Terms to Know Flashcards
Gender Identity
Internal sense of being male/female/not comforming to either
It is not the same as sexual orientation or the physical characteristics defining biological maleness or femaleness.
Sexual orientation
Individuals preferred sexual preference
Does not imply what sexual experiences that person has had
Transgender
Self identity and general sense of self doesn’t not conform to the physical gender
Gender identity is influenced by culture, race, class, etc. becasue norms differ in each group or society
Gender nonconforming in one setting may be conforming in another
Can imply a diverse blending of male and female roles/characteristics/expression rather than distinguishing between extremes of male and female
Transsexual
A person who has undergone treatment to become recognizable as a gender different from their birth or assigned gender
Gender non-conforming
Not corresponding to usual male/female identity of that culture
Gender dysphoria
Physical or assigned gender does not align w/ gender identity and causes distress.
The physical and psychological mismatch is not a pathology, but the stress that it causes is
Goal of treatment is to reduce distress.
Rx includes feminizing and masculizing hormones, sex reassignment surgery, counseling. Effective rx is unique to each person.
Gender conforming or cis-gender
Gender identity and assigned gender are the same
Prevalence of transgender/transsexual/gender nonconforming
Difficult to study
Male to female: 1:7000 - 1:20,000
Female to male: 1:33,000 - 1:500,000
Most frequently cited is 0.3%
Mental health issues of transgender individuals
High incidence of anxiety and depression
Not inherent to being transgender
Related to “minority stress”
90% face gender discrimination
26-54% of transgender youth have attempted suicide
Factors influencing
Interplay of biology, environment, culture
Awareness of gender identity develops in early childhood and is influenced by childhood experience
Sexual differentiation of the brain in the presence of androgens
Genetics
Disorders of sexual development
These patients have a discrepency between external genitalia and gonadal and chromosomal makeup
Typicall in the past a gender at birth based on apperance of genitalia
Ambigious genitalia - variation in urethral opening, clitoral or penile size, location of gonads, partial fusion of labia
Studying these individuals shows us that prenatal and postnatal androgen exposure influences gender identity.
Gender Identity Genetics
Studies of monzygotic twins shows 39% concordance of gender dysphoria
No specific gene
Pubertal suppression
Completely reversible delay of the development of secondary sex characteristics to provide time to explore gender identity before permanent changes.
Buys time
Male to female: GnRH or progesterone
Female to Male: GnRH
Early use may avert social and emotional consequences better than later use
Complications: decreased bone density, decreased attainment of height, insufficient development of penile tissue for vaginoplasty
Can be used for a few years and then oophorectopmy or orchiectomy can be performed.
Suppresses ovulation and sperm production
Hormone Therapy
50% use illegaly obtained hormones due to barriers to health care
Lack of insuarance, lack of providers willing to perscribe, lack of coverage of hormones, and surgery and mental health care
Patient must have diagnosis of gender dysphoria established by a qualified mental health provider
Informed consent
Other mental health issues should be addressed
Estrogen therapy
Contraindicated w/ history of DVT, estrogen dependent neoplasm, or cirrhosis
Increased risk for embolism, gall bladder disease, weight gain, hyperlipidemia, lft abnormalities
Possible increased risk for: CV disease, HTN, type II DM
No evidence for increased risk for breast cancer
Spironolactone allows for smaller dosages for the same effects.
Tolerance
A reduced sensitivity requiring higher quantities of alcohol to achieve the same effects
Withdrawal
A set of sx that occur when an individual reduces or stops alcoholic consumption after long periods of uses
Withdrawal Syndrome
Two of the following
Increased hand tremor Insomnia N/V Transient hallucinations Psychomotor agitation Anxiety Tonic-clonic seizures Autonomic instability
Craving
Desire or urge to consume alcohol
Physical
Psychological
Patterns of Alcohol Use
Men drink more than women
Whites have the highest rates of alcohol use, Asians the lowest
The majority of AI people did not drink last month
Increasing education is associated w/ increased use
AI have highest binge rate
Trend = better off –> more social drinking but less binge; worse off –> less social drinking but more binge drinking
CAGE Assessment
Cut Down - have you ever felt you should cut down on drinking?
Annoyed - have people annoyed you by criticizing your drinking
Guilty - Have you ever felt bad about your drinking
Eye opener - have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover.
Asessment of alcohol abuse
AUDIT
Treatments
Alcoholic Anonymous (AA) Motivational Interviewing (MI) Relapse Prevention (RP) Harm Reduction
AA
Self-help approach
12 step program
Spiritual basis
Abstinence based
Motivational Interviewing
Person centered
GOAL ORIENTED
method of communication
enhancing intrinsic motivation to change
exploring and resolving ambivalence
Stages of Change
Precontemplation Contemplation Determination/Preparation Action Maintenance
Goal is to move along path, not get to zero
A few simple non judgemental statements can make a huge difference
Ask, Assess, Advise, Assist
SPIKES
Setting Perception Invitation Knowledge Emotions Strategy
For breaking bad news
When can I decline to treat
Scope of practice (legal and ethical)
Clinical skills (legal and ethical)
Exposure of infection (legal; not ethical)
Torture/Execution (ethical?; legal?)
