Deck 8 Flashcards
What is stress?
Stress is an imbalance between the demands made on us and our personal resources to deal with these demands.
Life events (LE): work problems or changes, debts, relationship difficulties, extended family problems, house move, examinations, diagnosis of physical illness.
It isn’t the LEs themselves that cause stress, but the interpretation and meaning to the individual.
LE > Appraisal > Stress
What is the difference between primary and secondary appraisal?
Primary Appraisal - appraisal of event.
Secondary Appraisal - appraisal of personal coping abilities or personal resources and also the resources external to them, mainly in the immediate social network.
What are the four types of stress response?
Emotional – feeling on edge, feeling sad, irritability, tearful, over-reacting
Cognitive – difficulty concentrating, difficulty switching off, sensitive to criticism, self-critical,
indecisive
Behavioural – Comfort eating, loss of appetite, drinking, smoking, over/under activity,
disturbed sleep
Physiological – Increased HR, increased RR, tense,
perspiration
People may misinterpret their physiological symptoms (e.g. increased heart rate > heart attack), leading to anxiety and increased stress (physiological) response.
What is a Medically Unexplained Symptom?
Medically Unexplained Symptoms are physical symptoms not explained by organic disease which cause distress and impair functioning and for which there is positive evidence or a strong assumption that the symptoms are linked to psychological factors e.g. (stress/distress/mental illness)
These symptoms are produced by unconscious mechanisms. Patients are not deliberately ‘putting them on’
Patients have varying degrees of insight or acknowledgement that a proportion of their symptoms are related to psychological factors
Most MUS are transient, but a substantial minority are more persistent and associated with medical consultation
MUS may also be referred to as psychosomatic illness, functional symptoms/overlay, somatoform disorders. They are given medically descriptive terms, such as:
Irritable bowel syndrome
Chronic fatigue syndrome
Fibromyalgia
Atypical non-cardiac chest pain
Non-epileptic seizures
Multiple chemical sensitivity syndrome
Irritable bladder
Explain the Biopsychosocial model of MUS.
Some MUS may arise from ‘normal’
bodily sensations (physiological processes) with misinterpretation (SEE STRESS RESPONSE)
Some MUS may arise from minor pathology and are exaggerated at times of stress
Other mechanisms at a neurobiological level
What is the indirect effect for chronic stress to affect disease?
- Poor compliance with medication.
- Increased alcohol intake.
- Increased smoking.
- Reduced excersise.
- Poor diet.
What is the direct effect that stress has on illness?
- Stress activates the hypothalamic-pituitary-adrenocortical axis (HPA) causing cortisol secretion and the sympathetic-adrenal-medullary system (SAM) causing catecholamine secretion.
- Plausible these systems are having dirrect effects at a cellular level but the final pathways are less clear.
What factors are you assessing in a mental state examination?
Appearance
Speech
Mood
Thought content
Abnormal beliefs and interpretations of events
Cognitive state
Insight
How do you assess appearance and behaviour in the mental state examination?
General appearance – self neglect, poorly fitting clothes, clothes not suitable for weather, flamboyant clothing.
Facial appearance – downcast eyes, vertical furrow forehead and downturned mouth may indicate depression. Manic patients look euphoric and less or more irritable. Relatively fixed faces may be parksonian side effects from medication or the disease itself.
Posture and Movements…. In schizophrenia you may see abnormal movements, e.g. echopraxia (imitation), posturing where the patient adopts a bizarre posture for a long time. Tics are repeated irregular movements involving a muscle group. Poor eye contact and hunched shoulders may indicate depression. Increased movements and inability to sit down may show mania. Restlessness is often a feature of anxiety.
Underactivity…. Stupor is when they are mute, immobile but fully conscious. Depressive retardation is a lesser form of psychomotor retardation seen in depression. Obsessional slowness is secondary to repeated doubts and compulsive rituals.
Overactivity is psychomotor agitation. It is usually not productive and leads to restlessness. Compulsion is repetitive and seemingly purposeful behaviour, e.g. cleaning, checking. Social behaviour
Try to establish a rapport. Is social behaviour within accepted social norms?
