Behavioral-sciences-dr-mowadat rana (1).pdf

Behaviour physcology by Dr Mowadat Rana for BSN and MBBS student

1. CONTENTS
Section
A.
1
Introduction
to
Behavioural
Sciences
1
Holistic
vs.
Traditional
Allopathic
Medicine
2
Health
Care
Models
and
their
Clinical
Applications
3
1.
Bio-Psycho-Social
(BPS)
model
of
health
and
disease
3
2.
The
Integrated
ModeL
of
Health
Care:
Correlation
of
Body,
Brain,
Mind,
Spirit
and
Behavioural
Sciences
5
3.
The
Public
Health
Care
Model
g
Non-pharmacologicaL
Interventions
(NPIs)
in
Clinical
Practice
11
1.
Communication
Skills
11
2
Counselling
14
3.
Informational
Care
(IC)
16
.
Handling
Difficult
Patients
and
their
Families
i8
5.
Breaking
Bad
News
20
6.
Crisis
Intervention
and
Disaster
Management
27
7.
Confticl.
Resolution
29
Empathy
32
Sample
MCQs
and
Essay
Questions
33
Section
B
35
Medical
Ethics
and
Professionatism
36
Relevance
of
Ethics
in
the
Life
of
a
Doctor
37
;.
Scope
and
Meaning
of
Medical
Ethics
37
2.
Guiding
Principles
of
Medical
Ethics
38
3.
Common
Ethical
Issues
in
Medical
Practice
39
4.
Common
Ethical
Dilemmas
in
a
Health
Professonat’s
Life
43
.
Doctor-Patient
Relationship
48
Rights
and
Responsibilities
of
Patients
and
Doctors
49
a.
Rights
of
the
Patient
49
b.
Responsibilities
of
the
Patients
50
c.
Rights
cf
the
Doctor
50
d.
esponsibilities
of
the
Doctor
50

2. Psychological
Reactions
in
Doctor-Patient
Relationship
52
a.
Social
bonding
52
b.
Dependence
53
c.
Transference
53
U.
Counter-transference
54
e.
Resistance
55
f,
Unwell
Physician
/
Burn-out
56
Professionalism
in
Heatth
Care
57
-
a.
Knowledge
57
b.Skills
57
c.
Attitudes
58
Sampte
MCQs
and
Essay
Questions
61
Section
C
63
Psychotogy
in
Medicat
Practice
63
a.
Role
of
psychologicaL
factors
in
the
aetiology
of
health
probLems
63
b.
Role
of
psychological
factors
in
the
precipitation
(triggering)
of
iltnesse
63
c.
Role
of
psychological
factors
in
the
management
of
illnesses
64
U.
Role
of
psychological
and
social
factors
in
diseases
causing
disability.
handicap
and
stigma
64
e.
Role
of
psychological
factors
in
patients
reactions
to
illness
64
f.
Medicat[y
Unexplained
Physical
Symptoms
(MUPS)
64
Principles
of
Psychology
65
1.
Learning
65
2.
Metacognition
72
3.
Memory
74
4.
Perception
81
5.
Thinking
85
6.
Emotions
92
7.
Motivation
94
8.
Intelligence
97
9.
Personality
Development
101
NeurobiologicaL
Basis
of
Behaviour
108
Emotion
109
Language
114

3. Memory .
116
ArousaL .
117
Sleep
118
Sample
MCQs
and
Essay
Questions
123
Section
D
125
Socio[ogy
and
Anthropology
125
Introduction
125
1.
Sociology
and
Health
127
2.
Anthropology
and
Health
135
Sample
MCQs
and
Essay
Questions
141
Section
E
143
Psychosociat
Aspects
of
Health
and
Disease
143
Health
and
NormaLity
143
Defence
Mechanisms
145
Psychosocial
Assessment
in
Health
Care
14$
ClinicaL
Situations
Demanding
a
Comprehensive
PsychosociaL
Assessmer
148
Psychological
reactions
to
IlLness
and
Hospitalization
149
Psychosociat
Assessment
...
153
Psychosocial
Issues
in
SpeciaL
Hospital
Settings
157
a.
Coronary
Care
Unit
157
b.
Intensive
Care
Unit
158
c.
The
Emergency
Department
159
d.
Psychosocial
Aspects
of
Organ
Transplantation
159
e.
The
Dialysis
Unit
i6o
f.
Reproductive
Health
161
g.
Paediatrics
Ward
163
h.
Oncology
167
i.
Operating
Theatre
168
PsychosociaL
Peculiarities
of
Dentistry
170
PsychosociaL
Aspects
of
Atternative
Medicine
174
Common
Psychiatric
Disorders
in
General
Health
Settings
175

