History, social, ethical (MRCP) Flashcards

Question

``` Which of the following described delusions as un-understandable? A. Jean Piaget B. Erik Erikson C. Karl Jaspers D. Eric Fromm E. Aaron Beck ```

Answer 1

C. Jaspers was both a psychiatrist and a philosopher. He studied psychopathology in depth; the descriptive psychopathology and psychiatric phenomenology used in current psychiatric practice are largely Jasper’s contributions. According to him, a specifi c quality of delusions is their ‘un-understandability’. This distinguished primary delusions from delusion-like ideas or secondary delusions that arose out of a different psychopathology. for example hallucinations.

Answer 2

D. Contrary to widely held belief, spirituality is not defi ned as affi liation to religious practice or accepting God. It rather refers to deeply held beliefs about the meaning of one’s life.

Answer 3

C. The IPSS (International Pilot Study on Schizophrenia) was a global, multicentre study carried out by the WHO. The main fi nding was a strikingly similar core symptom profi le irrespective of cultural differences and more or less similar life-time morbid risk (though this has been disputed; See McGrath NAPE lecture 2004). Surprisingly, outcome of schizophrenia was better in the developing, rather than the developed countries.

Answer 4

B. Somatization is consistently found to be higher among South Asian populations, especially in females. Linguistic differences could explain an apparent inability to verbalize emotions, leading to requests for medical interventions for physical symptoms. Cultural sensitivity is essential to detect undiagnosed depression in different ethnic groups.

Answer 5

B. Using different interpreters for different sessions of clinical encounter with the same patient will lead to confusion and needless anxiety due to the presence of a new person during each doctor– patient meeting. It is advisable to stick to the same interpreter when dealing with a particular patient. Knowing the interpreter’s social and ethnic background might help in utilizing the interpretation better. Also, the Mental State Examination can be misinterpreted by a lay person – it is often necessary to instruct the interpreter to translate certain parts of the clinical interview verbatim

Answer 6

A. An unequal distribution of social class is noted in anorexia. Higher representation from upper classes of society, good literacy rates, and higher frequency of non-immigrant populations is noted among clinical samples of anorexia patients. This strengthens the aspect of culture specificity of anorexia nervosa

Answer 7

C. Sick role, as defi ned by Parsons, excludes patient from taking all responsibility for becoming ill. It is perceived that illness is unavoidable and any ill person must seek help, as illness is undesirable and an attempt must be made to restore the previous state of health. Untill this happens the person is relieved of certain social responsibilities. This social perception of illness drives a person to occupy what is collectively termed as the sick role.

Answer 8

D. Enmeshment has not been discussed as a component of expressed emotions (EE). Enmeshment stands for deranged family dynamics, characterized by blurring of normal hierarchy and intergenerational boundaries in a family. Enmeshment is linked to various child psychiatry problems, including eating disorders. EE is characterized by warmth, hostility, and critical comments and emotional over-involvement. High EE is implicated in relapse of various psychiatric illnesses, especially schizophrenia. It is also demonstrated that being on long-term antipsychotics can alleviate the relapse-provoking effect of a high EE environment to some extent. Vaughn and Leff studied EE in depth.

Answer 9

B. The Camberwell Assessment of Needs scale, also called as CAN, was developed by the Section of Community Psychiatry (PRiSM) at the Institute of Psychiatry. It is a tool for assessing the needs of people with severe and enduring mental illness, including both health and social needs. It has clinical and research versions, and also a shorter version for routine use. The Camberwell Family Interview is a different scale from CAN, and assesses the feelings and experiences of relatives with regard to a patient’s admission to hospital. In the Camberwell Family Interview, three measures of EE – criticism, hostility, and emotional over-involvement – are assessed.

Answer 10

A. It has been shown that the effect of high expressed emotions on relapse of psychotic episodes is lesser if contact with family members lasts less than 35 hours a week. This dose– response relationship adds strength to the role of the family’s emotional expression on the course of schizophrenia. The degree of EE can be higher if any of the family members has mental health diffi culties themselves.

Answer 11

D. It is widely acknowledged that captives may not be the ideal, representative sample of everyone who indulges in criminal activity. Captives may be a special population with lower than normal skills to escape or avoid a sentence or arrest. Often the IQ of captured criminals may be lower than the IQ of non-captured criminals, on average. So studying captives for the rate of mental illness or effect on crime secondary to treating mental illness could not be generalized to wider social criminalities. Most criminals are mentally sound. Crime is under-reported rather over reported, on the whole.