How do you assess speech in the mental state examination?
Rate may be increased in mania and reduced in depression. Quantity may be increased in mania and anxiety but reduced in dementia, schizophrenia and depression. Volume should also be noted.
Pressure of speech = increased rate and quantity. Poverty of speech = restricted amount of speech. Mutism = complete loss of speech. Dysarthria = difficulty in articulation of speech.
Forms of speech –
Flight of ideas. Accelerated thoughts, abrupt changes of topic, no central direction
Neologism. A new word constructed by a patient or a normal word used in an abnormal way.
Echolalia. Automatic imitation by patient of another person’s speech, even when they don’t
understand it.
Thought blocking. Sudden interruption in train of thought, leaving a blank and the patient
cannot recall what he/she had been saying or thinking.
Knights move thinking. Odd associations between ideas leading to disruptions in continuity
of speech.
All of the above changes in the form of speech can be described as a sign of thought disorder, which is a pattern of disordered language presumed to reflect disordered thinking. Psychosis is an abnormal condition of the mind, with a loss of contact with reality.
How do you assess mood in the mental state examination?
Mood can be defined as a persuasive and sustained emotion that, in the extreme, markedly colours the person’s perception of the world. Objective assessment based on history, appearance, behaviour and posture of patient. Subjective assessment as described by the patient.
Dysphoric mood is an unpleasant mood
Low or depressed mood may be accompanied by anhedonia, which is the loss of ability and
interest in regular and pleasurable activities.
Euphoria is a personal feeling of unconcern and contentment
Elation is an elevated mood or exaggerated feeling of well-being
Irritable mood presents with a tendency to be annoyed and provoked to anger
Anxiety
internal danger. There is phobic anxiety, free floating anxiety and panic attacks.
is a feeling of apprehension, tension or uneasiness owing to anticipation of an external or
An affect is a pattern of observable behaviours in that is in the expression of emotions. Inappropriate affect to the thought or speech expressed would occur, for example, if someone appeared cheerful when talking about recent bereavement. Flat affect is total or almost total absence of signs of expression of affect.
How do you assess thought content in the mental state examination?
Preoocupations – Note any thoughts, preoccupations and worries – e.g. hypochondriasis, the preoccupation with the fear of having a serious illness.
Obsessions – repetitive senseless thoughts that are recognised as irrational by patient and usually resisted.
Phobias – persistent irrational fear of an activity, object or situation, leading to avoidance. Fear out of proportion to real danger and cannot be reasoned away, being out of voluntary control.
Suicidal and homicidal thoughts.
Delusions – fixed, false personal belief based on incorrect inference about external reality firmly sustained in spite of what almost everyone else believes and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the culture. A primary delusion arises fully formed without any connection with previous events. Secondary delusion arises when a person is trying to make sense of their experiences. Passivity phenomena is a belief that an external agency is controlling oneself. This includes thought insertion, withdrawal and broadcasting. A delusional perception is when the patient attaches new and delusion significance to a familiar real perception, e.g. school bell rang, therefore I am the king.
Sensory deceptions such as illusion (a false perception of a real external stimulus) and hallucination (false sensory perception in the absence of a real external stimulus).
Pareidolia – vivid imagery occurs without conscious effort while looking at a poorly structured background such as a fire
Disorders of self-awareness - Disturbance of awareness of self-activity including depersonalisation – patient feels altered or not real; Derealisation – in which the surroundings do not seem real
How do you assess cognitive state in the mental examination?
Orientation – time, person and place
Attention and concentration – serial 7’s
Memory – immediate recall, registration and short term memory. Ask re recent events as
well as long term e.g. patient’s place and date of birth
General Knowledge – current prime minister, monarch, current news events
Mini-Mental State Examination - Scoring is out of 30 – to be used when there is memory loss
Orientation time and place 10 marks
Registration 3 marks
Attention and Calculation 5 marks
Recall 3 marks
Language and Praxis 9 marks
How do you assess insight in the mental state examination?
