Week 7 Flashcards
What is a refugee
A person who has been forced to leave their country of citizenship in order to escape:
War
Natural disaster
Persecution for reasons of race, religion, nationality, membership of a particular social group or politics
Public opinion shifted
In 1905 the ‘alien act’ ended the liberal attitude of welcoming refugees into britain
Asylum seeker
A person who has left their country of origin and applied for asylum in another country but whose application has not yet been concluded
Also a person who is not legally allowed to work and a person who’s benefit entitlement is only £39.63 Per week
What is an undocumented migrant
A person who enters or stays in the UK without the necessary documentation required under immigration regulations
It may be a person who has been trafficked into the country
It may be someone who has not yet received legal advice about their claim to asylum
it may be someone who has outstayed their visa
Moral reasoning
Any time we think about why something is the right or wrong thing to do we engage in moral reasoning
Doctors who can reason morally are better doctors
-better clinical performance
-fewer malpractice claims
Kohlberg’s stages of moral development
Stage 1: authority- punishment
Stage 2: egoistic exchange
Stage 3: “being good” (interpersonal conformity)
Stage 4: societal maintenance
Stage 5: the greatest good
Stage 6: commitment to ethical principles
Kohlbergs model expansion of earlier work by Piaget, developmental model this can be lifelong, the principle concern is justice and ‘justice reasoning’ is seen as pinnacle
Care ethics
Ultimate ethic is about meeting human need
‘This is the right thing to do because it fulfills the needs of this person’
Reductionist
Ignore the complexity of the situation reducing the complex human framework to something easy to work with
Applies abstract principles without much regard for the specifics of detail of the context
Is principally concerned with what is right- not really the downstream, longer term consequences
Fundamentally rights are competing- this is by nature an adversarial system there is the assumption that one individual must ‘win’ and that there will be a cost to be borne by others
The care response
Orientated arounds the needs of the wife and that these are ongoing
Not concerned with whether specific acts can be justified but with the ongoing, evolving situation
Seen this as part of an unfolding narrative where all are held in a web of relationships which need to be sustained in the longer term
Wiling to come up with a novel solution other then the two offered in order to achieve this- rejects a reductionist view of the situation
What is right depends on sacrifices what is right is what best meets the needs of everyone involved
A different worldview
Both justice and care are humanist in their derivation
Justice orients more around human rights care around human needs
Care ethics presents a completely different vision of what is an ethical society
Although care ethics was not described until the 1970s theres a clear care ethics element in the NHS constitution- concept of clinical need
Care itself has ethical value
Caring relationships have ethical import
Humanistic care
Attitudes and behaviour that demonstrate interest in and respect for patients psychological, social, spiritual concerns and values
Whole person care
Respect for peoples intrinsic value
Considering others perspectives
Suspending judgement
Recognising universality- finding common ground humility in the face of shared humanity
Relational focus
What are the legal entitlements of refugees
Become a citizen of the UK and have the same entitlements as every other citizen
Once granted refugee status have 28 days before eviction for asylum accomodation
Granted ‘leave to remain’ for 5 years
What do children develop
Cognitive: psychomotor skills, perception, memory, language, reasoning
Social: attachments, how to behave/rules, relationship, peer friendships
How do children develop
Piaget: developmental biologist, keen to understand how children see the world, children progress through a series of fixed stages, stages appear related to brain growth, brain not fully developed until late adolescence (males later)
Erikson: ascribed ‘psychological’ rather than ‘sexual’ stages of development, each stage has a normative crisis struggle 2 conflicting personalities, based on own observations and clinical practice
Vygotsky: emphasises social and cultural influences, microgenetic, ontogenic, phylogenetic and sociohistorical, tools of intellectual adaptation, zone of proximal development scaffolding guided participation
Birth-2 years
Cognitive: sensorimotor: acquire knowledge through sensory experiences and motor activity, changes from babies who respond through reflexes into goal orientated toddlers, process of 6 sub stages 0-2 years
Social:
0-1 years: trust vs mistrust, primary social is interaction with mother, trust in life sustaining care
1-2 years: autonomy vs shame & doubt, primary social interaction with parents, toilet training, holding on and letting go, the beginnings of autonomous will
2-7 years
Preoperational: aware only of immediate environment, thought remains empirical rather than logical, development of locomotion. Cannot generalise from one experience to another, differentiate poorly btw selves and outsides world, dont spontaneously conceptualise the internal parts of body, magical thinking-people have power over others, confuse physical and psychological causes of illness, developing language skills, dont understand permanence of death
3-5 initiative vs guilt: primary social interaction is nuclear family, start of ‘oedipal’ feelings, development of conscience as governor of initiative, identifies with own gender, enjoys group play
7-12 years
