Week 7

Question 1

What is a refugee

Answer 1

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

Question 2

Public opinion shifted

Answer 2

In 1905 the ‘alien act’ ended the liberal attitude of welcoming refugees into britain

Question 3

Asylum seeker

Answer 3

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

Question 4

What is an undocumented migrant

Answer 4

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

Question 5

Moral reasoning

Answer 5

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

Question 6

Kohlberg’s stages of moral development

Answer 6

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

Question 7

Care ethics

Answer 7

Ultimate ethic is about meeting human need
‘This is the right thing to do because it fulfills the needs of this person’

Question 8

Reductionist

Answer 8

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

Question 9

The care response

Answer 9

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

Question 10

A different worldview

Answer 10

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

Question 11

Humanistic care

Answer 11

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

Question 12

What are the legal entitlements of refugees

Answer 12

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

Question 13

What do children develop

Answer 13

Cognitive: psychomotor skills, perception, memory, language, reasoning
Social: attachments, how to behave/rules, relationship, peer friendships

Question 14

How do children develop

Answer 14

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

Question 15

Birth-2 years

Answer 15

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

Question 16

2-7 years

Answer 16

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

Question 17

7-12 years

Answer 17

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

Question 18

Age 12+ (at earliest)

Answer 18

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

Question 19

Early adulthood

Answer 19

Intimacy vs isolation: primary social interaction intimate relationships

Question 20

Middle age

Answer 20

Generatively vs stagnation: primary social concern is establishing and guiding future generations

Question 21

Old age

Answer 21

Integrity vs despair: primary social concern is a reflective one: coming to terms with ones place in the world and with relationships with others

Question 22

Reasons for variation in development

Answer 22

Individual differences
Environmental factors
Developmental or congenital disorders

Question 23

What to look for- problems with development

Answer 23

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

Question 24

Precocious puberty

Answer 24

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

Question 25

Adolescence

Answer 25

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

Question 26

Puberty

Answer 26

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

Question 27

Why interested in adolescence health

Answer 27

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

Question 28

Aggression

Answer 28

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

Question 29

What affects a young persons body image

Answer 29

Pressure to live up to an ideal body type Media Parents and family members Peers

Question 30

Peer acceptance and popularity

Answer 30

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

Question 31

Peer popularity

Answer 31

Helps to have a pleasant temperament and academic skills Good social-cognitive skills and behave in a socially competent way

Question 32

Sexual activity and adolescence

Answer 32

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

Question 33

Adolescent health determinants

Answer 33

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

Question 34

Globally

Answer 34

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

Question 35

Building blocks of a healthy life

Answer 35

Having a place to call home Secure and rewarding work Supportive relationships with friends, family and community

Question 36

Population as a whole is aging

Answer 36

Older population living longer Improved health care Decreases in infant and childbirth mortality Improved standards of living

Question 37

Development in the adult years

Answer 37

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

Question 38

Why do we age. Biological theories of ageing

Answer 38

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

Question 39

Physiological changes

Answer 39

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

Question 40

Psychological and cognitive changes

Answer 40

Information processing Attention Psychomotor speed Mental and psychosocial health concerns Organic mental disorders Changing relationships

Question 41

Cognitive abilities

Answer 41

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

Question 42

Healthy lifestyle factors and cognitive decline

Answer 42

Physical activity Mental stimulation Avoiding excessive exposure to alcohol Treating depression and managing stress Controlling common medical conditions

Question 43

Social relationships

Answer 43

Research has shown that social relationships are important for successful ageing The more varied network the more healthier and happier a person will be

Question 44

Menopause

Answer 44

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

Question 45

Dementia

Answer 45

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

Question 46

Elder abuse

Answer 46

Risk factors: individual, relationships, community, socio cultural factors Abuse within institutions

Question 47

Ageing and health

Answer 47

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

Question 48

What is healthy ageing

Answer 48

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

Question 49

Successful transition to retirement

Answer 49

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

Question 50

Consultations with difficult personsalities

Answer 50

Histrionic patients Dependent patients Demanding patients Narcissistic patients Suspicious patients Help-rejecting patients Manipulative patients

Question 51

Histrionic patients

Answer 51

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

Question 52

Dependent patients

Answer 52

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

Question 53

Demanding patients

Answer 53

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

Question 54

Narcissistic patients

Answer 54

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

Question 55

Suspicious patients

Answer 55

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

Question 56

Help rejecting complainer

Answer 56

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..”

Question 57

Manipulative patients

Answer 57

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

Question 58

Diagnoses in disputed territory

Answer 58

Somatisation disorder Hypochondriacal disorder Conversion disorder Body dysmorphic disorder Factitious disorder and Factitious disorder by proxy

Question 59

Somatisation

Answer 59

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

Question 60

Somatisation disorder

Answer 60

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

Question 61

Hypochondriacal disorder

Answer 61

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

Question 62

Conversion disorder

Answer 62

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

Question 63

Types of conversion disorder

Answer 63

Motor symptoms eg weakness Sensory symptoms eg sensory loss, blindness, diplopia Seizures or convulsions Mixed presentation

Question 64

Body dysmorphic disorder

Answer 64

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

Question 65

Factitious disorder

Answer 65

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

Question 66

Types of Factitious disorder

Answer 66

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

Question 67

Factitious disorder by proxy

Answer 67

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

Question 68

Malingering

Answer 68

Consciously motivated Intentional production of signs or symptoms Clear external incentives: avoid jail or military, obtain drugs (opioid analgesics), obtain food and shelter

Question 69

Personal issues HCP

Answer 69

HALT: hungry, angry, late, tired Identifying with patients Sexual inappropriateness Patients we dont like Conflicts of interest Transference/ counter transference

Question 70

Issues with identifying with patients

Answer 70

Over identification Potential lack of appropriate detachment

Question 71

Transference and counter transference

Answer 71

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