4. a.
Mixed
Anxiety
and
Depression
in
b.
Panic
Disorder
179
c.
Unexplained
Somatic
Complaints:
Persistent
Complainers
181
d.
Dissociative
and
Possession
States
182
e.
Drug
Abuse,
ALcohol
&
Tobacco
Use
184
f.
Suicide
and
Deliberate
SeLf
harm
(DSH)
188
g.
Delirium
189
PsychosociaL
Aspects
of
Gender
and
SexuaLity
192
Sexual
Identity
192
Gender
Identity
193
Sexual
Behaviour
194
Gender
differences
in
Sexual
Behaviour
194
Masturbation
195
Sexual
orientation
195
Psychiatric
morbidity
ig6
SexuaL
Disorders
196
SexuaL
Dysfunction
196
Disorders
of
SexuaL
Preterence/
Paraphilias
197
Gender
Dysphoria
(DSM
V)
or
Gender
Identity
Disorder
(lCD
io)
198
Management
of
Gender
and
Sexuality
Issues
199
PsychosociaL
Aspects
of
Pain
201
Psychosocial.
Aspects
of
Aging
207
Psychosocial.
Aspects
of
Death
and
Dying
210
Psychotrauma
211
Psychosocial
Aspects
of
Terrorism
214
Stress
and
its
Management
220
Job-related
Stress
&
Burnout
222
Response
to
stress
222
Stress
Management
225
Sample
MCQs
and
Essay
Questions
228
Appendix
230
Suggested
Reading
232

5. £4Pt’

6. hitroduction
to
Behavioura’
Sciences
As
the
name
implies,
behavioural
sciences
deal
with
the
study
of
human
behaviour
through
an
integrated
knowledge
of
psychology.
neuroscience,
sociology
and
anthropology.
It
is
now
widely
recognised
that
the
psychological
and
social
sciences
play
a
role
equal
to
biotogical
sciences
in
determining
states
of
health
and
disease.
Amongst
the
behavioural
sciences,
psychology
and
neuroscience
contribute
to
the
study
of
the
human
mind
and
the
roLes
played
by
its
various
functions.
They
examine
the
role
of
functions
such
as
emotions.
thoughts,
cognitions.
motivations,
perceptions,
and
intelligence
in
maintaining
health
or
causing
disease.
Psychology
also
seeks
to
understand
how
the
development
of
personality
takes
place.
Another
major
influence
on
human
behaviour
is
the
role
ptayed
by
the
family,
the
society
and
the
community.
The
study
of
sociology
helps
a
doctor
understand
the
influence
of
society
and
its
various
units
and
institutions
on
the
processes
of
heaLth
and
how
they
can
change
to
cause
disease.
The
role
of
family.
gender
issues,
social
classes,
socioeconomic
circumstances,
housing,
employment,
social
supports
and
social
policies
in
maintaining
health
or
causing
disease
is
studied
in
this
domain.
Medical
anthropology
is
the
study
of
the
effects
of
the
evolutionary
history
of
human
beings.
It
highlights
their
cultural
history,
racial
classification,
geographic
distribution
of
human
races,
and
effects
on
health
and
signs
and
symptoms
of
disease.
It
also
involves
the
study
of
cultural
methods
of
deating
with
diseases
and
other
distressing
events
of
human
life.
What
disease
is
to
be
stigmatised,
which
symptom
is
to
be
kept
secret,
what
is
to
be
handed
over
to
the
doctors
and
what
is
to
be
dealt
with
by
the
faith
healers
is
determined
largely
by
anthropological
influences
on
a
culture.
Understanding
the
health
belief
model,
attitudes
of
a
society
and
the
rote
culture
assigns
to
a
sick
person
can
highlight
the
importance
of
anthropology
for
a
health
professionaL
F
ECTIONA
èhaviourai
Sciences
and
their
Relevance
to
Healthcare
—
OUTLINE
Introduction
to
Behavioural
Sciences
Holistic
vs.
Traditional
Medicine
Models
of
Health
Care
Non-pharmacological
Interventions
A
The
behavioural
sciences
add
to
the
disciplines
of
anatomy,
physiology,
and
biochemistry
to
support
the
study
of
holistic
medicine.

7. t
Chapter
1
Holistic
vs.
Traditional
Allopathic
Medicine
Holistic
medicine
is
inspired
from
the
theory
of
Holism,
which
states
that
reality
(including
all
living
matter)
is
made
up
of
unified
wholes
that
are
greater
than
the
sum
of
their
parts.
Each
sub-part
is
linked
with
the
other
in
a
dynamic
way.
Holistic
medicine
considers
mind,
body
and
spirit
sub-parts
that
form
the
person;
a
whole
that
is
greater
than
the
sum
of
its
parts.
It
denies
the
separation
of
mind
and
body
advocated
in
traditional
atlopathic
medicine. Traditional
allopathic
medicine
works
on
a
biomedical
model
that
aims
to
treat
the
diseased
part
of
the
human
being.
Holistic
medicine
on
the
other
hand
is
committed
to
the
restoration
of
health
and
wellness
to
the
person
as
a
whole,
rather
than
focusing
on
the
diseased
part
alone.
A
health
professional
committed
to
holistic
medicine
is
expected
to
understand
the
following
elements
of
this
approach:
Person,
Environment,
Health
and
Physician.
Person:
A
human
being
who
has
the
well-integrated
etements
of
mind,
body
and
spirit
held
in
a
dynamic
balance.
Environment:
A
set
of
external
forces
that
can
inftuence
our
experience
of
health
and
disease
such
as
family,
community,
culture,
socioeconomic
resources,
access
to
health
care
and
quality
of
heaLth
care.
These
external
factors
help
shape
our
attitudes
and
health
beliefs,
Attitudes
and
beliefs
that
we
learn
from
our
environment
have
the
capacity
to
either
support
or
disrupt
the
dynamic
balance
of
our
mind,
body
and
spirit.
TraditionalADopathic
Medicine
methodology:
Ju5t
x
the
pmbLem
Artist
Laura
Zomhie
HeaLth:
A
dynamic
state
of
well-being
achieved
through
a
mind-body-spirit
balance
that
hetps
an
individual
realise
their
full
potential.
While
the
former
three
teach
about
the
body,
psychotogy
and
neuroscience
educate
the
physician
about
the
mind,
sociology
and
anthropology
illustrate
the
evolution
of
human
spirit
and
the
factors
that
constantly
inftuence
it.
T
I.:
Physician:
A
person
who
supports
health
(as
defined
above)
rather
than
one
who
merety
treats
disease.
A
practitioner
of
holistic
medicine,
therefore,
believes
that
health
results
from
a
dynamic
and
interactive
reLationship
between
the
person,
his
environment
and
the
physician.
4

