelings of security based on how th infant is trgated by the parents/caretakers. AGE PEflIOD ERIKSONS EASIC DEVELOPMENTAL DEVELOPMENTAL FREUD’S COMPONENTS TASKS HAZARDS psycHosExuAl. STAGES infanqv - - Trust Biahtol8 months vs - Mistrust Early Childhood Autonomy l8monthstothree - vs years Shame Abuse. neglect in Infancy. premature or harsh weaning Oral stage Pleasure focused on mouth - chewng. sucking and biting Anal stage Pleasure is focused on bowel and bladder emptying Late Childhood initiative Child feels g sense initiative 3-Sysars -. vs toundarsl.andtheworld. - - Guilt and their main word goes - - from 7’JoI to whyT -. I ftation of adult behaviOur • r occurs. The child’s - imagination starts to - - . - Reality testing begins School Age 6-lZyeere Adolescence 12-20 years Latency 6 years puberty Playing with the same gender. dormant sexual feelings Industry vs inferiority Identity vs Role Confusion Young Adulthood Intimacy 18-25 years - vs latIon Generetivigr vs Stagnation -- Old age integrity 6syearstOdeeth vs - Despair Child feels accomplishment in learning and mastering now skills. Identity development of who one is Capacity for love, mutual dafdoliort commitment to workand’telatlonships: impdrsohal reiationshlps. Creativity, productivity. concern for others, self- indulgence. impoverishment Of self Acceptance Of the worth and uniqueness of oneg llfe sense orioss. contempt tor Qthers -- Genital Stage Puberty onwards Seauci interests mature Failure due to personal limitations or extreme competition leads to sense of inferiority and poor work habits Society fails to pfoeide well defined roles or roles are undesirable leading to contusion isolation or lack of personal relations FaIlure to perfect and master developmental tasks, leading to stagnation Ineblityto find Meaning in life Adulthood 25’65 years
- 111. Determinants of Personality Thestudy of personality cannot only be based on how it is manifested and changed overtime but rather what factors determine, or affect personality. Charles Darwin in his ‘Origin of Species’ proposed that a person’s person ality originates in the mother’s womb with genetic and hereditary factors contributing to our primal personality traits. Scholars like John Locke argued that the human psyche and psychological traits are formed pri marity due to the environment and surroundings that the person is raised in. Angyat (1941) believed that the determinants of personality are neither exclusively organismic nor environmental but rather a combination of both. When studying the development of personality, therefore, one must take a holistic approach and consider biologicaL psychological and social factors. Biotogical factors Biological determinants of personality include inherited traits and characteristics as well the workings of the nervous system. glands and blood chemistry (Kumar, 2015). Factors such as heredity are de termined at birth and can be referred to as physical structure, mus cle density, facial structure, attractiveness that one inherits from the biological makeup of their parents. Basically. the way we look plays an important role in how others treat us and how we in turn, treat others. Krueger and Johnson (2008) found that genes contributed to individual differences in alt of five of the Big Five personality fac tors. As we grow older we acquire different aspects of our parents’ personalities. Siblings may differ in their appraisals of situations as well as in their overall outlook on life. Proponents of lhe nature over nurture argument would suggest that these personality differenc es are due to the differences in the children’s’ observation of their parents’ behaviour. Sociat/Environmetita[ factors Factors such as social structure and the environment play a vital role in the formation of a child’s personality. Numerous studies have shown that a constructive learning environment, social support and a nurturing family, all positively affect the development of personal- ity. Environmental factors may include the culture that children are raised in and the societal norms that guide behaviour. Environmental factors can be used to manipulate/suppress the genetic predisposi tion to express undesirable emotional and behavioural responses of individuals. In 2000, Collins et at found that factors such as parent ing and other early life experiences affect the expression of genetic personality traits. Personality Types: Relevance to Clinicat Conditions Many readers would have observed that it is a common tendency for peo ple to categorise others on the basis of their personal characteristics. Even in your class there are bound to be ‘shy’ students and the ‘sociable out going’ type. Classifying people into types is one device by which we try to make sense out of others’ behaviour and anticipate how they wilt act in the future. The notion that people can be classified into certain types is one of the oldest ideas about personality Personatity classifications date back to 400 BC. Hippocrates, a Greek physician grouped people into four types on the basis of their temperaments. These were sanguine (cheerful, vigorous,
- 112. Type A personsare driven and competitive. They tive under constant pressure, which is usually setf-created. They also take on multiple activities with rigid deadLines to meet. These people may function weU. most of the time and may be competent and efficient. Under stress, however, they are likely to become hostile, anxious and disorganised. They may feeljittery and irritable prior to examinations and are constantLy in a hurry’. The underlying cause of an increased incidence of heart disease in Type A personality is the constant outflow from the sympathetic nervous system in response to stressors. Type B persons are easy-going, non-competitive, placid and cooL They remain calm and composed under stressful states. Given a task to do, Type-A’s usually perform near their maximum capacity no matter what the situation is. Type B persons only work hard when given a deadline. Interestingly, when placed in Long lasting stressfuL situations over which they have little controL Type A personalities tend to give up. They exhibit he[p[essness and be come less responsive than Type B personalities. PersonaLity types that can influence heatth personnel: There are distinct personatity types that doctors and medical students may come across in hospitals and in their personaL lives. KnowLedge and under standing of personality profiles can help them dealwith these individuals more effectively. The foremost amongst personality types that may be difficult to handte are those with histrionic or sociopathic personatity traits or types. These individuals have the following characteristics; • manipulative behaviour superficiaL charm • loud in their expression (both in language as well as dressing and demeanour), • tell fantastic stories (mostly false), Personality types and heart disease optimistic), metancholic (depressed). choteric (hot- tempered) and phlegmatic (slow moving. unexcitable). According to the Type theory of personality, people can be divided into extroverts and introverts. Extroverts share a tendency to be outgoing, friendly and talkative whereas introverts can be described as people who share characteristics such as shyness. sociaL withdrawal and a preference to spend time alone, Heart disease has traditionally been linked to smoking, obesity, diabetes and inactivity. In recent years, however, a link between heart disease and personality types has emerged. Two specific behaviour pattern types are now known to be associated with increase and decrease chance of coro nary artery disease; Type A and Type B. • exaggerate their symptoms, • take advantage of naive medicaL students (asking for uncalled for investigations, petty cash, small time favours, drugs. cigarettes). • prefer to be treated by junior doctors (for fear of being discovered or identified).
- 113. The common ploysused by such patients include stories of being mal treated by their own family, work setting, or the society in generaL These individuals readily share sob stories of being ‘cheated” or ‘abandoned” in life. They may say they are in dire need of money to pay for a lifesaving procedure or drug. A dangerous strategy they use is appearing to develop ‘strong feelings of love” for the doctor or the medical student. The story of Miss X in section on psychological reactions in doctor patient relationship in Section 2, revealed that she had histrionic traits. The case report goes on to reveal the complications that can arise if a medical student/doctor is caught unaware. While it is crucial to be wary of such personalities and to be constantly on the lookout, it is equally important not to judge, pun ish or prosecute them. These individuals have deep rooted psychological conflicts and complexes and require professional psychiatric help. This help should be offered to them at the earliest. It is always better to hand over the care of patients with such attributes to the senior members of the health team. Clinicat descriptions of their behaviour must be entered in their case histories, for future reference. The table briefty describes the important features of the various types of personality disorders. Chapter 3 Neurobiological Basis of Behaviour The evolution of our understanding of the mechanisms of human be haviour has undergone many different stages (see table). The most recent and perhaps the most dependable expLanation is the neurobiological basis of behaviour. While we study exhaustive texts on iow the brain works in terms of our most basic functions, we as students tend to gloss over the anatomy. biochemistry and neurology of what makes us who we are. The purpose of this chapter is to shed light on some of these areas. It is, however beyond the scope of this book to go intodetails of neurobiolo gy and cognftive neuroscience for which the reader must consult a more exhaustive text and ongoing research articles on the subject. It must be brought to the reader’s attention that the human brain is not like a house with rooms, in which certain functions take place only in certain areas. It is, in fact, the connectivity between various areas of the brain that leads to this. The following text works to highlights some of these connections, and should work to create awareness that such connections exist.” We do not h’now everything, and not alt of what we betieve we know is correct,” - Anon Religion ch Neurosdence - -,,---_j Ge Progression of our understanding ofhuman behaviour Cluster A CMad”) Paranoid: Distrustful, preoccupi with conspIracy theones Schizotypal: socially odd, magica thinking Cluster B (“Bad”) Histrionic: provocative, dramatic shallow emotionally fri’—I [ I Nardssisstic: Grandiose, self loving lack empathy, sense of entitlement Borderline (emotionally unstable): Impu swe. unstable intense relationships. proni to deliberate self-harm, drug abuse Obsessive compulsive: perfectionist inflexible morals, preoccupied with rules/orderliness Dependant: submissive, helpless, clingy, excessively needy Personatity disorder
- 114. Emotion Emotion may bedefined as a feeling with its set of unique thoughts, elec trical and biochemical changes, and the range of behaviours it can Lead to (See Section C, Chapter 2). There are two different kinds of emotions: inher ent and learnt. Inherently found emotions include those that all human be ings are born with the capacity to experience. These can range from anger, sadness, fear, love and amazement. These emotions are derived primarily from our basic human drives such as hunger, thirst, sex and the need for social interaction. The Learnt emotions include: envy, pride, guilt, pity. resentment and af fection, alt of which are housed in the frontal cortex. The more complex emotions like jealousy, greed, paranoia, and lust are a mix of the inborn and learnt emotions. There is Less known about the neurobiology of these highly complex emotional states but there is a fair amount of research on the inborn and learnt emotions. Neuroanatomy of Emotions The neuroanatomical site for the manufacturing’ of emotion is the limbic system. The range of behaviour patterns that may result from a given emo tion is decided by the frontal cortex. The frontal cortex is the smart” part of the brain where planning for the future, decision making and executive functions are carried out. It is the chief executive of the brain, and what makes us “ashraf-ut-mahhtooqaat” (The Superior Species). The prefrontal cortex is what allows us to behave in a civilised fashion even when our emotions urge us to do otherwise. This is essentially what it means to be human, as animals have a limited capacity to perform these functions. These functions are performed specifically in the prefrontal cortex which can be divided into 3 parts: Dorsotateral, Ventromedial and OrbitofrontaL The dorsolateral prefrontal cortex is primarily involved in managing cognitive processes. moral decision making. inhibition of emotion, altruism and telling the truth (or tying!). It allows the individual to have the ability to entertain multiple ideas at the same time and plan for the future. It is also involved in motivation, attention and the drive to complete tasks. It is par ticularly active in tasks that require deductive and syllogistic reasoning.[3;1 It also plays a role in the behavioural response an individual has to anxiety and works to prevent in behaviour likely to be harmful to the individual. [61 The ventromedial prefrontal cortex has a role in emotional regulation and decision making involving morality. [31 This was famously seen in the case of Phineas Gage who suffered damage to his ventromedial prefrontal cortex. [41 It is the part of the prefrontal cortex that allows one to [earn from their mistakes. It also allows people to detect irony, sarcasm and detect tying in other people. The ventromedial prefrontal cortex allows people to use emotions to make moraljudgements. This can be explained using the Trolley dilemma (Thomson,1g86), in which a person is asked to save five people from certain death by a trolley crashing into them by pulling a switch redirecting the trolley to kill only one person. The majority of people felt that it was moral to let one person die and save five people. If, howev er, people were asked to physically push one person in front of the trolley to save the five people, they refused, despite the end goal of both being the same. The ventromediat prefrontal cortex used the emotions telt in the situation to come to a decision, as seen by Green et al. (2011). When the amygdala becomes active in situations causing anger the ventromedial prefrontal cortex is able to control the urge to act impulsively. [51
- 115. The orbitofrontal cortex(so called because it represents the area above the orbits) plays an important role in emotional regulation, specifical ly anger management. It functions to associate possible outcomes of a certain behaviour by weighing pros and cons based on reward and pun ishment and makes a decision. Iii In one study people with more outgoing personalities were found to have higher volume orbitofrontal cortex, while more introverted people were found to have a higher volume ventromediat prefrontal cortex. [2] A part of the cingulate cortex, the anterior cingulate cortex (ACC) is the area where the integration of emotional input with attention occurs. It, therefore, controls emotional arousal and emotional self-controL It is involved in gen erating empathy and social awareness and becomes active when individu als indulge in acts of bravery. [41 To summarise, the prefrontal cortex (the smart’ part of the brain), takes into account the emotions elicited and decides the most logical and rational action to take in a situation. 171 The limbic system, specifically the amygdala, works to integrate inputs from the thalamus and frontal cortex with outputs involving the endocrine and autonomic nervous systems. This results in the expression of emotion. • The amygdala is the main mediator of the fight, flight or freeze response. It is invo[ved in the mediation of aggression, fear, sexuaL orientation and social interaction, including the number and kind of people one is friends with and interacts with in a social context. It also regulates personal space, in that it is stimulated when another human being gets “uncomfortably close.” [81 The right lobe of the amygdala houses negative emotions such as fear and anxiety. The left lobe, on the other hand, mediates and stores both positive emotions such as pleasure and happiness and negative emotions such as fear. In one study, poLitical conservatism was linked to increased volume of the right amygdala. [9] Distinct gender differences have been seen in the male and female amyg data. The mate amygdata has a larger right lobe, while the female amygda Ia has a larger left lobe. As the right lobe is associated with negative emo tions and action, men are more likely to react physically in situations that are emotionally stressful. The left lobe is important in the recall of emotion ally charged memories and details, leading to more intense thought, which may explain why women are more likely to not react in physical ways to emotional stress. The amygdaLa also mediates the formation of memories that have an emo tional content. When sensory input is received, it is relayed by the thalamus to both the frontal cortex and the amygdata. The amygdala then checks with the hippocampus to see if there is an emotional memory of a similar experience. If one is found, we tend to react in a similar fashion, if not; the prefrontal cortex kicks in to make something of the novel experience and forms a new response. Activity of the amygdala has been linked to clinical depression, anxiety disorders, and posttraumatic stress disorder. liD] Despite the tact that the prefrontal cortex is the smart part of the brain, the amygdala exerts far more control over it than the prefrontal cortex does over the amygdata This can be understood it the amygdata is equated with the moon which despite its size may eclipse the sun. This “limbic eclipse” is th reason that “love is blind” “ghussa akal ko khaajaata hai”
- 116. (anger makes youirrational) and durr se behosh hona” (fainting with fright) occur. As seen in each of these expressions, an emotion that is essentially less ‘smart” completely clouds the judgement of the smarter higher centre, the frontaL cortex. Neurochemistry of Emotions Biochemically, certain neurotransmitters have been [inked to feeling spe cific emotions. Amongst the most highty researched of these are serotonin, dopamine, oxytocin and norepinephrine. Serotonin has been hailed as the feet good” neurotransmitter in the brain. It, among other things, leads to a feeling of well-being and satisfaction liii. Lower than normal levels have been linked to clinical depression. This is evidenced by the improvement of symptoms of depression with the use of serotonin reuptake inhibitors tSSRIs & SNRIS) h21 [131. Dopamine is the main neurotransmitter released in anger, aggression and excitement. Dopamine levels also increase when an individual experiences complex emotions [Ike paranoia and jealousy. Dopamine is also the primary neurotransmitter in the reward pathway. The reward pathway is activated by drugs that lead to increased dopamine, gambling (where winning leads to dopamine release), and playing video games. This is also why all of these activities are addictive. Dopamine is responsible for the kick” that normal people experience in moments of excitement and anticipation when they are looking forward to something. Higher than nor mal levels of dopamine can lead to difficulties in impulse control, aggression and eventually, psychosis [‘41 [151. Oxytocin is the neurotransmitter of love and bonding. It exists in the body both as a hormone and a neurotransmitter. It was previously studied as being released in targe amounts during childbirth, and immediately after, for breastfeeding. In newer research it has been hailed by many as ihe propagator of the human species.” This is not only due to its role in child birth and reproduction (large amounts are released during sexual inter course) but also due to its ability as a neurotransmitter, to cause ‘pro- social” behaviour 1161. Higher levels of oxytocin have been found t make humans more likely to make decisions that promote the well-being of a group rather than the individuaL The bond, kinship and love that any two human beings share is mediated by the presence of oxytocin, which is why it has been called the love hormone. It has also been known to decrease stress and anxiety and lead to a greater degree of trust, altruism and feel ings of safety between people. In a study published in the 2013 in the Proceedings of the National Academy of Sciences of the USA Journal (PNAS), administration of oxytocin was revealed to cause greater fidelity between couples, making men more likely to be monogamous and more sensitive to other people’s emotions t171. It is thus helpful to see dopamine as the neurotransmitter released when one first becomes intrigued by a mysterious stranger, oxytocin as released when one falls in love and serotonin as causing the sense of satisfaction and well-being when we live “happily ever after.”
- 117. —-— - 5ota* -Oytocm Progression otourunderstanding ofhuman behaviour Corpus callosum COMPONENTS IN THE DIENCEPHALON Anterior group of thalamic nuclei Hypothalamus Mamillary body COMPONENTS IN THE CEREBRUM Cingulate gyrus Parahippocampal gyms Hippocampus I I Lepreon ftorFit a’n The Limbic System
- 118. References i.Kringelbach, M. L.(2005) “The orbitofrontal cortex: Unking reward to he donic experience. Nature Reviews Neuroscience 6: 691-702. 2. Schoenbaum G, Takahashi Y, Liu T, & McDannatd M (2011). “Does the orbi tofrontat cortex signal vaLue?” Annals of the New York Academy ofSciences 1239: 87-99 3. Hu, C; Jiang, X (2014). “An emotion regulation role of ventromedial pre frontal cortex in moratjudgment.” Front. Hum. Neurosci 8: 873. doi:10.3389/ fnhum.2o14.oo873. 4. Nicolle, A. & Goet, V. (2013). What is the role of ventromedial prefrontal cortex in emotional influences on reason? In I. Btanchette (Ed.), Emotion and Reasoning. Psychology Press. 5. Schwartz, Carl E., et aL “Structural differences in adult orbital and ventro medial prefrontal cortex predicted by infant temperament at 4 months of age.”Archives ofgeneral psychiatry 67.1 (2010): 78-84. 6. Carlson, N. (2012). Physiology of Behaviour filth Ed.). Hartow: Prentice Hall. . Chan, R. C. K., Shum. D., Tou[opoutou, T. & Chen, E. Y. H., R: Shum, D: Tou lopoulou, I; Chen, E (2008). “Assessment of executive functions: Review of instruments and identification of critical issues.” Archives of Clinical Neuro psychology. 2 23 (2): 201-216. 8. Kennedy, Daniel P., et al. “Personal space regulation by the human amyg data.” Nature neuroscience 12.10 (2009): 1226-1227. 9. Kanai, Ryota, et at “Political orientations are correlated with brain struc ture in young adults.” Current biology 21.8 (201;): 677-680. 10. Sheune, Yvette I., et at “Increased amygdata response to masked emo tional faces in depressed subjects resolves with antidepressant treatment: an fMRI study.” Biological psychiatry 50.9 (2001): 651-658, ii. Peirson AR, Heuchert JW. Correlations for serotonin levels and measures of mood in a nonctinica[ sample. Psychot Rep 2000:87:707-16, 12. Flory JD, Manuck SB, Matthews KA. et at. Serotonergic function in the central nervous system is associated with daily ratings of positive mood. Psychiatry Res 2004:129:11-9. 13. Muldoon MF, Mackey RH, Williams KV, et at. Low central nervous sys tem serotonergic responsivity is associated with the metabolic syndrome and physical inactivity. ] Clin Endocrinol Metab 2004: 89:266-71. 14. Schultz W (2007). “Multiple dopamine functions at different time cours es.” Annual Review of Neuroscience 30: 259-88. 15. BjOrktund A, Dunnett SB (May 2007). “Dopamine neuron systems in the brain: an update.” Trends in Neurosciences 30 (5): 194—202. i6. Lee HJ, Macbeth AH, Pagani JH, Young WS (Jun 2009). “Oxytocin: the great facilitator of tite.” Progress in Neurobiology 88 (2): 127-51. 17. 01ff, M.. FrUling. J. L., Kubzansky, L. D., Bradley, B., Ettenbogen. M. A., Car doso, C & van Zuiden, M. (2013). The role of oxytocin in social bonding, stress regulation and mental heatth: an update on the moderating effects of context and interindividuat differences. Psychoneuroendocrinotogy, 38(9), 1883-1894.
- 119. Motor and SensoryRegions of the Cerebral Cortex Language Language forms a quintessential part of what it means to be human. Human language is unique compared to the communication techniques used by other animals. Other animats communicate using a finite num ber of ideas that can be expressed. Human language. on the other hand, is open-ended and productive meaning. Humans, can, thus produce an infinite range of expressions from a finite set of elements to create new words and sentences. [ii Speaking is the default mode for language in all human cultures. Humans produce language using control of the lips, tongue and the rest of the vo cal apparatus. They are able to differentiate spoken sounds white attaching contextual meaning to the sounds. In other words we can understand what is being said, and what it means in a certain situation. These abilities are [inked to a neurological apparatus to acquire and produce language. 12] While, language is processed in various areas in the human brain, the two areas that are mainly involved in language processing are Wernicke’s area, located in the posterior section of the superior temporal gyrus, (temporal lobe) and the Broca’s area, located in the posterior inferior frontal gyrus (frontal lobe) of the dominant hemisphere. Wernicke’s area is used for lan guage comprehension and Broca’s area is responsible for language artic ulation. Language is the only human behavior that has two controlcentres. thus the famous idiom pehte tolah phir boto’ (think before you speak). Primary motor cortex (precentr& gyms) Somatic motor association area (premotor cortex) Prefrontal cortex Sri Broca’s area— (production of speech) Primary sensory cortex (postcentml gyms) / Somatic sensory association area Visual association //_ area Visual cortex Auditory association area / - -- I Wemicke’s area Auditory cortex (understand speech)
- 120. Language comprehension isknown to consist of three distinct steps. The first step known as phonological processing, takes place in the frontat lobes, where individual sounds, such as vowels are recognised. The sec ond step is known as texicat processing and is localised in the left temporal lobe. Lexical processing matches heard sounds with words or sounds that already exist in the individuat’s memory. In the third step, known as seman tic processing. words recognised during the lexical processing step are connected to their meaning. Semantic processing activates the middle and superior gyri of the left temporal lobe. Brain areas required for the under standing of the conceptual content ot words are distributed all over the cortex, as been in brain imaging. Language production occurs in the opposite direction from language comprehension. This basically means that it proceeds from the cortical semantic processing to the teft temporat lexical processing, finally going to the phonologicat processing area (for speech) or the graphomotor system (for writing). Prosody, the emotional and ffective component of language. or ‘body language.” appears to be [ocalised in the right hemisphere. Linguistic functions such as intonation, tone, stress, and rhythm form part of pros ody. Prosody provides information on the various non-semantic aspects of communication, such as the emotional state of the speaker, the nature of what is being said as welt as the presence of irony or sarcasm. These nonverbat elements are created using motor operations of the face, mouth, tongue, and throat and are associated with Broca’s area in the left frontal lobe. The processes needed to understand these nonverbal elements oc cur in the right-hemisphere perisylvian area, particularly Brodmann area 22. Language exhibits a high degree of hemispheric lateralisation. Damage to the right inferior frontal gyrus diminishes an individual’s ability to use the nonverbal aspects of communication such as conveying emotion or emphasis by voice or gesture. Damage to the right superior temporal gyrus diminishes an individual’s ability to understand the nonverbal meaning of the voices and gestures of others. In summary, as is largely known, the left hemisphere is the part of the brain that is mathematical, calculating and analytical. To put it in terms of an unfair stereotype the left hemisphere is the ‘accountant”, while the right hemisphere is the “artist’ where lies the appreciation of art, music and literature. In other words. while the Wernicke’s area that processes lan guage is in the left hemisphere (in most right handed individuals), the right hemisphere is where the processing of the context, sarcasm, irony, body tanguage, facial expression and intonations occurs. In any given spoken sentence, therefore, the left hemisphere hears what is said while the right understands how it is said. References 1. Hockett, Charles F. (1960). ‘Logical considerations in the study of animal communication.” In W.E. Lanyon: W.N. Tavolga. Animal sounds and animal communication. pp. 392-430. 2.. Trnsk, Robert Lawrence (1999). Language: The Basics (2nd Ed.). Psychology Press.
- 121. Memory Memory is definedas the mental capacity to encode, store, and retrieve information. [ii Clinically we are concerned with three, testable periods of memory which have distinct anatomical correlates: Immediate memory functioning over a period of seconds: recent memory applicable over a scale of minutes to days: and remote memory ranging over time periods spanning months to years. Immediate memory can be understood as the ability to follow a train of thought. It is divided into phonological and visuospatial components. The phonological component is localised in the left hemishphere and the visuospatial in the right.. Immediate memory is often related with recent memory using the concept of working memory. Working memory is defined as the ability to store information for several seconds while other cognitive operations take place using this information. The dorsolateral prefrontal cortex is required for working memory along with the certainty with which the information is known. [2] Some researchers locaUse working memory predominantly to the left frontal cortex. Three brain structures are critical to the formation of memories: the medial temporal lobe, certain diencephalic nuclei, and the basal forebrain. The hippocompus is part of the medial temporat tobe. Adjacent to the ante rior end of the hippocampus is the amygdata. The amygdala and the hip pocampus work in tandem to store emotional experiences. The amygdala rates the emotional importance of an experience and activates the level of hippocampal activity. This phenomenon is called the memory enhance ment effect and is the reason why emotionally intense experiences are etched in memory. This is why most of us would find it hard to recall what we had for lunch last Tuesday, but remember in great detail what the menu for a close family wedding three years ago was or the exact sequence of events when vie were in a car accident. The amygdata also plays a role in the formation of long-term memory by moduLating synaptic plasticity, which helps to retain a memory. It helps to visuaLise memory as a grassy path, that when used repeatedly becomes a place of common fare. Long-term memory for learning events is not formed immediately. These memories are slowly made over time, through a process called tong term potentiation These are enhanced and made permanent when they are potentiated by experiences. This is also why you don’t remember last minute cramming after a few weeks. It is, therefore, imperative for a medi cal student to ensure that all forms of knowledge are enriched by seeing a patient or dealing with a relevant clinical experience in real Life settings of a hospital. The lesser the gap between studying and clinical experience, the higher the chance that the knowledge will remain in memory for the long term. The association areas are required for the formation of memory for motor acts. The performance of a new action requires feedback from the sensory cortex and association areas. Neuroimaging has shown activation of the large parts of the cortex, during performance of unskilled acts. When per forming repeated activities initially the medial temporal lobe is activated, however with time the performance of the act results only in the activation of the premotor and left parietal cortex. This phenomenon is known as the
- 122. corticalisation of motorcommands, The repeated acts of [earning how to pass a catheter or intravenous injection ensure perfection and thus the idiom practice mal?es perfect! Within the diencephaton. the dorsal medial nucleus of the thatamus and the mamillary bodies appear necessary for memory formation. References 1. Gerrig, Richard J. & Philip G. Zimbardo. Psychology And Lite, ;6/e. Pub tished by Allyn and Bacon. Boston, MA. Copyright (c) 2002 by Pearson Education. Reprinted by permission of the publisher. 2. Sadock, Benjamin J., and Virginia A. Sadock. Kaplan and Sadock’s synop sis ofpsychiatry: Behavioral sciences/clinical psychiatry. Lippincott Wit hams & Wilkins, 2011. ArousaL Arousal is defined as the physiotogicat and psychological state of being reactive to stimuli. While there are many different neural systems involved in the establishment and maintenance of this state, research has shown the involvement of mainly five systems. each originating in the brainstem. These systems are based on five neurotransmitters: norepinephrine, ace tylchoUne, dopamine, histamine, and serotonin. The noradrenergic system. originating in the locus coeruleus causes wake fulness by the release of norepinephrine. The cholinergic system based in the pons and basal forebrain causes cortical activity and alertness. Both the dopaminergic system and the serotonergic system’s neurons project into the limbic and prefrontal cortex and are important for mood control and regulating motor movements. The histaminergic system neurons proj ect into the cerebral cortex, thalamus, and the basat forebrain, stimulating the release of acetytchohine into the cerebral cortex. All these systems are related to the development of a feedback mechanism to establish and maintain arousal. - (,rW I Image is taken from ChristofKoch ((20p4) “Figure 5.1 The Chotinergic Enabling System” in The Quest for Consciousness; A Neurobiological Approach, . Roberts & Co., p. 91 ISBN.’ 0974707708. with permission from the author under license
- 123. There have beenattempts to explain different temperaments in humans by examining variations in a person’s brain stem, Umbic system, and thatamo cortical arousal system using Electroencephalogram (EEG). [1] Limbic sys tem activation has been [inked to neuroticism, with high activation showing high neuroticism.[2] High cortical arousal has been shown to be associated with introversion. People with high extraversion and low neuroticism have been shown to have the towest overa[[ levels of internal arousat. Converse ly people with high extraversion and high neuroticism have been shown to have the lowest intrinsic thatamocortical excitation. References 1. Robinson, David (6 November 2000). UH0w brain arousal systems de termine different temperament types and the major dimensions of per sonality.” Elsevier. Personality and Individual Differences i: 1233—1259.doi: 10.1016/s0191-8869(oo)0o2;1-7. 2. Robinson, David; Gabriet, Katchan (22 February 1993). Personality and Second Language Learning(PDF). Personality Individual Differences i6 (1): 143—157.dOi:10,1016/0191-8869(94)90118-x. Retrievedl2 November 2012. Steep Steep is a recurring state of altered consciousness, imperative to nor mal brain and body function. Approximately one third of our lives is spent asleep. Steep is characterised by decreased awareness and interaction with surroundings, lowered sensory activity and inhibition of voluntary muscles. The awake state is characterised by beta and alpha waves on the electro encephalogram. Beta waves are commonly seen during active mental con- centration whereas alpha waves are seen when a person c[oses their eyes and relaxes. Each stage of the sleep cycle is characterised by a specific wave form on EEG. Mapping the transition of sleep from one stage to another is known as sleep architecture and this changes with age. The normat sleep cycle is divided into rapid eye movement (REM) steep and non-rapid eye movement (NREM steep). REM sleep is a period of high levels of activity in the brain and a level of physiological activity similar to when the person is awake. During NREM sleep, physiological activity is less than when an individual is awake. NREM has four stages (1-4).