Degree of insight can be assessed by asking
“Do you think you are ill?”
“Do you think you have a mental illness?”
“Do you think that treatment is necessary?”
Define risk.
Risk is the potential for harm.
Risk is a concept that we all use and think that we understand as we face the uncertainty of the future. We wish to be safe and secure, and to ensure death is as remote as possible
Risk is usually considered to be the simultaneous appreciation of the likelihood (that is how often) and consequence value (that is how good or bad) of some situation or event occurring
What is ‘risk society’
• We are all vulnerable – and the vulnerability of others makes us feel more so ourselves. Risk assessment are conducted in the midst of a worried and anxious public. There is a rampant language of risk and fear in public debate and private lives.
Risk Society…
The contemporary term is ‘Risk Society’
Life is not more hazardous but previously hazards came from some ‘other’ eg gods or nature (metaphysical)
Risk is now viewed as a product of human action and decision-making and it has become a political issue.
That is intervention/decision-making transforms incalculable hazards into calculable risks. Paradoxical Outcome of Assessing Risk…
• Risk is closely linked to reflexivity, accountability and responsibility.
What is the precautionary principle?
If an action or policy has suspected risk of causing harm to the public or the environment, in the absence of scientific consensus, then those advocating action should provide the burden of proof.
Origins in the Earth Summit in Rio 1992
This principle allows policy makers to make discretionary decisions in situations where
there is evidence of potential harm in the absence of complete scientific proof.
The principle implies that there is a responsibility to intervene and protect the public from
exposure to harm where scientific investigation discovers a plausible risk
In the European Union, the application of the precautionary principle has been made statutory requirement
What are some critiques of the sick role?
Diagnosis not always clear
Patients don’t always seek help (symptom iceberg)
Should patients follow doctors instructions no matter what? Some patients know more
‘expert patients’
What about pregnancy?
Sometimes, patients are responsible for their illness…
What is medicalisation?
Medicalisation describes the process by which non-medical problems become defined and treated as medical problems, usually in terms of illnesses or disorders’
Three commonly held views of medicine:
Main determinants of health and disease are biological (e.g. germs, genetics, virus etc)
Medicine based on (objective) science – ‘experts’ know best
Biomedicine is a superior way of responding to illness and disease
What factors lead to improve health outcomes?
Environment – nutrition and hygiene
Behavioural – reproduction
Medical – immunisation and therapy
Public health medicine rather than clinical
Argues that the success of biomedical interventions have been overplayed. Need fo a psycho-social model rather than a biomedical mentality
When can medicalisation take place?
Traditional forms of control are deemed by some as unacceptable – shifts in norms and values
Control mechanisms exist (e.g. treatments) and an organic basis identified
Medicine accepts the ‘deviance’ under their jurisdiction
Commercial interests can gain (e.g. selling and marketing of drugs)
Consumers demand interventions e.g. child behaviour not about parenting but a ‘illness’…
This helps remove individual’s sense of responsibly - ‘I can’t help it, I’m ill’ or as we now
know – have taken the sick role
What problems exist within the medicalisation perspective?
People may be ‘treated’ when they are ‘normal’
Notions of ‘normal’ are altered (who is normal?)
All interventions have side effects
Non medical means of responding to difficulties may be devalued or lost
Social, economic, cultural and political factors which give rise to difficulties may be eclipsed; public issues become private matters
We may see ourselves as victims and so not take action
Doctors may feel under pressure to prescribe solutions and ‘solve’ problems
Technological interventions and treatments are expensive
In assessing risk, what are the duties of you as a doctor, when diagnosing and treating a patient?
Make the care of your patient your first concern Provide a good standard of practice and care.
Keep your professional knowledge and skills up to date.
Recognise and work within the limits of your competence.
You must take steps to monitor and improve the quality of your work
Take prompt action if you think that patient safety, dignity or comfort is being compromised
Be honest and open and act with integrity
Never abuse your patients’ trust in you or the public’s trust in the profession.