Answer 12

B. Various measures to combat stigma has shown only modest benefi ts over the century. Destigmatization campaigns, public education, and vigilant media policy can be helpful. It is clear that in the past few decades, the closure of asylums and psychiatric hospitals has increased community living of patients with mental health problems. But this has not translated into lower rates of stigma and discrimination – if anything this has got worse, assuming different forms

Answer 13

D. Stigma has not reduced in anyway over last two decades in spite of improved literacy rates. The perceived stigma is more generic for mental illness and does vary with the diagnosis to some extent. Stigma leads to delayed help seeking and social exclusion, making outcome worse

Answer 14

A. Acculturation is a social–anthropological phenomenon which refers to the adoption of cultural practices of one group by another due to the effect of living close to each other. It does not refer to being civilized or non-civilized in cultural practice. The tendency for a cultural group to enforce their values on another group is called assimilation. Acceptance of rules and regulations of a mental health institute is related to the process of institutionalization, described by Goffman

Answer 15

B. Koro is a culture-bound syndrome that is most often seen as genital retraction anxiety rather than delusional state. It usually affects young males, and is accompanied by anxiety that genitals are shrinking. It is an acute condition with favourable prognosis compared to chronic psychotic illnesses. It is often reported in Malaysia, Taiwan, Philippines, and other parts of south-east Asia. It is referred to as Shook Yang in Japan. Koro literally means head of a turtle (which retracts

Answer 16

B. Latah is a culture-bound syndrome seen mainly in women in south-east Asia. It is characterized by severe startle response together with loss of control over behaviour, echolalia, and echopraxia. Such patients are noted to obey any commands issued to them.

Answer 17

B. The prevalence of ‘all cause’ hallucinations are higher in the Caribbean population living in the UK compared to other ethnic groups. It is noted to be 2.5 times more common in this group. South Asian migrants come next in the list, followed by native White populations. Cultural differences exist not only in disease prevalence but also in non-clinical but abnormal mental experiences measured in community samples.

Answer 18

E. It is now accepted that immigration is a clear risk factor for developing schizophrenia, irrespective of the prevalence rates in the country of origin, genetic loading, or cannabis use. This effect is not limited to the generation that migrates – it extends to the second generation immigrants as demonstrated in the AESOP Study in the UK. It has also been shown that in neighbourhoods where minority status is signifi cant due to the high population of majority ethnic group in the locality and poor socioeconomic status of immigrants, incidence of schizophrenia is increased. This applies to any minority group irrespective of racial status.

Answer 19

C. Labelling theory was applied to explain mental illness in 1966 by Thomas Scheff. He claimed that mental illness is manifested solely as a result of societal infl uence. The society views certain actions as deviant. A label of mental illness is placed on those who exhibit deviant behaviours in order to explain these behaviours. The expectations then placed on these individuals unconsciously change their behaviour – giving them the role of mentally ill. Social causation and drift theories attempt to explain the association between lower socioeconomic status and mental illness. Social causation theory proposes that low socioeconomic status breeds mental illnesses. Social drift theory takes the view that a decline in social status occurs following development of mental illnesses.

Answer 20

B. Often patients who lack capacity to make treatment decisions agree to follow a treatment plan passively. This special group is termed ‘compliant not capable’. Learning disability services, dementia care, and geriatric care often face challenge with such patients. The Bournewood case refers to a patient with autism who was kept in hospital against the wishes of his carers as he complied with hospital admission. Though he did not have capacity to decide on his treatment he was not detained under the mental health act as he was compliant to stay at the hospital. This case revealed a wide gap in English mental health law.

Answer 21

B. Justice is one of four primary ethical principles. Justice is the moral obligation to act on the basis of fair judgement between competing claims. Justice is classifi ed into: (1) fair distribution of scarce resources (distributive justice); (2) respect for people’s rights (rights based justice); and (3) respect for morally acceptable laws (legal justice). In health ethics, distributive justice means equity for all where ‘equals are equally treated’; it concerns economic distribution and healthcare resource allocation

Answer 22

B. Capacity by defi nition is a legal concept; it refers to the ability to enter into valid contracts. Every adult is presumed to have capacity unless proved otherwise. Capacity is also task specifi c; one can have capacity to decide on treatment but can lack capacity to dispose of an estate. A test for capacity includes: (1) able to understand the nature of a decision that needs to be made; (2) able to weigh risks and benefi ts of any decision; (3) able to retain information long enough to make a decision; and (4) able to communicate the decision clearly. It is not necessary for the patient to believe in the information given to him.

Answer 23

B. For an informed consent to be valid, as a general rule, fi ve areas of information must be provided: (1) description of the medical condition or problem; (2) nature and purpose of the proposed treatment; (3) risks and benefi ts of the proposed treatment; (4) viable alternatives to the proposed treatment; and (5) prognosis with and without treatment. The most important ethical principle preserved by obtaining informed consent is that of patient autonomy

Answer 24

E. Personal information should not be disclosed to a third party without the patient’s express consent, except when: (1) serious risk to third parties outweighs the interests on patient’s privacy, for example child abuse; (2) disclosure of information is required by law, for example a notifi able disease; and (3) patient explicitly agrees to disclosure to a third party. Death of a patient does not waive one’s responsibility to maintain confi dentiality.