- 124. Hypnograrn ,,•.Jlri4’1 .dnhiig MIiiighi 11311 By!,RazerM, CC BY-SA 3.0, https://commons.wikimedia,org/w/index. php?curid=;7745252 Stages of Steep When we ñrst fall asleep, we enter into a NREM cycle which lasts forgo minutes. These go minutes are composed of the following four stages: Stage 1 is the lightest stage of sleep with theta waves on EEC and is char acterised by a sense of calmness, slow pulse, respiration and a decrease in blood pressure. This constitutes 5% of the sleep cycLe. Stage 2 shows sleep spindles and K complexes on an EEG. This stage constitutes about 45% of the sleep cycle making it the largest portion of sleep time. Stage 3 and 4 are characterised by the delta waves or slow wave steep and is the deepest and most relaxed stage of sleep. Sleep disorders such as nightmares, night terrors, sleep walking and bed wetting occur during this stage. After about 90 minutes, the NREM cycle is followed by REM sleep. Rapid Eye Movement (REM) steep is characterised by a saw-tooth EEG showing beta, alpha and theta wave patterns. Dreaming occurs during this part of sleep along with an increase in pulse, respiration and blood pressure. REM periods of 10-40 minutes, occur about every 90 minutes throughout the night. Sleep disorders The quantity and quality of steep changes with age. The elderly show more frequent awakenings during the night white teenagers tend to remain awake alt night and steep during the day. Changes in steep are believed to be due to changes in internal body rhythm, (catled Circadian Rhythm), emotional stress, physical illness and drugs. The chronic use of sedatives and hypnotic is not known to improve steep. On the contrary they are implicated in many of the dyssomnias. Due to stow metabolism the elderly tend to accumulate more of the sedatives in their bodies which may lead to delirium, daytime drowsiness and loss of equilibrium. w : St1ge 2 3 4
- 125. IF Primary Sleep Disorders Dyssomnias PrimaryInsomnia Difficulty falling asleep, staying asleep, or sleeping but feeling as if one has not rested during sleep sle.p1n.ss lp)ng q . Sleep attacks during daytime. Daytime naps relieve sleepiness “••-• i RNathlng ,alated . Abnormal breathing during si.ep sleepdIiorder r 1.ads tesi pdIsuptlonvid diytlme sleepiness , - -______ Circadian rhythm Disturbance ofsleep due to a mismatch between a persons sleep disorder intrinsic circadian rhythm and external sleep wake demands Parasomnias Nightmare disorder Repeated episodes ofscary dreams that wake one from sleep usually during REM sleep d.pb’ rdungslee en bslMdusl may sit up orscream end appear extremely frightened. Occurs during delta sleep Recurrent sleep walking often coupled to other complex motor activity There are two types of sleep disorders: primary and secondary steep disorders. Primary disorders occur as a direct result of disturbances in the steep-wake cycle. Secondary steep disorders occur as a consequence of other disorders such as depression or due to a general medical condition (e.g. pain) or substance abuse. Sleep hygiene The following factors contribute to improvement of sleep: • Sleeping and waking up at around the same time daily (even on weekends!) • Increased physical activity in the afternoon and early evening hours • Cooler room temperatures are more conducive to sleep than warm temperatures • Light bedtime snacks that have calcium and small amounts of sugar • Evening relaxation routines such as progressive muscular relaxation and evening prayers. • Avoidance of long naps, especially during the later part of the day. Narcolepsy Sleep walking disorder Making and cleaning your bed every day.
- 126. • Getting intobed only when ready for sleep. • Eating at reguLar times daily and avoiding large meals near bedtime. • Avoidance of sensory stimulation at night by substituting TV and cellphone usage with light reading. • Avoidance of caffeine and fizzy drinks in the evenings. Avoidance of excessive smoking in the evenings (as nicotine is a stimulant). • Avoidance of stimulant drugs such as amphetamines, cocaine and MDMA. Steep induction Sleep control is a mental technique that you can use to enter normal physi ologicaL sleep any time without the use of drugs, using the following steps • Lie down in bed. ctose your eyes and graduatty guide your mind to visualise a chatkboard. You witt mentatty have chatk in one hand and an eraser in the other. Mentatty draw a targe circte on the chatkboard Then draw a big X within the circle, You witt then proceed to erase the Xfrom within the circte starting at the centre of the X and erasing towards the inner edges of the circte. Be carefut not to erase the circle in the teast. • Once you erase the Xfrom within the circle, to the right and outside of the circle write the word “deeper.” Every time you write the ward “deeper” you will enter a deeper level in the direction ofhealthy sleep. Write a big number 100 within the circle. Proceed to erase the number 100 being careful not to erase the circle in the least. Once the number 100 is erased to the right and outside of the circle you wilt go over the word “Deeper” • Every time you go over the word “Deeperyou wilt enter a deeper healthier level ofmind going in the direction of normal natural healthy steep. You will continue using numbers within the circle on a descending scate until you enter a normal natural healthy physiological sleep. Whenever you enter sleep with the use of steep control you wilt awaken at your customary time or you can remain asleep for as long as you desire. When you wake up, you will feet well-rested and refreshed. Attention to detail It is important that you mentally draw a large circle not a small one, You shoutd make the numbers in the circle large enough to reach the edges. Then erase them carefully paying attention to details. If you are paying close attention to details like this you will not be thinking of the day’s prob lems and letting them keep you awake. In fact what you will be doing wilt be boring, so boring that you will go to sleep rather then keep doing it. If your attention wanders and you forget what number you are on, just start again with any number. If you feel that the technique may not be working properly for you, review the instructions and make sure you are doing it exactly as instructed. Perhaps you are not erasing completely, for instance.
- 127. Coping with Insomnia Inprimary insomnia it is useful to encourage regular habits and exercise and discourage indulgence in tobacco, caffeine and alcohoL If insomnia is secondary to another condition, this should be treated and general mea sures to promote sleep (discussed above) should be advised. The use of short term hypnotics, such as benzodiazepines, shoutd be avoided due to their high addictive potential. Hypnotics may be prescribed for a few days, in severe cases only. Withdrawal of hypnotics can lead to insomnia that is as distressing as the originat sleep disturbance. Prolonged use can lead to the development of dependence, tolerance (needing ever increasing dos es to achieve the same effect) and impaired performance during the day. Effects of Sleep deprivation - Irritability - Cognitive impairment - Memory lapses or loss - - Increased heart rate variability - Impaired moral - Risk of heart disease judgement - Severe yawning - Hallucinations - Symptoms similar t0ADHD p. Once you are successful, you can start experimenting to see if you can find a variation that works better for you. At first you may need to go through quite a few numbers before you go to sleep but the next night you wilt go to steep more quickly. Eventually you will be able to fall asteep in only a few moments with this technique. It witt become very effective if you persist until you succeed. I- - Impaired immune system - Increased reaction time - Decreased accuracy - Tremors -Aches - Risk of diabetes Type 2 - - Growth suppression - Risk of obesity - Decreased temperature i-
- 128. 1. A medicalstudent who has just failed his Anatomy viva returns to his room in the hostet and sees that his roommate is watching a movie. He immediately starts yelling at him for making too much noise. This reaction is most likely due to use of the defense mechanism of: a) Suppression. b) Displacement. C) Identification. U) Reaction formation. e) Repression. 2. A 14 month otd has to be taken to the hospitat for her vaccination. As soon as she enters the hospitat, injection is even brought in, she sees a doctor and smetts the antiseptics: This is an example of: a) Systematic desensitisation b) Classical conditioning. c) Operant conditioning. d) Shaping. e) Modelling . A first year medical student reports to a psychiatrist saying that she faints with fear at the sight of the cadavers and therefore cannot attend her anatomy lectures. She even has troubLe walking by the anatomy lab atone. The psychiatrist determines that she has a phobia. The best way to treat her phobia would be: a) Anxiotytics prescribed for the first two years of medical coLlege b) To ask her to consider giving up medicine as a career c) Write her a report excusing her from attending the Anatomy lab, for medical reasons d) Systematic desensitization. e) Reassurance 4. What kind of memory involves the recatt of the indications for endoscopy? Iniplicit memory. Semantic memory. Explicit memory. Episodic memory. Procedural memory. I - -.-— SAMPLE MCQ FOR SECTION C a) b) c) U) e)
- 129. 5. Which ofthe following can be used to make a clinical assessment of dementia? a) History taking and physical examination b) Mini mental state examination (MMSE) C) Blood CP and Urine RE d) MRI Brain e) CT Scan Brain SampLe Short Essay Question For Section C Qi. Briefly describe the stages in the formation of memory. What type of memory is required to remember how to suture? Q2. What are the different stages of sleep? How do they appear on EEG? Answers i. b 2. b 3. U 4. b 5. b I
- 130. ECTION D ciology andAnthropology — OUTLINE4 Chapter 1 Sociology and Anthropology Introduction Sociology and anthropology form an important knowledge base in the understanding and practice of holistic medicine (Section A). It is necessary to understand the social and cultural setting as welt as the person and the physician to have a holistic view of health, or its absence resulting in dis ease. This includes culture, values, norms and health belief models. These factors are important for a health professional to study as they influence: • rates of spread of diseases, • preventive strategies, • pathways to health care facilities, • choices and options of treatment, • chitd rearing practices • social barriers to health care • compliance or treatment adherence, • cultural understanding of the disease • illness behaviour • utilisation of health services. The study of sociology and anthropology can help a health professional in making a sound psychosocial assessment (at par with biomedical mea sures) to determine a comprehensive list of determinants of health and disease. Sociology and Health • Famity Social groups Social class Gender • Child Rearing Practices Roles Sociot Support • Religion • Stigma • Sich Rote Death and Dying Comptiance Anthropology and Health Culture Culture and Public Health
- 131. Case ILlustration Muhammad idreeswas a securityguard who wasseverety injured white guarding agovernment office in Pakistan which was attacked by mititants Both his Legs were fractured and his spinal cord was injured His treatment costs were covered by his brothers pooting theirmonetaryresources dona tions by his emptoyers andZakat from his neighbours His fractured Legs were operated upon successfully but he became paratyzed due to his spinat cord injury As he could no longer continue working as a securityguard his brothers and parents set up a smalL cornershop in his village His etdestson stopped his education afterMatricutation to assisthis father in the shop. He had to rely on his famiLy and friends to help with his tong term medical care as there was minimal organisational and governmentsupport A local NGO provided him with crutches and Later a wheel chair He went through a period ofgriefand depression after the incident but finallyrecovered with the support ofhis famity and friends When askedhow he had coped with the trauma and the permanent disability he responded that he had accepted Allahs will and considered himselffortunate to have the opportunity to save so many innocent tives that could have been tost in the attack Greg Martin was a fire fighterfrom Belgium, who sustainedinjuries to his spinal cord while rescuing people from a high nse building which was on fire His wife and two children lived with him at the time As he was medically insured, he received verygood medical care and a motorised wheel chair: His family and fnends initiallyprowded emotional cnd moralsupport but were constrained by their own responsibilities and obtigations He retired from the fire department with futt financiat benefits and receivedphysical rehabilita tion and counselling services to help him with adjustment after the accident He alsojoined a communitygroup ofretired fire service veterans to help him cope with this life change His wife and chiLdren were verysupportive and caring He felt proud that he had been abte to hetp so manypeopte during his work as a fire fighter and this helped him cope with the disability His wife had to take care ofthe home and the children mostly by herselfnow as wetl as look after his increased medical needs after this accident She also re ceived counselling to help her deal with this addedstress Greg went through a phase ofdepression andreceivedpsychotherapyfor theproblem At three yearsfollow up he was receiwng treatment for alcohol dependence that he developed after the accident and his marital retationship had become strained
- 132. 1. SocioLogy andHeaLth Sociology is the scientific study of patterns and systems of human inter action. It is undertaken by focusing on the social structure of a society and social interactions amongst its inhabitants. The role of sociology in behavioural sciences is to study social determi nants of health and disease. The following are some of the important sociat determinants of health and disease: Family Family, as the basic unit oa society, is the building block upon which a society is constructed. Family constitutes two or more people related by blood, marriage or adoption living together. The traditionaljoint family where grandparents, parents, siblings and cousins lived together is be coming increasingly rare in Pakistan. A more common form now is the extended family, where parents, grandparents (mostly paternal), and oc casionally, unmarried aunts and uncles live in the same household, There is a growing trend to tive as a nuctear famity. where the husband and wife live with their children. The single parent family, where one parent, often the mother, resides alone with her children, is as yet a rarity in Pakistan but may not remain so in future. Famity structure and functioning is the way a family is organised in terms of its boundaries, emotional bonding and inter actions outside the family. These parameters greatly influence health and disease patterns and reactions to both. A family that has cLosed boundaries allowing minimal or no interaction with other units of the society. leads to enmeshment or loss of boundaries within the family. This consequently results in serious mental and physical health issues. A family with open boundaries, with strong ties to each other forms the basis of healthy inter actions as well as better physical and emotional health in its members. The way we respond to symptoms. cope with stress, follow health ad vice, or tet our illness affect our close relationships, points to the central role family has in influencing health and disease. [[ness does not exist in a socially neutral environment. An ill member of the family changes the structure and functioning of this basic unit. This influence is maximally seen in psychiatric disorders, chronic illnesses, head injuries, stroke, and cancer. The influence of infectious diseases like hepatitis, tuberculosis, sexually transmitted diseases, HIV-AIDS, skin diseases and neurological disorders can be equally severe. In our social settings (with minimal or no govern ment social services available for health care), the entire burden of care fatls on one or all members of the family. A sensitive health professional is familiar with the concept of ‘carer’s burden’ and its impact on the health of the carer. Another influence that family exerts on a member’s disease is the role it plays in decision making as regards pathways to care, choice of treatment and even adherence to treatment. Health professionals should regularly draw genograms (family trees) of the patients family to familiar ise themselves with the structure and functioning of the family. A health professional aware of this immediately wins over the key mem ber in the family. They will then include him/her in the decision making process to ensure their positive input. A typical example of this process is the role that a pregnant lady’s mother plays during the pregnancy and throughout the reproductive health process. A similar role is played by the reactions of the in-laws towards the pregnant mother. Supportive handling by the husband and in-laws can yield huge benefits in improving the
- 133. PYGENDEP 1I IMPLICATiONS FOP EXTENT OF URBANISATION F.NMLVPELAONS FAULTSTASIUTYI INDMDUAL Conceptuat framework for understanding the rote offamily as an agency for attainment of health and disease physical and mental health of the mother and foetus. Ihs is why the bio psychosocial and integrated care models identify family as an important partner in the assessment and the therapeutic process. Social groups A group is formed when individuals join together for a common pur pose that cannot be achieved atone. Primary groups are small, intimate social groups. These are commonly seen amongst family, friends and/ or like-minded people. An example of a primary group is the ‘committee group’ bound by financial interest (money pooling) that also ensures social interaction (‘kitty parties’) on a regular basis. Religious organisations also form primary groups to spread their message. People who go to the same mosque also behave as a primary group. These primary groups can play an influential role in promotion of health and disease. They do this by serving as a support system, influencing beliefs about health, referral pathways, lifestyles changes and even preventing or causing spread of disease. Secondary group is a larger groups where face- to-face interaction amongst members of the group may not be possible, yet the common ality of interest or purpose joins the members. Secondary groups can be formed on the basis of communities, religious, cultural, politicaL or sec tarian allegiance. The advent of social media has made the formation of secondary groups far more common through social networks. Secondary groups have a great deal of public heatth development potential. Health parameters in Gitgit and Baltistan have improved on account of the positive role by one such secondary group. SOCIOECONOMIC FAMILY BACKGROUND COMPOSmON FAMILY STRUC1UPE ROLE POWER & STATUS I I DY AGE I STAT US OF WOMAN. CILD
- 134. Seconday group Usually largein size High level of intimacy amongst members Less intimacy amongst members Relationships are personal Relationships usually formal frequent interactions between members Limited contact between members Members are accepted regardless Members are accepted on the basis of of who they are what they can do for the group xample Family, group of friends Example Political party Social Class ALL societies have ways of pLacing people in social strata. These can be based on weaLth, education, inheritance or other criteria. Social grading may often have direct relevance for health care provision, interpersonal communication, outlook on Life and knowledge. Providers of health care must be aware of the prevailing division of the society into social cLasses. The Western method of dividing a society into six classes is as fot[ows: I: Professionats II: Managers and Technicians NI: Non-manuat-skitted IV: Manual SkitLed V: Partly Skilled VI: Unskilled Due to the remnants of the caste system stilt prevalent in the rural and semi urban sections of the society, this division may not be retevant to us. In our society individuals are classified on account of their land holding and professions into I. Feudal, II. Businessman, III. Technician. IV Farmer. V. Labourer, Social class in cities in Pakistan is often determined by wealth. power, area and size of housing. social connections or networking, and types ofjobs. Health parameters may greatly vary amongst social classes. Social class es may differ in types and patterns of diseases, prevalence of infectious and lifestyle diseases, longevity, quatity of life and disabilities. The type of health infrastructure utilised by each class is the single biggest health variable, Lower socioeconomic classes rely largely on public sector health facilities or are at the mercy of non-professional (yet culturally endorsed) health workers such as quacks. omits, and charlatans. The higher social classes largely rely on private health care infrastructure or treatment in other countries. Smaller in size
- 135. From a behaviouralsciences perspective it is useful to divide these sec tions of the society into the advantaged’ and the disadvantaged’. This division is based on access to education, scientift and modern health services, clean water, sanitation and shelter. Gender Gender is reinforced at the family Level through socialisation to determine • the male and female behavior in social life. Larkoy rotoy nohi hain (“boys don’t cry’), and torkiyon oisoykaproynahipehnti”C’girls don’t dress that way”) are statements commonly given to children to help them make appropriate gender associations. Gender as a determinant of health and disease is debatable but clear differences exist in terms of patterns, and health parameters. On the whole, men are at a higher risk of dying earli er (shorter life expectancy), and women are at a higher risk of ill-health. Females report a higher number of symptoms in a clinical consultation and are at a 2-3 times higher risk of developing anxiety and depression related disorders. Females also seek medical and spiritual help far more com monly than men. This could be one reason for their longevity as compared to men. It is also interesting to note that marriage is a protective factor for health in males and a risk factor for female health. ChiLd Rearing Practices Parents and families shape the behaviour and lifestyles of their children by a combination of rewards and punishment (operant conditioning) and by modelling behaviour which the child emulates. The growing middle class means that more people are able to afford domestic help to care for their children. With the advent of the nuclear family, children who were previ ously cared for by aunts, uncles and grandparents are now being cared • for by a domestic servant/maid. The implications of this family system are many and manifest. The joint famity system as a melting pot of various in dividuals and their experience was a place parents would have a chance to learn from the mistakes and advice of other parents raising their children in close proximity. In the absence of books about raising children in our part of the world, training/workshops on parenting or experienced individuals, new parents must learn the do’s and don’ts of the most important and diffi cult job one can do, from trial and error. One recurring problem seen in this generation is that of permissive (apologetic) parenting [see tablel. The last generation of parents practised primarily authoritarian parenting, where the parents’ word was law, and children were meant to be “seen and not heard.” Punishments were handed out to those who disobeyed and the primary emotion was fear. The result was well-behaved children, who were afraid to voice their opinions. Partly as a reaction to this, when these children grew up and became parents, they decided to approach parenting in a com pletely different way to their own. Their children are the Little rulers of the house: their wishes are always catered to and their word is law. The result is children who are badly behaved and have a sense of entitlement. One advantage of nuclear families is consistent parenting. This may not be the case with joint families, where multiple authority figures such as the grandparents may contradict each other. A serious problem with families in which domestic servants are the primary care-givers for all or part of the day, is that these children are at a high risk for physical, emotional and sexual abuse. There is also little opportunity
- 136. 7 Type of ParentingDescription ----,,r- V i’.4- Authoritarian . Parents impose rules and expect complete obedience.’ Permissive Parents submit to children’s demands V Autttatiw Parents demand obed’i also responsive totheirchlldren for emotional and intelLectual development. n the absence of profession al child care with both parents working, however, there may be no other choice. Parents, especialty mothers who are doctors who may spend up to 36 hours at a stretch on call and away from their children, may become guilty for their absence and try to overcompensate in the time they do spend with their children. They may do this by trying to stuff their children with food, or even worse, spend all their time with their children “teach ing” them coursework or completing homework. The problem with this is that time previously spent with parents learning vatues. and attitudes and having fun is now entirely monopolised by “studying.” This may lead to the child resenting the learning process. Effective child rearing depends on tailoring the demands to the intettectual stage of development of the child and providing clear and consistent re assurance and rewards. However some children seem to be “difficult” from the very start. Such a child is characterised by a negative reaction to events and objects (meal, stranger, new toys), magnified emotions, slow adapt ability to new situations and irregular biological functioning (e.g. sleeping and eating). Specialised family therapy techniques and behaviour therapy can greatly reduce the degree of stress in a family with such an offspring. Rotes Roles consist of a set of expectations about how people should behave in various circumstances. The doctor’s role, for example, is that of a carer who is scientific, impartiaL knowledgeable and courteous. The patient’s role (sick role) involves being excused from various obligations, a commitment to wanting to get well and to following medical advice. Rote conflict refers to when one individual has multiple roles which have conflicting demands on the individuaL An example of this when a doctor has to run a busy clinic (fulfil her rote as doctor) but also has to manage her household responsi bilities (fulfil her role as homemaker) and take care of her children (fulfil her role as a mother). SociaL support Research shows that having social support ameliorates the effects of physical and psychological stress and hastens recovery from surgery and illness. This social support may be in the form of family members, friends, work colleagues or other agencies that provide emotional and/or practical support. Support may also enhance adherence to health advice and reha bilitation. it is, therefore, the duty of a doctor practicing holistic medicine to mobilise social support around a patient as an essential therapeutic strate gy. This can come from amongst family members, friends or volunteers
- 137. Retigion Retigion may beconsidered a collection of beliefs and practices that are external expressions of spiritual experience. Spirituality may be considered an orientation towards or experiences with the transcendental or sacred • dimensions of life. It is possible for peopte to engage in religious activi ties independent of having spiritual experiences. Similarly certain people consider themselves intensely spiritual without being religious. Religious practices such as regular prayers and fasting are an essential component of almost all formal religions, especially the Islamic faith. Western co-re lational studies have shown a positive association of religious/spiritual involvement with improved health outcomes and longer life spans. Reli gious/spiritual minded individuals suffer less from cardiovascular disease and hypertension. They are more likely to be engaged in health-promot ing behaviours, They also have a decreased risk of depression, anxiety, substance abuse and suicide. They are better at coping with illness and have better health-related quality of life. Despite this, doctors must never make recommendations for patients to follow various religious practices from their personal faith. This practice grossly undermines the respect that every health professional must have for the patients’ religious beliefs and what they might find comforting. It is, therefore, enough to highlight the research based positive inftuence of faith, spirituality and religion in healthy life styles and coping with stress and the challenges of chronic illness and hospitalisation. Stigma Stigma is defined as a mark of disgrace or having a”shameful difference.” Some stigmatised conditions such as infertility, delay in onset of menstru ation, congenital malformations and physical deformity may be obvious. Other conditions such as epilepsy or mental illness may have a stigma that is hidden but just as severe. People witb stigmatised illnesses are socially rejected, which can compound their difficulty. Often the families of such individuals are also rejected by society. Health professionals, especially doctors, should be aware not only of this additional stress on patients and their families but also that they may be one of the few sources of support and advice for these people. A common example of this is the public’s stig ma against the mentatly ill due to the association of mental illness with vio lence. The belief that people with mental illness are dangerous and unpre dictable is a popular misconception which arises from sensational media reporting. What the media fails to report is that only a very small minority of mental patients commit violent or serious crimes, a finding which has been established by several studies. Also it must be stated that the vast majority of people with mental illness are not mentally ill. or formally enrolled social workers from the community. A social worker in charge of mobilising and optimising social support for a patient must be recognised as an important member of the health team. Stigma can delay the detection of an illness, obstruct provision of scien tific management and undermine the social, occupational and economic standing of the patient. Some methods of dealing with stigma include reaching out to stigmatised groups (such as the mentalLy ill) and integrat ing their care in general health care and the use of media to launch destig matising campaigns.
- 138. Sick RoLe The sickrote invotves being excused from various obligations and duties, and not being blamed for being ilL It occurs when a patient continues to maintain the tote of an unwell person long after the initiat ittness has settted. A patient adopting the sick rote, continues to have symptoms that are not related to his/her previous illness and cannot be attributed to any other disease or disorder. This exaggerated response is often an indication of underlying anxiety. rote contusion, unresolved conflicts and personality vulnerabilities. Social factors such as positive or negative reinforcement of the sick rote can be disastrous and may tead to the patient becoming an invalid. The ideal intervention includes early detection, removal of reinforcing factors, and withdrawal of the perks of the sick role. It is important that the patient is neither confronted, nor bLamed. S/he needs to be reassured of the benign nature of their symptoms and made to see the benefits of health, The symptoms should be sensitively listened to, but not attended, explained or rationalised. Uncatted for investigations and over enthusiastic symptomatic treatment can further reinforce the sick role. The use of ‘gold en injections’, ‘spirit ammonia’ or multivitamins (“taaqat ka sherbet’3 and other dramatic measures shoutd always be avoided. It may help to invotve psychiatric services in the assessment of the patient and rule out underLy ing conflicts, stress or the possibility of a latent disease. It is important to note that both over reporting of symptoms (as in a sick role), and under reporting are influenced by socioeconomic factors. What these symptoms mean to the individual at a psychotogica[ level is also of significance. Death and Dying Death of a patient, in our cutture is seen as ‘will of God’ (Attah ki marzy). This should never stop a doctor from undertaking a scientific enquiry/audit into the causes of death in a patient. The attribution of death and disabitity to nature is fast giving way to the influence of the west, where more and more people may seek a scientific understanding of the cause of death. Such a change is tikety to lead to the culture of suing health professionals in a court of law for what may be perceived as negligence. SociaL institutions of grieving such as ‘iddat’ ‘sog and ‘phuree’ provide psychosocial relief to the aggrieved and hetp resolve grief. There are atso times when the friends and family of the deceased are unwitting to accept the outcome and resort to viotence against the health care providers. This is usuatty the conse quence of a breakdown of communication between the treating doctor and the family of a terminatty itt/a patient who dies suddenly. A constant update on death being a possible outcome in such patients should be shared with the famity from the very beginning and at regutar intervals of the management process. Impact of sociat factors on Treatment Adherence (CompLiance): Failure to foltow heatth retated advice (sometimes termed “non-compli ance”) is widespread. According to the WHO up to 50% patients do not take medication as advised. This includes taking medications incorrectly or not at all, forgetting or refusing to make essentiat behavioural changes and persisting in behaviours such as smoking that mayjeopardise their heatth.
- 139. FaiLure to adhereto treatment is determined by: • patients age, • socioeconomic status • education status type & chronicity of illness, lack of social support • patient-doctor trust • miscommunication and ignorance of side-effects of treatment • failure to understand the doctor’s advice depression • cost of drug • dosing frequency • multiple medication use Non-compliance is counter-therapeutic and an economic drain. It should not be underestimated. As a result of their failure to adhere to recommended treatments, patients might become more seriously ill, and treatment-resis tant pathogens may develop. Failing to recognise patients’ non-adherence may prompt physicians to adjust medication dosages, and to be misled in their diagnoses. Practitioners and patients tend to become frustrated by non-adherence, and the time and money spent on medical visits is wasted. Some of the clues which shoutd alert a physician that a patient might not be adhering to the treatment plan are as follows: • Indifference and lack of involvement in the treatment/healthcare pLan • Appearance of unquestioning obedience • Depressed patient • Lack of response or inconsistent response to treatment • Confusing clinical picture Treatment adherence, or the lack of it, is often on account of social reasons. Advice from a neighbour, a wise man siyana’, or another patient is often the basis of the path that a patient or the family will take. Essential elements required to improve a patient’s compliance are sum marised below: • Accurate communication of information between patient and doctor. • Emotional support for the patient • Awareness of patient’s health belief models • Choosing an acceptable course of action to which a commitment can be made. • Focus on the overall quality of life of the patient • Development of a specific plan to implement the regimen • Recognition of the patient’s depression or hopelessness
- 140. 2. AnthropoLogy andHeaLth Anthropology Anthropology is the study of evolution of civilizations, their social charac teristics. languages, cultures and ways of life. A health professional com mitted to the biopsychosocial and integrated models of hea[th is a provider of culturally sensitive heatthcare. This is why anthropology is relevant to behavioural sciences. A health professional must be aware of and accept cultural differences; collect data about the patient’s culture, and adapt the scientific care plan accordingly. S/he must also remain aware of and understands his/her own biases and attitudes. For example, some doctors may find themselves giving more attention and care to patients able to give histories in English, rather than patients from a rural background. A culturally sensitive doctor is interested in learning all the cultural variations in the patient population and then tries to merge his/her professional knowledge with each patient’s health beliefs. S/he needs to interact as directly as possible with individu als from diverse cultural backgrounds and collect valuable data about their norms, values and beliefs regarding health and diseases. In a culturally sensitive health care approach social aspects are treated at par with biological determinants of disease. The social dimension of health is thus an integral part of history taking, assessment, diagnostics and ther apeutics. The understanding of terms like culture, subculture, beliefs, val ues, and norms, society, family, social class, social roles, and child rearing practices is basic to this form of health care. Culture Untike att other creatures, human beings are unique in that they are abte to transmit ideats, knowledge, betiefs, vatues, and patterns of behaviour from one generation to the next. This sociat heritage is catted “culture. It is what makes our species human and sets us apart from other primates. As one anthropologist has put it: “Without the presence of culture, conserving past gains and shaping each succeeding generation to its patterns. homo sapiens woutd be nothing more than a terrestrial anthropoid ape, slightly divergent in structure and slightty superior/n Thteltigenc& (Linton in ‘The Individual and Society’ 1936). CuLture is the set of values, mores, beliefs and perceptions of the world that are passed on from one generation to the next. It is thus our social her itage. We share it with other members of our society as our common world view. It is our culture that makes us behave like those around us and thus makes our behavior acceptable to others. Culture is dynamic and, therefore, continues to evolve, although never at the same pace as scientific, economic or technological progress. It is revealed in people’s language, art, architecture, religion, norms, values and health care beliefs and practices. ft is not inherited biologically, but is learnt from the environment. Culture provides one with a sense of identity. encourages group survival and gives its members a useful picture of the universe. Pakistan is a country that brings together a variety of cultures in its four provinces, Gilgit, Baltistan and Kashmir. Subcultures may develop within a culture. These result in a distinctive set of standards and behaviour patterns in which a small group within a larger society operates. People living in and around shrines, with their distinctive
- 141. behaviour patterns androutines are an example of a subculture, The typ cal example of subcultures relevant to health are the language, learned acceptable behaviour patterns and a shared view of the world that prevails in hospitals and medical colLeges. Cultural influences are seen in many beliefs and practices of doctors as well, in addition to their patients. For example, the doctor knows best; patients must comply with the doctor’s orders if they want to get better. If they do not listen to the doctor, they do not want to get better, and therefore, are not worthy of their time.” This belief is part of the doctor/ hospitaL subculture. Most people believe that their culture is superior to all others. Cultural and societal biases, prejudices and ethno centrism must, therefore, never be confronted in a doctor-patient relationship. They can best be addressed by understanding the following: The easiest response to transcultural conflict is to behave as if it does not exist, and is not a barrier in the doctor patient relationship. Every individual is expected to behave according to unwritten ethnic customs. These traditions and the diversity of behaviour should be accepted, and catered for, in outpatients. wards, waiting areas and therapeutic interactions. One can make mistakes in transcultural interactions but one should readily accept and acknowledge them and learn never to repeat them. Understanding Culture in Health Care Beliefs, values, norms, mores, folk ways and laws form the fabric of society. They are the basis for social control and the ‘do’s and donts’ of cultures and subcultures. They tend to evolve and change but hardly ever com pletely transform ih a single lifetime Beliefs are tenets with a shared meaning in a culture that are held to be true e.g. in most Islamic cultures, the benevolent role of God in the healing process is an established belief. This is reflected in all doctor- patient inter actions which nearly always end with a mutual prayer such as “Only Allah granteth health” (Allah sehat denay wala hai). Values are those aspects of a culture that are held in high regard, are desirable and, therefore, worthy of emulation. A doctor’s deatings with patients must never be commercial’, ‘elders always know better’, ‘the sick must always be visited in the hospital’ are commonly held Eastern values. Culturally sensitive doctors must keep beliefs and values in mind as they may need to cater for them in the administrative running of wards. This may save unnecessary worry over matters such as families not adhering to ‘visiting hours’, or ‘far too many visitors’, and relatives asking details about the health and prognosis of the patient. Norms refer to principles of right and wrong that govern acceptable and unacceptable behaviour in a society. Abortions, euthanasia, intake of alco hot, cannabis and heroin, nursing of femate and mate patients in the same wards (except in emergency or intensive care settings) for example, are all against local norms. A doctor needs to have a flexible approach regard ing a patient’s beliefs, values and norms and try not to pass judgments on them. It is equally important, however, to not break professional norms (such as that of confidentiality) and not let the two clash.