Referral (not legal or ethical)
Reproductive health (legal and ethical) *
*separates personal and professional ethical assessment –> conscience clauses
Conscience clauses
For reproductive health –> legally permit professionals to not provide certain medical services, based on MD’s personal beliefs (i.e. ocps, abortion, stem cell rx) in some cases also applies to refusing to provide info about referrals for these services
Substituted judgement
Decisions based on patient pregerences
Sources for guidance for SJ -written documents; living wills (legal forms) -Discussion -Life story, life style "biographic knowledge"
Bests Interests
Pt wishes unknown or never known
Decision on what is best for the patient
Sources for guidance:
- pain and suffering
- Functionality; prognosis
BI is only used if no info on patients thoughts
When you don’t need informed consent
EMTALA (legal)
Children (legal age)
Good Samaritan
Best interests criteria vs default of full care (ethical)
Futility
Aka non-beneficial care
Not obliged to provide care that you don’t believe to be scientifically beneficial
Limits pt autonomy –> pt can’t demand care
Assessed using: clinical prognosis (MD assessment); social, spiritual, perosnal, family goals (pt assessment), costs and benefits (societal assessment)
When can we forego medical interventions
When it is likely to offer little benefit to patient (i.e. CPR, feeding tube, ventilation, dialysis).
But may be perceived as life extending – then not forego unless all agree
Facilitated by trusting Dr-Pt relationship
Ethics:
- ) first align autonomy & beneficence
- ) understand/explain non-maleficence
Conflicting interest
Risk of use can compromise patient outcome
Financially: investment in drug under investigation; enrollment fees; inducements; prescribing to owned facilities
Legal and Ethical issue
Avoid conflicts, and when cannot –> disclose conflicts (clinically; giving talks; publishing etc.)
Competing issue
Both have claim and must happen
Negotiate to accomplish both (i.e. kid at soccer game and clinic or have assistant do informed consent to avoid coercion)
Ethical not legal issue
Privacy
Limited government role
Family decisions; family planning; abortion
Termination of life-sustaining treatment
Confidentiality
Government involved
HIPAA : letter and spirit of the law
Key is to never open a chart w/o a legitimate reason
Confidentiality exception issues
Public health reporting (infectious - epidemiology, containment, contacts, notificaiton, vaccination, quarantine-, firearms, elevated blood lead, cancer, birth defects)
Tarasoff - known risk factors to known persons
Impaired professionals
Emancipated minors
Patients/others at risk (think driving in elderly)
Tarasoff v U of Cal
A case in which the Supreme Court of California held that mental health professionals have a duty to protect individuals who are being threatened with bodily harm by a patient. The original 1974 decision mandated warning the threatened individual, but a 1976 rehearing of the case by the California Supreme Court called for a “duty to protect” the intended victim. The professional may discharge the duty in several ways, including notifying police, warning the intended victim, and/or taking other reasonable steps to protect the threatened individual.
Shiavo
The trial included testimony from eighteen witnesses regarding her medical condition and her end-of-life wishes. Michael Schiavo claimed that his wife would not want to be kept on a machine where her chance for recovery was minuscule. According to Abstract Appeal Trial Order, her parents “claimed that Terri was a devout Roman Catholic who would not wish to violate the Church’s teachings on euthanasia by refusing nutrition and hydration.” Judge Greer issued his order granting the petition for authorization to discontinue artificial life support for Terri Schiavo in February 2000. In this decision, the court found that Terri Schiavo was in a persistent vegetative state and that she had made reliable oral declarations that she would have wanted the feeding tube removed.[21] This decision was upheld by the Florida Second District Court of Appeal[24] (2nd DCA) and came to be known by the court as Schiavo I in its later rulings.[25]
Tuskagee Syphilis Study
as an infamous clinical study conducted between 1932 and 1972 by the U.S. Public Health Service to study the natural progression of untreated syphilis in rural African-American men in Alabama. They were told that they were receiving free health care from the U.S. government.[1]
Baby Jane Doe
The Baby Doe Law or Baby Doe Amendment is the name of an amendment to the Child Abuse Law passed in 1984 in the United States that sets forth specific criteria and guidelines for the treatment of seriously ill and/or disabled newborns, regardless of the wishes of the parents.
Proxy
Decision maker picked by patient
Surrogate
Decision maker picked by patient
Guardian
Decision maker chosen by courts
Conservator
Decision maker chosen by courts
Basic Principles of Motivational Interviewing
Collaborate
Evoke
Encourage
Elicit values, fears, hopes, and expectations, feelings
Barriers to Change
Social - norms, secondary gain
Spiritual - suffering/depressed
Psychological - depressed/anxious
Biology - exercise hurts
Typical Day assessment
Good way to gather a lot of information
Develops rapport
Unhealthy behaviors tend to cluster in individuals
Chance to aks “how do you feel about … smoking, drinking, lack of exercise, etc.”