You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must:
adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient
promptly provide or arrange suitable advice, investigations or treatment where necessary
refer a patient to another practitioner when this serves the patient’s needs.
In providing clinical care, you must..
Prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs
b) provide effective treatments based on the best available evidence
c) take all possible steps to alleviate pain and distress whether or not a cure may be
possible
d) consultcolleagueswhereappropriate
e) respect the patient’s right to seek a second opinion
f) check that the care or treatment you provide for each patient is compatible with any
other treatments the patient is receiving, including (where possible) self-prescribed
over-the-counter medications
g) wherever possible, avoid providing medical care to yourself or anyone with whom you have a close personal relationship
22. You must take part in systems of quality assurance and quality improvement to promote patient safety. This includes:
a) taking part in regular reviews and audits of your own work and that of your team, responding constructively to the outcomes, taking steps to address any problems and carrying out further training where necessary
b) regularly reflecting on your standards of practice and the care you provide
25. You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.
a) If a patient is not receiving basic care to meet their needs, you must immediately tell someone who is in a position to act straight away.
b) If patients are at risk because of inadequate premises, equipment or other resources, policies or systems, you should put the matter right if that is possible. You must raise your concern in line with our guidance and your workplace policy. You should also make a record of the steps you have taken.
c) If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or us. If you are still concerned you must report this, in line with our guidance and your workplace policy, and make a record of the steps you have taken
28. If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients.
29. You should be immunised against common serious communicable diseases (unless otherwise contraindicated).
30. You should be registered with a general practitioner outside your family.
Lazarus and Folkman (1984) define coping as ‘constantly changing cognitive and behavioural efforts to manage external and/or internal demands that are appraised as taxing or exceeding the resources of the person’
There are five classes of coping strategies. What are they?
1) Direct-action response: the individual tries directly to change or manipulate his/her relationship to the stressful situation, such as escaping from or removing it.
2) Information seeking: the individual tries to understand the situation better, and to predict future events that are related to the stressor.
3) Inhibition of action: doing nothing, this may be the best course of action if the situation is short term
4) Intrapsychic or palliative coping: the individual reappraises the situation or changes the internal environment (through drugs, alcohol, relaxation or meditation)
5) Turning to others for help and emotional support.
What are the maladaptive mechanisms for coping?
Overcompensation
Aggression, Hostility: Counterattacks through defying, abusing, blaming, attacking, or criticizing others
Dominance, Excessive Self-assertion: Controls others through direct means to accomplish goals
Recognition-seeking, Status-seeking: Overcompensates through impressing, high achievement, status, attention-
seeking, etc.
Manipulation, Exploitation: Meets own needs through covert manipulation, seduction, dishonesty, or conning
Passive-aggressiveness, Rebellion: Appears overtly compliant while punishing others or rebelling covertly through
procrastination, pouting, “backstabbing,” lateness, complaining, rebellion, non-performance, etc.
Excessive Orderliness, Obsessionality: Maintains strict order, tight self-control, or high level of predictability
through order & planning, excessive adherence to routine or ritual, or undue caution. Devotes inordinate time to
finding the best way to accomplish tasks or avoid negative outcomes.
- *Surrender**
7. Compliance, Dependence: Relies on others, gives in, seeks affiliation, passive, dependent, submissive, clinging,
avoids conflict, people-pleasing.
Avoidance
Social withdrawal, Excessive autonomy: Copes through social isolation, disconnection, and withdrawal. May
demonstrate an exaggerated focus on independence and self-reliance, rather than involvement with others. Sometimes retreats through private activities such as excessive tv watching, reading, recreational computing, or solitary work.
Compulsive Stimulation-seeking: Seeks excitement or distraction through compulsive shopping, sex, gambling, risk-taking, physical activity, novelty, etc.
- Addictive Self-Soothing: Avoids through addictions involving the body, such as alcohol, drugs, overeating, excessive masturbation, etc.
- Psychological Withdrawal: Copes through dissociation, numbness, denial, fantasy, or other internal forms of psychological escape