- 142. Norms may bedivided into three types on the basis of the kind of disap proval that resutts when they are violated: fotkways, mores, and taws, Mores are considered vital for the group’s welfare and survival, thus mak ing them very important. They define what is morally right and wrong and as a consequence, their violation results in strong disapproval and even severe punishment. Respect for sexual boundaries by a health profession al, for example, is a more. Persons who violate mores may be ostracised, imprisoned, or killed. Conformance to mores is taken for granted and most people in a society accept them without question. Unlike laws, mores are not formally written but are respected with the same fervour and commitment. Many mores are incorporated into law and serve to reinforce it. In fact, laws are most effective when they are rooted in the mores. Abortion is legally prohibited as well is considered against the mores in Pakistan. At times, however, mores and folkways may conflict with the laws, The classic example is that of the jurisdiction of Pakistan Medical and Dental Council. This is a formal body that enforces regulations pertaining to health care in the country. It is empowered to take punitive action against medical practitioners when found guilty of ftouting a certain regulation. or in cases of malpractice. It does not, however, currently have jurisdiction over prac titioners of alternative medicine or even aamils, charlatans, and self-styled hakims who openly practice their own methods of ‘health care’. This is on account of the permissiveness to these practitioners by the mores of our culture. Inftuence of cu[ture on heatth care Culture determines beliefs about health and disease. The way Pakistanis view health, causes of disease, the meaning of various symptoms. ap proach therapeutic interventions and determine their relationship with health professionals is largely influenced by their culture. For the predominantly Muslim population of the country. health and dis ease, like life and death are predestined by the will of Allah. The process of healing and cure similarly rest with the Almighty. Virtually every health outlet, and the prescription letterheads of physicians have Arabic inscrip tions from Holy Quran that endorse the same belief. This unfaltering belief forms the basis of trust in the physician as a mere executioner on behatf of God. Practitioners of health care for the same faith also share this cultural and religious belief with their patients. Fotkways are customary patterns of everyday life that specify what is socially correct. These are social niceties such as referring to health profes sionals as “Doctor Sahib”, offering a seat in the bus to a lady or an elder, and not calling parents or elders by their names. Laws are formally compiled written rules and regulations coded after debate and deliberation. They are then enforced by organisations com posed of persons authorised to use force if necessary. Laws are similar to folkways and mores in many ways but are far more adaptable to changing times. Our culture tends to classify diseases into those caused by supernatural forces, stresses of life, unhealthy lifestyles and habits, environmental fac tors and germs and chemicals. Social and family problems and feuds are often seen as causes of the evil eye (“nazar”) or a curse leading to illness.
- 143. In our culture,most psychiatric disorders, epilepsy, fits and related chang es in consciousness, and headache are attributed to supernatural causes or ‘evil eye’. Heart conditions, diabetes, and hypertension are attributed to stress, poor dietary habits, and unhealthy lifestyles. Liver and kidney disease are attributed to eating the ‘wrong food’ ( “garam taseer”). Sexual diseases are considered a curse of nature, caused by moral depravity. Cultural views on treatments and interventions are largely diverse and vary with social class, educational background. urban and rural setting and in- fluence of prevailing subcultures. Altopathic medication are Largely viewed as ‘goram’ and dangerous. and essentially lesser of the two evils when confronted with disease. Pharmacological preparations are called ‘ongrezi dawayi’ (a reference to the days of the British Pa]). This is to distinguish it from ‘des! dawa’ (local or medicine of our own heritage). ‘Des! dawn’ is considered ‘thand/’ and thus, more appropriate in a predominantly hot and humid temperate setting. Local translations of the words ‘tablet’, ‘injection’ have dangerous connotations e.g. ‘tablet’ is translated as ‘got/which is the same as ‘bullet’, injections are often just referred to as “su/”fneedle). The most preferred and the first line of treatment in our culture are house hold remedies and herbs based on past experience and conventional wisdom. These are supplemented by prayers to The Almighty by the individuaL his family, and sometimes the pit, the local faith healer, or the prayer leader at the local mosque. Alms, sadqo, taweez, and holy water are also used. It is only after the failure of these convenient, easily accessible, inexpensive and trustworthy interventions that professional treatments and interventions are considered an option. Alternative medicine, folk medicine, healing through spiritualists, omits, sorcerers, shamans, and faith healers are often reserved for patients with psychiatric disorders and epilepsy. Often inhumane methods of ‘treatment’ are used by these agents in the presence of and in connivance with the referring members of the family. Cuftura[ty Sensitive Clinical Assessment A culturally sensitive assessment may not he required in all patients and not always at the start of a treatment plan. It would, however, be urgently required when a patient is obviously from a different ethnic background e.g. a patient from rural Sindh, central-Punjab, Balochistan or Northern Areas being nursed in Lahore, Karachi or Islamabad. It is also important to consider the concept of heritage consistency. This refers to how closely an individual is influenced by or practices his/her particular ethnic back ground. The lifestyle, health belief model, or practices of an individual may not always be the same as their cultural heritage, In case a patient has a high heritage consistency, the next step is to note how much of his/her beliefs are influenced by the cultural background. The following questions can be asked in a clinicat setting to ensure a deeper cultural understanding of the patient’s explanatory model of illness • What do you call your problem? What name does it have? • What do you think has caused your problem? • How do you think it started and what course do you think it will take? A recommended approach for culturally sensitive health professional was suggested by Fowkes and Berlin in lg8os. This approach can yield not only invaluable information about the patient and family’s cultural understand ing of the disease (their health belief model HBM) but also improves
- 144. treatment adherence andtheir ownership of the health care plan. It can be remembered with the acronym LEARN: 1. Listen: Active listening and understanding of the patient and the family’s cultural views is central to this approach, A conscious attempt to elicit the health belief model of the patient and family has to be made by the health professional. 2. Explain: At this stage the doctor explains the scientific basis of the dis ease without chaltenging, rejecting or ridiculing the health belief model of the patient and family. This view is presented in simple language using symbols from the patient’s cultural context. Making simple drawings on a piece of paper while doing so (as illustrated in the section on informational care), can be helpful. 3. Acknowledge: The differences between the two explanatory models are discussed to achieve consensus and common understanding. This witI ensure treatment adherence and improve prognosis and follow up. 4. Recommend: A line of action regarding further assessment, diagnos tic tests and short and long term management plan, with options, is then recommended. A sensible physician will give the patient the final choice to proceed with the plan or opt out, without feeling offended or hurt. 5. Negotiate: Offer a jointly conceived plan of action in which the doctor, patient and family are all active partners. This adds to ownership of the healthcare plan and chances of treatment adherence. I Inftuence of sociocuLturat factors on therapeutics Patients with different sociocultural backgrounds look at treatment from different perspectives. The traditional concept of the “taaseer of the medicine, whether it is ‘hot’ or ‘cold’ is respected by the culturally sensitive doctor. S/he must adapt scientific knowledge to the patients’ language to explain the different aspects of therapeutics. Many patients hold very strong views about injections because in their culture and social setup, injections are correlated with ‘dramatic results’. In other cultures, inject ables are viewed with fear as they denote extreme illness or the last stage of treatment’. Interestingly, many Asian races are traditionally known to respond to low doses of psychotropic medications as compared to their western coun terparts, who need higher doses. A practitioner of holistic medicine must understand these differences and belief models and address them tact fully using language and context that the patient understands. The stigma attached to many modes and methods of treatments needs to be ad dressed on the same principles as stigma. Some patients need education about their treatment options while others requirejust the word of doctor to make them adhere to treatment. The doctor must understand the strong influence these sociocultural factors play in the treatment of disorders. ii. Cutture and PubLic Health Clinics and hospitals are not the only places where a culturally sensitive approach is beneficial. It also yields good results in public health settings. Prevention of illness and promotion of health depends largely on an indi vidual’s attitude towards help seeking and the value of health. The health betief model has a number of variables, all of which contribute to some
- 145. extent to healthbehaviour, These include: concern with health matters, be liefs about susceptibility to illness, ideas about illness and its severity, ben efits and costs of various treatment and howwe[tthose measures will work. The heatth belief modet also emphasises the importance of the opinion of respected people in the individual’s life and the amount of personat control that people perceive they have over events. The health betief model and illness explanatory models of a community determine the pathway that a patient will follow in pursuit of health. A comprehensive plan to promote health literacy, develop health infrastructure and allocate resources must, therefore, be based on this pathway. Such a culture sensitive approach im proves community ownerships and participation in public health initiatives. It also adds to acceptability, utilisation and sustainability of preventive and promotive public health initiatives.
- 146. SAMPLE MCQ FORSECTION D 1. A 35 yr old worker injured himself on the construction site and Lost a Limb. The sociaL support, in our cuLture, that he can rely the most on, will come from: a) The owners of the construction site b) Volunteers. C) Health care system. d) NGO’s e) Family members 2. A 56 year otd tabourer diagnosed with hypertension is prescribed an ACEI. He refuses to take it, insisting that “angrezi dawai garam hoti hai” and is not appropriate to take in the hot weather. He says he wittjust get his faith heater for dum (prayer) and this witl make him better. How shouLd you respond? a) Hand the patient the prescription and tell him to do as he pleases, you’re too busy to argue. b) Tell the patient that there is no such thing as “garam dawai” and he will suffer and become very ill if he does not take it c) ExpLain to the labourer’s educated son how important the medication is for him and ask him to hide it in his food d) Tell the patient you understand his concerns but this drug has been tested on people in the region and they got much better, Faith healers cannot cure hypertension e) TelL the patient that the medication is safe, and he can take it as well as see the faith healer and he wilt feet better, God witting 3. Stigma refers to: a) Having a dangerous illness b) Being shameful. c) The inability to interact with normat people. d) Suffering from mental illness. e) Having a difference that is considered disgraceful or shameful by society 4. Doctors can help reduce the stigma regarding mental iltness by: a) Ignore the stigma and providing the best avaiLabLe treatment to the mentally ill b) Think of methods to rehabilitate the patient after s/he recovers C) Start a sociaL media/public health campaign to change the mind of the public about the mentatly ill d) Reach out to the mentally ill; integrate their care in general heatth care and use the media to run a destigmatising campaign. e) Inform the family and everyone you know that stigma worsens the effects of mental illness
- 147. . How shoulddoctors behave in the face of cutturat differences between the patient and themselves? a) Try to read up on the patients cutture and behave with them accordingly b) Agree with patient’s notion that the culture he comes from is the best one, in order to get him to do what is required c) State categorically that we are all one human race and cultural differences are meaningless d) Behave as if the conflict does not exist and is not a barrier in doctor-patient relationship. e) State the doctor do not object to patient’s cuLtural practices. SampLe Short Essay Question For Section D 01. Briefly discuss the concept of Beliefs, VaLues and Norms as it appLies to BPS ModeL of heatth care. 02. How does culture affect treatment adherence? Answers i.e 2. e 3. e 4. d 5. d
- 148. Chapter 1 Psychosocial Aspectsof Health and Disease The World Health Organization (WHO) defines health as a state of com plete physical, mental and social well-being and not the mere absence of disease. In order to understand the factors contributing towards a state of psychological and sociaL well-being we must acknowledge that a human being is a complex organism with a multi-dimensional existence. HeaLth and Normality The parameters that describe a state of psychosocial health and normality include: • Dynamism • Optimisation • Personal contentment • Social responsibility- Occupational efficacy • Economic emancipation • Relief from pain Homeostasis Dynamism Dynamism refers to the various roles and functions a person has in life, and their changing and evolving nature. In one tifetime s/he performs many roles and contribute to their own growth, that of the society and the world at large. One person may simultaneously be playing the roles of family member, student, teacher, friend and breadwinner. The more roles a person performs the more dynamic s/he is. Illness and disability limit the dynamism of a human being. OUTLINE PsychosocialAspects of Health and Disease Psychosocial Assessment Psychosocial Issues in Special Hospital Settings Psychosocial Peculiarities of Dentistry Psychosocial Aspects of Alternative Medicine Common Psychiatric Disorders in General Health Settings Psychosocial Aspects of Gender and Sexuality PsychosocialAspects of Pain PsychosocialAspects of Aging, Death and Dying Psychotrauma Psychosocial Aspects of Terrorism Stress and its Management
- 149. Optimization When a personperforms most of his roles in an optimum state, s/he is considered psychosocially healthy. While it may not be possible to stay at your best alt the time, a healthy person views themselves as being in a state of productivity in most roles a majority of the time. Personat contentment Personal contentment is when despite failures and difficulties and inability to be the world’s best scientist or best parent, a person accepts them selves as ‘good enough’. S/he is able to focus on the positive aspects and achievements of their Life to attain a sustained state of satisfaction and contentment. Sociatresponsibitity A healthy person takes responsibility of the roles and duties assigned by the society. These begin from the immediate family to the neighbourhood, town and country, to the world at large. S/he works towards making this world a better place for their own self and subsequent generations. OccupationaL efficacy In order for an individual to be normal and healthy, they must be well- versed in the knowledge, skills and attitudes required for their occupation, i.e they must perform effectively. Such individuals are also helpful to so ciety through their occupation, and attempt to pass their skill, knowledge and wisdom to others. Economic stabitity A core component of health and normality is economic stability. This means that whatever a person’ means of earning may be, s/he is free of the pressure to acquire the basic necessities of life. This allows an individu al to pursue their goals of self-actualisation. Retief from pain and discomfort In order for an individual to be healthy, s/he must be devoid of distress, discomfort and pain at the physical as well as at a psychological level. S/ he must also be able to form and sustain relationships that are free of mis trust, deceit, jealousy, prejudice, and ignorance. Homeostasis When a person respects the rights of others in their interactions with other human beings and gives due importance to the laws of nature in his/her interaction with the environment they are said to maintain homeostasis
- 150. with the worldaround them. S/he neither threatens the environment nor do they feel. threatened by it, but instead make an earnest effort to improve it. They are able to, thus, be in harmony with their internal and externat environment. Defence Mechanisms In order to acquire and maintain a state of health and normality, a person uses different psychological mechanisms which help to endure the chal lenges of le. These are called defence mechanisms. Some of these are basic defences of all human beings in a particular situation, whereas others are more complex defences which come into play under certain circum stances. Defence mechanisms function to help individuals cope with their internal and external states of anxiety and distress. Defence mechanisms have the following characteristics: • They emerge in a developmental sequence from less mature to more mature. • They can be brought under conscious controL to ward off anxiety. • They maintain a sense of wellbeing and safety. • They may be episodic or become more habitual and pervasive. • They may contribute towards formation of personality traits. This is a list of many other defence mechanisms which people use unconsciously. Some of these, in addition to those mentioned in the example above, are: repression. • denial, • displacement, • projection, introjection • rationalization • intellectualization • identification attruism • sublimation Repression Unconscious exclusion of an unwanted or painful feeling, thought or mem ory from the conscious mind is called repression. It is one of the basic de fences of the mind that we almost regutarly use to push away unpleasant happenings, thoughts and impulses from our active memory. One tends to forget the painful details of an exam faiture, a setback, or an insult, through the use of repression. RationaLization Unconsciouslyjustifying one’s feelings. impu[ses and thoughts that are un reasonable and unacceptable in reality in order to seek retief from anxiety or guilt is called rationalization. It is usually seen in people who have per sonality traits of being obstinate and stubborn. People in stress and those with limited capabilities, tend to use this defence mechanism as a routine.
- 151. Displacement Discharging pent-upfeelings on people less dangerous then those who initially aroused the emotion. A student who has just received a low grade on a ward test starts to shout on the junior paramedical staff over a ttIial misunderstanding. Reaction formation It is the devetopment of a conscious attitude, opposite to an attitude in the unconscious, to avoid awareness of unacceptabe feeling, fear or impuLse or a thought, It is usuaLly seen in peopte taking on sky diving to master their fears of heights. Defence Mechanism Definition Example Symbolic satisfaction of A student struggling through wishes through non-rational graduate school thinks about thought a prestigious hIgh paying job sure wants Separating an emotion from an Idea or thought because the emotional reaction is too painful to be acknowledged. A man learns from his doctor that he has cancer, 14e studies the physiology and treatment ofcancerwlthout axperiendng any emotion Rationalization Falsification of experience through the construction of logical or socially approved explanations of behaviour. A patient misses out on hlslhex daily dose of medication and thInks that aJhe doesn’t need it any more Repression UnconscIously keepIng unacceptable faellngs out of awareness, Amen lsjealous of a good fri.nd’t success but Is unaware of hIs feelings,
- 152. Case Scenario A youngdoctor brings his 52 year otd father who has met a road-traffic accident and suffered serious injuries, to the casuatty department ofthe hospitaL Incidentatty the surgeon arrives tate to examine the patient. By the time she examines the patient, he has already passed into a state ofun consciousness with falling breathing. Att resuscitative measures fqit and the patient dies. The son is shocked but insisted that his father should be taken to the intensive care and put on a ventilator, and that he was, in fact “not really dead (shock and disbelief). He regained control after a while and with a mask like face, started to take responsibitity for alt the affairs of the family (denial; acting as ifnothing has happened). He was seen handling his moth er and other siblings and relatives, consoling them, arranging for the coffin, transportation ofthe dead body, informing other relatives about the news, making arrangements for the funeral, arranging for food and lodging ofthe guests. Never during this whole period did he shed a tear. Eventually after the burial the doctor returned to go to hisjob in a week’s time. During this peri od, he found that he was unabte to steep property and felt exhausted every morning. He tried to manage as best as he coutd, but one day saw his dead father in a dream and woke up in a state ofpanic and felt a huge sense of weight over his chest. Fearing he may be having a heart attack, he went to a cardiologist When he was found fit and healthy by the physician, he suddenly burst out making accusations and blaming doctors for being inept, inefficient and irresponsible (anger). He blamed ‘all doctors and hospitals’for killing his father and claimed that they are going to kill him as well (projection and displacement; putting the blame and responsibility on somebody ets&. His accompanying retatives took him home, but he continued with his outburst, eventually exhausting himselfand gave in to dying and weeping loudly tike a child (regression). Since the death ofhis father this was the first time he had cried in 20 days. The crying continued offand on for the next few days, until one day he decided to visit Data Darbar. He prayed to Allah and promised to give away food to one hundred people, ifgiven a chance to see his fatherjust once (bargaining; “IfGod gives him back I’ll sacrifice so and so”). After dis tributing the food to street dwellers, he waited for signs ofhis father’s return but nothing changed. He started feeling responsible for his father’s death. He would talk ofthe incidents when he had disobeyed his father; when he had hurt peoples’ feetings, or had committed some other sins (depression). He started to believe that Allah was punishing him (Introjection; taking the blame on his own self). This tasted for few months until finatly he accepted that nothing could bring his father back, no matter how hard he may try and a big vacuum had been created in his life (acceptance; “There is a problem”). Grad ualty he started to return to his life and his routines to resolve his bereavement (resolution; “Life moves on”). Grief: An exampLe of use of psychological defence mechanisms A patient’s death is an unfortunate yetsometimes inevitable event at hospitals. It bring into pLay a whoLe series of defence mechanisms. The following cage scenario illustrates the sequence of defence mechanisms that come into play in such a setting: I
- 153. In order tobear the toss of his father the doctor in this scenario passed through 7 different stages of grief, listed in the brackets as denial, anger, bargaining, depression, acceptance and resolution. These stages invotve use of unconscious defence mechanisms which hetp him resolve his toss. These stages of grief are universal and present in all cultures. In fact different cultures have varied rituals tohelp people move through the grief e.g. the rituals of bain, Qul, Daswan and Chaleeswan’ or Chehtum’ all are events that facilitate the resolution of the bereavement process. As health care providers we need to be sensitive towards these stages of grief and wherever possible must proactively work through with the griev ing people to ensure a smooth and early return to routines of life. PsychosociaL Assessment in HeaLth Care Practitioners of a biopsychosocial model of health care are expected to make psychosocial assessments of their patients as well as the biological assessment. Psychosocial assessment is a study of the mental, familial and cultural aspects that can inftuence health. These factors affect the etiolo gy, presentation, diagnosis, interventions and management of illness and prognosis in an individual. Certain questions asked by a health professional may hetp develop a comprehensive understanding of the patient. The goal of this is not only to determine treatment goals but also include social and psychological treatments that the patient may need. Such an assessment ensures the comprehensiveness of a treatment plan. While the psychoso cial assessment is routinely undertaken for psychiatric patients, it is often ignored in pediatric, medical, surgical and reproductivehealth settings. CLinicaL Situations Demanding a Comprehensive PsychosociaL Assessment While psychosocial assessment should be routinely undertaken for all patients, it becomes crucial in the following settings: 1. Patients affected by natural and human-made disasters and catastrophes (wars, violent crimes, floods, earthquakes, tsunamis etc). 2. History of psychological trauma 3. Cancer patients 4. Psychiatric patients 5. Sexually transmitted diseases like AIDS, and infectious diseases 6. Lifestyle disorders such as diabetes mellitus, hypertension, coronary artery disease, cancer, cerebro-vascular accident fCVA), depression 7. Dementias • 8. Intractable diseases such as spinal injuries, paraplegias. How to undertake a psychosocial assessment? A comprehensive psychosocial assessment must include the following 1. Identification of stresses in a patient’s life, 2. Emotional and psychological reactions to these stresses, 3. Symptoms, 4. Challenges to health, 5. MentaL state examination, 6. Assessment for risk of deliberate self-harm or suicide 7. Risk of violence or harm to others F -—-- —
- 154. It must resultin a List of expectations or needs of the patient that are to be fulfilled, particularly at the psychological and social levels and his personal goals of treatment. - L Psychological reactions to ILlness and Hospitatization As all of us who have ever fallen ill may realise, disease and hospitalization are a source of major stress to a patient, The severity of stress and individual’s response to it plays a major role in the suffering the patient experiences and prognosis of the illness, Major concerns about the illness include its infectious nature, the possibil ity of passing it to the next generation through inheritance, how long the treatment will last and whether there are any consequent/residual disabil ities. While these questions lurk in the patient’s mind, s/he often expects the health professional to read their mind and many a time may never ask them. In case the health professional is not sensitive to this need of the patient, these questions can serve as a source of fear and anguish for the patient. (How to address these questions and answer them appropriately is discussed in Chapter 3) The result is of this is stress that combines with a variety of other situations to become an important perpetuating factor for the disease. 1. Stress due to ilLness In addition to the effects of the illness the patient also experiences the stress of the illness in the following ways: Change of rote: The patient is usually relieved of alt his obligations and consequently is assigned a passive role. S/he is not considered well enough to manage anything or even think for their own self. Financiat toss: The disease and the consequent disability may result in a temporary or permanent loss ofjob. In the absence of insurance or free health care the consultation with the health professional, inves tigations. treatment and hospitalization result in a significant financial burden on the patient and family. Stigmatization: Cardiovascular diseases and iiabetes are considered ‘acceptable’ diseases. Psychiatric illnesses, tuberculosis, venereal disease, sex-linked disorders, AIDS, epilepsy and skin diseases, on the other hand, carry myths and stigma. This leads to concealment, secre cy, delay in seeking help, somatization and ‘cover-up’ presentations. Loss of seLf-esteem: The passive role, stigma. feeling of being a source of financial stress and distress caused by the disease lead to the patient feeling like a burden and having a poorer view of them selves. Fear of becoming handicapped: Failure of treatment, fitness resulting in a disability, handicap or a cosmetic or functional loss all generate a fear that haunts the patient all through the illness. Uncertain prognosis: The short and long term prognosis as well as the possibility of a relapse are a major source of stress for the patient and his family. . . . . .., —. — 0< isL Lora Zombie
- 155. Intervention: Most of thefactors Listed above require a mere explanation and reassur ance based on facts and scientific data. The information sought needs to be furnished in the Language best understood by the subject with minimal technicaljargon. The stress can therefore be significantly relieved and the resutt is a positive impact on the prognosis of the disease and a greater patient satisfaction. 2. Stress of Hospitalization: Hospital is a place associated with disease, disability and death that we learn to fear from our childhood. The word hospital is synonymous with bad news’ and thus a source of major stress. The prospect of being admit ted in it heralds a variety of losses and [imitations on our being. Anatomy and physiology of hospitals: The layout. arcnitecture and design of hospitals, particularly in the public sector settings is, unfortunately. far from pleasant. The most traumatic parts such as the trauma centre, the emergency, and the intensive care units are set at the front of the hospitaL A person accompanying the sick, visiting a patient or someone who merely is there to get their blood pressure checked may be traumatised and fear ful for the rest of their life at the prospects of going to a hospital. The functioning of public sector hospitals is mostly bureaucratic, with a series of long cues for a chaotic rush) at registration points, outpatients, and pharmacies. Offices of consultants, as well are manned by often rude, overworked assistants with little understanding of the stressful mind set of a patient or an anxious family member accompanying them. Private hospitals and clinics are often aesthetically pleasing and run by staff that is not as stressed due to fewer number of patients but their func tioning is driven by financial considerations, resulting in gross inequity. Stresses relating to the hospitalization are thus over and above those of illness. The common stressors include: Loss of privacy: Once admitted in a hospitaL the individual finds him self surrounded by patients and hospital staff. S/he is expected to eat, steep and perform all routine tasks without any privacy, in the midst of virtual strangers. This is usually not the case when one is well and the patient may be helpless in changing this which may cause a great deal of stress,. Loss of autonomy: Once an individual is assigned the role of patient”, his diet, dress, bedding, lodging, sleep and pattern of all routine tasks will now be decided either by their care-givers or health personnel. While some patients might enjoy this departure from decision mak ing and feeling of control, others may find it disturbing. The patient may find it impossible to adjust to this change and is, therefore, seen seeking an early discharge from the hospitaL At times, the patient may take a ‘ftight to health’ i.e. a sudden disappearance of all symptoms, appearing to be ‘fit for discharge’. Separation: Most patients are admitted without attendants and are ex pected to meet no visitors or a minimal number, during visiting hours. A sense of loneliness ensues and the day is spent in awaiting the dear ones. The parents, children, spouse. friends, relatives and neigh bours are all expected to visit and share the sorrow of the patient. Any absentees are noted with concern, resulting in strained ties of friend ship or family. Often these absentees may be cast out from the social group, deemed callous and uncaring.
- 156. Handing over healthmatters: While the doctor is a fairly familiar figure for the patient, the rest of the hospital staff are all new to the patient. This may serve as a source of great stress when they take for granted that the patient will hand over all matters relating to his physical and mental health to them with little or no inhibition. Threat to social or financial circumstances: A hospital admission can mean loss of much-needed income, which may cause financial dis tress to the entire family. Other causes of stress are the care of young er children and etderly retatives. Unsatisfactory information: Under most circumstances in the acute situation leading to the patient’s admission the doctor is more focused on management. Thegueries of the patient and the family are mostly ignored or postponed. This adds to the patient’s and family’s anxiety and causes stress. 3. Reaction of the Patient to Ittness and Hospitatisation In the circumstances surrounding the illness and subsequent hospitalisa tion the patient has a myriad of different reactions to what is going on in and around him/her. These include: • Denial Anger • Depression • Dependance Patients who are at a higher risk of reacting to the stress of illness and hospitalisation include those suffering from psychiatric illness, those with a past history of psychiatric illness, elderly patients, children and those with poor pre-morbid psychosocial and psychosexual adjustment. DeniaL: Hospitalisation may be an overwhelming challenge to some individuals. Their response may initally be a state of disbelief and de niaL The patient may refuse to believe that the admission is required. or in some cases deny they are ill at alL Such a state may be shared by the family and may last for few hours to a day. Need for doctor’s approval: Health professionals enjoy unparalleled prestige and status. Their word is given a special consideration and often considered irrefutable. The vulnerability of the patient further enhances the aura of the doctor. S/he, therefore, tries to get the ap proval of the ‘saviour’ by being the model patient who follows advice, never argues or asks questions, and always nods ‘yes’ when asked “Are you feeling better”? This model is gradually being replaced by that of a more critical, argumentative patient who is informed of his/ her rights. S/he speaks as a client who is trading health services for the large sum of money paid in cash, insurance or in taxes. Anger: The state of denial may give way to anger. The degree of anger is influenced by the personality and emotional stability of the patient. This anger generated may be directed towards self or the hospital staff, When directed to the patient’s own self it may be in the form of refusat to take medication or meals, disturbed sleep, and frequent losses of temper with or without provocation. A team of health professionals sensitive to this displacement of anger gives the patient
- 157. It is evidentfrom the above description that the stresses of illness and hos pitalization are responsible for ‘secondary suffering over and above those directty caused by the illness. A vast majority of these can be prevented by prediction, identification sensitivity and understanding at the appropri ate hour. Nearly alt these states respond welt to the empathic attitude of a considerate health professionaL (who may be joined by the family / attendants) the chance to venti late. It is important to avoid both an apologetic and a confrontationat attitude. Depression: A state of resignation, apathy and depression may ensue by about the third day. The state is often transient as benefits of the treatment start to become visible. A delay in recovery, worsening or persistence of symptoms may however aggravate this stage. It may lead to a depressive reaction or syndrome with adverse effects on biological functions such as appetite and sleep. Dependence: The combined effect of the disease, the stress of hospi talization and the consequent stresses often result in a strong de pendence-hunger’. The patient has a constant need on the part to be pampered, sympathised and helped white eating, drinking or perform ing routine tasks. The extent of this dependence varies with the kind of experience the patient had when previously ilt, and the sociocuttural context.