Questions to elicit change talk
Desire: Do you want, like, hope…?
Ability: Is it possible, what could you do? How would you do that?
Reasons: What would the benefits be for you? Why would you make this change?
Need: What should/do you need to do.
Remember D.A.R.N. change is hard!
Questions to initiate conversations about change
What are the benefits and drawbacks to the proposed plan for change?
It sounds like you don’t like… What would you like? Because? How would that feel?
What can the medication do for you?
What worries you the most about surgery?
What problems have you had with exercise in the past?
Four productive questions to ask in MI?
How important is this change to you?
How confident are you that you can make this change?
How has this behavior kept you from moving forward?
Does it feel like there is a block?
How to properly listen
Eye contact
Reflect what you’ve heard every 1-2 min
First part is most important
Silence is OK
I’m sorry- can be enough
Be honest w/ your time limitations
If you feel stuck, the patient probably does too. Listen for tone in voice.
REFLECTIVE LISTENING. SUMMARIZE EARLY AND OFTEN.
Change talk that predicts action
Commitment: I am going to, I will, I intend to…
Taking steps: I actually went out and…
Informing patient in motivational interview
Don’t overwhelm patient
Consider the priorities of the patient***
Offer choices
Talk about what others do
Deliver w/ care
Ask permission
Support home and optimism for change
Reasons why a patient doesn’t hear you
Bewildered Overwhelmed High emotion Mood Distractions White coat syndrome Want's to look good for you
Motivators
Make it personal!
People change when they see change as relevant to something important to them (activities, identity, values)
Recreation Relationship Sex Work Family
Identities can motivate change (good parent, spiritual, good christian, good spouse/partner, responsible)
Why people do not change
Ambivalence
Resistance
Personal struggles
Ambivalent patient
Most people want to feel healthier and feel uncomfortable with change
Patients usually know good reasons for change and they enjoy the status quo too
Reason to change
Reason not to change
Stop thinking about change
Ask patient to tell you their pros and cons
Ask what’s next
Resistant patients
Natural tendency
Pushing for adherence can decreases adherence!!!
Many reasons for resistance to change (money, lack of support, religious beliefs, etc)
Key is to ask about sources of resistance, avoid arguing/lecturing/reflect/offer empathy
Encourage the patient to come up w/ a new perspective/way to solve the problem
Ask what has worked in the past.
Use scale 1-10
I can see what you mean but…
Offer patience and acceptance
Reflect both sides of patient’s ambivalence
Just tell me what you think I should do
Ask how will this work for you?
I really can’t cope at all…
Patient overwhelmed
Convey understanding
Point out patient strengths
Chronic Pain Patients
Use more time
Furstrating - no concrete findings
Psych and Social problems exacerbate sx
Legal problems (litigation, rx for drug abuse, rx forgery
Stages of Chronic Pain
- ) Injury
- ) Initial Distress
- ) exacerbation of pscyhological and social problems
- ) Acceptance of sick role - family patterns, disability
How many severely suicide commiters have seen a pcp in last month? Psychotherapist?
45% PCP
20% therapist
Referral issues w/ mental health
1/3 to 1/2 of primary care patients refuse referral to a mental health professional
Being seen medically does what to depression prevalence
Goes up w/ more intense care
5% in general pop
10% in medical outpatient setting
15% in inpatient.
Why integrate behavior health and physical care services
We don’t have enough time - 6 problems for 13 minutes
- ) compromised physical health is associated w/ behavioral health prblems
- ) Compromised behavioral health may lead to physical problems
- ) Stigma and underutilization/underavailability of mental health services
- ) Compartmentalized understanding of health
Factors underlying link between heart disease and a/d
- ) Lack of self-care - poor diet, minimal exercise
- ) Sleep problems - insomnia triples heart risk
- ) Obesity –> depression –> heart dx
- ) Blood vessels changes - a/d have increased production of free radicals and fatty acids
- ) Stress - increased insulin and cholesterol levels, increased bp, effects on immune system
Anxiety doubled risk of death from any cause
D&A triple risk (70% were heart attacks)
Core Components of Integrated Care
- )Biopsychosocial Spiritual model
- ) Collaboration - flattened hierarchy, mutual respect
- ) Three world view -financial clinical, and operational points of view in mind when treating patient
Process of Coping
Environmental Event (i.e. test) –> Primary Appraisal (assessment of the situation i.e. must pass test) –> Secondary Appraisal (assessment of resources that are available i.e. notes, flaschcards, etc.) –> coping behaviors (i.e. studying, sleeping, eating well) –> coping outcome (biological, psychological, and behavioral)
Coping is adaptive if it decreases stress
Coping is maladaptive if it makes stress worse
Coping techniques
Relaxation CBT Stress inoculation Exercise Social Support Pharmacologic interventions (B-blockers and benzos are first line for phsyiologic stress relief) Biofeedback
Learned helplessness
Repeated efforts to exert control in situations that fail to achieve an organism’s desired effects lead to a sense of helplessness or loss of sense of control.