8. Holistic
medicine
demands
that
a
physician
must
be
a
person
who
has
the
following
characteristics:
•
BeLief
in
the
potential
of
the
heating
act
•
Capacity
to
listen
and
empathise
Respect
for
the
dignity
of
human
beings
•
Tolerance
for
difference
of
opinion
4’
•
A
gentte
spirit
•
Ability
to
mix
creative
thinking
and
intuition
with
scientific
thought
•
Will
to
never
give
up
hope
even
against
heavy
odds
The
knowledge
of
physical
sciences
and
anatomy,
physiology,
and
biochemistry
provide
adequate
basis
for
the
practice
of
traditional
allopathic
medicine.
The
practice
of
holistic
medicine,
however,
demands
the
knowledge
of
behavioural
sciences
as
welt
as
natural
sciences.
Chapter
2
Health
Care
Models
and
their
Clinical
Applications
;.
Bio-Psycho-Sociat
(BPS)
modeL
of
heatth
and
disease
In
1977,
George
Enget
theorised
the
importance
of
integrating
the
traditional
biological
(pathophysiological
or
structural)
aspects
of
medicine
with
the
behavioural
sciences
(psychology,
sociology
and
anthropology).
He
put
forward
the
concept
of
the
Bio-Psycho-Sociat
(BPS)
perspective
of
health
and
disease.
Engels
BPS
model
was
based
on
three
principles:
a)
Disease
is
a
result
of
multiple
factors
that
interact
to
make
an
individual
feel
ilL
Illness
and
disease
are
not
a
consequence
of
biologicaL
factors
alone.
b)
An
individual
is
composed
of
a
complex,
integrated
system
composed
of
interacting
subsystem
elements
of
mind,
body,
spirit
and
social
relationships,
alt
having
feedback
loops.
Any
change
in
one
will
result
to
changes
in
other
systems.
c)
Biological,
psychological,
and
social
factors
form
a
triad
to
interact
and
serve
as
determinants
of
disease.
BIOLOGICAL
Biopsychosociat
Modet

9. He
proposed
that
the
biological,
psychological
and
social
systems
work
together
to
cause
disease.
The
biological
system
ensures
a
structural,
biochemical
and
a
molecutar
study
of
a
disease.
The
psychological
system
provides
insight
into
the
role
of
personality,
attitudes,
attributes
and
motivation
in
the
genesis
of
the
illness.
The
social
system
emphasises
the
impact
of
family,
society,
social
forces
and
culture
on
the
aetiotogy,
presentation
and
the
management
of
a
given
illness.
The
biopsychosocial
model
stresses
that
understanding
and
manipulation
of
the
psychosocial
environment
of
a
patient
is
just
as
important
to
recovery
as
the
study
of
pathophysiological
processes
and
methods
of
treatment.
Engel
proposed
that
death
of
a
significant
other,
grief,
loss
of
self-esteem,
a
threat
to
one’s
life,
property
or
integrity,
even
victories
and
reunions
were
events
that
can
trigger
a
medical,
surgical
or
a
psychiatric
condition.
The
biopsychosocial
model,
therefore,
provides
a
comprehensive
clinical
approach
towards
the
practice
of
holistic
medicine.
This
approach
lays
great
emphasis
on
the
doctor-patient
relationship.
This
involves
psychosociat
assessment,
the
use
of
communication
skills,
infor
mational
care,
counselling
crisis
intervention
and
extension
of
care
to
the
family.
One
of
the
significant
contributions
of
the
BPS
model
in
health
care
is
the
emphasis
it
assigns
to
the
use
of
interventions
that
do
not
involve
surgery
or
drus:
the
non-pharmacological
interventions.
Ctinicat
AppLication
of
BPS
Model
It
is
useful
for
a
health
professional
committed
to
holistic
medicine
to
approach
patients
using
the
BPS
model.
Research
shows
that
biomedical
and
behavioural
factors
come
into
play
in
infectious
as
well
as
non-infec
tious
disordets.
A
patient
of
dengue
fever
is
suffering
at
a
biological
level
on
account
c
breakdown
of
the
body’s
reticuloendotheLial
system.
Social
issues
related
to
drainage
of
fresh
water,
poor
disposal
of
waste,
however,
are
also
contributing
factors.
Psychological
and
anthropologicalfactors
such
as
risk
taking
behavior
and
inappropriate
dressing
in
high
risk
settings
are
equally
important
in
the
spread
of
this
infectious
disease.
Sexually
transmitted
diseases,
HIV-AIDS,
and
hepatitis
epidemics
may
atl
occur
due
to
risk
taking
behavior
and
poor
protection
strategies.
Non-infectious
disorders
ar-
also
affected
by
biopsychosocial
factors.
This
includes
heart
disease,
di&’•
tes
mellitus,
cancer,
and
depression.
This
is
because
changes
n
hormones,
immune
factors,
metabolism
and
neurotransmitters
re
alt
associated
with
socioeconomic
stressors.
Occupational
hazards,
dietary
habits,
child
rearing
practices,
personality
development,
exposure
to
childhood
trauma
are
alt
governed
by
culture
and
geography.
Many
metabolic
disorders
are
now
called
‘life-style
disorders’
due
to
the
socio-cultural
and
psychological
factors
that
work
hand
in
hand
with
biological
factors.
Another
example
of
the
BPS
model
determining
disease
is
seen
in
road
traffic
accidents
due
to
drug
and
alcohol
abuse.