- 158. Chapter 2 Psychosocial Assessment ModetPsychosocial Assessment And Management Protocol You have been asked to undertake the psychosocial assessment of a 26 year old, single, male: MrX. Presenting Probtem Mr X is admitted in a medical ward with the diagnosis of Hepatitis B. He is also being investigated for spikes of high grade fever, unexplained by the diagnosis of hepatitis. In spite of the ward staff’s repeated requests, He leaves the ward every now and then and returns after two hours or so. He sometimes fights with fellow patients and ignores rules and regulations of the ward. He occasionatly refuses treatment and states that he does not want to live anymore. Personal Status Mr X is the youngest of six sibs. He has two sisters and three brothers. He was born in Sheikhupura. and his father, a cobbler, shifted to Lahore when X was a six year old, to put up a roadside stall. None of X’s sibs went to schooL S/he collects waste from the waste disposal dumps on the banks of River Ravi. S/he started to smoke cigarettes at the age often. He now smokes chars (marijuana) and is addicted to heroin. S/he inhates the heroin on a silver foil. X is HIV positive. He gives a history suggestive of repeated urinary tract infections and gonorrhea. Famity History and Current Relationships X has been in an extended family system for the first ten years of his life. He lived in Sheikhupura in a three room pukka house with his paternal cousins and uncles. The family practiced some basic Islamic rituals but was not very religious. He was physically abused by his father and a paternal uncle. S/he was bullied and sexually abused by a cousin regularly till his family moved to Lahore. S/he never attended a regular school, but went to a Local madressa to study religious text. S/he would get physical beatings at the madressa as he was poor in studies. His father earned about five hundred rupees on the days he worked. His mother worked as a household servant to earn five thousand rupees a month. He often fought with his siblings and had no confiding relationship except with his mother. Positive Support Systems Mr X feels comfortable in the company of his mother, and a friend from whom he usually buys chars and heroin. He hates his father as he is ag gressive and has beaten him repeatedly on account of his smoking and drug use. Lately Mr X has started to attend the local mosque. The prayer leader there gives him sermons about leading a pious life and assures him that he will be granted Allah’s mercy if he gives up his bad habits. He feels some com fort in the company of the prayer leader. It is he who brought him to the hospital for treatment.
- 159. Crime and Delinquency MrX has had repeated run-ins with the police on account of possessing charas and heroin. He has also been arrested and sentenced for selling drugs. He once beat up a fellow drug addict. He has been to prison twice. Education X has never attended a format schoot and was taught onLy to read Quran at the madressa. He can do simple counting and count currency. He cannot Write. Emptoyment X has been making three to four hundred rupees a day by selling used syringes and ptastic bottles picked from the dumping grounds on Ravi. He once worked for six months at a tea bar near Daata Darbar, Lately he has been emptoyed by a syringe packing factory as a daily wager for two months. Readiness for treatment X has opted for treatment of hepatitis but is still unsure about giving up charas and heroin. Available social, economic, occupationaL resources X is admitted in a public sector hospital receiving free treatment, but has to pay for interferon therapy. He has no job to return to and is a poorly skilled labourer, working on waste disposal area which is a high risk setting. His bond with brothers and sisters, and father is weak. Personal Values and Attitudes Mr X often prays at the mosque for the last six months but was raised in a house with little or no religious values. He cheats and tells lies. He is bisexual, and has had several sexual liaisons with mates and females since the age of twelve. He has been involved in petty thefts from his home and various shops. Mental Status Exam Appearance and generat behavior Mr X is a young mate with a medium build. He appears older than his age, is shabbily dressed, and poorly groomed. He is cooperative and forms a fair emotional rapport but is restless and fidgety. Speech: He speaks in a low tone and volume, giving brief and relevant replies, but starts to speak with pressure, and rapidly while discussing religious beliefs. Mood and affect: His mood is anxious and defensive. His affect is appropriate to his speech and mood state.
- 160. Thoughts.’ His thinking processesare normat. logical, and he has no delusions. He does have some overvalued ideas about the relationship of his medical and drug issues with his fate: he considers them Gods curse on him because of his inability to serve his mother, Perceptions.’ Mr X denies any visual or auditory illusions or hallucinations at presenc He states that he does have hallucinations of police sirens getting closer while under the effect of drugs. This state has never occurred white he is sober and drug free. He has not noticed any change in his perception of taste, olfaction or bodily sensations. There are no obsessive-compulsive phenomenon. He does not experience any phobias, dereaUsation or depersonalisation. Cognitive Functions.’ He is fully conscious, attentive and is able to concentrate. He is oriented in time, placeand person. and has normal short, intermediate, and long term memory. His abstract thinking is intact, and his arithmetical skills and general knowtedge are appropriate with his educational and cultural setting. His judgment is not impaired. Insight: He is aware of the physical and drug abuse issues he is facing and wants to seek appropriate treatment from the hospitaL Suicide and homicide risk: He has thought of killing himself by taking an overdose of heroin, but has not attempted it so far, and has a moderate risk of self-harm. He has no plans to harm anybody. Diagnosis AXIS I: (Psychiatric Diagnosis) Heroin and Cannabis dependence AXIS II: (Personality): Sociopathy / Antisocial Personality Disorder AXIS III: (Medical Condition): Hepatitis B, HIV positive, gonorrhea AXIS IV: Problems related to family, police, and hospital administration AXIS V: (Social and occupational functioning): Global Assessment of Functioning (GAF) score: 71 PsychosociaL Management: Major Issues: Medical and Psychiatric illness Antisocial personality Poor socioeconomic status Inadequate family support Unemployment, and intermittent exposure to hazardous waste and infected syringes due to occupation
- 161. No housing Legal problems Easyaccess to drugs of abuse Strengths And Weaknesses: Strengths: Cooperative, has insight, and adequate cognitive functions, link with the local mosque and religious inclinations, strong bonding with mother. Weaknesses: Multiple psychosocial issues listed above, poor motivation to give up drugs, antisocial personality traits and delinquency history, mild to moderate suicide risk. Management Goals: 1. Improvement of motivation to overcome drug dependence 2. Adherence to hospital norms and rules, as well as social values 3. Meaningful occupational skills and employment and giving up current exposure to syringes and infected material 4. Mobilisation of family support particularly improved relationship with father and brothers 5. Estrangement from drug dealers, and drug abusers 6. Risk reduction regarding sharing of needles, dissemination of hepatitis B, suicidal ideation, and safe sexual practices 7. Informational care on medical and psychiatric diseases, drugs, follow up, prognosis, cross infection, treatment adherence 8. Relapse prevention through active engagement with medical, and psychiatric services -- 9. Availability of medication .- - Strategies and Interventions: 1. Motivational interview to deal with drug abuse issues 2. Informational Care session 3. Counseling and support to refuse peer pressure in drug abuse, avoid risk taking, and high risk situations, mobilization and re-establishing family bonds. 4. Occupational therapy 5. Improved treatment adherence and follow up 6. Conflict resolution at home and hospital settings 7. Medicolegal / forensic support 8. Mobilisation of economic support for treatment of medical and psychiatric disorders g. Cognitive behavior therapy to deal with issues related to suicidal ideation, social bonds, drug abuse. 10. Anger management and impulse control methods 11. Group counseling / group therapy for drug abuse
- 162. a. Coronary CareUnit Coronary Artery Disease (CAD) is commonly seen in people who have a characteristic combination ambition, time urgency, anxiety, competitive ness and hostility (Type A personalities). It is more likely to occur in persons with high environmental stress, life dissatisfaction, less social mobility, sta tus incongruity and those with personal loss. These patients when hospi talised to CCU nd themselves faced with a situation when their health and environment is not in their control. The surroundings of CCU depict a very grim picture. Patients are attached to different kinds of tubes, wires and gadgets and neighbouring patients are being resuscitated or dying. For a patient, therefore, the CCU may appear to be a ‘chamber of horrors’ and further complicate his state. Certain patients, however, may feel calm and “protected” in the same setting. The common psychological reaction in patients in CCU settings is a state of anxiety, fear, distress and/or a sense of loss following the cardiac event. This is known to lead into clinical depression in up to one-third of the pa tients, who may present with weeping spells, low mood, disturbed sleep. loss of appetite and even non- cardiac chest pain. Some of these patients may use the defence mechanism of ‘denial’. In this state they may appear joviaL talkative and found cracking jokes. The co-morbid depression and anxiety ma, delay recovery and adversely affect the short and long term morbidity and mortality. To manage this certain physicians may prescribe benzodiazepines in cardi ac patients as a routine. Benzodiazepines are not currently recommended in clinical guidelines for long term use due to their addictive potentiaL This practice may result in benzodiazepine misuse, abuse and dependence. Family members visiting the patient or those asked to wait outside the CCU may be equally distressed and anxious. Their anxiety is often on account of a lack of information and awareness about the events taking place inside the CCU, hidden from their eyes, They are often found waiting on the edge of their seats, walking anxiously in the corridors or feeling exhausted after waiting for long hours in the open or the poorly furnished waiting rooms. Interventions: A medical student or a doctor on duty in CCU must actively look for the above mentioned psychological reactions, make clinical notes and promptly start treatment or make a referral for a psychiatric opinion. The effectiveness of biological treatment and clinical outcome in CCU settings can be greatly enhanced using nonpharmacological interventions (NPIs). Use of informational care, counselling and ventilation sessions, progres sive muscular relaxation, visual imagery, relaxation techniques, hypnosis, meditation and biofeedback can help. Opportunities for stable patients in CCU to interact in groups with each other and share their experiences have tremendous therapeutic value. Group sessions conducted by doctors and cardiologists to educate patients on behaviour modifying strategies regarding smoking, anger, time and stress management can also enhance the therapeutic outcome and prevention of future cardiac events. Chapter 3 Psychosocial Issues in Special Hospital Settings
- 163. Alt CCUs shouldideaLLy ensure comfortable, dedicated waiting rooms and rest rooms for famiLy members and attendants. A regular flow of informa tion about the patients state progress based on scientific data should be ensured through a medical officer or a senior nurse, trained in principles of effective communication (Section A). This is preferable to the usual “tassalti” with statements such as “atl is well ‘mareez theek hai or 5mareez ki halat theek nahin.” b. intensive Care Unit Long periods of sensory deprivation and sensory overtoad will often give rise to a state called CU- Psychosis or Intensive Care Syndrome. This syndrome is characterised by increased wakefulness, disorientation and visuat hallucinations, depression, social withdrawal, anxiety, delusions and delirium. There is a combination of sensory overload and sensory depri vation in ITC syndrome. Sensory overload occurs in the form of noise of monitors, activity of the staff, constantly lit setting, and high level of activity. The sensory deprivation as a result of immobility, restraints and bandages, contribute towards the ICU syndrome. The lack of familiar orienting objects such as clocks, calendars, windows, meals, and close proximity to other patients further worsen this condition. An already distressed patient is ex • posed to constant attendance by physicians, nurses and technicians. S/he also suffers sleep deprivation, physical and emotional pain of disease, fear of mutilation or death, unfamiliar medical procedures, (often conducted without consent and information) and minimal control on one’s draping and dress. All this leads to extreme stress and a feeling of powerlessness. The • typical psychological reaction of hyperactivity, anger and anxiety in ICU • patients should not, therefore, come as a surprise. Interventions A redesigning of CU’s architectural and administrative layout with the is sues identified above in mind can greatly reduce the risk and frequency of ICU syndrome. The steps that can be undertaken to improve psycho care of patients in ICU can be divided into those focused on the inside of the CU and those aimed at their family waiting outside. Inside the ICU: • Educate and prepare the patient. Use orientation devices e.g. clocks and calendars. • Minimise pain through pharmacological as well as non- pharmacological interventions. • Be careful while discussing the patient’s plight assuming the patient to be unconscious, comatose or sedated. Many patients in these states report having heard and painfully remember the negative and sometimes insensitive remarks of the health care staff. • Reduce environmentaL stressors. Outside the ICU: • Designate a space for the family and visitors. • Provide support and educate the family using Informational. Care principles. • Set up a counselling or a ‘solace room’ where those in distress can be
- 164. attended to. Thesame space can be used to breakbad news. Hospital staff shoutd be trained in counselling and non- pharmacological interventions in ICU and CCU settings c. The Emergency Department The emergency department is the face of a hospital and often the most frequently visited part. It is, therefore, crucial to incorporate psychosocial care in deaLing with patients brought to this part of hospitaL With emotions running high in a crisis situation, Emergency health professionals often are forced to handle anger, frustration, guilt, depression, dependency and infantilisation in patients and families. Patients who have gone through a health issue requiring emergency care become reluctant to resume routine tasks and adoption of sick role” is a common associated finding. The pa tient’s family fears the unpredictability and outcome of the illness, change of rotes and economic burden of treatment of the patient. Interventions • Educate the patient and the family. • Keep the patient informed about the progress of his illness, • Give the patient a chance to express him/herself and work through the problem with them • Manage ‘sick role’. Aim for early rehabilitation and return to previous level of functioning. A comprehensive psychosocial assessment and intervention in emergency department can prevent uncalled for admissions and save the family, the patients and the doctors a great degree of distress and resources. d. PsychosociaL Aspects of Organ Transplantation While the future holds promise for transplants of possibly all or many organs, the most common are the kidney. bone marrow, liver and heart transplants. Other than the ethical issues and the legal bindings now in position in Pakistan, the psychosocial aspects of this intervention are often ignored. While the recipient is of primary significance on account of his or her severe illness, the donor must never be forgotten. Before, during and well after donating the organ the donor has to be cared for with sensitivity and concern. Other than the surgical and medical risks that s/he may carry, S/he is looking for approval, and support from the medical staff. A profuse and oft repeated thankful stance, and eulogising of his altruistic behaviour is the least that we can do. This aspect is often left to the family of the recipient or the recipient himself; which many a times is not enough. As a medical student it is important that you ask for the donor, visit him, and use principles of effective communication such as understanding for emotions, active listening and above all, empathy, in interacting with him. A single in teraction of this kind can lift his psychological state and may be enough to comfort him. It is also important to give him or her a detailed informational care session to remove his myths and misconceptions, respond to his con cerns and reassure him that s/he is not a disabled individual after donating an organ and can still lead a full and productive life. Particular emphasis needs to be given to the impact on his diet, sleep, sexual life, return to work, and address his concerns about Perhez.
- 165. e. The DiaLysisUnit Memoirs of a young doctor; The turning point in my medicat career came in final year MBBS when I was on rotation in the medical ward of the hospital attached with our medical cottege. I was to take histories ofsome patients and carry out physical ex aminations. I was surprisingty drawn towards one 65 year oLd fernate patient who was admitted in the ward with chronic renal failure. She needed a kidney transplant but the family could not afford to have the surgery. She was under going haernodialysis at regutar intervals in an effort to somehow maintain her failing health. The frequency ofdialysis required gradually kept increasing as her kidneyfunction deteriorated. As the family and the patient herselfslowly seemed to be preparing for the inevitable outcome, I fett I was witnessing the realistic limits ofour health care system. As a medical student, I could not offer her much technical assistance, but I would always take some time in the evenings to come and listen to her I saw herprogress from frustration and anger to gradual acceptance. I was able to see how the whole familypulled together in an effort to make herjourney easier, and how they foundpeace and comfort in their cutturat and spirituat beliefs. She said, and I believed, that the opportunity to talk to a caring and non-judgmental individual helped her I realised that one of the gaps in medical care in Pakistan is that our doctors and nurses are not trained in practical counselling skills that they can use in their daily interaction with patients. That was when I decided to take up mental health as my future specialization, becoming a psychiatrist and finally a stress counsellor. The training also helped me answer another unresolved question, ‘why was I drawn towards this particularpatient?’! realised that this patient unconsciously reminded me ofsomeone very important to me: my mother Psychosociat concerns and interventions in a diaLysis unit Acute uremic encephalopathy, intra-cerebral thrombotic stroke or hemato ma, dialysis dementia (characterised by dyspraxia. facial grimaces, myoc Ionic seizures, schizophrenia like state, mania and depressive symptoms), maladaptive coping behaviour, loss of independence, difficulty in perform ing routine tasks, fulfilling family and financial obligations are a cause of many psychosocial concerns in a patient admitted to a Dialysis Unit and her/his family. These include: 1. The burden of treatment costs, 2. medication, 3. special diet 4. transportation, 5. loss and change in function, 6. roLe reversals, marital difficutties 7. Depression, with or without suicidal thoughts 8. Emotional reactions are seen with such patients such as guitt, hostility and ambivalence. Interventions: • Emotional support • Education and preparation of the patient, and the family through regular Informational care and emotional support through
- 166. counsetting sessions cangreatly reduce the distress of patients and families in a Dialysis Unit setting. • It is also important to detect the co-morbid psychiatric conditions and treat them early. f. Reproductive HeaLth The WHO defines reproductive health, within the framework of the defini tion of health, as a state of complete physical, mental and social well-being and not merely the absence of disease of the reproductive system. Reproductive health is central to general health. It a reflection of health in childhood and adolescence and sets the stage for health beyond the re productive years for both women and children. It includes women’s health in general as well as safe motherhood, fertility regulation, prevention of infertility, prevention and management of cancer, prevention and manage ment of reproductive tract infections and sexually transmitted diseases. Only the key times in the reproductive life are however addressed here. Puberty A fairly regular sequence of events happen between the ages of 9 and r6 years. Vaginal secretions are generated for the first time and may lead to misconceptions e.g. ‘the body is dirty or diseased’. Increased body fat is perceived as ugly” before final feminine features mature. There are concerns about breast size. Many negative reactions occur in response to menstruation, particutarly if it is precocious. All these factors generate anxiety. mood changes, anger and a desire for tonetiness and confiding relationships. Changing moods can cause family conflicts and frictions and [ow self- esteem in them within the peer group. Interventions Close and healthy bond based on free communication within the family (mother, elder sister) to share anxieties and worries usually improves the situation. Professional advice should be sought also for delayed / preco cious puberty, and a sensitive physician is expected to address the con cerns of the adolescent and the family members with reassurance. Myths such as perceiving normal vaginal secretion (“leukorrhea”) to be unclean are often brought to reproductive health professionals for treatment. It is up to the health professional to debunk this and other myths, instead of “throwing drugs at the problem” as overuse of drugs. especiaLly antibiotics, is already showing dangerous consequences worldwide. Pregnancy & childbirth During pregnancy both parent have concerns about genetic endowment, intelligence, temperament. physical health and stature of the child. Cultural practices and myths of the society greatly influence on parental expec tations. A prevalent example of this is the diet that a pregnant woman is asked to consume. Various cultures, deem different food groups out of bounds for the pregnant female, with next to no evidence or research base. The parents’ own childhood experiences and how prepared they feel to become parents also greatly influences the parental expectations. Con genital anomalies due to non-inherent factors such as nutrition, medica tions, alcohol, caffeine, cigarette, toxin, infection are some of the other con cerns of parents at childbirth. All these factors contribute towards quality of
- 167. bonding of eachparent with infant, The child bears high risk in this regard if the mother develops puerperal psychosis or depression. Pregnancies at risk for Devetoping Psychosocial Complications • Primigravida, precious pregnancy, unwanted pregnancy • Past history of psychiatric illness or family history of psychiatric illness • Strained maritaL relationship, • Poor social support • Children under the age of 14 years • History of drug abuse Minor problems in pregnancy, like heartburn, nausea, cough, generalised itching, varicose veins etc. may generate undue anxiety, particuLarly if organic cause has not been effectively ruled out. Unlike the west, in our culture adequate training for labour and psychological support during labour is preferred from mother or elder sister rather than from husbands. However with changing times more and more husbands are playing a more supportive role during the pregnancy, labour and even in the care of the offsprings. Majority of deliveries in Pakistan are still done by Traditional Birth Atten dants (TBAs) and Dais. This increases the risk of birth complications. On the other hand a number of Caesarean sections are also done without giving an adequate trial of labour. World literature provides evidence for better results from natural childbirth. Problems with breast feeding may occur, amongst mothers on account of the misconception about disfigurement if they feed their children. While mothers milk is considered to be, by tar the best feed for the baby. Psychosocial issues during Puerperium The risk of developing morbid psychological reactions during the puerpe rium is higher amongst the primigravida, those with past history of psychi atric illness, family history of psychiatric illness, past history of puerperal illness, previous childbirth with congenital abnormality, poor social support or poor marital relationship. The common psychiatric conditions that can develop during puerperium include: • Postpartum btues: a self-limiting state of low mood, weeping spells and disturbed sleep that lasts for 10-14 days. • Puerperat depression: If the sad mood and disturbed biological functions lasts for more than 2 weeks, puerperal depression should be considered. • Puerperat psychosis: A relatively rare state, characterised by delusions and hallucinations and gross abnormalities of behaviour. Both Puerperat depression and psychosis should be treated by a psychi atrist. An early referrat of such patients to a mental health professional is therefore mandatory.
- 168. psychiatrist is thebest option. g. Paediatrics Ward A poem Alt the way to the hospital The tights were green as peppermints Trees of black iron broke into teaf ahead ofme, as if I were the lucky prince in an enchanted wood Summoning summer with my whistle, Banishing winter with a nod. Swung by the road from bend to bend, I was aware that btood was running Down through the delta ofmy wrist And under arches of bright bone Centuries, continents it had crossed; from an undisclosed beginning spiralling to an unmapped end. Crossing tat sixty) Magdaten Bridge Let it be a son, a son, said the man in the driving mirror, Let it be a son. The tower held up its hand: the college bells shook their blessings on his head. I parked in an atmond’s shadow blossom, for the tree was waving, waving at me upstairs with a child’s hands At seven-thirty the visitors’ bell scissored the calm of the corridors. The doctor walked with to the sticing doors. His hand is upon my arm, his voice - I have to tell you - set another bell beat ing in my head: Your son is a Mongol the doctor said. How easily the word went in -clean as a bullet leaving no mark on the skin, stopping the heart within it This was my first death Wrenched from the caul ofmy thirtyyears’ growing, fathered by my son, unkindly in a kind season by love shattered and set free. You turn to the window for the first time. I am catted to the cot to see your focus shift, take tendril-hold on a shaft ofsun, explore its dusty surface, climb to an eye you cannot meet You have a sickness they cannot heal the doctors say’ locked in your body you wilt remain. Welt, I have been locked in mine. We will tunnel each other out You seal the covenant with a grin. In the days we have known one another my little Mangol love, I have learnt more from your tips than you will from mine perhaps: I have learnt that to live is to suffer, To suffer is to live. Ctinicat situations with a high risk of psychosociaL morbidity in Reproduc tive Health Settings Couples with infertility, females with vaginismus and those who have tong-standing premenstrual syndrome, dysmenorrhoea. chronic petvic pain or those who undergo hysterectomy form a high risk group for devel oping psychiatric morbidity. An early detection of psychosociat correlates in these patients should be followed with informational care sessions and the use of N P15. Long-term use of benzodiazepines, analgesics, placebos and megavitamin therapies are often unproductive measures, and should be avoided. In case the symptoms do not improve, a prompt referral to a - Jon Stallworthy
- 169. PsychosociaL aspects ofparenting a child with disabiLity Having a child with a physical or mental disability is an emotionatty, phys ically and often financially challenging experience. Many parents experi ence periods of extreme stress as they adjust to the demands of parenting a disabled child. These feelings are often similar to those commonly expe rienced after a significant loss such as a divorce or death of a loved one. 1. Denial of the Childs Disability. One or both the parents may deny their childs disabitity, especially if it is not an obvious one. A patent in denial will avoid talking about the disability and will make up excuses and alternate exptanations of the problem. They may behave as if everything is fine, completely ignoring the child’s problems. A child whose parents are in denial is at risk for being punished for his poor performance. This is inappropriate and may cause psychological damage to the child. This stage is especially difficult when the parents disagree about the degree of the child’s disability and how the problems should be handled. 2. Anger and guilt about the child’s disorder. Anger is a common reaction in parents of children with disabilities. Parents struggling with anger may become argumentative, demanding, and verbally aggressive when dealing with a child’s problem. They may project their anger toward a teacher, their spouse, and worst of atl, their child. Some may also be angry with themselves over the child’s disability and their inability to ‘fix” the problem. 3. Blaming others for the Disabitity. Some parents of children with disabilities attempt to cope by blaming others for the disorder. The parent in the blaming stage may believe or say that the other spouse. doctors, school staff, or even the chitd themselves is at fault or making excuses. Again, this stage is especially difficult and stressful when both spouses disagree about who is responsible. Furthermore, the blamer may become unable to get past blaming someone to focus on coping with the child’s problems. 4. Grief: Parents of disabled children may go through a grieving process that begins when they learn about the disability. Parents who grieve over their children’s disabilities are usually concerned that their children may struggle for the rest of their lives. They may worry that the child will not be successful in life because of the disability. Parents may feel new grief over the years if their child has difficulties achieving various milestones when other children succeed. Passing a driver’s test, college entrance exams, and similar events may trigger this grief. 5. Worry: Worry and grief often go hand-in-hand in parents of disabled children. Patents may worry about their child’s self-esteem, achievement and ability to make it through school. They worry whether the child will learn to read, write, or perform other important life skills, whether the child will be able to attend college or a vocational program, have a successful career; have a family and/or lead a normal adult life.
- 170. Psychosociat issues facedby a child with disability Various disorders can render a child partiatty or ftilty handicapped leading to restrictions on movement, ptay and/or diet. These timitations over an extended period of time can result in psychosocial problems both at home and at school. Frequent absences from school, low expectations of teach ers and parents and poor grades lead to [ow self-esteem. Such children have few or no friends at alt. The result is inadequate or stow verbal and language proficiency, which may make matters worse. In the event of un controlled seizures, memory and thinking may be affected and scars and disfigurement may occur. These issues lead to further decline in the poor self-concept and a state of chronic dysphoria and gloom. Delayed sexual maturation may further complicate the situation by causing poor peer inte gration and a state of alienation. On the other hand, if a child with disabitity receives the proper guidance, psychosociat and practical support, s/he can overcome these disabilities. to become a highly successful professional and a highly motivated human being. The basic principle is the same as with alt so called normal” chil dren: to provide a safe, non-threatening environment in which they can learn to manage their apparent disabilities and explore and develop their strengths. Psychosocial interventions As mentioned earlier, timely psychosocial intervention with the family and individual in such a situation is imperative to their prognosis and integration into society. The following guidelines may provide structure to such an intervention: • Informational care by the senior member of the health team, in a frank and honest fashion to the patient and/ or parents in simple language, as early as possible, is recommended. Both parents must be seen together and involved in the care simultaneously. • Adequate time for this interviewshoutd be spared so that issues can be discussed in detail and alt the queries of the parents, patient and the siblings dealt with, without any rush. A home visit by the health professional or the mental health social worker is regular practice in the West. This may not be possible locaLLy but a formal setting of the hospital cad be used effectively. Privacy must be ensured for an open expression of emotions, when such an issue is being discussed. • A multidisciptinary approach involving a psychologist or a social worker, nurse and doctor is ideal. Elective surgery, if indicated, should not be scheduled during the sensitive period of psychosexual development between 4-7 years in order to avoid heightened anxiety and possible psychological trauma. Ideally, the patient should not be segregated from the general population. S/he may be taught to be appropriatety dressed, and taken along to the various festivals and social gatherings. In the long run this approach helps to reduce the stigma and enhances the self-esteem of the patient and the family. A fair amount of peer contact in games, play, television watching, telephone conversations and reading stories can work wonders after the peer group has been adequately guided. Communication skills and training at the verbal and non-verbal level should be taken up as early as possible. Verbal communication to
- 171. convey warmth, acceptance,empathy, care, while nonverbal communication (tone of voice, facial expression) to convey humanistic concern should be encouraged. Evaluation of the psychosocial environment that influences the child has to be done on a regular basis. it is important to ensure emotional support for the family of a child with a disability, as a whole. Recognition of the roles of all the members indi vidually and due appreciation and valuation should never be forgotten, Encouragement and facilitation of needs through parent-to-parent support amongst the affected families is most helpful. it is also useful to teach and train the family in the techniques of coping with stress (discussed later in this section). Dear Professionals: What Parents Want to Tett You (Adapted from a piece by Muriel Hykes) ;. Please don’t predict the outcome for a specific case. You can give general advice, but caution that nobody can predict how this child wilt turn out 2. Do not write offa complaint as “Goes with the syndrome.” Just because a child has one diagnosis, does not mean that all his other problems are due to that 3. Ptease don’t get angry with our questions. We are worried and trying to do our best for our child. 4. Be open. Realise that the parents are going to be looking for a cure and will pursue alt avenues. Please respect that 5. When the parents are depressed and in shock, be avaiabte for them. Find something good to say about the patient’s development Appreciate their efforts 6. Promote a team approach to the child’s rehabilitation: practice “family-centred” care. Do not be surprised ifother doctors have told the parents conflicting information or failed to tetl them something. Coordinate care with alt other team members. z Understand that most parents are new to this...atl the medical terms, conditions and stuff So please go slow and be patient with us. On the other hand, recognise that some of us are very wett versed on our kids situation, andyou need to address us as your peer in the treatment of our child. 8. Remember that your patients are little human beings who feel and hear, and do thingsjust like otherpeople. Itjust takes them a bit tonger to achieve those goats. Be careful how you talk about them in front of them. Setf-esteem, confidence, and acceptance are major needs for everyone. g. Please be careful when using words like “handicap” and “disabled” because they hurt us like knives. These arejust children with special needs, and nobody knows what our chitdren can achieve.