6-puberty: industry vs inferiority: primary social is interaction outside home, enjoys peer relationships of Same gender, impressed by older role models, learns behaviours from parents, peers, role models
Concrete operations: emergence of clear differentiation btw self and others, understand more than one dimension of situation, can still only understand phenomena from real world and not hypothetical situations
Age 12+ (at earliest)
Formal operations: begin to think hypothetically and abstractly, fill in gaps in their knowledge with generalisations from prior experiences, differentiate selves from external world
Adolescence: identity vs role confusion: primary interaction with peers/ heterosexual relations, identity crisis, consolidation from previous stages into coherent sense of self, orientated towards present rather than future, preoccupied with self presentation, physical maturity, initial sexual intimacy and self exploration, distancing from family, make own decisions etc
Early adulthood
Intimacy vs isolation: primary social interaction intimate relationships
Middle age
Generatively vs stagnation: primary social concern is establishing and guiding future generations
Old age
Integrity vs despair: primary social concern is a reflective one: coming to terms with ones place in the world and with relationships with others
Reasons for variation in development
Individual differences
Environmental factors
Developmental or congenital disorders
What to look for- problems with development
At any age- loss of skills or language
Up to 24 months: by 12 months no babble or gesture, by 18 no single words, by 24 no two spontaneous words
By 2 &3 years onwards: communication problems, lack of poor eye contact, extreme emotional reactions and aggression, over or under sensitivity to stimuli
Precocious puberty
Pubic hair or genital enlargement in boys with onset before 9.5 years, breast development in boys before appearance of pubic hair and testicular enlargement
Pubic hair before 8 or breast development in girls with onset before 7, menstruation in girls before 10
When puberty occurs too early
Hypothalamus signals the pituitary gland to release hormones that stimulate ovaries or testicles to make sex hormones
Induces early bone maturation and reduce eventual adult height, emotional and social consequences, can be harmful to children who are mature physically at a time when they’re immature mentally, develop a sex drive inappropriate for their age, could indicate presence of a tumour
Adolescence
Chronological age often used as marker-WHO= 10 years
Marked by onset puberty: attainment of reproductive maturity (primary), secondary sexual characteristics
Period of numerous hormonal changes
Dramatic physical and psychological changes
Continued brain development until late adolescence - connections between neurons not complete
Increasing independence and sexual curiosity
Puberty
Biological event- growth spurt
-boys-significant increase in muscle tissue
-girls- significant increase in fatty tissue
Typically starts earlier in girls
First period and first ejaculation definite markers
Biological reproductive maturity reached in teens sleep longer
Social and intellectual maturity takes longer
Early puberty
Breast cancer risk
Later maturing girls taller thinner
Why interested in adolescence health
Unhealthy behaviours predict later development of disease
Healthy behaviours initiated in childhood/ adolescence are likely to be maintained in adulthood
Adolescent risk taking behaviours tend to cluster
Aggression
Is a reasonably stable attribute for males and females
Children’s aggression can be reduced by creating play environments that are not aggressive
By using behaviour control procedures like time out and incompatible response technique
What affects a young persons body image
Pressure to live up to an ideal body type
Media
Parents and family members
Peers
Peer acceptance and popularity
Popular children- liked by many disliked by few
Rejected children- disliked by many liked by a few
Neglected children- few nominations as liked or disliked
Controversial children- who are liked by many peers by disliked by many others
Average status children- who are liked and disliked by a moderate number of peers
Peer popularity
Helps to have a pleasant temperament and academic skills
Good social-cognitive skills and behave in a socially competent way
Sexual activity and adolescence
Age of first sex decreased
Number of casual partners increased
Adolescent pregnancy associated with neonatal morbidity and mortality
Associated with increased risk of STDs
Adolescent pregnancy associated with less opportunities in life
Adolescent health determinants
Young people from disadvantaged backgrounds report lower levels of health promoting behaviours
Living in deprived areas-likely to be twice as likely to be obese twice as likely to report they smoke, twice as likely to conceive
More likely to be admitted to hospital for asthma
Globally
Unintentional injuries are leading cause of death and disability
Drowning is among top 10 causes of death, 2/3 are males
Suicide is second leading cause of death
Depression is another leading cause
~ 2.1 million adolescents were living with HIV in 2016
Among 15-19 year old females complications in pregnancy is leading cause of death
Building blocks of a healthy life
Having a place to call home
Secure and rewarding work
Supportive relationships with friends, family and community
Population as a whole is aging
Older population living longer
Improved health care
Decreases in infant and childbirth mortality
Improved standards of living
Development in the adult years
Types of ageing:
-primary- natural decline
-secondary- results from disease, disuse, or abuse
Limited changes after puberty:
-cognitive (piaget) and social (erikson)
-some small physical changes
Middle Ages onwards:
-women- menopause
-men- gradual decrease in sperm production and testosterone