10. ‘U
-
college
together
Hamid
decided
to
stay
in
the
hostel
as
he
belonged
to
a
dtstant
village
while
Hassan
preferred
to
come
to
cottege
ftam
home
eveiy
day
Soon
the
stress
of
medical
studies
started
to
mount
Hatndpraposed
that
they
should
try
smoking
a
cigarette
to
qchieve
‘better
concent,r%
ion
white
studying
Hassan
readily
agreed
and
they
both
started
to
iridutge
ip
smoking
white
studying
together
in
the
evenings.
Hamid
soon
developed
a
cough,
but
continued
to
smoke
HassdAsparet7ts
found
out
and
discussed
the
dangerous
consequences
of
his
habit
Hassan
opted
out
of
smoking,
joined
a
gym
and
started
to
exercise
regularly
He
consulted
his
behavioural
sciences
teacher
to
learn
some
innovative
methods
oftudyIng
and
techniques
to
give
up
smoking
This
helped
him
feel
healthier
and
conceritmte
befterin
his
studies
He
tned
to
convince
Hamid
to
join
him
in
these
newly
learnt
techniques
btHamtd
did
not
Usten
Within
a
year
Hamid
went
on
to
start
use
of
cannabis
and
a
few
months
later
became
addicted
to
a
stimuLant
Msgiades
as
welt
as
his
physicat
health
detenorated
and
he
failed
his
annual
exams.
He
started
to
develop
repeated
episodes
of
chest
infections
Repeated
absence
fann
classes
and
poor
per
foiwance
in
the
academics
ted
to
his
eventuat
wfthdrawat
from
medicat
college,
while
Hassan
went
on
to’
continue
his
medicqt
studies
enjoying
good
fi7ysicat
health.
The
story
of
Hamid
and
Hasan
illustrates
an
interplay
of
bioLogicaL
psychologicaL
and
social
factors
resulting
in
contrasting
outcomes
on
account
of
the
differences
between
the
two
friends
in
these
domains.
The
story
highlights
how
homeostatic
mechanisms
failed
Hamid.
On
the
other
hand,
restorative
and
predictive
atlostatic
behavior
(discussed
below)
such
as
parental
concern,
joining
a
gym
and
counselling
by
the
behavioural
sciences
teacher
helped
Hasan
overcome
a
stress
they
both
shared.
The
outcome
of
disease
in
Hamid
and
health
in
Hasan
was
decided
by
an
integrative
interplay
of
all
three
domains,
Social
support
and
allostatic
mechanisms
were
in
place
for
Hasan,
but
none
of
these
were
avaiLable
for
Hamid.
Hasan
managed
to
effectively
turn
the
stress
of
studies
into
eustress,
He
was,
thus,
able
to
achieve
a
better
state
of
heaLth.
a
The
Integrated
ModeL
of
HeaLth
Care:
CorreLation
of
Body,
Grain,
Mind,
Spirit
and
BehaviouraL
Sciences
The
integrated
model
of
health
care
is
a
step
ahead
of
the
biopsychosocial
modeL
It
suggests
a
dynamic
functional
link
between
five
domains
of
human
beings:
biological,
cognitive,
behavioural,
sociocu[tural,
and
environmental.
In
this
model,
health
is
a
state
of
a
harmonious
equilibrium
between
these
domains
which
occurs
in
response
to
eustress
or
distress.
This
state
is
achieved
through
processes
called
homeostasis
and
attostasis.
‘1p
Homeostasis
is
a
reactive
state
that
ensures
harmony
within
the
body
systems
through
adaptive
negative
feedback
loops.
It
also
uses
reactive
behavioural
adjustments
in
domains
operating
outside
the
body.