- 172. Psychosocial issues inchronic illnesses and disabilities The reactions of a person who has been diagnosed with a chronic illness or devetoped a disability, are similar to reactions after other major life loss es. The individual experiences deniaL, anger. depression, and attempts to figure out how this change will affect them. f these feelings are resolved one can accept the new set of circumstances and [imitations. Long-term painful thoughts and emotions can lead to alienation, Loss of friends, more symptoms, feeling alone, and so on. The onset of a disability Lat er in life creates dramatic changes in how to live and feet. Studies show that people who are born with disabilities tend to be better adjusted than people whose disabilities came later in life. A person who goes blind at 20 years old deals with issues around the loss of never seeing what’s around them again, and the fear of, ‘Will I be okay? Can I still live without seeing?” Someone who has done physical work his whole life may experience a tremendous struggle. Finding out that s/he can no longer work or be inde pendent can be especially debilitating. Effects on care-givers Many people who suddenly become disabled, or develop an illness which creates a disability, suddenly have a greater need for support, both physicalty and emotionally. At times, just when a family member thinks everything is ‘under control”, more needs or emotions may arise. As many disabilities and iltnesses take place later in life, many times these people are in committed relationships. This creates a special set of conditions affecting the spouse. It is a problem they have little control over. Many new issues surface, not just in coping with the issues of the person who’s ill, but also coping with what one’s commitment is, finances, change of lifestyle, increased responsibility. It becomes an ongoing. lifetime struggle. Some one diagnosed with multiple sclerosis, for example. sees their abilities disappear. and can see their family trying to accommodate. They see their state deteriorating and their need for assistance increasing and therefore, feel Like more of a burden. It may become imperative to an individual’s mental and physical health to get support from friends, family. or a coun sellor/mental health professional. h. OncoLogy Patients admitted to Oncology Wards face a high morbidity and mottality risk. They have grave concerns about the unpredictability of their illness and about their loved ones. They are faced with the painful side-effects of chemo and radiotherapy and have fears of disfigurement and disability. This fear, and that of impending death and associated pain and distress be come the major preoccupation for these patients. Some of these patients would not even understand the meaning of their illness. Others may have strange unexpected reactions upon hearing the news for the first time. This may include manic reactions, dissociative reactions, denial, panic reactions and depression. Some individuals may even begin to think about suicide. The patient’s relatives may also have similar reactions to the news. Most of them expect a miracle from the doctors and staff and it may take time for the realities of the illness to set in. In addition to the patients and relatives, the staff and doctors working with patients of terminal illnesses also undergo slow and gradual changes in their attitudes. Exhaustion and emotional burnouts are common amongst
- 173. oncologists. Working asa team, taking time out for catharsis, ventilation and for relaxation and changing the monotony of this very demanding job are some of the methods to prevent against such conditions. Interventions Studying and seeing the reactions that people have to hearing bad news may give the naïve health professional the idea that it should be avoid ed, As discussed in Section A. to decide what information is to be given to the patient is not the prerogative or choice of the doctor. The patient must be specificatly asked what information they would like to receive regarding their illness. Breaking bad news to the patient and the relatives is a common scenario in oncology wards. It requires some skitls in coun selling techniques (See Section A, Non-Pharmacological Interventions). Each patient and family is different and requires a unique and personatised approach towards breaking the news. It is advisabte that the senior doc tor or consultant should take the responsibility of delivering the news and handling of the reactions, afterwards. With most patients this may be all that is required. In some, however, the help of a mental health professional may be needed to help the patient work through their sense of loss. The patient’s role in the house may determine what the loss would mean to the family when the patient is gone. Ifs/he is head of the family, they may need time to delegate responsibiLities before starting the treatment. The treating doctor should give due consideration to the patient’s needs. If the patient goes into a state of dependency and loses all witl to fight his/ her illness or becomes depressed s/he may require treatment with anti- depressants and professional handling. All available social and emotional support must be mobilised for the patient. The queries of the relatives and the patient about the illness and its treatment, likely outcome, side effects of the drugs, prognosis and duration of the treatment and any alternatives should be discussed. The doctor must arrange a separate session for providing this informational care. i. Operating Theatre Operating theatres (01) are viewed as sinister places by the patients. They feel that “nobody knows what goes on behind those closed doors, till they themselves enter the room. Most of them are scared of what is going to happen to them. The fears are of being vulnerable, being undressed and exposed to the eyes of complete strangers, of going through pain, of being under the knife and of dying on the table. When in fear people may react with anxiety, restlessness, irritability, anger and frank outbursts of aggression and panic. These reactions of the patient should be viewed as natural response to a fearful situation. The existing envi ronments in the theatres are such that they depict a coLd and indifferent atmosphere to the patients that further increases their anxieties and fears. Machines, surgical instruments, bLood spills here and there, shouts of panic and heLp from staff members to each other adds to the patients’ anxieties and Leave him/her aLone to handle them. The casual communication of the doctors and nurses may further enhance the scary image of the OT. The patient’s reLatives, waiting outside, are in a state of extreme distress, fear and apprehension about the outcome of the surgery. The fears are not only about the success or otherwise of the surgery and the Life of the patient.
- 174. interventions Most of thefears and anxieties of the patients are alleviated by reassur ance and providing informational care. The surgical procedure and its likely results, how long the surgery will last, what kind of pain is expected all need to be discussed with the patient prior to surgery. An introduction of the surgeons help in removing apprehensions of patients. Receiving the patients in the theatre by the operating surgeon or assistants in an empathic and professional manner helps removing many uncertain ties of the patients. An informational care session about the procedure, anaesthesia and tike[y results to the relatives helps in mobilizing necessary social and emotional support to the patient. The patient has a right to be informed of any complications in the surgery. This is less stressful for alt parties involved if the surgeon discusses prob lems that are tikely to occur with the patient before the surgery. I
- 175. Chapter 4 Psychosocial Peculiaritiesof Dentistry ,The oral cavity is one ofthe most tender and most vulnerable parts of our body. We teed ourselves through it and kiss our loved ones with it The mouth is literali.y a path to our innermost setf. The tongue is the only organ in our body which is fully developed at birth and functions during the first 2 months of life. Infants are de pendent upon it for nourishment, to communicate and express their feelings, and to’explore the world (we all know how infants put everything they touch into their mouthsD. During this early part of our lives, we are helpless. dependent vulnera ble and unable to express oursetves fully. Avisit to the dentist is unlike any other medical experience. During dental interven tions, we place our mouths in a vulnerable position. The feeling of hetptessness that ilievitably arises from these infant experiences of dependency and vulnera bility come from our unconscious minds. The resutt is anxiety. We place ourselves in a physically vulnerable position and suspend our usual physical boundaries. We render ourselves unable to communicate in the usual way (since our mouths are what is being tended to) and anticipate pain, while remaining conscious and fully alert. The close physical proximity of the dentist may also be perceived as threat- ening. Ifwe add to the mix the negative associations many of us have with doctors • or other authority figures. it is easy to see how feelings otanxiety might arise in typica dental settings. DentaL anxiety and phobias Dental anxiety or fear of the dentist is a major stumbling block for many people. It usually prevents otherwise intelligent, rational peopLe from optimizing and main taining their oral health. Dental phobia is a fear and avoidance of going to the dentist or fear of any dental treatment or care. It is believed that more than half the population fears dental • treatment and because of this avoid seeking dental treatment It is a serious con dition that leaves people panic-stricken and terrified. People with dental phobia have an awareness that the fear is totally irrational but are unable to change t They exhibit classic avoidance behaviour that is, they will do everything possible to avoid going to the dentist People with dental phobia usually go to the dentist only when forced to do so by extreme pain. Other signs of dental phobia include: • Trouble sleeping the night before the dental exam. • Feelings of nervousness that escalates white in the dental office wailing room. • Crying or feeling physically ill at the very thought ofvisiting the dentist • Intense uneasiness at the thought of, or when actually objects are placed in the mouth during the dental appointment or suddenly feeling like it is difficult to breathe. Causes of Dentat Phobi,and Anxiety There are maiy reasons why some people have dental phobia and anxiety. Some of the common reasons include: • Fear of pain is a common reason for avoiding the dentist, This fear usually sterns from an early dental experience that was unpleasant or painful or from dental ‘pain and horror” stories told by others. 170
- 176. Thanks to themany advances in dentistry made over the years, most of today’s dentaL procedures are considerably less painfuL or even pain free. • Fear of injections or fear that the injection won’t work. Many peopte are terrified of needles, especially when they are inserted into their mouth. • Fear of anaesthesia and its side effects Peopte may fear that the anaesthesia has not yet taken effect or was not a large enough dose to knock out any pain before the dental procedure begins. Some people fear the potential side effects of anaesthesia such as nausea, dizziness or feeling faint. Others do not like the numbness or “fat lip” associated with local anaesthetics. • Feetings of hetplessness and toss of controt. It is common for people to feel these emotions considering the situation — sitting in a dental chair with your mouth wide open, unable to see what is going on. • Embarrassment and toss of personat space. Many peopte feel uncomfortable about the physical closeness of the dentist or hygienist to their face. Others may feel self-conscious about the appearance of their teeth or possible mouth odours. Most individuats with dental phobias have had very negative experiences with either unskilled or incompetent dentists. The most important step for many patients to overcome dental anxiety is to find an expert dentist. An expert dentist is one who: • communicates effectively. • is highty competent. • endeavours to make each meeting pain free. • genuinely cares about the patient. • has the ability to nurture a patient through past traumas. The most significant factor in reducing dental anxiety is the ability of the dentist and staff to quickly develop rapport with each patient. With ade quate rapport. the patient feels understood, safe and protected. Knowing how to ask the patient what they are thinking and feeling is crucial to de veloping a connection. By eliciting this information, the dentist can respond to each patient appropriately and meaningfully. Additionally, a connection with each patient is fostered when the dental office environment is relaxed, welt organised, and the staff is friendly, warm and caring. Psychological techniques to reduce anxiety There are a number of psychological techniques that can be used to re duce levels of anxiety. i. Psychological support and counsetting Counselling can help with a whole range of phobias. There are several different approaches, but generally the aim is to discuss your anxieties in a way that can hetp to overcome them. This may involve: • exptoring the origins of a feat in chitdhood. • looking at the thinking patterns that arouse a fear.
- 177. • facing feargradually so that one may learn to cope with it. • teaming ways to cope, such as relaxation techniques, breathing exercises or meditation. ii. Distraction techniques It is sometimes heLpful to draw attention away from the treatment. This can be done in a number of ways: • Listening to music. For children cartoons may be played on a tv that has a view from the chair • Concentrating on relaxing each part of the body in turn. • Thinking about something one is looking forward to. iii. Hypnotherapy Hypnotherapy creates an attered state of mind that feels [ike being very relaxed. In this state, suggestions made by a therapist (or a dentist trained in hypnotherapy) can help people to receive dentat treatment. People can also be taught how to do this for themselves. Hypnotherapy may not work for everybody, however, while some people may be more susceptible than others. Dental appearance and psychosociaL welt being Aesthetic dentistry has become a prominent force in today’s popular culture, with treatments ranging from bleaching to “invisible” braces being commonplace. A healthy and attractive smile is undoubtedly valuabte, given the current focus on aesthetics. It is understandable that any devia tions from an “ideal” dental appearance could be detrimental to a person’s • psychosocial well-being. A number of investigations of craniofaciaL malformations (such as cleft lip with or without cleft palate) have sought to eLucidate the psychosocial im pact these conditions have on affected people. These people are generally welt-adjusted psychosocially: however, they reportedly have decreased social interactions, fewer close relationships and feelings of self-con sciousness regarding their facial features. For these reasons, patients with clefts should be treated early to prevent or interrupt negative psychosocial outcomes. Research has documented the effects of malocclusion and motivations for orthodontic treatment. Malocclusion has been identified as a potential threat to one’s body image and seLf-concept in both adolescence and adulthood. Many of these patients have a negative self-image as motivation for treatment. These individuals frequently report experiencing a level of psychological distress concerning their appearance that warrants intervention. It is essential that all health care providers understand how dental health and appearance fits into the larger picture of overall health and well-being. Teeth are important to an individual’s self- perception during adolescence, but by aduLthood other factors have greater significance. The importance of having the perfect smile changes as people age. This is why although it may make a minor contribution to an individual’s perception of self-worth, orthodontics cannot be justified on psychological grounds alone. I I
- 178. Stress Reductive Objective To conditionmuscle relaxation response Symptoms primarily related to anxiety Symptonis secondarily aggravated by anxiety Bwxism or clenching activity Muscle pain Techniques Relaxation techniques Biofeedback training Anxiety Disorders and Oral Health • Patients with anxiety disorders may disregard their oral health altogether and are at an increased risk for dental caries, periodontal disease, and bruxism (grinding). • Oral health problems associated with anxiety disorders can manifest in tle form of canker sores, dry mouth, Lichen Planus, mouth ulcers. burning mouth syndrome, and ternporomandibutarjoint dordes. • Anxiety disorders, which include phobias. panic attacks. generalised anxiety and post- traumatic stress disorders (PTSD). are serious conditions with oral health implications that can be treated with a variety of methods. Medications such as anti-depressants and some anti-psychotics decrease the mouth’s ability to produce saliva, which can increase the risk of developing tooth decay and periodontal disease. A liaison of the mental health professionals with dentists can benefit such patients. Temporomandibutar and Facial pain It is an established fact that temporomandibular and facial pain have mul tiple causes with the role of stress being significant in aggravating them. Condition such as Burning Mouth syndrome’ usually seen in elderly women may sometimes have a psychogenic origin. Conversely, in cases where an organic pathology exists, a chronic history of pain and dysfunction can pro duce psychologicat changes. These patients may frequently display charac teristics of ‘chronic pain syndrome’. This is characterised by increased anxiety, depression and reinforcement of illness behaviour. These features lead to an increase in the patient’s pain behaviour and an increase in pain perception. When taking the history of such a patient, it is prudent to ask questions such as “What does this pain or dysfunction keep you from doing?” If the patient complains of significant alteration in occupational or social activities as a result of the pain, a careful evaluation needs to be done. This process though time consuming may be therapeutically reward ing in the long run. Stress Reduction Techniques Stress produces physiological responses in the body such as release of adrenaline, contraction of sketetat muscle, restriction of blood flow to the digestive system, increased blood flow to the brain, increased heart rate and increased blood pressure. Pain in the TM joint movement that results from stress induced muscle contraction can benefit from a variety of stress reduction techniques. Most famous of these is the Jacobson’s technique which teaches the patient to become aware of a particular muscle, usually by contracting it. The goal of the relaxation training is to condition the mus cle to achieve a relaxed state quickly and for a prolonged period of time. This process is also facititated by relaxation audio tapes designed for the patient. Biofeedback is another technique that has been shown to be helpful in reducing stress-induced muscle activity. Biofeedback teaches the patient voLuntary control over automatically regulated functions of the body. It provides the patieht with instant monitoring of the physioLogical parameters of stress. For example Electromyographic (EMG) biofeedback monitors the level of muscle activity and the patient can monitor this through visual and auditory displays indicating the degree of contraction of selected muscles. With good training the patient learns to adequately relax these muscles -—-- -j
- 179. Chapter 5 Psychosocial Aspectsof Alternative Medicine The term alternative medicine refers to atl medicine that has not been tested using the scientific method, and has no evidence to prove its efficacy. This includes homeopathy, acupuncture. hikmat and other forms of herb al medicine. In our culture, alternative medicine is usually the first line of treatment that a patient adopts when s/he first becomes ilL It is practiced by anyone and everyone who has ever experienced illness, and alternative medical advice can be sought from anyone, whether it is a fruit vendor, a neighbour or your grandmother. The reasons for this are that traditionalLy a[Lopathic medicine was considered a western invention, harsh’ on the body and unsuitable for the subcontinentat climate. It was only to be turned to if and when all else had failed, and the healing properUes of household remedies had failed. A return to the use of alternative medicine is seen in patients in situations where allopathic medicine suggests a painful cure, or does not have one. White anecdotal evidence states that these alternative methods are ef fective there is no scientific evidence to back this claim. Homeopathy, in particutar, according to the NHS UK has been cited as ‘performing no better than placebos.” The National Institute of Health and Care Excellence (NICE) guidelines do not recommend the use of homeopathy for the treatment of any ailment. In a 2013 large scale study conducted by the Nationat Health and Medical Research Council of Australia, 57 systematic reviews containing 176 individual studies, published between 1997 and 2013 were evaluated by an independent contractor overseen by a body of homeopaths. The study found that there is no evidence that homeopathy caused greater health im provements than placebo. or caused health improvements equal to those of another treatment. This finding has been repeatedly confirmed by find ings in various peer reviewed journals. tl][21[3][41 As health professionals it is therefore, unethical to recommend homeo pathic treatment to any of our patients, even if we have personally feel that they are effective. Any patients who report that they are using homeopathic medication must be informed that there is no evidence to support their effi cacy. They must also be instructed to continue the use of altopathic medi cine if they insist on using homeopathic or other remedies. References 1. Fisher, P., & Ernst, E. (2015). Should doctors recommend homeopathy?. www.bmj.com 2. Australian National Health and Medicat Research CounciL Statement on homeopathy. 2015. www.nhmrc.gov.au/_ffles_nhmrc/pubtications/attachments/camo2_nhm- rc_statement_homeopathy.pdf. 3. Ernst E. A systematic review of systematic reviews of homeopathy. British journal of clinical pharmacology. 2002 Dec 1;54(6):577-82. 4. Campbell A. Homeopathy in perspective. Lulu, 2008. 5. Cucherat M, Haugh MC, Gooch M, BoisselJP. Evidence of clinical effica cy of homeopathy. European Journal of Clinical Pharmacology. 2000 Apr 1:56t1):27-33. 6. Smith K. Against homeopathy—a utilitarian perspective. Bioethics. 2012 Oct 1;26(8):398-409.
- 180. Chapter 6 Common PsychiatricDisorders in General Health Settings The workings of the human mind have remained mysterious since the beginning of time. Psychiatry. the medical specialty devoted to the study. diagnosis, treatment, and prevention of mental illness, is just as Little understood, despite being the oldest profession known to man. In prehis toric times, people haunted by ‘evil spirits” were taken to medicine men to have holes drilled into their skutts to let the spirits escape. The need to understand the way our minds work coupled with lack of scientific prowess to investigate the mechanics of the brain led to the perpetuation of these myths. The first psychiatric facilities were set up in the 8th century in the Islamic world but methods more humane than exorcisms did not come into use until the seventeenth and eighteenth centuries. Psychiatry has come a long way since then but sadly the perceptions surrounding it are very much prehistoric, especially in our part of the world. The myths and misconceptions surrounding mental illness, treatments and mental health professionals themselves are many and manifest. The war against the stigma of mental illness is one that we alt fight. whether we are protesting against being called “crazy” or fighting for a loved one to get help. According to the WHO Mental Health Action Plan 2013-2020 Re port, “mental, neurological and substance use disorders exact a high toll, accounting for 13% of the total global burden of disease in the year 2004, Depression atone accounts for 4.3% of the global burden of disease and is among the largest single causes of disability worldwide Eli % of all years lived with disabitity globally], particularty for women. The economic conse quences of these health losses are equally large: a recent study estimated that the cumutative global impact of mental disorders in terms of lost eco nomic output will amount to US$ 16.3 million between 2011 and 2030.” Some of the most common myths and misconceptions surrounding mentaL health issues, their treatments and mentat health professionals are being dealt with here hi: Myth: Psychiatric Illnesses do not exist or are caused by magic and evit spirits Reatity: Psychiatric illnesses are caused by structural and chemical chang es in various structures of the body, especially the brain, and are just as much a “curse” as any other illness or adverse life event. The reasons for this are genetic, biochemical, behavioural and environmentaL According to a WHO Report, one in every four people in the world wilt be affected by mental or neurological disorders at some point in their lives. Psychiatric Illnesses constitute 15% of all diseases incurred in people throughout the world. 33% of all hospital attendances are for psychiatric diseases. Myth: Psychological factors do not cause any other diseases Reality: Psychological factors are acause of the disease for at least 60% of alt patients with any disease. In fact, mental illnesses such as depression may predispose one to developing infections, heart disease, diabetes and even cancer. •xed!n istHyaKhan
- 181. Myth: Psychiatric patientsare dangerous: theycan harm tife and property: Reality: gg% of aU.violence, crimes and homicides are committed by the so-called “normaL” The large spectrum of patients with mental illnesses is non-viotent and not dangerous to other people. In fact, according to a study published in The Lancet, “people with psychiatric disabilities are far more tikely to be victims than perpetrators of violent crime (Appteby, et al., 2001). “People with severe mental illnesses, schizophrenia, bipolar disorder or psychosis, are 2 Y2 times more likely to be attacked, raped or robbed than the general population (Hiday. et aL,;ggg). Myth: Psychiatric Patients Are ‘“Fraudulent, Matingerers, Hysterical”, Be having Abnormalty To Fulfil Ulterior Motives Reality: Extensive research has shown that those who were labetled “fraud” ‘fake” “attention seekers” were in fact misdiagnosed and misun derstood. Follow up studies conducted ten and fifteen years after people were Labelled matingerers and frauds, revealed very high rates of death and disease amongst the “frauds.” The nature of psychiatric disorders is such that people are unable to cope with their daily routines, experience a lack of motivation, and start to behave differently. They, therefore, seem to be malingering or “seeking attention.” The real reason for this is the brain experiencing neurobiologicaL chemical or structural changes. As all bodily functions are controlled by the brain, patients with psychiatric illnesses also experience changes in their appetite, sleep and sex lives for extended periods of time. Myth: Psychiatric treatments are lifelong, addictive, put you to sleep and render you incapable of living your tife Reality: Psychiatric treatment includes a myriad of different kinds of treatments including medication and therapy. Medication is not addic tive if used according to prescription, white therapy is conducted for a set number of sessions. Only a certain class of prescribed medication induces sleep. The main aim of treatment in psychiatry is, in fact, to ensure patients are abLe to return to their daiLy routine and living their lives as fully as possible. Myth: Spiritual Interventions, homeopathy and “ghareLu totkas” can be used in place of medication prescribed by the psychiatrist. Reality: Medications and psychotherapy should be used in conjunction with spiritual interventions and neither should replace the other. Both med ication and psychotherapy use in the treatment of psychiatric issues have been researched extensively and found to be effective. According to The National Health Service of the UK “There is no good-quality evidence that homeopathy is effective as a treatment for any health condition.” The larg est to-date analysis of all data on homeopathic treatments, conducted by the National Health and Research Council of Australia has concluded that they are ineffective in the treatment of any clinical conditions in humans. Myth: Psychiatrists give “electric treatment” to alt patients ReaLity: Electroconvulsive therapy or electroptexy is a welt researched, safe, painless and effective treatment used for serious issues in very specif ic disorders.
- 182. Myth: “Once apsychiatric patient...Atways a psychiatric patient’ Reatity: Psychiatric itlnesses are not Like heart disease, diabetes or hyper tension (all of which require lifelong treatment). Mote than sixty percent of psychiatric illnesses are curable and adherence to medication as pre scribed can lead to cure within 6 months to a year. Following is a brief account of some of the most commonty encountered Priority Psychiatric Disorders as far as the general heatth settings are concerned. All health professionals must have an understanding of the presentation and management of these disorders. a. Mixed Anxiety and Depression Mixed Anxiety and Depression may present initiatly with a history of two or more weeks of physical symptoms such as fatigue and pain. Further inquiry will reveal depressed mood and feeling of fear, apprehension, or a state of gloom. When symptoms are not severe enough for the individual to be diagnosed with either an anxiety disorder or a depressive disorder, a diag nosis of mixed anxiety and depression can be made. Diagnostic Features: • Low or sad mood, • Loss of interest in activities • Loss of pleasure in things previously found enjoyable. • Inability to cope with routines/duties, at work and/or at home • Prominent anxiety or worry. Disturbed sleep, • Poor concentration expressed as forgetfulness, • Change in appetite, • Dry mouth, • Tremors, • Palpitations, • Dizziness, • Suicidal thoughts or acts. Differential Diagnosis • If either depression or anxiety is severe, consider depressive disorder, or anxiety disorder as independent conditions. • If hallucinations (hearing voices, seeing visions) or delusions (strange or unusual beliefs) are present consider Acute Psychotic Disorder. If excitement, elevated mood, rapid speech is present, consider Bipolar Affective Disorder Management Guidelines If the diagnosis of anxiety and depression is made follow the steps as listed below: Provide Informational Care The patient and family members must be provided informational care regarding the aetiotogy, management and prognosis. The following
- 183. must also bementioned, in tight of the stigmaandmythssurrounding mental illness: • Stress or anxiety has many physical and mental effects. The symptoms are reat and understandable. They can be managed and relief is possibte. • These problems are not due to weakness or laziness; patients are trying their hardest. Do not blame the patient for not trying hard enough or consider him weak and timid. Do not repeatedly tell him! her to use wilLpower, go on a holiday, change jobs, etc. to get better Counsetting • Teach the patient to practice relaxation methods such as progressive muscular relaxation, deep breathing exercises or visuaL imagery to reduce physical symptoms. Ask the family to remind and encourage the patient to undertake the exercises. • Ask about risk of suicide in explicit terms — can patient be sure of not acting on suicidal ideas? (See box) • Help the patient to plan short-term activities which are relaxing, distracting or are known to build confidence in the patient. Resume activities which have been helpful in the past. • Identify exaggerated worries or pessimistic thoughts. Discuss ways to chaltenge these negative thoughts. • If physical symptoms are present, discuss the link between physical symptoms and mental distress (Reattribution). • If tension-related symptoms are prominent, advise relaxation methods to relieve physical symptoms. Medication Consider antidepressant drugs if depressed mood is prominent. In mixed anxiety & depression tower doses may be effectiv, e.g. imipramine starting at 25 mg each night increasing to 150 mg by the 15th day, or fluoxetine 20 mg/ after breakfast. Explain to the patient that: • Medication must be taken every day • Improvement wilt build over 2-3 weeks. • Mild side effects may occur that usuatty fade in 7-10 days, or become less disturbing. These may inctude dryness of mouth, constipatior’i. excessive sweating. • Check with the doctor before stopping medication as abruptly stopping it may result in discomfort. • Continue antidepressant for 6-8 months after the symptoms improve. Specialist ConsuLtation/Referral If suicide risk is severe, consider urgent referral tothe nearest psychiatric facility after admission. Refer the patient to nearest psychiatric OPD if the patient does not respond to the management plan even after 06 weeks of treatment.
- 184. b. Panic Disorder PresentingComplaints These patients usually present to the Emergency Room with one or more physical symptoms such as chest pain, dizziness, shortness of breath, feeL ing of suffocation and fear of having a ‘heart attack.” Further inquiry shows the full pattern described below. Diagnostic Features 3-4 attacks of sudden onset of anxiety or fear in which there is a feeling of dread, impending disaster, accident and the patient feels as ifs/he is about to die. It often occurs with physical symptoms such as palpitations. chest pain, a choking feeling, churning stomach, dizziness, feelings of unreality, or fear of some disaster (losing control or going mad, heart attack and sudden death). A typical panic attack begins suddenly. builds rapidly. and may last only a few minutes. Symptoms start white the patient is at rest. It often leads to fear of another attack and avoidance of places where attacks have oc curred. Patients may start to avoid exercise or other activities which pro duce physical sensations like panic. Differentiat Diagnosis Many medical conditions may cause symptoms similar to panic attacks, such as coronary artery disease (CAD) and asthma. These can be ruled out with appropriate history such as onset of pain or breathlessness on effort. changes in rhythm, rhonchi or crepitations on examination of the chest and typical changes in ECG. This exercise should not be repeated with each subsequent attack once the diagnosis of panic attack is established. • If attacks occur only in specific feared situations, consider Phobic Disorders. • flow or sad mood is also present, consider Depression. Management Guidelines Provide InformationaL Care Essential Information for Patient and Family • Panic Disorder is common condition and effective treatments are available. • Anxiety often produces frightening physical symptoms. Chest pain. dizziness, or shortness of breath are not necessarily signs of heart disease, asthma or similar disorders. None of the symptoms being experienced are dangerous or fatal. They are like a storm. that comes and then passes. Alt you have to do is tie low. do not start to rush to the hospital, or GP, and practice deep breathing and progressive muscle relaxation. Keep repeating in the mind that the symptoms of a panic attack are transient and always pass. They cannot cause any harm to heart, brain or any of the vitaL organs. To develop a belief that a panic attack is not a threat to life is an important step in effective management of a panic attack. -..... ,, ,, .. . .. L.
- 185. • Mental andphysical anxiety reinforce each other. Concentrating on physica’. symptoms will increase fear. • Do not withdraw from or avoid situations whereattacks have occurred; this will strengthen anxiety. CounseLling Counsel the patient and family to: • Concentrate on controtting anxiety. not on medical worries. • Practice slow, relaxed breathing. Controlled breathing will reduce physical symptoms. • Identify exaggerated fears which occur during panic (e.g. patient fears, he is having a heart attack). Discuss ways to challenge these fears which occur during panic e.g. the patient could tet[ himself am not having a heart attack. This is a panic attack and it will pass in a few minutes. • While the symptoms may appear scary, the patient must be left alone when they are having a panic attack to practice their relaxation exercise, and learn how to calm their ownsetves. The panic generated by family members on seeing their condition will only worsen matters. Medication • Many patients with panic disorder will not need medication. The use of relaxation exercises and reassurance is sufficient. • If attacks are frequent and severe or if significant depression is present, antidepressants may be helpful e.g. imipramine 25 mg at night increasing upto 75— 100 mg at night after 2 weeks. • For patients with infrequent and limited attacks, occasional use of anti-anxiety medication may be helpful: torazepam one mg up to three times a day for two to three weeks but never more than five weeks. • Always taper the dose in allowances of 1/4th of the dose every fifth day. Regular use of benzodiazepines may lead to dependence and is likely to result in the return of the symptoms when discontinued. Avoid unnecessary medical tests or therapies. Speciatist Consuttation/Referrat • Consider a referral for consultation with psychiatrist, if severe attacks continue after the above treatment, for 4 weeks. • Avoid referral for medical consultation for exaggerated worrying regarding medical symptoms. _.1
- 186. c. UnexpLained SomaticComplaints: Persistent Comptainers Presenting Comptaints Any physical symptom may be present, but the symptoms may vary ac cording to the geographical and cultural settings of patients. Complaints may be singLe or multiple. but tend to be atypical or unusuaL Some of the common complaints incLude a feeling of gas’ or ‘gota’, aches and pains from head to toe, headache, stomachache, backache, shoulder or neck ache in a peculiar and circumscribed site that cannot be explained on medical or anatomical basis. These are accompanied by an extraordinary concern of harbouring a dangerous or dreadful disorder. Diagnostic Features • Physical symptoms without medical explanation (proper history and physical examination are necessary to determine this). • Frequent medical visits and laboratory investigations that yield no unusual findings. • Patient may be overty concerned about medical illness. • Symptoms of depression and anxiety are common, but are not forth coming. Differential Diagnosis • If anxiety symptoms are prominent, consider Panic Disorder, and manage as mentioned above • If low or sad mood is prominent, consider Depression. If it is severe or associated with suicidal ideas or psychiatric features such as delusions and hallucinations, admit the patient, and seek psychiatric consultation. • If strange beliefs about symptoms are present (e.g. belief that organs are decaying) consider Acute Psychotic Disorder. Refer to the nearest psychiatric facility. • If the diagnosis of unexplained somatic complaints/somatization is confirmed: move to implement following steps. Management Guidelines Provide Informationat Care Essentiat Information for patient and famity: • Stress often produces physical symptoms. • Focus on managing the symptoms. not on discovering their cause. • Cure may not be possible: the goal is to live the best life possible even if symptoms continue. Counselling • Acknowtedge that physical symptoms are real. They are not lies or inventions or “veham.” The patient is not imagining these symptoms. • Ask about what the patient thinks is causing the symptoms, offer appropriate reassurance (e.g. abdominal pain does not indicate cancer). Advise patients not to focus on medical worries.