Why do we age. Biological theories of ageing
Wear and tear
Cellular:
-type 1: Hayflick limit, limit to number times cells can divide, divisions decrease as we age
-type 2: cross linking, proteins in cells interact to produce molecules makes body stiffer, increase as we age
-type 3: free radicals, interact with molecules and cause cellular damage and shut organs down
-type 4: DNA is unable to replicate itself when cells divide/ DNA repair system
Rate of living
Programmed cell death
Physiological changes
Brain: age related structural changes in neurons, cell body and axon (neurofibrillary tangles), dendrites, plaques
Cardiovascular: accumulation of fat deposits, stiffening of walls of arteries due to tissue change
Respiratory: rib cage and air passageways become staffer
Appearance and movement: skin, muscle tissue decline, internal bone mass decline
Senses: transmissiveness/ cataracts
Immune function: changes in immune system cells
Psychological and cognitive changes
Information processing
Attention
Psychomotor speed
Mental and psychosocial health concerns
Organic mental disorders
Changing relationships
Cognitive abilities
Crystallised abilities, fluid abilities, steady decline in fluid abilities form 20-80, crystallised abilities improve until 60 then plateau
Memory, new learning, executive cognitive function, speech and language, visuo-special processing
Measurable changes with normal aging, cumulative knowledge and experimental skills well maintained, age related disease accelerate the rate of neuronal dysfunction, health lifestyle can decrease the rate of cognitive decline
Healthy lifestyle factors and cognitive decline
Physical activity
Mental stimulation
Avoiding excessive exposure to alcohol
Treating depression and managing stress
Controlling common medical conditions
Social relationships
Research has shown that social relationships are important for successful ageing
The more varied network the more healthier and happier a person will be
Menopause
End of reproductive years occurs in all women
Caused by a decline in oestrogen (& possibly endorphins) instability in thermoregulation
Primary symptoms: hot flushes and night sweats
Secondary symptoms: vaginal dryness, depression, somatic symptoms, fatigue
Larger cultural variations in hot flushes and night sweats
Treatment: has been HRT but less so now
Lifestyle impacted in occurrence and management of symptoms
Dementia
Family of diseases Alzheimer’s most common
High prevalence
Relentless progressive cognitive decline, permanent brain damage, incurable
Microscopic changes involving neurons, neurofibrillary tangles, neuritic plaques
Elder abuse
Risk factors: individual, relationships, community, socio cultural factors
Abuse within institutions
Ageing and health
People worldwide are living longer
Challenges to health and social care systems
Common conditions: hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis COPD, diabetes, depression and dementia
What is healthy ageing
WHO defines healthy ageing as the process of developing and maintaining the functional ability that enables wellbeing in older age
Persons ability to meet their basic needs
To learn, grow and make decisions
To be mobile
To build and maintain relationships
To contribute to society
Successful transition to retirement
Financial planning
Maintaining a life beyond work
If not motivated to retire- delay retirement
Keeps busy- voluntary work
Maintain friendships, see friends regularly make new friends
Be optimistic
Consultations with difficult personsalities
Histrionic patients
Dependent patients
Demanding patients
Narcissistic patients
Suspicious patients
Help-rejecting patients
Manipulative patients
Histrionic patients
Have a dramatic, emotional, overwhelming style of presenting
May be seductive towards their doctors because of fear that if not sexually desirable they will not be taken seriously
They often come across as emotional and flirtatious
The risk is that the doctor will respond inappropriately to the seductive charm of the patient
Dependent patients
Some patients need an inordinate amount of attention and yet do not appear to feel reassured
Needy, passive and clinging behaviour a fear of separation, inability to make decisions even everyday decisions without reassurance
They’re likely to make repeated urgent calls between appointments and to demand special consideration
Risk that doctor may react with callous disregard
Demanding patients
Difficulty delaying gratification and demand that their discomfort and problems be eliminated immediately
They often act entitled and superior to mask their own sense of helplessness and weakness while engendering depression fear and rage
They’re easily frustrated and can be angry and hostile
Narcissistic patients
Trait of self love
Grandiosity an excessive need for admiration, personal disdain and lack of empathy for other people
These patients act as though they’re superior to everyone else including doctor
Initially they may idealise doctor but soon changes to feeling of contempt for doctors inadequacies
May be rude arrogant hostile and demanding
Suspicious patients
Have a chronic deeply ingrained suspicion that other people are unreliable and untrustworthy and only want to cause them harm
They’re likely to misinterpret neutral events as evidence of a conspiracy against them
May behave in a hostile or stubborn manner. They may be sarcastic which often elicits a hostile response from others which may seem to confirm their original suspicions
Hypersensitive to criticism, argumentative and defensive
Help rejecting complainer
Some patients only appear to communicate through a litany of complaints and disappointments
They often blame others
Also make people feel guilty for not doing enough or caring enough
May see themselves as self sacrificing
When help is offered they usually respond by saying “yes but..”