11. -*
BEHAViOURAl.
Integrated
Modet
of
Heatth
Care
Attostasis
is
an
adaptive
mechanism
in
which
the
individual
makes
the
adaptations
by
predicting
changes
in
advance,
rather
than
in
reaction.
These
adaptations
are
creative
and
organised
multisystem
changes
made
in
anticipation
of
a
possible
challenge
to
health.
A
typical
example
of
homeostasis
is
the
increased
intake
of
fluids
and
salts
while
working
on
a
hot
summer
day.
Allostasis
on
the
other
hand
would
be
to
organise
your
work
schedule
in
advance
to
be
undertaken
at
the
time
of
the
day
when
it
is
Least
hot,
so
that
you
may
not
need
the
extra
salt
and
fluids. In
the
Integrated
Model,
an
optimum
degree
of
stress
called
Eustress
is
considered
appropriate
and
necessary
for
a
person
to
function
and
stay
healthy. Eustress
is
seen
as
moderate,
motivating
and
inspiring.
It
ensures
optimum
functioning
of
homeostatic
and
atlostatic
mechanisms
that
keep
alt
five
domains
(biological,
cognitive,
behavioural,
socioculturat,
and
environmental)
working
in
synergy.
SOCIO-
ENVIRON
cucll.rnAL
MENTAl.
Distress
is
a
state
in
which
the
homeostatic
and
atlostatic
mechanisms
of
biological,
behavioural,
cognitive,
environmental
and
sociocultural
domains
are
challenged
by
extrinsic
or
intrinsic
factors.
Challenge
to
any
one
domain
influences
alL
the
other
domains
and
sets
up
a
restorative
feedback
loop.
If
the
systems
respond
with
effective
homeostatic
and
allostatic
responses
health
is
restored.
If
the
stressor
worsens
to
result
in
distress,
a
failure
of
homeostatic
and
allostatic
mechanisms
resuLts
in
disease
and
illness.
Clinical
Application
of
Integrated
Heatth
Care
Model
Separating
Disease
from
Sickness,
Distress
and
Stress
Alt
patients
who
develop
symptoms
and
report
to
hospitals
are
not
suffering
from
disease.
The
body
and
mind
respond
to
any
disturbance
in
biological,
sociaL
cognitive,
behavioural
and
environmental
domains
through
unpleasant
experiences
which
can
be
called
symptoms.
Most
of
the
time,
symptoms
serve
as
a
stimulus
for
adaptive
mechanisms
and
homeostasis
is
restored
through
changes
in
the
body,
mind,
social
support
and
environmental
manipulation.
Not
all
individuals
reporting
to
hospitals
are,
therefore,
‘patients’
in
the
biomedical
sense.
They
may
not
require

12. Distress:
This
is
the
earliest
unpteasant
departure
from
a
state
of
happiness
and
health.
This
state
appears
when
homeostatic
and
allostatic
mechanisms
in
the
body
and
mind
are
challenged
by
stress.
This
sets
into
motion
immediate
restorative
mechanisms
in
the
body
in
order
to
attain
a
feeling
of
health
through
physiologicat
means.
No
structural
or
psychologicat
damage
takes
place
at
the
level
of
the
body
and
mind.
Changes
are
visible,
however,
in
the
individuaL’s
behaviour
and
social
roles
as
functioning
of
the
individual
may
be
affected.
S/he
can
readity
return
to
normal
following
the
restoration
of
homeostasis
without
any
biological
interventions
in
the
form
of
medication
or
surgery.
Minor
environmental
manipulation,
mobilisation
of
social
support
and
adjustments
in
cognitive
and
behavioural
domains
may
be
all
that
is
required.
Distressful
states
may
present
with
the
same
symptoms
as
that
of
a
disease.
Common
distress
symptoms
include
headache,
backache,
vague
bodily
discomforts,
feelings
of
indigestion,
heaviness
in
abdomen,
lack
of
sleep,
appetite,
lethargy,
fatigue.
weakness,
dizziness
and
Light
headedness.
Individuals
may
also
experience
an
urge
to
remain
silent,
avoid
responsibility
at
home
or
work
and
have
a
general
feeling
of
inability
to
cope.
These
feelings
in
a
state
of
distress
usually
last
for
a
few
hours,
or
a
day
or
two,
but
never
beyond
a
week
in
one
go.
They
are
self-limiting,
and
improve
with
pleasant
occurrences
such
as
meeting
friends,
sharing
feelings,
indulging
in
a
hobby
or
joyful
pursuit
or
even
a
couple
of
paracetamot
tablets.
PERFORMANCE
RELAXED
A
INACTIVE
ANGER/FRUSTRATION/PANIC
FATIGUE
EXHAUSTION
___________
-
I.
EUSTRESS
STRESS
BURNOUT
OVERLOAD
STRESS
Stress-Performance
(Yerkes-Dodson)
curve
laboratory
and
radiological
tests
or
treatment
with
medication.
It
is,
thus,
important
to
separate
disease
from
distress,
sickness
and
iltness.
STRESS
UNDERLOAD
FAILUREI
‘,,
BREAKDOWN
Sickness:
The
state
of
distress
can
sometimes
give
way
to
or
be
replaced
by
a
feeting
of
being
sick’
or
unwell,
or
nauseous.
This
unpleasant
state
can
appear
without
any
disease
or
any
pathological
change.
On
the
other
hand
one
may
have
a
disease
and
not
appear
to
feel
sick
at
all
(as
in
the
case
of
some
diseases
in
early
stages,
like
cancer).