- 187. • Discuss emotionalstresses that were present when symptoms arose. • Reattribution: link physical compLaints ith emotional distress. Discuss emotional stresses that were present when symptoms arose such as feeling of anger. envy, jealousy, grief, loss, disgust. fear, sadness or threat. • Relaxation methods may help relieve symptoms related to tension (headache, neck or back pain). • Encourage exercise and enjoyable activities. Do not wait until all symptoms are gone to return to normal routines. Medication • Avoid unnecessary diagnostic testing or prescription of new medication for each new symptom. Offer reassurance, reattribution, relaxation exercises, massages, and physical exercises in place of symptomatic drugs. • Antidepressant medication (e.g. fluoxetine 20 mg per day) may be helpful in some cases e.g. those with headache, bowel symptoms, atypical chest pain. • Do not use benzodiazepines, antacids, analgesics. multivitamins or placebos as symptomatic treatment in these patients. Specialist ConsuLtation Avoid referrals to medical specialists; these patients are best managed in primary care. Keep in mind that patients may be offended by a psychiatric referrat and seek additional medical consultation elsewhere. d. Dissociative and Possession States These occur when a patient is brought by family or friends on account of violent or unmanageable behavior due to being possessed by ajinn or evil spirit. These states are often an involuntary attempt by the individual to escape from a stressful or demanding situation. Presenting CompLaints • Reduced awareness of self and surroundings (I can hear sounds but cannot respond to them) or a constricted level of consciousness. • Disturbed memory. where simple information is forgotten for short periods (patient is unable to answer queries Like what is your name, who are you, where are you, how many Legs does a cow have?). • Attention and concentration lapses. • Wandering away from home, to be found at a place where others can recognise him or her and return home, or sleep-walking. • Change or loss of motor and sensory function of a part or whole body or inability to talk, swallow, see, or hear without any neurological signs to support the change in function.
- 188. • Statements ofbeing possessed by a jinn’ or ‘bhoot’, or a supernatural force or deity. causing a change in language. voice tone, and assuming of another identity. Diagnostic Features: As mentioned earlier these symptoms occur due to the individual’s inability to cope with reatity. They are a form of escape from reality into a situation where the individual is more able to deat with their issues. Females are more likely to suffer from these symptoms. This is a result of their voices often being suppressed and their opinions not considered. It may be an expression of a social, relationship-related stress, or physical or psycholog ical stress. It may also be seen in soldiers, people affected by disasters, and survivors of psychotrauma. Extensive and uncalled for investigations and tests with a view to rule-out’ all posible physical causes should be avoid ed. The diagnosis of dissociative and possession disorders is a positive di agnosis based on a deeper understanding of the patient and their psycho social world using good clinical sense and effective communication skills. Questions about disturbed mood, biological functions, any suicidal wishes, and psychosocial stress must always be asked, Patient often re ports having a family member with similar presentation or has lived with or seen another patient with possession state. A belief about supernatural forces, ‘evil-eye’ and a cuttura[ endorsement of possession states often prevails in patient’s own and family’s belief system. DifferentiaL Diagnosis Dissociative and possession symptoms can many a times be an earty symptom of an underlying serious physicat. social or a psychiatric patholo gy. The symptoms should be therefore be approached like PUO (pyrexia of unknown origin). Underlying or co-morbid severe depression, anxiety, psy chosis, psychomotor epilepsy, should be considered while managing and investigating the patient. Serious disorders [ike cancers, multiple sclerosis and degenerative disorders may rarely present initially with dissociative symptoms. Management Guidetines No punitive measures should be adopted. Patient must never be ridiculed, challenged, or confronted. Statements like “you are malingering”, you are making it up”, “you have no disease” ‘makar naa karo” ‘dramay karna band karo”, should never be given. An informational care session conducted in simple easy to understand terms is imperative to the management of this state. It is most important to highlight the involuntary nature of symptoms white reassuring the patient and family that they are not life-threatening or dangerous. It must be con veyed to the patient and the family that the symptoms are an expression of an underlying conflict, nervous exhaustion, fatigue and inability to cope with a situation. Answers to queries like “Kya mareez per jin ya bhoot ka saya hai?” should be responded with statements tike “These phenomena are not my area of expertise, I can however, try to find and treat the sci entific basis of the problem and help you and the patient understand the condition better from a sLientific point of view. “Mujhe iss baray mel toh itm nahi hal mdgar sciencey tahqeeq ye kehti hal k ye musta zehn ka hal our mel iss ko science h nuqt-e-nazar se hut harne hi hoshish harun ga/gifl
- 189. Reassure that thesymptoms may be toud and dramatic to look at but are not dangerous and often result in recovery with specialised psychosociaL care and medication if needed. The family must be couneled against the use of force, undue attention and gathering around the patient or trying to hold or physically handle the patient during the attack. The family must leave the patient alone and only approach the patient to prevent any serious bodiLy harm. The patient must be encouraged to try and predict when an attack is about to occur and use relaxation techniques to overcome the state preferably by staying in a calm setting away from crowded places. A supportive, kind and re [axed approach with the patient with repeated empathic reassurances can help relieve the symptoms. Rest, adequate ftuids and food, adequate sleep and tranquil settings help in early recovery. Medication: There is no specific medication to relieve the symptoms of dissociation. The use of antidepressants or small doses of tranquillisers may help if they are associated with an underlying symptom of depression and anxiety. Specialist Consultation Such patients should be referred for speciatised psychiatric help as soon as possible, especially if they have associated depression or psychosis. Earlyinvolvementofa mental health facility may help in making a quicker diagnosis and they may be better equipped to manage such a patient. e. Drug Abuse, ALcohoL & Tobacco Use Smoking and drug abuse is common amongst adolescents, young adults and sometimes even medical students and health persQnnel. Alcohol abuse is also becoming common in the same sections of the society. Depending on their specific personalities and various other environmental factors, these people resort to drug abuse mainly for the following reasons: • An escape from painful reality and responsibility of adulthood • Peer pressures for identifying with their specific peer group • To avoid physically painful conditions, e.g. narcotic injections for relieving pain cause by a fracture. • To seek novelty and thrill. • Misconceptions about drugs such as ‘doing it once in a while does not make you an addict’. • To use drugs to copy or imitate an ideal or famous figure. Management The management of tobacco dependence and drug abuse is assessed on the following parameters: • Cutturat and social pressures that led to the start and are now leading to the abuse of tobacco or a drug • Patient’s motivation
- 190. Create an individuaUsedpLan for the patient that includes: • Detailed smoking history, • Assessment of degree of addiction to nicotine or the drug of abuse • A bio-psycho-sociaL perspective of the patients smoking or abuse patterns, Realistic expectations • A specific date to quit. The physical symptoms of nicotine withdrawal syndrome subside within 1 -3 weeks but the psychotogical addiction lasts much Longer. Nicotine chewing gum and tow tar cigarettes can be used as alternatives during the initial phase. The withdrawal state with stimulants, solvents and opiates may last for one to two weeks. It is important to view the use of tobacco, alcohol and drug abuse in the same bracket. All three can cause the following states: i. Addiction ii. Physical and Psychological Harm iii Ever-increasing Demand iv, Withdrawal leading to: - Tremors, chills - Cramps - Emotional problems — Cognitive and attention deficits — Hallucinations — Convulsions and even death. The tobacco, alcohol, and drug abuse need to be seen as disease states for which the sufferer requires help and support. A medical or a dental stu dent who is challenged by these disorders may initially seek counselling and support from the behavioural sciences teacher and for severer forms with psychiatric services. Patients should be encouraged to learn and practice healthy coping skills for high risk situations such as negative mood states, sudden boredom, and social situations that cause anxiety. Many medical students start the use of tobacco, alcohoL and drugs of abuse to “learn quickly”, “stay awake for longer hours”, improve memory”, and sometimes to enhance “sexual pleasure.” All of these states can be effec tively managed through physiological and healthy means. Drugs of abuse. alcohol and cigarette smoking may work in the short run but may cause serious long term damage. • Simple techniques that can be used to avoid cigarette smoking, alcohol, and drug abuse include: • distraction, • detay, • not giving in to the urge, • deep breathing.
- 191. • physical exercise •escape. • positive statements, • cognitive restructuring and recommitting to the benefits of quitting. Physicat exercise, sports, and relaxation techniques have been found to be particularly effective in dealing with nicotine withdrawaL It is important not to abandon patients of tobacco, drug and alcohol abuse, to deal with their challenges all.by themselves. They require support. guidance. and constant patronage. They can be rescued far more effectively and quickly through peer and social support accompanied with professional help. Con stant bickering, criticism, long lectures on morality and hazards of smok ing and drinking, and threats for dire consequences by parents. teachers, elders, and friends may cause more damage than good. The Healing Time Line A realistic look at how long takes foryour body to recover after your last puff S Tenyasro: Yotntiskotat smoking- related cancers wxhaskerg, mouth, and moat decreases by up to 50 percent. E .Twenly minutes alter quitblng, year blood pe0550re decreases. Eight hours: The amount of carbon non snide hr yow bleed drops bockto normal oxygen increases to normal, • Fortysight hours: Your nerve endings 03rtlnregnO mate, and you can noelt and tunIC things bettor. 0we year. The added risk of heart disease decleses to half of that of a smoker. One 10 nine months: Coughing. dew csngen bow, larigue, arid diiorttmess at breath decrease. O the years: Your steths risk nsaybe reduced to that of someone Mrs sever nnohe4 ) Fifteen years: Yaw rink at heart disease and orioking’ retalod death is nowskreiarto that of seone one who never nnoke anawncavtnessocoooe
- 192. CNS Depressants CNSStimulants Opiates Cannabinols c—a • mncNtJs - Umg fectio • Lung cancer • LOSS Of ihofttwn m.mcry concentration and abitract tNnldng •AnxI.ty. Personality disturbances Daçx.sslrs • Aniotivadon Syn dmmW set of parsonall tychangeslh which users less active and ambitious Unconcerned about th. future and unwilling or unable to ma long-tacos plans. • Amotjvadoni vyrrdrotr • Totersnc.. tolansory end other peychologica affects occtan es icon a theseosrdorthkdd, of auccaisjve LSDw. -Olthcets.dbyplbnl cal hlurywhan ISO use Impalrsjudgnsanteg about trflcoraper wn’sebllltytofly nood Barbiturates Axnphetarninas Morphine HaShish Nicotine Long-term • Alcoholic hepati Effects tis, • Peptic ulcer dis ease •cNs damage • Pana.atith •incraased bid denc. otcaicer of head nedcoe sophagus, stom ad-i. hepatic,co ionk. end tI.aIg cancer • Mak-,utrWon •Fatigu. •Insomnla • Sevrn anxiety • immunosuppr.s slon • BizarneMoient behatilour • Amphetamine psychosis • chronic contdpa tion • Impairad vision -Mood swings Instability • As tolerance develops, the user can no longerget the pleesurabie effects, but must continue taking the drug to pie vent withdrawaL •Wthrae:ç•1Nmo 4.upIa .H.adacb.
- 193. f Suicide andDetiberate Self harm (DSH) All patients of depression must be screened for suicide risk as go% of those committing suicide or deliberate self harm are suffering from a psychiatric illness. It is one of the top 10 causes of death in all age groups and one of the top 3 causes in young adults and teenagers. Certain risk factors are particutarty associated with completed suicide including: • Gender (elderly white males being at highest risk), • Psychosis, • Alcoholism, • Chronic physical illness, lack of social support and use of generally lethal methods in the past (e.g. Gun rather than overdose of medication). (For more, see box) Medical students and young doctors may be reluctant to explore suicid al ideation in the mistaken belief that asking about suicide may actually increase a patient’s risk or give them ideas of suicide.” In fact, the opposite may be true. Assessment of suicidal tendencies usually reassures patients, reduces anxiety for both patient and doctor and facilitates partnership in suicide prevention. The assessment should begin gradually by asking questions such as Sometimes when people who are going through the circumstances that you are, they may start to feel like life is not worth tiv ingr and then asking more specifically about a history of suicidal attempts. any specific current plans, hopelessness and any specific current inten tions. Deliberate self-harm is a term used to describe an act in which an individ ual deliberately causes injury or harm to themselves, without the intent to commit suicide. This may be in the form of cutting, or ingesting substances in non-lethal doses. Where doctors globally have a lower mortality rate from cancer and heart disease relative to the general population, they sadly have a significantly higher risk of dying from suicide [3]. In fact, according to a survey in 2015, doctors are the most professionals to commit suicide, followed closely by dentists. The leading cause of this is the prevalence of depression in med ical students and postgraduate trainees. Completed suicide is also more prevalent amongst medical professionals partialLy because of availability and access to lethal means. Medical students and trainees are at particular risk because they are unlikely to report a history of depression. Sadly. even when it is reported, it may be neglected. This is due to myth that people who ctaim to be having suicidal ideas are not likely to commit suicide. The truth is 67% of individuals who committed suicide had confessed to some one that they wanted to kill themselves. The famous Urdu saying o garajte ham wo baraste nahi’ is untrue when it comes to a risk assessment of sui cide. Any suicidal ideation being reported should, therefore, immediately be considered as serious and requiring intervention. A detailed suicide risk assessment must be carried out in all such cases. ‘The biggest risk of sui cide is a direct statement of intent” [41 . These statements should never be ignored, or responded to with statements of how the person is just looking for attention” or ‘doesn’t reatly mean it.”
- 194. Protective factors ofsuicide Sane. ofconnectadneas Having Chfl*.n Good health flestrictad Access to means • U&. gender • Early adufrage • Psychological/emotional problems • P,dcal health problems •Stranful I wants • Major Depression •4polerAfbctlveDbuitler • Subetanc.abus. plenrd.r • Antioclal Personality Dlsord.r • HLstoryofpsychlattlccare • Previous 5ulcldai b.hauiow •Slngh • Separated • Family conflicts • History oFchUdhood abuse •Family history ofsuicide . r g. DeLirium Delirium, also referred to as acute confusional state, refers to an acute de dine in consciousness, cognition and attention. There is an incidence of up to 55% in medicat and surgical inpatients 12]. Presenting Complaints Families rather than the patient may request help because the patient is often in a state of confusion or agitation. Delirium may commonly occur in patients who are hospitalised for medical conditions, particularly in inten sive care units and acute surgical units. Diagnostic Features Delirium is characterised by its sudden onset of hours or days. Confusion is often present and patient struggles to understand surroundings. The following neuropsychiatric symptoms are common: Individualised Family Related Social Environmental Risk Factors Risk Factors Risk Factors Risk Factors • Socioeconomic .. Easy access to methods disadvantage • cuturaisuppcttersuicisie • Migrant population M.dio UflernpbYrneflt Suicide among peers •Soc • Clouding of consciousness • Poor memory, • Agitation, • Changi ng/ftuctuating emotions, • Loss of orientation,
- 195. • Tremors • Nystagmus Asterixis •Urinary incontinence • Wandering attention, • Auditory hallucinations (hearing voices without anyone speaking), • Withdrawal from others, • Visions or illusions, • Suspiciousness • Disturbed steep/reversal of steep pattern. Symptoms often develop rapidly and may change from minute to minute and hour to hour, but are worse at night. There may be periods of clear consciousness or lucid intervals. DeLirium may occur in patients with previ ously normal mental function or in those with dementia. Mild stresses such as medications or mild infections may cause delirium in the elderly. Dilferentiat Diagnosis Attempt to identify and correct any physical causes of confusion. Common causes include; • Alcohol intoxication or withdrawal • Drug intoxication or withdrawal Cncluding prescribed drugs) Severe infections • Metabolic changes (e.g. liver disease, uremia, dehydration electrolyte imbalance, alkalosis/ acidosis) If symptoms are persistent and delusions and disordered thinking predom inates, consider Acute Psychotic Disorder. Management Guidelines Informational Care Essential information for patient and famity: Strange behaviour or speech is a symptom of a medical ilLness; as primary cause is treated, patient will return to complete normality. Counsetting • Take measures to prevent the patient from harming himself or others (e.g., remove unsafe objects, restrain the patient if needed). Supportive contact with familiar people can reduce confusion. Visits by unfamiliar individuals should be stopped. Provide frequent reminders of time and place with clocks and calenders in full view of the patient to reduce confusion. Place the patient’s bed facing a window, trying to keep tights as dim as possible at night. Introduce yourself to the patient even if you are a close friend or a relative of the patient.
- 196. Medication • Avoid useof sedative hypnotic medications such as benzodiazepines (except for the treatment of alcohot or sedative withdrawat). • To controt agitation, prescribe antipsychotic medication e.g. hatoperidol 1-2 mg by mouth or by injection up to three times per day. SpeciaList consuLtation • Patients in delirium should always be admitted, preferably in intensive care settings. Necessary investigations should be conducted promptly and assistance and advice from consultant physicians should be urgently sought, for diagnosis and management of underlying cause. • Referral to psychiatrist is only needed if residual psychiatric symptoms are seen even at the end of the treatment of the primary cause of delirium. References 1 http://depts.washington.edu/mhreport/facts_violence.php 2. Kaplan & Saddock’s, Synopsis of Psychiatry 3. Schernhammer ES, Co[ditz GA. Suicide rates among physicians: a quanti tative and gender assessment (meta-analysis). American Journal of Psychi atry. 2004 Dec ;;;61(;2):22g5-3o2. 4. Cowen Philip, Harrison Paul, Burns Tom. Chapter 16. Suicide and Deliber ate self harm. fl: The Shorter Oxford Textbook of Psychiatry 6th edn.
- 197. Chapter 7 Psychosocial Aspectsof Gender and Sexuality The World Health Organisation defined sexuality as a central aspect of being human that encompasses sex, gender identities and roles, sexual orientation, eroticism, pteasure, intimacy and reproduction. Sexuality is ex perienced and expressed in thoughts, fantasies, desires, betiefs, attitudes, vaLues, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psycho logical, sociaL economic, political, cultural, legal, historicaL religious and spiritual factors.” (WHO, 2006a). In society at large and since the beginning of time, sexuality and the fac tors associated with it have remained a source of taboo, and thus, curiosity. This is not the case in clinical settings where health professiOnals are often faced with issues related to gender, psychosexual issues, sexual dysfunc tion and sexually transmitted disease. While the medical aspects of these can be found in physiology and pathology textbooks, there is a need to clarify terms in use and the provide insight into how to manage issues of such a delicate nature. As health professionals we may feel not only ill-equipped to handle these issues, but even uncomfortable in speaking of them without educating ourselves on the matter. This chapter aims to relieve some of that discomfort by educating health professionals in the basic factors pertaining to human sexuality. Human sexuality depends on the following factors: Sexual identity • Gender identity • Sexual behaviour Sexual orientation These factors are also known as psychosexual factors as they determine the interaction between personality and sexuality in a human being. Sexuat Identity This refers to the biological sex of the individuaL This is determined by chromosomes, internal and external genitalia and hormones. Embryology studies show that alt genitalia in both XX and XY embryos is initially female. The presence of genes such as SRY and SOXg leads to the production of androgens which then cause the genitalia to differentiate into male in the 6th week of life. In the absence of these genes the genitalia devetops and differentiates as female. In normat individuals all these factors may fall into one or the other classi fication of either male or female. In individuals with ambiguous genitalia, or chromosomal abnormalities such as Klinefelter’s (XXY) and Turner’s syn drome (XO) this may not be the case. In hermaphroditism both ovaries and testes may coexist in the same individual white having a genotype of 46XX or 46XY, Virilising adrenal hyperplasia, the most common female intersex disorder can be caused by an XX foetus becoming exposed to excessive androgens.
- 198. “Z_z. Gender Identity This refersto how individuals identify themselves as belonging to a certain gender. This is most often retated to the sexual identity of the individuaL but may not always be the case. The gender identity that an individual takes on is determined by two factors: the temperament of the child, and his/hei interaction with the parents and their attitude towards the child. The gender identity of a child is often solidified by the time they are three years of age. Children are now placed in a certain category of boy or girl and treated as such. This is often seen as when children start to refer to themselves with gender specific pronouns. They give statements such as “Mai nahi khetta” or “Mai nahijaoon gi. It is important to notice here that these statements in the English language are gender neutrat, which helps to illustrate the influence the effects culture, language and sociat factors ptay in determining gender. Gender identity is determined largely by parental inftuence and that of other adutts surrounding the child. In cultures such as ours, it is considered extremely important that the child be placed in one of two gender categories as early as possible. This is be cause this may be in many cases the only determinant of what behaviour is expected and acceptable in a child. A boy child may cause a great deal of concern if seen playing with dolls, while it may be laughed off when a girt chitd prefers to ride her bike rather than play ‘ghar ghar. This is reversed when the individual reaches puberty as this is considered a time in which the gender of the individual will determine what is appropriate. Girls, in particular, are expected to dress differently, sit, walk and eat in an appro priate manner and become more aware of their bodies physically. Boys of that age may be allowed more freedom to leave the house while girls may have a lesser degree of it. While this is certainly a measure adopted for the security of the child, certain measures may undermine or cause dissatisfaction with the gender of the individual. One such example is that of teenage girls being allowed to leave the house only in the company of a mate relative, even if the male is younger than her. In the same way. while girls may often be allowed to express all their emotions, boys are expect ed to remain more indifferent, (“Larkay rotay nahi ham”) and often the only emotion that may be considered acceptabte is aggression. Research reveals that children, whether boys or girls. are largely similar in their behaviour. Some notable differences are that boys are more likely to exhibit aggression (both physical and verbal) than girls. Girls are also less likely than boys to throw tantrums after a8 months of age. Parents often bring their sons to health professionats due to concern that the boy “does not behave like a boy.” They may be worried that the boy spends mote time in the kitchen, or prefers to play with dolls rather than cars. In situations where there is one male amongst many female sibtings this becomes more common, especially in the absence of a strong father figure. The male child has only female modets to emulate and at times this confusion is worsened by the sisters dressing him as a girl and a lack of activities considered “boyish.” These children may be ridicuted for being effeminate by other children with mote definite gender identities. Often this may be a phase in a child’s tife and with age and more male exposure to emulate may disappear. Parents should be discouraged from forcing the child into only doing what they consider “gender appropriate” as this may cause significant distress and according to research yields no benefits (Zucker 2006).
- 199. Sexuat Behaviour Certain areasof the brain have been identified as ptaying pivotal totes in human sexuality. The limbic system, as previousty mentioned, is involved in generating emotion and sexual desire. This has been determined in studies in which electrical or chemical stimulation of hippocampus, the preoptic area, anterior thalamic nuclei resulted in penile erections. During orgasm, female brain areas involved in anxiety and feat showed significantly [ow activity. The regulation and processing of sexual desire and stimuli is conducted by the cerebral cortex. The prefrontal cortex is involved in the inhibition of sexual impulses. white the orbitoftontat cortex processes emotional input from the amygdala. Right caudate nucleus activity factors into the determination of whether arousal will lead to sexual activity. The left anterior cingutate cortex ptays a role in the sexual arousaL as well as hormonal controt. Afferent input from the pelvic, pudendal and hypogastric nerves conveys sensory stimuli to the spinal cord, where arousal and orgasm are. Sexual reftexes are mediated in the lumbosacral segments. Neurotransmitters that play a role in sexual function include serotonin, dopamine, oxytocin, norepinephrine and epinephrine. Oxytocin is released following sexual activity and leads to bonding between sexual partners, as wetl as feelings of contentment, calmness and security. Stimuli that increase dopamine increase sexual desire. Inhibition of sexual function is mediated by serotonin released by the pons and the midbrain. Certain hormones have long since been known to mediate sexual be haviour. Chief amongst these are testosterone and oestrogen. In both mates and females, testosterone is known to increase sexual desire. Oestrogen, in females teads to increased sensitivity to sexual stimulation and teads to lubrication caused by arousaL Progesterone. cortisol and excessive prolactin lead to decreased sexual desire. Gender differences in SexuaL Behaviour Contrary to myths regarding the matter, men and women both experience sexual desire (Hyde 2005). Men, however, tend to experience a greater frequency of sexual thoughts, and readiness to engage in sexual activity. It must be stated here thatdue to human socialisation, sexual desire may not be the only reason to engage in sexual activity. This is especially true for women. Women are more tikely to engage in sexual contact (even in the absence of desire to do so) for reasons such as pleasing and maintaining the interest of their partner, as welt as establishing a closer relationship. It is also important to note that in women physiological arousal may not always coincide with a subjective sense of arousal or a desire to indulge in sexual activity, That is to say, physiological sexuat arousal in women cn occur independently of psychological arousal. Men and women differ in the determination of their sex drive (Baumeis ter, 2000). In men sex drive appears to be biologically determined, white in women, factors such as cultural background, education, religion and parenting all may play a part. Furthermore in culfures such as ours, wom en may indulge to hold on to” their male counterparts, as they have their sense of security (financial and otherwise) invested in the mate partner.
- 200. Masturbation No other formofsexual activity has been more frequently discussed, more roundly condemned, and more universally practiced than masturbation. - Kaplan and Saddock, Synopsis of Psychiatry Masturbation refers to the physical stimulation of genitalia by oneself for sexuat pteasure. This is a normal part of psychosexual devetopment. It is an activity shrouded in shame and mystery despite the fact that nearly all post-pubescent males and up to three fourths of females indutge in it (Kinsey). Children become aware of their genitaliajust as they become aware of their other body parts. Upon reaching puberty. however, due to the in crease in sex hormones and development of secondary sexual characteris tics, masturbation may become a regular activity. Myths and misconceptions such as “masturbation may result in loss of sexual prowess and potency” and “masturbation can cause mental illness” or “masturbation may result in a loss of manhood and mate virility” abound, especially in our culture. There is no scientific evidence to support these claims. Masturbation is a symptom of an emotional disturbance (not a sexual one) only if it results in the individual losing control and compulsively indulging in it ho]. SexuaL orientation According to the American Psychological Association, sexual orientation refers to the sex of those to whom one is sexuatly and romanticatl.y attract- ed. For the majority of the population (according to census data worldwide) sexuat orientation is heterosexual i.e. individuals are attracted to the oppo site sex. Statistics suggest that about 1-5% of the population of the world has different sexual orientations. This number may be understated, how ever, given government and religious taws banning homosexuality in most parts of the world. This may be homosexual, i.e attraction to the same sex, bisexual, i.e attraction to both genders and asexual, i.e no sexual attrac tion. Another subset of individuals exists, who feel that sexuality cannot be labelled. These individuals refer to themselves as “queer” or pansexual or polysexual. Some research indicates that for some individuals, sexual orientation may be fluid. This may be especiatly true for women (e.g.. Dia mond, 2007; Golden, 1987; Peptau & Garnets, 2000), As of July 2015, 72 countries and five sub-nationaljurisdictions have laws criminaUzing homosexuality. A majority of these countries, inctuding Paki stan are in Asia and Africa. According to Darwin, natural selection dictates that any variations that occur have to be ‘useful to man’ i.e. they must aid in an organism’s struggle for survival and procreation. Homosexuality defies laws of natural selection by preventing procreation due to same-sex sexual behaviour. Despite this, it remains a stable population level trait in humans and animals, resulting in a so-catted Darwinian “paradox.” Evolutionary models propose that genes influencing homosexuality have a reproductive benefit on heterosexual carriers of the gene 121. This may be the reason that homosexuality continues to persist.
- 201. In 2006, astudy found that human sexual preference has a significant ge netic component. [41. It was also seen that biological and congenital factors regulate human sexuatity 13]. These findings were corroborated in a study 2015, in which a Large scate genome-wide scan resulted in findings that support the existence of genes on chromosome 8 and Xq28 influencing the development of mate sexual orientation. ti] . Another study found linkage between male sexual orientation and markers on the X chromosome of the mother in some famities. The study found that the X chromosome played a role in regutating sexuat orientation in a subgroup of homosexual males [41. Some studies indicate females with hyperadrenocorticalism are more likely to be homosexual as welt as bisexual than the general population. Research in this field has been, for the most part, inconclusive. This may he due to the tack of definitive samples, the abstract concept of attraction or the taboo associated with nonheterosexuality. Continued research efforts are required to enhance understanding of the genetics factors affecting human sexuality. Psychiatric morbidity Research shows that non-heterosexual individuals are more likely to suffer from poor general health [71. They are also twice as Likely to suffer from depression, panic disorder, generatised anxiety disorder and have a higher risk of suicide [51181. This is especially true for younger adults [6]. They also have significantly higher rates of alcohol dependency and drug abuse Ig]. One factor in this is of course, the societal pressures and religious taboo associated with non-heterosexuality. Due to this taboo, such individuals may often present to a health professional with medically unexplained symptoms, and/or severe depression and anxiety. Sexuat Disorders According to the International Classification of Disease, Tenth Edition, sex ual disorders encompass three categories: sexual dysfunction (not caused by organic disorders), disorders of sexual preference (paraphilias) and gender identity disorders (gender dysphoria). These are of importance due to the higher number of psychiatric morbid ities associated with them. These individuals are more likely to suffer from anxiety, depression and somatoform disorders. They also have higher risks of suicide and deliberate self-harm. Often the clinical presentation may he that of persistent headache, backache, abdominal discomfort. and gener alised aches and pains. Low mood and other depressive features, especially guilt and severe anxiety may he present. SexuaL Dysfunction Sexual dysfunction occurs when there is inability, difficulty or pain involving sexual intercourse. This includes disorders such as those described in the table above, The presence of any sexual dysfunction is a difficult situation for not just the individual but also the sexual partner. In cases where the dys function is severe enough to not allow for consummation of the marriage or lead to reproductive problems. the entire family may become involved. This can be a source for great discomfort for the individual. This is especially true for males as they are expected to be ‘more informed’ in the sexual act and all its nuances), even if they have no prior experience. Also in males, sexual prowess or lack thereof, is closely connected to their self-esteem.