Answer 25

E. When a person is passively compliant it is necessary to consider absence of informed consent. This is often seen when patients are prescribed ECT – without knowing all required information, they will agree for a course of treatment passively as the doctor has prescribed it. Legal privilege is the right to maintain secrecy or confi dentiality when summoned by court. The right of legal privilege belongs to the patient. Therapeutic privilege is different from this legal privilege. Therapeutic privilege is used when a psychiatrist withholds information in the belief that giving a patient all of the information would harm the patient. This is not commonly practised. While detaining a patient under the mental health act, often there is no consent from the patient for hospitalization. But this is commonly done against patient’s approval on the grounds of safety of the patient and the others. An incompetent person is one who is incapable of giving informed consent; in which case, consent can be granted only by that person’s guardian, or other persons with legal authority to give consent (e.g. a lasting power of attorney for health-care issues). Consent is presumed when a person is suffering from an emergent situation that requires treatment but is unable to give consent. Waiver is a situation where a patient asks the therapist not to give him a particular part of health information as that would be detrimental for him to know it. Again, this is rarely used

Answer 26

E. Ethology refers to the biological study of animal behaviour. Imprinting is a specialized form of learning which occurs early in life (critical phase). The exposure to the stimulus situation must occur during the critical period, and the exposure can be of short duration without any reinforcement. This type of learning is particularly resistant to change. It has not been clearly demonstrated in human infants so far.

Answer 27

A. Two months before killing his exgirlfriend Tarasoff, Poddar had declared his intentions to his psychotherapist. The psychotherapist tried to have Poddar detained but he was soon released. Police were informed of the risk, but the court ruled that apart from a duty of care to the patient, and duty to protect by informing the police, there is a duty to warn the third party directly. This is called the Tarasoff ruling.

Answer 28

A. Impairment (I) is defi ned as any loss or abnormality of a bodily structure or function. Disability (D) is the restriction to perform an activity in a normal manner due to the impairment. The social disadvantage for a given individual in terms of role fulfi lment resulting from the disability is called handicap (H) (I leads to D; D leads to H). Reversibility of loss is not considered as a discriminating feature in defi ning handicap.

Answer 29

C. Goldberg conducted a survey of a national sample of males aged 25–34 on their fi rst admission to a mental hospital in England and Wales for schizophrenia. This showed an expected excess of patients in lower social class v Lower economic class was seen as a cause for schizophrenia (social causation). But when the social class distribution of the fathers at the time of the patients’ birth was studied, it transpired to be very similar to that of the general population. This is explained by the hypothesis that schizophrenia results in a downward drift of socioeconomic status rather than poverty being a cause for schizophrenia. (This social drift hypothesis was fi rst suggested by the Chicago study of Faris and Dunham, 1922–1934).

Answer 30

D. The Helsinki declaration is associated with research ethics. The efforts to streamline ethical principles of conducting research on human subjects started following the Second World War. Gillick competence refers to the assessment of ability of a child (16 years or younger) to consent to his or her own medical treatment, without the need for parental permission

Answer 31

A. Ballet dancers and models have a high prevalence of anorexia nervosa as a result of pressures to sustain a slim fi gure consistent with their professional requirements

Answer 32

A. Common law principle of necessity allows medical interventions only if they are life saving, emergency measures. Irreversible procedures such as transplantation cannot be carried out. It is not good practice to administer depot under ‘emergency’ situations. Psychiatric detention must follow Mental Health Act principles whenever required.

Answer 33

C. Running amok (derived from Malay word amuk, meaning ‘mad with anger’) is a Malaysian culture bound syndrome. It usually affects a young male who will develop a sudden frenzy and acquire a weapon in an attempt to kill or injure anyone indiscriminately. Amok episodes can lead to serious violence or suicide

Answer 34

A. Johann Christian Reil coined the term psychiatry to describe the practice of psychological medicine. He was a German doctor and used the word ‘Psychiatrie’ in 1808.

Answer 35

B. Thomas Szasz has expressed strong views against the current conceptual models of disease in psychiatry. Antipsychiatry refers to a heterogeneous school that challenges the fundamental theories and practices of psychiatry. Aubrey Lewis was an English psychiatrist associated with the Maudsley Hospital. Adolf Meyer proposed psychobiology.

Answer 36

D. Interpretation is an interview technique and not a boundary violation. It is increasingly realized that subtle violations of doctor–patient boundaries often occur in psychiatric setting. Boundary crossing is defi ned as intentional or unintentional incursions occurring during a therapeutic relationship. When such boundary crossings produce harm to the patient, then they are called boundary violations. This can be both sexual and non-sexual violation.

History, social, ethical (MRCP) Flashcards

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