13. Sick
Rote:
This
is
a
state
that
an
individual
may
assume
at
home
or
in
office
settings
to
show
his
inability
to
perform
his
routine
roles
or
duties.
This
role
may
succeed
in
freeing
the
individual
from
their
routine
duties.
S/he
is
expected
to
seek
medical
help
and
follow
the
advice
of
his
well-wisher.
If
they
do
not
do
so,
they
may
be
seen
as
a
malingerer.
Malingering
is
a
derogatory
term
used
to
describe
a
frauduLent
sick
role
that
an
individual
assumes
to
avoid
responsibitity
or
gain
a
social
or
a
financial
advantage.
A
competent
doctor
is
hesitant
to
jump
to
this
‘diagnosis’
and
always
seeks
a
more
experienced
colleague’s
opinion
before
labelling
a
patient
as
a
‘malingerer’.
Many
patients
who
are
seen
initiatly
to
be
feigning
an
illness
have
been
known
to
develop
the
same
or
some
other
serious
disease,
Ittness:
is
an
overall
view
that
an
individual,
the
family
and
the
society
take
of
a
person
who
is
feeling
sick
or
unwell.
The
explanation
that
each
has
of
the
sickness
decides
the
course
of
actions
and
health
care
plan
that
wilt
follow.
If
the
family
and
the
community
have
no
obvious
or
known
explanation
of
the
symptoms
experienced
by
the
sick
individual,
the
likelihood
of
a
medical
consultation
is
rare.
The
patient
wilt,
instead,
be
taken
to
a
spiritual
healer,
an
aamil,
or
a
charlatan.
This
is
especially
true
of
patients
suffering
from
psychiatric
disorders,
epilepsy,
and
many
behavioural
disorders.
Most
patients
suffering
from
anxiety
and
depressive
disorders
experience
physical
symptoms
for
which
they
prefer
to
undergo
tab
tests
and
consultations
with
physicians
and
neurologists
rather
than
psychiatrists. Disease:
The
diagnosis
of
disease
is
made
when
the
symptoms
of
an
individual
are
attributed
to
a
cause
or
aetiology.
This
can
be
in
the
form
of
injury,
an
organism,
a
substance,
a
pathological
or
structural
change
or
a
defect
leading
to
changes
in
functioning
in
biologicat,
behavioural,
and
social
spheres.
These
factors
are
severe
enough
to
not
only
challenge
but
disrupt
and
even
destroy
homeostatic
and
allostatic
mechanisms.
They
have
the
capacity
to
change
the
restorative
negative
physiological
loops
in
the
body
so
that
pathological
processes
begin
to
worsen
the
state
of
the
individual,
instead
of
initiating
repair
and
equilibrium.
In
a
diseased
state,
it
is
assumed
that
a
reversaL
of
the
causative
pathoLogy
would
result
in
heal
ing
of
the
disease.
Typical
examples
would
be
enteric
fever,
a
fracture,
or
insulin
dependent
diabetes
mellitus,
Here,
a
complete
return
to
health
and
reversal
of
disease
is
guaranteed
through
a
medicat
or
surgical
intervention. It
is
important
for
health
professionals
to
note
that
all
of
the
above
states
may
or
may
not
co-exist
in
the
same
patient
at
a
given
point
in
time.
A
person
may
feel
distressed
and
sick
without
any
disease.
S/he
may
move
around
performing
routine
roles
and
duties
even
while
harbouring
a
serious
disease.
WelL
trained
health
professionals,
clear
about
distress,
sickness
and
disease
should
not
call
for
unnecessary
lab
and
radiological
tests,
They
should
also
not
prescribe
ptacebos
in
the
form
of
pain
killers,
muttivitamins,
intravenous
drips,
‘brain
tonics’
and
‘high
energy
pills’
to
individuals
who
report
to
hospitals
in
a
state
of
distress.
All
medical
and
surgical
interventions
are,
thus,
only
to
be
used
once
the
diagnosis
of
a
disease
has
been
made.
I