- 202. This makes itmuch harder to confront a problem and seek help for it.. n females, this is tess often the case. Due to the taboo and emphasis attached to virginity, however, they may be poorLy acquainted with their own anatomy. as well as poorly educated about the sexual act and its stages. variations, and nuances. Most health professionals may feel embarrassed, uncomfort able or nervous, while talking to and managing such patients. especially f they are the opposite gender. It is important here to remind oneself of the neutrality of one’s gender in a clinical situation. One is neither a ternate nor a mate in the white coat, simply a heater. This situaton is, thus, best approached as one would approach an invasive physical examination: begin by informing the patient that you would like to discuss their sexual problem in further detail. Acknowtedge that they might feel uncomfortable but that as a doctor you are only asking to understand the problem better and provide evidence based solutions. Encourage the individual to be as frank as possible. Provide frequent reassurances, Remember to reiterate that laws of confidentiality apply and, therefore, you cannot share any of the information they give you with anyone thout their consent. Often mild to moderate problems of sexual dysfunction may be solved with an open, frank and honest informational care session in which expec tations are managed and fears and anxieties acknowtedged and discussed. In the absence of organic causes, severe cases of sexual dysfunctions are best managed by a psychiatrist, and a referral must be made Disorders of SexuaL Preference/ Paraphitias As previously discussed, a major determinant of sexuality and what is ac ceptable is society and culture. Paraphitias refers to sexual acts or interests that are considered abnormal by society, According to Diagnostic and Sta tistical Manual of Mental Disorders. 5th ed.2o;5, these disorders collectively involve “any intense and persistent sexual interest other than sexual interest in phenotypicatly normal, physically mature, consenting human partners.” Individuals suffering from these disorders are onty able to achieve Sexual Dncti Sexual desire disorders Sexual arousal dIsorders Or5asm disorders Premature Ejaculation Sexual pain disorders Sahibrdonism Fetishism Paedophilia Sadomasochism FetishiStic transvestitIsm L L
- 203. sexual pleasure fromperforming abnormal sexual acts. This does not inctude people who may hve abnormal sexual thoughts; only those that behave and iridulge in abnormal sexuat acts. Some of these disorders are considered punishable by law, according to the Pakistan Penal Code. As such, if a health professional is confronted with a situation in which the patient is a perpetrator of such an act, confidentiality must be breached and the individual reported, especially if a human victim is invoLved. There are two main types of disorders of sexual preference: i) Disorders reLating to the object of sexuat interest. 2) Disorders relating topreferences in the sexual act. Disorders relating to the objectbf sexual interest include paedophilia, objectophilia and fetishism. These involve sexual interest being directed towards children, inanimate objects, animals or non-consenting humans. Disorders relating to the abnorml preferences in the sexual act include sadomasochism, exhibitionism and voyeurism. Such individuals are able to achieve sexual pleasure only from either causing or receiving painful stim uli, exposing themselves inappropriately or observing the sexual activities of others. I. These disorders are best managed by a mental hea[th professional, and an urgent referral must be made. 4 I Gender Dysphoria (DSM V) or Gender Identity Disorder (lCD io) According to Robert Stotter gender is socia[ and sex biologicaL: “Most often the two are relatively congruent, that is, males tend to be manly and females womanly.” In some individuals, however, this may not be the case. An individual who is biologically male, may feel like “a woman trapped in a man’s body and vice versa. Transgender individuals experience what is referred to as “gender dysphoria” in the Diagnostic and Statistics Manual, Fifth Edition. Individuals who are transgender may biotogically be one sex but identify as the other, i.e there is a discord between the gender they have been assigned and the gender they experience or feel themselves to be. The International Classification of Disease, ioth revision refers to this as Gender Identity Disorder. The term transgender encompasses those who - are: a) Transsexual: individual who prefer to have the body of the sex opposite to their own. b) Gender-queer: Individuals who prefer to belong to neither gender c) Cross-dressers (Dual Transvestitism): Individuals who identify with their biotogicat sex, yet prefer to dress in clothes of the other gender. They do not wish to change genders.
- 204. Management of Genderand Sexuatity Issues Some say that sexuot orientation and gender identity are sensitive issues. I understand. Like many ofmy generation, I did not grow up totking about these issues. But! teamed to speat’ out because tives are at sta1’e, and be cause it is our duty under the United Nations Charter and the Universat Declaration of Human Rights to protect the rights of everyone, everywhere.’ — UN Secretary-Generat Ban Ki-moon to the Human Rights Council, 7 March 2012 In the management of atl clinical problems, a health professional is ex pected to react with empathy. Often in issues related to gender, however, socialisation, religious beliefs and stigma may make t extremely difficult to do so. The doctor may find themselves at a loss as to how to put them selves in the shoes of an individualwho is dealing with gender dysphoria or issues with their sexuality. In such a situation, the most important emotion that a health professional can express is compassion. A health profession al’s presence may be the only place where an individual with these issues can expect to not to be judged. In most clinical situations related to gender and sexuality issues, non-judgemental compassion and giving the patient room to express their fears and problems may be the only intervention re quired. It is also important at this juncture to remind oneself of the role as a health professional, rather than a member of a particular society or culture. The individual who has presented to a health professional is not looking for a personal opinion, a religious judgement or an argument. The health professional is equipped only to treat any health related issues and should limit their interaction to this alone. It must be added here that according to the ioth revision of the International Statistical Ctassification of Diseases and Related Health Problems ((CD-b): “Sexual orientation alone is not to be regarded as a disorder. Individuals who are nonheterosexuat (homosex uals and bisexuals) are, however, as mentioned earlier, at a higher risk for developing psychiatric morbidities. If signs of a major depressive or anxiety disorder, or risk of suicide are present, the individual must be referred to a psychiatrist urgently. In all patients with such issue, on account of the high risk of suicide, it must be directly enquired if the individual is having suicid al thoughts or has made any attempts in the past (See Section D). Again, this merits an urgent referral to a psychiatrist. I. I
- 205. References 1. Sanders AR,Martin ER, Beecham GW, Guo 5, Dawood K, Rieger G, Bad nerJA, Gershon ES, Krishnappa RS, Kolundza AS, Duan]. Genome-wide scan demonstrates significant linkage for male sexual orientation. Psychotogicat medicine. 2015 May 1:45(07):1379-88. 2. Burn A, SpectorT, Rahman Q. Common genetic factors among sexual orientation, gender nonconformity, and number of sex partners in female twins: ImpLications for the evolution of homosexuality. The journal of sexual medicine. 2015 Apr 1;12(4):1004-11. 3. Jannini EA, Burn A, Jern P. and Nove[ti G. Genetics of human sexual be havior: Where we are, where we are going. Sex Med Rev 2015;3:65-77. 4, Bocktandt S, Horvath 5, Vilain E, Hamer DH. Extreme skewing of X chro mosome inactivation in mothers of homosexual men. Human Genetics. 2006 Feb 1:118(6):691-4. 5. Prajapati AC, Parikh S, Bala DV. A study of mental heatth status of men who have sex with men in Ahmedabad city. Indian journal of psychiatry. 2014 Apr:56(2161. 6. Bränström R, Pachankis JE. Hatzenbuehler ML. Sexual orientation differ- ences in mentaL health morbidity: A population-based longitudinal study. The European Journal of Public Health. 2015 Oct 1:25(suppl 3):ckVl74-062, 7. Fredriksen-Gotdsen KI, Emlet CA, Kim HJ, Muraco A, Erosheva EA, Gold- sen J, Hoy-Ellis CP. The physical and mental health of lesbian, gay male, and bisexuat (LGB) o[der adults: The rote of key health indicators and risk and protective factors. The Gerontologist. 2013 Aug 1:53(4):664-75. 8. Cochran SD, Sullivan JG, Mays VM. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. Journal of consulting and clinical psychology. 2003 Feb;71t1):53. 9. Cochran SD, Mays VM. Relation between psychiatric syndromes and behavioraLly defined sexual orientation in a sample of the US, population. American Journat of Epidemiology. 2000b;151:516-523. [PMC tree artictel tPubMedl io. Kaplan and Saddock Synopsis of Psychiatry, Eleventh Edition, page 570. V
- 206. Chapter 8 Psychosocial Aspectsof Pain Was it onLy a tooth ache? Mrs H was a Pathan tady married into a Punjabi family. In the third year other marrJagMrsJ±devetapedpain in her upperjaw She initially used house hotd remedies for a few days without any retief She then saw a dentist who advised a tooth extraction ofthe third tett upper molar which was decaying. She experienced temporary reliefbut the pain persisted and started to radiate towards the teft ear and eye. The dentist gave her short courses ofparac etamot, aspirin, and mefenamic acid, but nothing worked. She then referred her to the eye and ENTspeciatists. No abnormalities were tound and she came home with escriptiOtis ofmore pain killers. Many months passed. yet Mrs H was not relieved ofherpain. She then saw a physician who discussed herpain in greater detaiL Mrs H described herpain as “dull, and disgusting.” The physician then asked about the symptoms that were associated with her chronic pain in thejaw. Mrs H readily expressed that she has had disturbed steep, a change in appetite, and has become irritabte and angry The sensi tive physician asked her about her domestic circumstances and personal life. He found out that Mrs H had a difficult mother-in-tow and a husband who did not find Mrs H attractive anymore. Mrs H broke into tears during the interview and totd the doctor that she was Ted up” with life and often wished for death. A detailed assessment revealed a diagnosis ofdepressive disorder Mrs H was counselled and placed on Amitnptytine, a type ofantidepressant, for six months. The doctQr involved Mr H and the family in the care plan to mobilise emotional and sociat support for Mrs H. Within six weeks, Mrs H’s pain was gone and she was symptom free at the end of the six month period. She then managed to form a fairly loving relationship with hr husband and a retation ship based on mutual respect and healthy communication with her mother in-law. It is fairly well established now that pain is not a straight forward specific sensation that is transmitted from the periphery to the brain by a simple transmission system. Instead it is a ‘complex perceptual and affective (emotional) experience determined by the unique past history of the individuaL by the meaning of the injurious agent or situation that s/he ascribes, by the state of mind at the moment, and the sensory nerve pat terns that evoked physical stimulation” (Gregory. 1987). Such an approach wouLd suggest that ‘pain’ has two aspects, a sensory and an affective (emotional) one. It is primarily the affective aspect which imparts the un pleasant quality to pain and is, therefore, of greater ctinicat significance. In the case of Mrs H, mentioned above, for example, the pain did not respond to analgesics alone and a combination of antidepressant medication and psychosocial support relieved the chronic jaw pain. The cognitive dimen sion greatly influences the patient’s reaction to pain as welt as attempts at analgesia, both in the short and in the long term. The psychology of pain. therefore. revolves around its affective, motivational and cognitive aspects.
- 207. Factors that influencethe content, and the quality of psychological correLates of pain are: • intensity of pain, • meaning of the pain to the individuat, (which in itself is influenced by the location and quality of pain), • personality traits of the individual, • psychosocial factors at home and at work, • past psychiatric morbidity • cultural settings of the patient. Psychosocial aspects of pain are different in different kinds and types of pain: i. Acute pain The subjective experience of acute pain is distinctly unpleasant. The emo tional content of such pain can be judged by the descriptions used by the sufferer. “Wretched”, “excruciating’. “boring”, ‘sickening” (‘dull and disgust ing” in the case of Mrs H) are few of the words used in the expression of pain. White the sensory words communicate a somatic sensation that can be at least vaguely tocalised to part of the body, the emotional words (e.g., pounding, throbbing, terrifying, killing) do not point to a specific region. These describe an emotion instead. Anxiety is another correlate of this kind of pain, characterised by a feeling of impending disaster and dread. • Patients with repeated episodes of acute pain often have traits of anxiety in their premorbid personatity. They may require more analgesic medication after surgery than other patients. Relief of anxiety by employing reassur ance, instilling a sense of control and the use of anxiotytics contribute to analgesia in an acute episode of pain. ii. Chronic pain Various psychoLogical abnormalities have been described in patients with chronic pain. The exact ‘cause and effect’ relationship between chronic pain and associated psychological morbidity remains to be established. Studies have shown presence of clinical depression in over 75% of patients with chronic lower backache. A change in the form of constant preoccu pation with the pain, seeking repeated medical check-ups and radiolog ical and laboratory .investigations, often just for reassurance is commonly seen amongst such patients. The chronic pain attains a central position in the sufferer’s life. S/he loses interest in extracurricular, social, intellectual and spiritual pursuits. Patients of chronic pain often seem to lose interest in family and friends, while their dependence on them for physicat and emotional support increases. Loss ofjob, financial worries and substantial hospital bills worsen the already grim picture. Poor self-esteem, a state of boredom and unhappiness, follow as a prelude to severe depression which can at times result in deliberate self-harm or even suicide, Disturbances of sleep, changes in appetite and undue irritability are often seen in patients of chronic pain (as in Mrs H).
- 208. • Insomnia • Anorexia •Constipation • A feeling of indigestion - Gases • Lethargy • Exhaustion • Fatigue Presence ot such a symptort complex is associated with poor pain toler ance drid these patierts run a higher risk of developing chronic pain. The commonest sites for chronic pain are the precordium. genitals, face and the cranium, Females are twice as more prone. Pain is virtualLy contin uous white the patient is awake, yet never wakes him/her from steep. The site of pain cisualty has a symbolic significance for the patient. It responds k to analgesics Backache, a common site for chronic pain. may be aggia’ated by underlying negative emotions such as unexpressed anger. h ust ation. jealousy or chronic psychiatric disorders such as depression .nd anxiety. The characteristic of such pain is that it is usually manifested in the extensor groups of muscles. Fibromyalgia is another common entity which reveals itself in the form of chronic widespread pain, fatigue and ?‘( essive pain in response to tactile pessure and is precipitated by stress md other psychotogicat factors. iv. Psychogenic pain disorder ihere is a proportion of patienls whose pain and associated symptoms do not fit any of the known psychiatric morbidities. The term used for such patiei its is ‘Psychogenic Pain Disorder’ and it has its own diagnostic criteria. The pain in these cases does not originate in response to a noxious stim ulus or a pain transmission anomaly. nor is it secondary to a demonstrable underl.,’ing psychiatric / structLiral illness. It has a mechanism similar to hallucnation, dreams or has ioots in the psychotogicat development of the individual. Psychodynamic mudets in the Freudian tradition and learn iiig theories have been proposed to explain this disorder but both remain speculative. It is also suggested that psychogenic pain could be mereLy a hieiqhtuned response to somatin pain seen in certain predisposed individ cials and. therefore. may not need to he considered a separate entity. It is rolunqecl and severe and inconsistent with anatomical distribution PsychotogicaL symptoms in chronic pain Chronic pain is often associated with psychiatric morbidity. Chronic pain has been proposed as a symptom of various psychiatric conditions, es pecially in cultures with a poor recognition and awareness of psychotog ica[ symptoms. People without a known cause of chronic pain have been shown to have a higher prevalence rate of depression, as compared to those with painful disorders such as rheumatoid arthritis. Dyssomnias tabnorrnatities of pattern of sleep). loss of libido and sociaLwithdrawalwere more common and more seJere in this group. These patients also have a higher percentage of positive family history for mental illness and often have a physically abusive spouse. Emotional conflicts are also common features. The foLlowing somatic expressions of depressive features are often seen in patients with chronic pain.
- 209. of the nervoussystem. The onset of psychogenic pain disorder is related to environmentaL stress. v. Pain behaviour (sick rote) If the patient has adopted the sick rote and pain has become a behaviour rather than a symptom. the following features start to determine the inten sity. type and location of pain: • Functional disabilities, • Overuse of medications. • Sleep disturbances • Decreased social activities The typical behaviour pattern in such cases is a new unhealthy lifestyle characterised by avoidance based on the feat of pain and reinforcement of passive learning. This involves the individual being in too much pain to work/study/indulge in physical activity but fine while watching TV, reading or indulging in other passive pastimes. Psychological management of pain The aim of psychological management of pain is to make a thorough and methodical evaluation based on the approaches discussed above. A treatment strategy tailored towards the specific needs of the patient can be developed by: • Allowing the patient to express feelings of distress. • Providing an opportunity to describe the experience and • Taking the patients views about the cause • Discussing the perpetuating and the precipitating factors All this has long term positive effects on the treatment of pain and its outcome. Steps of Management These inctude: • Psychological assessment • Psychotropic drug treatment • Psychological Interventions Psychological Assessment • Establish the primary cause of the pain i.e. is the pain organic. a symptom of a psychiatric morbidity or primarily psychogenic in origin. • Define the exact role of psychological factors (psychodynamic or cognitive) in the clinical scenario: are they etiologicaL precipitating or perpetuating in their influence? • Make an assessment of the various environmental factors i.e. interpersonal, social, occupationat. economic and cutturat as determinants of pain somatization.
- 210. Psychotropic Drug Treatment Otherthan the long Ust of narcotic / non - narcotic and non-steroidal anti-inflammatory (NSAID) analgesics, certain psychotropic drugs have also been found useful in the treatment of pain. This includes some antidepressants, e.g tricyclic antidepressants (Imipramine) relieve pain by blocking biogenic amine uptake, thus enhancing the inhibitory action of serotonin and nor-adienatine on the spinal pair transmission pathways. Phenothiazines and drugs [ike Carbamezapine. Valproic acid and Gabapentin are aLso hetpfuL. Benzodiazepines are primarity used for relief of associated anxiety. The following psychologicat interventions can be empLoyed to deaL with chronic pain: • Relaxation methods • Operant Techniques • Cognitive Strategies. • Social skills training • Assertiveness training • Coping Strategies Approach Relaxation Methods Using muscular biofeedback (EMG Biofeedback), progressive relaxation, cognitive relaxation and cue controlled relaxation the muscular tension is brought under control thereby breaking the pain cycle. Operant Techniques These are based on learning theory and aim to identify the problems and modify an individual’s responses to the problem. Techniques include activities training, medication reduction and activities focused on functional disability. The techniques resuLt in decreased disability levels and fear, and improved physical fitness and body image. The steps include: • Measuring the baseline level. • Selecting target activities, • Starting with simple activities and moving on to complex ones • Gradually increasing the activity level, • Reinforcing the activities by providing feedback and verbal praise. • Checking progress and modifying the target as necessary. • Selecting a new activity once the first activity has been accomplished. Operant techniques are also used in medication- reduction training in chronic opioid use. The drugs are dispensed using a “time contingent’ rather than a “pain contingert’ treatment technique. This improves pain retief, decreases pain behaviour and has a decreased addictive potentiat. In this technique the medication is provided at regular time intervals rather than pain intensity. The dose is then systematically reduced. *
- 211. *Von KorffM, MerrittJO,RutterCM, Sullivan M, Campbell CI, Weisner C. Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy. Pain. 2011 Jun 30;152f6):1256-62. Cognitive Strategies Cognitive strategies aimed at pain management focus on Dealing with stress • Modifying pain related cognitions This involves the stress oriented techniques like relaxation therapies and cognitive techniques such as a) Imaginative Inattention: thinking about something incompatible with the pain experience e.g. relaxing in a beautiful quiet place alongside transformations of context, that is, imagining that pain is actually occurring but under more appropriate circumstance b) Attention diversion methods: attention is diverted toward another engaging task e.g. counting or reading. iv. Sociat Skilts and Assertiveness Training Social skills training focuses on increasing social activities at work and at home. Assertiveness training is similar but focuses more on communica tion skills. It enhances quality of life and reduces pain-related stress. v. Coping Strategies Approach This focuses on the patients’ interpretation of the pain problem and various coping methods. Patients with chronic pain syndromes usually use passive methods of deating with pain such as hoping pain will go away). Coping skills training identifies methods of dealing with pain, belief about pain and resulting disability. Relaxation and activity programmes can later be added to the plan. Active coping: • Engaging in physical exercise or physical therapy • Clearing your mind of bothersome thoughts or worries Passive coping: • Restricting or cancelling your social activities Taking medication for the purposes of immediate pain relief
- 212. Chapter 9 Psychosocial Aspectsof Aging Every man desires to tive tong, but no man wants to be old. Jonathan Swift Medical advancements, improvements in heaLthcare and Living conditions mean people can now expect to live Longer lives than ever before. Today, the proportion of elderLy people in the world population is on the increase mainly because people are living longer today than in the past. The rise in the proportion of older people has been accompanied by an increase in research on the intelligence and personality of the elderly and the psycho social aspects of old age. Gerontology (the study of aging) and geriatrics. (the care of aging people). have emerged as important new medicaL fields Late adulthood or old age usually refers to the portion of human life cycle that begins at age 65. Wherever the elderly may live, they are recognised by characteristic physical changes. Aging is generally characterised by the declining ability to respond to stress, increasing imbalance and increased risk of morbidity and mortality, Aging refers to aging of cells The aging process or senes cence is characterised by a gradual decline in the functioning of all the body systems. The biological changes of aging occur at a cellular level and effects the immune, musculoskeletal, reproductive, cardiovascular, gastrointestinal, respiratory. endocrine and the central nervous systems. A popular theory holds that each cell has a genetically determined life span during which it can replicate a limited number of times before it dies Structural changes in cells occur with age In the centraL nervous system for instance, neurons show signs of degeneration ri certain age related disorders such as dementia of Alzheimer’s type, signs of degeneration are much more severe and characterised by severe memory toss and toss of intellectual functioning. Neurobiotogicat changes of aging • The weight and volume of the brain decreases by 5% between ages of 30 and 70, by 10% by the age of So, and by 20% by the age of go The ventricles and the sub-arachnoid spaces also increase in size proportionately. • Cerebral blood flow in frontal and temporal lobes decreases with age. Nerve cell loss occurs in the cortex, hippocampus, substantia nigra and cerebellum. The links between neurofilaments and microtubutes called Tau proteins can accumulate to form neurofibriltary tangles in some nerve cells. • Senile plaques are found in the normal aging brain in the neocortex. amygdala and hippocampus.
- 213. Psychologicat changes ofaging IQ peaks at 25 years of age, plateaus until 60-70, and then declines. Performance 10 drops faster then verbal 10. This may be due to reduced processing speed or to the fact that verbal 10 depends largely on familiar information while performance IQ involves novel information. • Problem solving deteriorates due to declining abstract thinking abiLity and increasing difficulty in applying information from one situation to another. • Short term memory fSTM) does not alter with age. Working memory, however, shows a gradual decrease in capacity and this is worse with increasing complexity of task and increased memory load. • Long term memory tLTM) declines, except for remote events of personal and emotional significance which may be recalled with great clarity. • There is a typical pattern of psychomotor slowing and impairment in the manipulation of new information. • Well-rehearsed skills such as verbal comprehension show little or no decline. • Given the physical and cognitive declines seen in aging, a surprising finding is that emotional experience improves with age. Older aduLts are better at regulating their emotions and experience negative emotions less frequently than younger adults. To keep cognitive functions and attitudes flexible, the brain must be exer cised. The elderly brain is as capable as the young brain of growing new connections between cells with use. Researchers have reported evidence of increased dendritic branching in healthy, aged human brains, which suggests the brain remains plastic even in old age. Many scientists have discovered that cognitive functions of the brain in the elderly can be main tained and even improved with training and environmental enrichment. Social problems of old age With the breakdown of traditions and family bonds in many modern soci eties; increasing numbers of the elderly population. especially in the West, live alone or in homes for the aged. Social problems include loss of their social status, independence, and/or the toss of a spouse/partner. Most of the elderly popuLation. especially in our society. have limited incomes, and are unemployed as well as dependent. Medical problems compound deficiency and care needs. Unlike the West where the eLderly face variable degrees of isoLation, marginaLisation and stigmatisation, most elderly indi viduals in Pakistan are well taken care of by their off-springs. This is primar ily due to traditional values and the joint family system that exists in many parts of the country. The future may see the culture of ‘old people homes’ in our part of the world as well. The belief that old age is associated with mental and physicaL illness is a myth. This stereotype image is a source of stigmatisation and discrimina tion. Most elderly individuals enjoy gooqi health through most part of their twilight years.
- 214. There are severalpsychologicaL and socia[ factors that have been linked to increased individual Lite expectancy and quality of tife in older adults. The majority of attention in the life extension and successful aging fieLd has fo cused on physical. factors such as exercise, diet, sleep and genetics. There is a growing body of evidence that suggests that psychological and socio logical factors also have a significant influence on how well individuals age. Jt is believed that adjusting to changes that accompany late adulthood and old age require an individual to be flexible and develop new coping skills. Aging research has demonstrated a positive correlation between religious beliefs, social relationships, perceived health, socioeconomic status, cop ing skills and their ability to age more successfully. The term successful aging has been defined by three main components: low probability of dis ease and disease related disability, high cognitive and physical functional capacity, and active engagement with life. Development during old age According to Erikson, old age brings with it a core developmental conflict: integrity versus despair (see Section C). Integrity can be achieved by inte grating attitudes, betiefs and experiences so that they fit together comfort ably and form a coherent whole. This results in a feeling of satisfaction with a life well-lived. Such integrity is most likely to occur among those who have cared for people and have adapted themsetves to different triumphs and disappointments. Without this integrity the elderly individual is filled with a growing sense of despair and a fear that time is running out on life. This despair manifests in the form of persistent irritability, disgust or a nag ging fear of death. Those who do achieve a sense of integrity and whole ness may develop one of the hallmarks of successful aging: wisdom. This wisdom forms the basis of seeking advice about complex life problems from the elderly in cultures such as ours.
- 215. Chapter 10 Psychosocial Aspectsof Death and Dying Death is, perhaps, the ultimate test with that we, as patients, relatives and members of the caring professions must face, No matter how experienced we become, coping with death is seldom easy. Death is a loss but it can aLso be a time of peacefut transition. t may represent failure or success, ending or beginning, disaster or triumph. When patients are dose to death, heatth professionals may have little or no control over what is happening. Medication can help us to mitigate some of the pains of dying but, with alt our knowledge. all of our patients will still die at some point. Despite this, patients and their families continue to turn to us for hetp. Death is a social event, it affects the lives of many people. n this circle of people. the patient is the centre of care as ton9 as they are alive: but white his/her troubles will soon be over, thqse of the famity mayjust be beginning. The traditional training of doctors and nurses does little to prepare us for the challenges of terminal and bereavement care. We are so preoccupied with saving life that we are at a loss to know what to do when life cannot be saved. Some of us deal with the problem by denying its existence; we insist on fighting for a cure until the bitter end. Sadly. the weapons that we em ploy too often impair the quality of the life that is left such that the end, when it comes, is truly bitter. Others acknowledge to themselves that the patient is dying but attempt to conceal it from the patient. If they succeed, the patient may die in blissful’ ignorance. but they often fail. As the disease progresses. the patient looks in the mirror and realises that somebody is lying. At a time when they most need to trust their medical attendants, they realise that they have been deceived. In either case, the family who survive are denied the opportunity to say ‘goodbye’. and to conclude any unfinished psychological business with the patient. Of course, it is not only the professional staff who find it hard to cope with people who are dying; friends. workmates and family members are equally at a loss. They may deal with their own feelings of inadequacy by putting pressure on us to continue treatment long after it can do good or to collude with them in concealing the true situation from the patient. ‘You won’t tell him/her that they’re dying. will you doctor? It would kilt him/her if they found out’. While such remarks on the part of the family are said in the spirirt of caring for the patient. they more likely reflect the informant’s own inability to cope with the truth rather than that of the patient. Psychological reactions in a dying patient Corn Zombi 4— Despite the fact that one hundred percent of people die, being given a terminal prognosis is intensety fear-provoking. Consequently talking about death is a taboo in many cultures. Reactions to the news can be seen as an extreme form of psychological stress, which results in common coping defence mechanisms. These include “denial” in which the fact is deliber ately blocked from conscious awareness. “Depression and anger” towards family, friends and health care workers are also common reactions and demand patience, tolerance and understanding from care givers. Many people eventually reach a stage of acceptance in which th.e wishes of the dying person,and plans for those who will continue afterwards can be dis cussed. All efforts should be made to make such people free of pain and be given the liberty to make their choices and exercise their will.