Manipulative patients
Patients who appear to use lying and manipulative acts as a means of communicating
They may use malinger to gain external objectives such as insurance settlements or obtain narcotic analgesia
May also have history of using violence as a means of obtaining their wishes or use threats of self harm to control doctors behaviour
Diagnoses in disputed territory
Somatisation disorder
Hypochondriacal disorder
Conversion disorder
Body dysmorphic disorder
Factitious disorder and Factitious disorder by proxy
Somatisation
Occurs when a patient with psychiatric disorder or psychological difficulties presents with physical symptoms which are attributed to a physical cause
Addressing psychological issues reduces or eliminates physical symptoms
Factors predisposing to development of Somatisation: childhood illnesses, family illness and consultation in childhood, physical illness in childhood, experiences and satisfaction with medical consultations, illness in family and friends, publicity in Tv and newspapers, knowledge of illness and treatment
Somatisation disorder
A history of at least 2 years complaints of multiple and variable physical symptoms that can’t be explained by any detectable physical disorders
Preoccupation with symptoms causes persistent distress and leads patient to seek repeated consultations or sets of investigations with either primary care or specialists doctors
Persistent refusal to accept medical advice that there is no adequate physical cause for the physical symptoms
Hypochondriacal disorder
Pre-occupation with fears of having a serious disease based on misinterpretation of bodily symptoms
Pre-occupation persists despite negative medical evaluation
Belief is not of delusional intensity
Symptoms last for 6 months of longer
Conversion disorder
Condition that presents as an alteration or loss of physical function suggestive of a physical disorder
Psychological conflicts or stressors precede the initiation or exacerbation of symptoms
Symptoms are not intentionally produced but are the result of unintentional or unconscious motives
After appropriate medical evaluation the condition cannot be explained by any physical disorder or any known pathological mechanism
Explanation: psychodynamic theory holds that symptoms are caused by the repression of unconscious psychological conflict the anxiety produced is converted into physical symptoms
La Belle indifference- a patient seems surprisingly unconcerned about their physical symptoms
Types of conversion disorder
Motor symptoms eg weakness
Sensory symptoms eg sensory loss, blindness, diplopia
Seizures or convulsions
Mixed presentation
Body dysmorphic disorder
Preoccupation with an imagined defect in appearance or if a slight physical anomaly is present, the persons concern is markedly excessive
The preoccupation causes clinically significant distress or impairment in functioning
Need to exclude other disorders
Sudden onset, sudden termination, sudden reappear nee
Most common preoccupations are with the nose, skin, hair, eyes, eyelids, mouths, lips, jaw and chin
Any part of the body can be involved and the preoccupation may is frequently focussed on several body parts
Perceived or slight flaws on the face, the size of the feature, acne, scars, wrinkles, altered complexion and asymmetry
Factitious disorder
Originally described by Asher in 1951
He described a number of patients usually admitted to hospital with apparently acute illness supported by plausible but dramatic history which is later to be found to be full of falsification
Previously known as Munchausen syndrome named after Baron von Munchausen 1720-97 who travelled extensively and told fantastic anecdotes
Intentional production of physical or psychological signs or symptoms
Motivation is to assume the sick role
External incentives for the behaviour ie financial gain are absent
Types of Factitious disorder
Acute abdominal type most common, included ingestion of foreign objects
Haemorrhagic type
Neurological type: convincing presentation of seizures, faints, headaches, cerebellar symptoms
Cutaneous type
Cardiac type
Respiratory type
Mixed and polysymptomatic type
Factitious disorder by proxy
Physical or psychological symptoms or signs intentionally produced or invented by a parent or carer
The perpetrator at least initially denies inventing or causing symptoms or signs
The symptoms or signs diminish when child is separated from perpetrator
Features: apnoea or seizures, false stories or smothering, repetitive poisoning, simulated bleeding
Here the parent seeks to assume the sick role by proxy
Important: child protection issues
Malingering
Consciously motivated
Intentional production of signs or symptoms
Clear external incentives: avoid jail or military, obtain drugs (opioid analgesics), obtain food and shelter
Personal issues HCP
HALT: hungry, angry, late, tired
Identifying with patients
Sexual inappropriateness
Patients we dont like
Conflicts of interest
Transference/ counter transference
Issues with identifying with patients
Over identification
Potential lack of appropriate detachment
Transference and counter transference
Project irrational feelings and attitudes from the past onto people in the present
Unconscious attitudes that a clinician or therapist develops towards a client in response to a clients behaviour