14. I
Integrated
Model
of
HeaLth
Care
Cilnicat
Scenario
Mr
Xis
aiar
oLd
cterkk
the
tnxatianoffica
HepresenL5
to
the
physician
with
increased
thirst
and
appetite
toss
of
sexual
feetings
al?d
weight
gain.
His
Ibstiog
bLoQd
UgatwaSfeufltb3OO
mg/dL
He
has
a
(omityhi
story
of
dibete&
He
is
nqsedas
Iiawng
Type
II
Diabetes
MeUitus
The
treat
ment
arms
are
maintenance
ofasgar-
dIeL
j%xstrng
blood
glucose
levels
j
or
infections
He
is
p1
aced
on.z
gram
of
metlbnntn/day
Hers
ciskedto
have
F
tyhome
‘.
meat
s
waik
to
his
offIce
in
the
mornings
andtakea3
km
walk
with
die
irithe
averii#
Biotogis.trzsulin
istc
dIstUrbedarbohydratemetaboLisnz
encfzctors
Magee,tMetfi2rmii7.
This
helped
in
ave
gtheb7sutin
ies&dnce
and
knpxove
the
carbohrate
met
qkoffstn
8ebavawoiiPeferencef&
h
Ca
esugarithfaO
a
sedentary
tifestyte
shssft(jØb
and
unhappy
mari&
Life.
ManngenentAttreversed
with
a
change
inea&
habits.
sha
it
bursts
of
pIcaLe’re
dLiring
working
hours
and
in7pioved
interaction
with
hIs
wife
dJrinre9uIarevenfrg
walks
CDislk..frpersonai
physique
and
thoughts
of
growing
oLd,
overweight
and
ugly.
rnaritatstress
anda
satIsed
maritaL
life
Management
Information
andunderstandingr
of
hazards
of
overeating
ond
.entanj
Lifestyle,
and
cQmrnitment
toa
healthier
way
of
thinking
about
self
future,
his
fqrnily
and
his
work!
in
generaL
sociocuLturaLjactoxs
Clerks
in
such
oie
regularly
receive
sweets
and
unheatthy
food
and
eat
unhealthy
high
calQrle
and
carbohydrate
nch
food
a
the
office
canteen,
cuture
of
working
long
hOurs
Enviro)metaLfactois
Colleagues
wiihsfmllar
unhealthy
eating
hat’its
and
lifestyles
Availability
of
unhealthy
food
at
the
canteen
absence
of
opportuni
ties
for
exercise
and
tack
of
access
to
healthy
food
Minorchonges
in
lifestyte
t
work
and
home
reversed
the
environnentatkl&1ence,
Management
Mr
X’s
refusot
to
accept
swAts
bip
lunch
from
home,.
simple
physical
exercises
during
ofñce
hours
for5
to
10
minutes
instead
of
constantty
sitting
on
the
choir
alt
helped
in
improving
the
culture
in
the
office
and
other
workers
soon
started
to
copy
Mr.
X
3.
The
PubLic
HeaLth
Care
Modet
Treatment
at
Primary
Care
Levet,
Prevention
of
ILlness,
Promotion
and
Protection
of
Health
Hospital
based
health
care
models
work
primarily
to
emphasise
treatment
of
disease,
This
kind
of
health
care
approach
is
one
of
damage
control
Public
health
care
models
on
the
other
hand,
work
not
only
to
treat
disease
but
also
to
prevent
it.
The
World
Health
Organisation
(WHO),
a
premier
stakeho[der
in
the
field
of
li
.4
heatth
care,
promotes
a
public
health
care
approach
in
addition
to
hospital

15. based
care.
This
model
is
committed
to
treatment
of
common
diseas
es
and
basic
health
issues
through
primary
health
care
centres.
Primary
heatth
care
centres
are
estabLished
at
the
grassroot
level,
where
the
maximum
rural,
and
semi-urban
population
resides.
In
Pakistan
these
are
called
Basic
Health
Units
(BHU),
and
Rural
Health
Centres
(RHCs).
These
Centres
work
towards
prevention
of
illness
and
promotion
and
protection
of
health
by
working
with
the
community
in
the
delivery
of
heaLth
care.
The
strategies
in
place
include
immunization
campaigns,
mother
and
child
health
programmes,
reproductive
health,
HIV-AIDS
programmes,
nationaL
programme
of
mental
heaLth,
narcotics
control,
antimaLarial
and
dengue
controL
programmes.
These
run
in
collaboration
with
national
and
international
governmental
and
non-governmentaL
organisations.
Health
legislations
on
smoking,
healthy
diets,
seat
belts,
helmets,
safe
sex,
population
welfare,
and
reduction
in
mentaL
health
gap
are
some
of
the
initiatives
undertaken
to
achieve
the
promotion
of
health.
SUMMARY
KnowLedge,
skills
and
attitudes
rooted
in
Behavioural
Sciences
are
an
essential
component
of
alt
the
models
of
health
care
currently
in
practice.
A
comprehensive
understanding
of
psychology,
sociology
and
anthropology
as
well
as
biological
determinants
of
health
and
disease
is
cruciaL
for
the
practice
of
scientiIc
medicine.
The
traditional
biomedical
model
of
reversing
biological
causes
of
disease
has
proven
to
be
inadequate.
An
integrated
model
of
health
care
in
which
the
psychosocial,
cognitive,
behaviouraL
and
environmental
stressors
are
considered
as
important
as
biological
causes
of
disease
is
the
future
of
modern
medicine.
This
approach
aims
at
restoration
of
homeostasis,
and
stress
reduction
to
optimise
functioning.
It
also
helps
attain
equilibrium
between
the
internal
and
external
world
through
allostatic
processes.
Interventions
that
go
beyond
medication
and
surgery
to
include
non-pharmacological
measures
heLp
achieve
health
in
a
far
more
effective
and
lasting
way.
This
includes
measures
such
as
mobilising
social
support,
influencing
existing
health
belief
modeLs,
ensuring
a
healthy
and
safe
environment,
providing
informational
care,
conflict
resolution
and
early
handling
of
psychotrauma.
A
public
health
approach
of
primary
and
secondary
prevention
which
emphasise
treatment
of
disorders
and
promotion
of
health
as
cLose
to
the
community
as
possible
helps
to
achieve
a
more
global
perspective
of
health.