- 216. Chapter 11 Psychotrauma Psychotogical traumaor psychotrauma is the result of extraordinarily stressful events that shatter a person’s sense of security, making him/her feel helpless and vulnerable in a dangerous world. Psychological trauma is a wound to the psyche due to an experience which has endangered one’s life and threatened one’s identity, integrity, honour and property. The experience is understood as a threat to one’s physical and psychological well-being and is a sharp confrontation with death or a challenge to life. A traumatic experience can leave scars on the mind and body. Traumatic experiences often invotve a threat to life or safety, but any situ ation that leaves a person feeling frightened and alone can be traumatic, even if it does not involve physical harm. Experiences such as verbal abuse. betrayal or any major loss can be just as traumatizing as a life-threatening event especially when they happen during childhood. Trauma can result when an experience is so overwhelming that a person goes numb or disconnects from what’s happening, whether the threat is psychologicat or physical, While this automatic response may be protective for a short while. it also prevents a person from moving on. Not all potentially traumatic events lead to Lasting psychotrauma. Some people rebound quickly from even the most tragic and shocking experi ences. Others are devastated by experiences that on the surface appear to be less upsetting. ft is not the magnitude of the catastrophe that deter mines whether an event is traumatic. but a person’s subjective emotional experience of the event. The more endangered, helpless and unprepared a person is, the more likely that they will be traumatised. Causes of psychotrauma Emotional trauma can be caused by one-time occurrences such as a house fire, a plane crash, a violent crime or an earthquake. Psychological and emotional trauma can also be caused by experiences of ongoing and relenttess stress, such as fighting in a war, living in a dangerous neighbour hood, enduring chronic abuse or struggling with a life-threatening disease. Although people respond differently to stressful experiences, a traumatic event is most likely to result in negative effects if it is: • Inflicted by humans • Repeated and ongoing • Unexpected or unpredictable • Intentionally cruel • Experienced in childhood. People are also more likely to be traumatised as adults if they have a histo ry of childhood trauma or if they ate already experiencing a lot of stress. Devetopmentat trauma Stressful experiences in childhood can be traumatizing whether it is a one time event such as a car accident or an ongoing situation caused by a neg ligent or abusive parent or family member. Developmentat or attachment
- 217. trauma “esults fromanything that disrupts a chitds sense of safety and security. This can include an unsafe environment, separation from a parent or a sei Quo iLlness. Developmental trauma is most severe when it involves betraya or harm at the hands of a cai’egiver. This trauma has a negative impact on a childs physical, emotional and social development. Children who have been traumatised see the world as a dangerous and frightening place. When childhood trauma is i ot resolved, this sense of fear and help tessness can carry over into adulthood, setting the stage for further trauma. Normal responses to traumatic events It is important to distinguish between normal reactions to traumatic events and symptoms of a more serious and persistent problem Following a traumatic event, most people experience a variety of emotions, including shock, fear, anger and reLief to be alive. Often they think or talk of nothing else except what they went through. Many others feei]umpy, detached or depressed. Such reactions are neither a sign of weakness nor a positive indicator of lasting trouble. They represent a normal response to an abnormal event. These feelings and symptoms typically last from a few days to a few months gradually fading as one processes the trauma. Recovering from trauma takes time and everyone heats at his or her own pace. However if despite passage of months, the symptoms show no sign of letting up, a person may be experiencing emotional or psychological trauma. Professionat help is required if a person has: Problems at home or work • Living with persistent fear and anxiety • Haunted by overwhelming memories or emotions • Avoiding more and more things that reminds one of trauma Posttraumatic Stress Disorder Posttraumatic Stress Disorder tPTSD) is a condition that results from the most severe kind of trauma. It is characterised by intrusive memories. flashbacks or nightmares, avoiding things that remind one of the traumatic event and living in a constant state of red alert, also known as hyperarousal. Common reactions to trauma Guilt and wff-blarne Mood swings nd lrtftablIftr Dlstr.sslng memories Social withdrawal Feeling sad
- 218. The process ofheating emotional trauma is stow and complex. It involves facing and resolving unbearable feetings and memories which a person has tong avoided. The heating journey involves processing the memory of the trauma through various techniques (see box) Posttraumatic Growth Although trauma is most frequently thought of in negative terms, it is also often seen to have some positive aspects. The term posttraumatic growth was coined in 1996 by psychologists Richard Iedeschi and Lawrence Calhoun. Posttraumatic growth describes a posttraumatic change in how people think of themselves, their relationships with others as well as soci ety, and profound philosophical, spiritual, or religious changes According to the proponents of this concept. trauma can lead to growth. though this is not always the case. They have found that reports of growth experiences in the aftermath of traumatic events far outnumber reports of psychiatric disorders. Posttraumatic growth can manifest in the form of improved rela tionships and new possibilities for ones future. It can also lead to a deeper appreciation for life, a greater sense of personal strength and spiritual de velopment. Some tosses can produce valuable gains and individuals may find themselves becoming more comfbrtable with intimacy and having a greater sense of compassion for others who experience life difficulties Techniques to manage trauma Managing Psychotrauma Educate yourself about anxlaty& PSD Reintegrate yourself Into your life: do not Isolate or avoid family friends or actMtlesyou previously enjoyed Know when to seek professional help Visit a mental health professional If your traumatic experience Is Interfering with your work and family life I
- 219. Psychosocial Aspects ofTerrorism Psychosocial Impact: Terrorism hasa negative heafth impact on the individual and on society.as a whole. It isolates individuats, families, communities, cultures, and even countries from others, It generates strong feelings of mistrust, paranoia, depression, anxiety, and can even have clinicaL consequences in form of conditions like posttraumatic stress disorder (PTSD). At an individual leveL the survivors’ reactions (see table) include changes j’ that may persist for several weeks. months and even years. These include a preference for isotation, intolerance for noise, marked irritability and hyper vigilance. Hypervigilance is a state of increased sensory sensitivity and an increase in the intensity of behaviours that defuse threats. This is the state when after hearing a gunshot, one starts to become acutely aware of every little noise, and may hide for cover even when hearing a door banging loudly. Survivors also experience periods of increased religiosity, followed by alienation from reLigion, intermittently. Survivors are at an increased risk for excessive smoking and misuse of tranquiltisers, cannabis, opiates and atcohot. They may also devetop a tendency to undertake reck[ess actions, particularly while driving. They also start believing in hearsay, false attributions and negative propaganda. A higher degree of greed, mistrust, jealousy, prejudice, need for revenge, paranoia and intolerance towards minorities and certain cultures tends to prevail amongst survivors of terror ist attacks. These individuals are more prone to develop psychiatric disorders like PTSD, Dissociative States, Depression, and MedicalLy UnexpLained Symp toms, and the lowered immunity leaves them vulnerable to autoimmune disorders in the years to follow. Many survivors may undergo an enhanced resilience and even Posttraumatic Growth (PTG) after recovering from their physical and psychological injuries. Chapter 12 It’s hard to fight an enemy who has outposts in your head. —Satty Kempton Terrorism has chattenged the physical, psychosocial, occupational. eco nomic, and spiritual health of Pakistan for more than a decade now. It has affected all geographic settings and sociocultural sections of the nation. What is terrorism? Terrorism is a violent and coercive intimidation strategy. It aims to generate fear, panic, insecurity, hopelessness and helptessness as wetl as mistrust in societal institutions. It is employed as a toot to challenge, destabilise, and destroy a country, or a society in the same way as war. Often, the country’s reaction to terrorism in the form of excessive use of force, disruptive leg islation and extensive security measures may add to the fear and distress of its people. Exhaustive coverage of terrorists and acts of terrorism by the media can also add to feelings of insecurity and mistrust in the public. 4 h I-
- 220. Reactions commonly seenIn Survivors of a Terrorist Attack Why me. Why not him” - : I want to bomb them ‘Nothing can be done’ ‘teave us alone’ They are partners with agencies and the West I do not want to offer prayers anymore” I w*ft Am ProfiLe of Suicide Bombers Suicide bombers are known to share the following sociodemographic parameters: Suicide bombers are oorne out of social settings challenged by poverty, ittiteracy. ignorance. intolers: .e. disease. insecurity and injustice They come from large families with many children cramped in small houses with minimal civic amenities in slums andkatchi abaadis. The absence of an effective authority figure in the house, leaves the younger members of the family more vulnerable to exploitative forces. The tack of adequate moni toring and falling out of regular schooling adds to the risks of fatling prey. High risk factors that add to this risk include: • homes with a culture of domestic violence • physical, emotional and sexual abuse, • history of delinquency. • conduct disorder, • timited availability of emohonal outlets like music, sports, gender interaction. A traumatic childhood filled with humiliation, feelings of powerlessness and lack of affection is exploited by charismatic trainers who provide group identity, strong affinity and ‘brotherhood’ to overcome isolation from family and community. Young people in their formative years can, thus, be easily indoctrinated. These individuals are plied with high doses of psychotropic and street drugs to tower their defenses. The agents of these forces often use the name of retigion. sectarianism, tribal and political divides to moti vate individuals. Sometimes even families and communities are manipulat ed in order to recruit individuals for ulterior motives. Some techniques used by trainers to ‘create’ terrorists are: • ritual communion, • bonding,
- 221. Visible change intheir earlier approach towards religion, cultural norms, values, and the world in general. Sodal lsolatlqfl and avoidance of routine faml!y and societal events, to becomea recluse Reduced interest in loved ones, family, friends and work. b.pearrIong pedodswWH ihoäbo.öften culturallyäIb asiaflgoracadef?çEveát’ñ it — tógttfrdtabbwhen asked to explain theirabseace, Giving away personal valuables, money, belongings. .. ylolent video games. .v ‘- psychological investment, • commitments of reaching heaven, • stories of futfilment of explicit psychosexual fantasies of adolescent years • promises of houses and palaces in heaven, for them and their loved ones These are achieved through lectures, sermons, videos, and dramatic reen actments. Males between the ages of 10 to 24 are the most common ‘recruits’ of this indoctrination. Recently, however, females have also begun to be recruited. A ‘suicide’ bomber is driven mainly by strong feelings of anger, revenge, and hatred. These feelings are accentuated and exploited by terrorist out fits through generating apathy, extensive training and use of hallucinogens, stimulants, and other drugs of abuse. With this extensive work and organ ised exploitation, it may not be difficult to transform an adolescent into a suicide bomber. Characteristic behavior patterns seen amongst terrorists planning to go on a mission/killing spree include the following: S I Obsession with, and interest in weapons, knives, chemicals and other potentially dangerous objects etc.
- 222. Is a terroristsuffering from mentaL ilLness? Terrorists are known to experience paranoid anxiety, envy, magical think ing, omnipotent denial, grandiosity and massive depression. At the same time they are often highly intelligent, sane, very focused, and have no identifiable psychopathology. It is, therefore, inappropriate to consider them sufferers of a clinicat disorder. The traits and behavior patterns of terriorists are cLoser to those of hardened criminals than patients. To label them ‘psychotic’ stigmatises patients of psychiatric disorders. Psychosocial Management of Consequences of Terrorist Acts Psychotrauma consequent to a terrorist act is often ignored while physi cal trauma and disabilities draw most attention. Extensive research on the subject shows that one third of uninjured survivors and two thirds of those injured in a terrorist attack are likely to develop long-term disabling psy chosocial consequences. Some key areas to be addressed include: i. Mobilisation of Psychotrauma Teams: In the same way as health professionals are trained to respond to injuries, trained teams of health professionals need to be formed to address psychotrauma. These teams need to operate as first responders. They can be formed by training volunteers, rescue workers, ambulance staff, including ambulance drivers, disaster relief workers, emergency health personnel social workers, and hospital staff. 2. Integration of Psychosocial Care with Surgical Care. Itis important to sensitise and train the surgical team members in psychotrauma and its management. Training in the use of effective communication skills, empathy. and awareness that fear and numbness can act as aggravating factors in the perception of pain and reactions to injuries can help in management. 3. Linking up Survivors and the Dead with Famities and Units/Centres. The biggest psychosocial support in response following a terrorist activity comes through help in establishing contact between the survivors of the act and their families and loved ones. In the chaos that sets in as the aftermath of such an act, the anguish of not knowing whether your loved ones are safe leaves a lasting impact. The longer it takes to reestablish contact. the more traumatizing it is for the family and friends as well as the survivor. Exact, reliable and valid information on the injured and dead is recommended from a behavioural sciences perspective. The strategy to gradually break bad news by initially announcing that no details are available, followed by statements like ‘has serious injuries, but will be alright’, ‘we are trying to save them’, for those who have been martyred in the terrorist attack is counterproductive. Breaking bad news sensitively and clearly about those injured or martyred is a far more appropriate approach. The news should, however, always be broken by somebody responsible and senior in the hierarchy. This helps the family and the loved ones overcome their initial shock, numbness and denial reactions. 4. Updating: In case exact information about the Lost, injured or dead is not available, it is important to not leave the affected families unattended with crowds, media, and irresponsible people often lurking outside such settings. Intermittent, updates at regular, clearly identified intervals and fixed timings by a nominated
- 223. representative of thedisaster management authority or the concerned agency can help the confusion that prevails. All information on the subject should flow out of this single source. Others involved in the rescue operation and initial response must be under clear instructions not to give interviews to the media. They must also refrain from making predictions about the affected personnel or the identity of the terrorists and the operation. 5. Reconstruction of Dead Bodies: The bodies of the martyrs in terrorist incidents may sometimes be found in a mutilated and deformed state. Seeing such bodies can a have a traumatizing imt5act. Attempts at reconstruction of these bodies by professionals and presentation of the dead bodies in customised coffin boxes may be considered. This should be done with utmost sensitivity to the religious, cultural, and ethnic values and norms of the aggrieved family. 7. Religious and Cultural Rituals: Sensitivity must be shown to the burial customs, and funeral rituals that a family or a community prefers. A genetic approach in this regard that does not cater for indiyidual needs may cause lasting distress in the members of the affeited family and community. 8. Ongoing Psychosocial Support for Survivors and Families: The exhaustive rescue operation following a terrorist attack is often followed by a period where everything goes quiet. The initial enthusiastic response and commitment shown must be followed up by a sustained effort to maintain medical, psychological surgical follow up after discharge from the hospital. A clearly defined and well-communicated plan must be formed for this. This must include plans for physical rehabilitation measures, including physiotherapy. prostheses, and reconstructive and plastic surgery needs. This is just as important as the acute response. The social, economic, occupational, legal, and emotional needs of the injured survivors as well as of the families of the martyrs also need to be addressed in both the intermediate and tong term. This continuity of care and follow-up saves the affected and the responders a great deal of suffering and improves their resitience. This ensures an early return to normality of the survivors as well as the affected families and communities, It also helps build the morale of the community and the nation in their resolve to fight terrorism. 9. Return to Normal Activity: An early restoration of life in all its vigour and normality is the key to building resilience and health. Affected chiLdren who do not have disabling injuries and are not suffering from any acute medical conditions should be encouraged to return to the pre-trauma routines of life as early as possible. • sports. • drawings, • supported discussion groups • mutual support and organised activities cooking and eating together
- 224. Some survvors andmembe 5F ffectcd famity deal better with their loss by sorkinci towards 5:e :vrhnl iltation and long term support measures of other chest cc They may also join disaster rnasacement and reter cIes:F is All these activities help in restoring the esem’ and aei le mnnqst the aggrieved and help the retu:c. to normality ic Care of Ca s. The fir :spc. - s terrorist act arc often traned rescue, potrce. oaramrt:r” ad :a{orv personnel ft is wrong to presume that n:embsrc nf such :.uidi a immune to the psychotraures cossecisent to ties h. .l.rci if iniired, and the dead. fact, alt first resoomfe ncisiu i’b ‘lance personnel drivers health persnase1. it the hesntsl nd th support staff are affected. Ti-., coo, the’ef’.ro 2t hira ‘ci’ rn develop psy’:hotr ama in the chart ter: :fl0 av show cigns of PTSD se’.’eral’a’eeks and months itc’. its ‘ p’wiait tc’ educate all of them about the effects 5d Otl’ :s :f a ws’estrarim_i The members of such teams r,:ev net flfic c.,. .Cflt d’anqes in their beha’. or the-nestess ts. heceE.: -s :‘ .; they ‘catch for these sionc in each other and offm cob :. :‘nn °nme of the- earliest sicin inctudo casio ftiqaK,litn, aT sc’’ acnhnn -nncentrstion, and short tess: mneoiort-. rmi- am es r nntH, H hi qc in 5c.boacai.foactonr - :i’ce co’o..e c. .:n’’o escac,t,cs may br- nn before the mme. cnsons V evcrtabitty. ftashoac.kn or h”er.. L. cL-co u. Lecial 5ecurt. and Dperatrcca. esses V-c sVci I;cifies and ndi:duets as vcell es the commcntc--. .rCH Vs nctn ei 3r more secure, comforted, ansi assured ,ttl cc .ro,’mm snt tc’ w enforcrng agencres respc.nrl to ito :c - scia ffest”ely and in an orciacosed fashron. Leeatsupocrt. cc a .oocsotcns ni effer.tr,e rehabilitation measures when crnn V ‘ffti’’e and rm relentless pursuts to apprehoec a 50 ict nci erect them adds to the resolve and resr’rerce as Vs n.:i a: volt as at the community level Any Vt-um Owl’ cr V.iiy Ly tho .o’esrned quarters on the other hen1 iss,ctr so ‘ci: secirscJ of nes des morbidities and rea:[cns. ThiS coca roasi to lsr,qmcLc ‘cons such as feeLings of onqe’n:e a, o rvct pc tt.at cm’ sVrt to surface amongst ndrvrduaV and the iod aces :“ mat” . ar’ ties niured. 12. Miscellaneous measures need to qo lflLD effect an the has’s of available resources, expertise. and tran;ng These ;ncbuci esues related to foltowng human rights charters. ntemat.onai Ii’s’s, and legislation. ihlS s particuLarly important n the • handling ot suspects • treatment given to FamiLies of suspects • buriaLs of the terrorists killed in the operation handling of media, • traininq of hum-an resource in resisonce and rescue operations • research and audits evabuatrag th. ecienr.y and effectiveness of the process.
- 225. Chapter]3 Stress and itsManagement Definition Hans Setye introduced the concept of stress into physiology from phys ics, where it generally refers to a force acting against some resistance. He defined stress as “the rate of wear and tear in the body” and “the state manifested by a specific syndrome which consists of all the non-specifical ly induced changes within a biological system.” In this General adaptation syndrome (GAS), glucocotticoids are secreted by the adrenal cortex in re sponse to adaptation demands placed on the organism by such disparate stressors as heat, cold, starvation, and other environmental insult. Any such stimulus to the body results in certain physiological changes in the body which are cumulatively termed as stress (Lazarus; 1984). Stressors are the environmental sources of threat to an organism, while stress is what occurs as a result of this. Richard Lazarus emphasised the potential threat of life events in causing stress. Individuals have a personal view of their stress, based on their perception of the event, past experiences, strengths. biographical assets and social support. Other factors which influence the outcome of stress upon an individual include race, gender. age, marital status, socioeconomic sta tus and early developmental experiences. For example, black people are more prone to develop hypertension than Caucasians. Females tend to live tonger and recover quicker from illness than males. They also show less physiological reactivity to stress as compared to males. The elderly are more vulnerable to all kinds of stressors. The general observation that work capacity decreases by 1% every year after 21 years of age, provides evidence that people.who continue to work with same routines beyond 50 years tend to have higher incidence of coronary heart disease. Marriage is considered a protective factor against stress and most illnesses in both genders. Educational and economic attainments provide more resilience against stress. Early parental loss, quality of love and care received in early life years and children’s early exposure to socializations shape the re sponse of people to different types of stress. Stress is conventionally divided into two types based on the causative factors: Physiological stress caused by temperature. noise, hunger, disease, smok ing, drinking and similar habits are considered generalised life stressors affecting most people. Psychosocial stress caused by psychological factors such as low self-es teem, social factors such as life events (see table), job stability, career satis faction, economic viability. marriage, children, relationships etc. Stressors bring about a physiological change in the body of a person. Some stressors produce impacts in a short span of time; such as loss of parents orjob. Others, such as distressed relationships or care of a disabled person in the house, inftuence the person gradually over a period of time. Individual and situational variables mediate the relationship between life change and illness.
- 226. Interpretation: An individuatis prone to devetop a stress related disorder e.g. depression if his score in a given year rises above 300. LCU Value: life change unit. is the impact each event carries for the person as as sessed in the 1994 survey Adapted from Holmes and Rahe scale, 1994 Among the psychotogicat variables that seem to mediate the stress response are: locus of conttoL the extent to which individuats prefer control of their lives and how much control they perceive they have over specific Ufe events, • need for stimulation, • openness to change. stimulus screening. self-actualization, use of deniaL • social support. People who are able to etfechvety combat high tevets of stress and stay healthy differ in hardiness” from those with high tevets of stress who devel op illness. Hardiness is a personal characteristic comprising the “3 C’s”, in which an individual has a sense of: • Commitment to self, work, family, and other important values; • Control over one’s life; • Change as a challenge rather than a threat. Recently researchers have suggested a fourth C”: coherence. Coherence is the belief that one’s internat and external environments are predictable and that things wilt work out as well as can be expected. 100 3 65 life vent Ranking of the event LCU Value Death of spouse Divorce Marital separation all term Death of close family member Serious personal injury Marriage Dismissal from work Marital reconciliation Retirement Change In health and behaviour o a family member I 5 63 7 59 9 45 U 44 p. V
- 227. Job-reLated Stress &Burnout Work-retated stress can be a source of persistent and intense stress and strain. Job strain is defined as a combination of high job demands and low perceived control. Studies have established that job strain is associated with increased carotid atherosclerosis among men. Burnout is a syndrome associated with untetenting stress. It includes symptoms of emotional ex haustion and a decreased sense of personal accomplishment. Response to stress The body responds to stress througft.physical, emotional and behavioural means. Physical manifestations of stress: Both sympathetic and parasympathetic nervous systems may go into overdrive when faced with stress. The sympathetic system comes into play when stress is acute and manifests in the form of increased heart rate, dilatation of pupils, dry mouth, pitoerection, increased muscle tone, rapid breathing and increased blood pressure. When this state is sustained for a prolonged period of time, three target organs - stomach, heart and blood vessels - are affected, but none are spared. There is increased acid secre tion in the stomach, increased gastric emptying, nausea, heartburn, upset stomach, chest pain, hypertension and muscle aches and pains. Parasympathetic system is stimulated when stress becomes chronic. Some people are more vulnerable to respond to stress through parasympathetic system. This causes increased hunger, delayed gut motility, constipation, increased sweating and disturbed sleep. Both systems operate through the hypothalamic- pituitary-adrenal axis, which is a physiological tract invoLved in stress response. Recent evidence indicates that chronic psychological stress can lead to increased production of proinflammatory cytokines, particularly interleukin fIL)-6, which is also triggered by infection and trauma. Proinflammatory cy tokines have been implicated in a range of diseases in oLder adults that can be traced to inflammation, including cardiovascular disease, osteoporosis, arthritis, type 2 diabetes, certain cancers (including multiple myeloma, non-Hodgkin’s lymphoma, and chronic lymphocytic leukemia), Alzheimer’s disease, and dental disease. IL-6 promotes the production of C-reactive protein, which is an important risk factor for MI. The outcomes of stress on the physical health of a person can be summarised according to its effects on each organ system: Cardiovascular System Stress aggravates all types of heart disease including coronary artery disease, congestive heart failure and sudden cardiac death. There is a connection between hostility (common in people with type-A personality) and cardiac disease. It has been shown that hostility contributes, independently of other risk factors, to the pathogenesis of heart disease through lipid accumulation, increased blood pressure, and heart rate and platelet pathophysiology
- 228. Centrat Nervous System Dizziness,vertigo, and other balance disorders often have stress as a causative or contributing factor. One of the most common neuro[ogic expressions of stress in clinical practice is headache. Tension headaches and migraine headache are two common types of headaches which are substantially influenced by patient stressors. Gastrointestinal. System Peptic ulcer disease may have an association with stress, Hyperacidity and excess enzyme production are hallmarks of the sympathetic arousal that occurs during stress. Irritable Bowet Syndrome (IBS), which is characterised by abdominal pain with altered bowel habits (constipation or diarrhoea) in the absence of a definable lesion or structural abnormality, frequently correlates with periods of emotional stress. Muscutosketetat System Some forms of arthritis show stress-related exacerbations. Complex syndromes such as fibromyalgia seem to have a psychosocial trigger. Temporo-mandihular joint (TMJ) dysfunction and its related pain syndrome are frequently associated with mental stress. Chronic pain tends to correlate with stress in a person’s life. Respiratory System Asthma and chronic obstructive pulmonary disease appear to be worsened by stress Conversely, one of the more powerful self- regulatory stress-control techniques is relaxed abdominal breathing. Asthmatics who participate in stress reduction programs have shown improved physical activity and decreased medical visits. Reproductive System Amenorrhea frequently occurs during stressful times in the lives of women Fertility also can be affected by stress. Dysmenorrhea. dyspareunia and impotence all have substantial stress and strain connections. lntegumentary System A variety of skin tosians and rashes have been associated with the stress response. Stress can tower the itch threshold by vasodilation and may account for the pruritus seen with many dermatotogic syndromes Emotional stress, fear, and pain are all accompanied by substantial drops in skin temperature of the fingers. Immune System Stress can manifest in the form of immune deficiencies ranging from the common cold to some forms of cancer. Although research on P the relationship between stress and cancer is still inconclusive, there is some evidence that stress and surgical excision of the primary tumour can promote tumour metastasis by suppression of cell mediated immunity. In HIV positive patients. rapid disease progression has been associated with greater concealment of one’s sexual preferences, more cumulative stressful life events, and less cumulative social support over a 5-year period.
- 229. Behavioural Manifestations ofStress SociatwithdrawaL poor sleeping and eating habits, poor exercise, ex cessive drinking and smoking, drug abuse, carelessness. problems with authority and rules and regulations, insubordination, impaired social rela tions, break up of old relationships and reckless behaviou are att types of behaviours that indicate a person is undergoing stress ir Eneir life and is unable to manage it, ,,Physical conditions with psychological components Essential hypertension. angina pectorls, tachycardia, arrhythmia, cardlospasm, Cardiovascular coronary artery disease, mitral valve prolapse, myocardial infarction, migraine. headache. Ji Irritable boI syndrome, gastric ulcer, G4rolnt.stlnal Uuod.nal u1ce! Cmbn’s disease, - . A - ulcratjye colitis. k .. Hypoglycemia, diabetes mellitus, Hormonal hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoparathyroidasm, premenstrual syndrome, obesity [‘W?”. ‘ ‘ ‘‘‘ ‘‘. ‘ - -.., • . Neurodermatitis, pruritis. psoriasis, Integumentary hyperhidrosis, urticaria, alopecia, acne, • herpes, genital warts - ChmnkpaIn,tiaadach.sacrofllacpain. I. Neuromuscular! . temporomandibularjoint pln, Skeletal I rheumatoid arthrftli, Peynaud’s diseesa .‘ Emotional Manifestations of Stress: People who respond with sympathetic reactions tend to show anxiety, fear, anger and irritability. They try to avoid the stressor by showing the fright and flight response. Hypervigilance, hyperarousat and increased startle response are seen. Parasympathetic system responders tend to show guilt. grief, sadness, depression, feelings of being abandoned and isolated and tend to avoid seeking support from others. 4 Respiratory Asthma, hyperventilation syndrome, tuberculosis
- 230. Managing behaviour It isimportant to not get fixated on past failures, the past cannot be changed. Focusing on what can be done now and in future is a more productive approach. Adopting the can do attitude, practicing anger management and remembering that you are the person in charge of your behaviour hetps. Unless you allow yourself to fall down, nothing can make 4 you surrender are important mind sets to get one through a tough situation. Time management Making a list of things to do each morning and prioritise the work that needs to be done goes a tong way towards managing time effectively. Rather than working tong hours with low productivity, it is far more produc tive to work for 45 minute stretches with short breaks in between. It is also important to take time out to evatuate and reflect upon the work done and efforts made. Learning to say ‘no’ to unreasonable demands on your time is an important skill. This is especially true of our culture where it is consid ered rude to say no, so instead we say yes, and avoid being truthiut about what we can accomplish. It is also important to give ones own self “guilt fre& time off to enjoy. Learning to delegate responsibility also greatly improves one’s own productivity. Managing stress Accepting the things that ate beyond one’s controt can sometimes be the first step towards relieving stress. It is also important to learn to deal with your stress response and adopt effective coping methods. Stress Management Managing stress is vital for the health and survival of a person. Poorly managed stress can result in disease and seriously impairs quality of life, in addition to undermining the achievements and objectives of a person. The goal of managing stress is to achieve a state of eustress, a state where a person is managing stress effectively, has good health, is relaxed and is improving his capacity and capabilities. Self-blame, wishful thinking, avoidance and taking things personally are recognised as negative coping methods and result in poor stress manage ment and disturbance to health. In contrast, problem sotving. seeking help and utilizing social support and remaining optimistic are positive coping styles for handling stress. Managing the stressor Managing the environment is the first step towards stress handling. There is always some aspect of the stressor that can be controlled. That as pect must be controlled and one thing to be taken at a time. Minimising the stressors may require imaginative problem solving and help from the individual’s support group. but it helps to create a sense of control over the environment Exercise and nutrition Exercising 3-5 times a week conditions the body to deal with stress by us ing the physical stress response. Keeping caffeine intake to minimum, stop ping smoking and eating less fatty and sugary food and more fibre, vitamin B complex and Vitamin C helps to prime your body to deal with stress as and when it occurs.
- 231. Progressive Muscle Relaxation inprogressive reIaxatlon each muscle or group of muscles Is contracted for 5 to? seconds and then relaxed for 20 to 30 seconds. The cycle is then repeated. Mcw.óthethIrdm*rmuIdemup-ch.st, abdaeean and lowrback. End with the fourth major muscle group - thIghs, buttocks, calves and feet areupsthatam *outd.perr&axatlon - Practice progressive relaxation while lying down or seated in chair with feet firmly on the floor. $gl*f I Do the same with the left fist- tensing relaxing, and noticing the difference. Progress through the next major muscle group - head, face, throat and shoulders H I Relaxation Practicing progressive muscle relaxation (see box), meditation, deep breathing exercises and engaging in hobbies provides energyand fuel for the body to combat stresses of all kinds. Social support Developing a circle of friends and family where one can talk openly and honestly can help one better understand stress and learn to manage it more effectively. It is also important to utilise resources that can help such as doctors or senior colleagues. p 4 Communicating With Patients about Stress A primary component of stress prevention and treatment involves the way stress is discussed with patients. A doctor must avoid phrases such as “it’s all in your head. Equally important is avoiding the message that ‘you are responsible for your illness’ This induces guilt in patients who become ill and makes them feet that they have failed at being a “better person Avoid ing negative emphasis, for example, ‘Your hectic pace is going to kitl you, in favour of a positive framing of the health benefits of stress management is more likely to have a positive influence. For example, the clinician can express optimism about the patient’s ability to influence health as follows: “Fortunately, there are many avenues available for evaluating and changing your way of responding to life challenges. I’d like to give you an overview of some strategies that we can discuss now and in future appointments.”
- 232. Non-pharmacologic Interventions forreducing Stress Improve time management Have a sense ofhumoAr Pursue personal and vocational activities I Engage in spiritual activities such as praying Clarify valugs Cultivate social support network . ro*a assertiveness• Reduce exposure to unnecessary stressors . Haipothati In anywayyou cm . I
- 233. SAMPLE MCQ FORSECTION E 1. A 35 year old gentleman has been admitted to the hospitat for the Last 10 days. His investigations reveal that his condition is improving, yet he appears stressed. What could the most important reason for this be? a) The bad attitude of the nursing staff b) The cost of the investigations C) Loss of autonomy and privacy d) Feeling betrayed at not being visited in the hospitat by the extended family e) Being dependent on other people 2. A 23 year oLd man is diagnosed with metastatic pancreatic carcinoma. The prognosis is poor and the treating doctor gives him the bad news that he onLy has a few weeks to Live. The first psychoLogicaL reaction in such a patient wiLt be: a) Anger. b) Bargaining C) Depression. d) Acceptance. e) Denial. 4 3. A 75 year otd gentLeman with chronic renaL faiture, suddenty starts to t - become irritabLe, refuses to recognise his famiLy members, and appears to be seeing things that aren’t there. His daughter reports that he does not steep at night and steeps throughout the day instead. The most Likety diagnosis is: a) Dementia b) Delirium c) Schizophrenia d) Depression with psychotic features e) Old age 4. In the case of the 75 yr oLd gentLeman mentioned above, after he is admitted to the hospitat, which of the fottowing are tikely to make his condition worse? a) Unfamiliar medicaL procedures conducted without provision of informational care. b) Psychological stress of disease and hospitalization. c) Lack of loving family members around the patient. d) Long periods of sensory deprivation as well as sensory overload. e) Antidepressants
- 234. . Defense mechanisms haveall of the following characteristics except a) They emerge in a deve[opmentat sequence from Less mature to more mature. b) They generally can be brought under conscious control to ward off anxiety. c) They operate to maintain a sense of welt being and safety. d) They may be episodic or become more habitual and pervasive. e) They may contribute towards formation of personality traits Sampte Short Essay Question For Section E 01. Briefty describe the psychotogicat stages of Grief Reaction hightighting various defence mechanisms. Q2. How does one differentiate between post-partum bLues and post-partum depression? Answers i.b 2. e 3. b 4. d 5b
- 235. Patient Examiner Date/ / Orientation Score Maximum What is the (year) (season) (date) (day) (month)? ( ) 5 Where are we (state) (country) (hospital) (floor)? ( ) 5 II APPENDIX U - - - - The Mini-Mntãj _i1MSE) - - L: - t 6 Registration Name 3 objects: I second to say each. Then ask the patient all 3 after you have said them. Give one point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record. Trials__________________ Attention and Calculation Serial 7’s 1 point for each correct answer. Stop after 5 answer. Althernatively spell world” backward. Recall Ask for the 3 objects repeatd above. Give I point for each correct answer. Language Name a pencil and watch. Repeate the following “No ifs, ands: or buts” Follow a 3-stage command: “Take a paper in your hand, fold it in half, and put it on the floor.” Read and obey the following: CLOSE YOUR EYES Write a sentence. Copy the design shown. ( ) (I t I 3 5 3 2 3 Total Score ASSESS level of consciousness along a continum Alert Drowsy Stupor Coma 24-30: within normal limits: 23: cognitive impairment (further formal testing recommended)
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