16. Chapter
3
Non-pharmacological
Interventions
fNPIs)
in
Clinical
Practice
The
use
of
these
interventions
is
advocated
in
the
BPS
model
for
their
established
efficacy
(as
seen
by
extensive
research)
in
augmenting
the
impact
of
drug
treatment
and
surgical
procedures.
Non-pharmacological
interventions
(NPIs)
enhance
patient
satisfaction,
improve
adherence
to
treatment,
and
strengthen
the
bond
between
the
doctor
and
his
patients
as
well
as
the
community.
The
NPI5
in
particular
that
a
medical
or
a
dental
student
can
use
to
diagnostic
and
therapeutic
advantage
include
the
following:
1.
Communication
Skitts
While
communication
seems
like
the
most
basic
and
innate
part
of
being
human,
effective
communication
is
a
vital
toot
in
clinical
settings
as
it
forms
the
basis
of
the
doctor-patient
interaction.
The
doctor
and
patient
undertake
a
joint
voyage,
many
a
times
into
an
unknown
territory
of
disease.
Problems
may
arise
when
the
two
travelers
9nd
it
difficult
to
communicate
or
understand
each
other.
While
the
physician
is
expected
to
know
the
patient’s
language,
the
patient
is
often
unaware
of
medical
jargon.
As
the
service
provider,
the
responsibility
for
effective
communication
ties
with
the
physician.
The
tools
that
can
be
employed
to
make
this
communication
effective
and
skillful
are:
i)
Attending
and
listening:
Attending
is
the
act
of
truly
focusing
on
the
patient.
It
involves
a
conscious
effort
by
the
doctor
to
be
aware
of
what
the
other
person
is
saying
and
trying
to
imply.
This
may
only
be
possible
if
the
interaction
with
the
patient
is
done
in
a
setting
of
exclusivityStanding
on
a
patient’s
bedside
with
fellow
students,
amidst
the
traffic
in
a
ward,
attending
to
mobile
calls
simultaneously.
or
eating/drinking
while
talking
to
the
patient
may
signal
that
you
are
not
exclusively
attending
to
the
patient
and/or
his
family
member.
A
screen
next
to
the
bed,
or
a
relatively
quiet
corner
of
the
ward
meant
for
interaction
of
patients
with
the
students
may
provide
a
setting
that
allows
for
more
effective
communication.
ii)
Active
listening:
This
is
a
process
that
goes
beyond
merely
hearing
and
making
notes
of
what
the
patient
says.
It
involves
a
simultaneous
focus
on
the
linguistic
and
the
paralinguistic
aspects
of
speech.
The
linguistic
aspect
refers
to
the
words
and
verbal
aspect
of
the
speech
Paralinguistics
refers
to
nonverbal
features
of
speech
such
as
timing.
votume,
pitch,
accent,
fluency,
pauses
and
ums’
and
‘errs’.
These
are
important
as
they
indicate
how
the
person
is
feeling
beyond
just
the
spoken
word.
An
understanding
of
body
language
of
the
patient
is
important
for
a
doctor
to
communicate
with
the
patient.
Body
language
refers
to
the
way
a
patient
expresses
himself
through
the
use
of
non-verbal
cues
such
as
facial
expressions,
proximity
to
the
doctor,
use
of
gestures.
body
position,
movements
and
eye
contact.
Li

17. Use
of
minimal
prompts
Lark
of
exclusivity
Sit
squarely
in
relation
to
the
patient
Preoccupied
oranoious
health
professionals
Open
body
position
In
relation
to
the
patient
Uncomfortable
seating
-
-
Lack
of
attention
to
non-verbal
cues
Leanmg
shghtly
towards
the
chont
during
active
listening
Maintaining
reasonable
eye
contact
Offensive
remarks
orjudgmcnt
by
the
health
professional
Pelaxed
attentive
health
professional
Frequent
interruptions
Listen
and
respond
to
feelings
Selective
iintening
-
-
-
Oay
dreaming
or
dosing
off
during
Note
all
pamlrnguist,c
and
nonverbal
cues
the
communication
It
shoutd
be
borne
in
mind
that
body
language
expressions
are
only
cues
and
not
‘ctinical
signs.
These
cues
should
be
pointed
out
to
the
patient
to
draw
his
attention
to
them,
to
understand
his
feelings
or
their
meaning
to
him,
e.g.
“I
notice
that
you
took
angry,
how
are
you
feeling
at
the
moment?’,
or
‘your
eyes
filled
up
with
tears
when
you
told
me
the
name
of
your
father.”
This
is
more
rational
than
making
the
wrong
assumption
about
his
gestures
or
body
language.
This
is
essential
as
methods
of
non-verbal
communication
vary
in
patients
and
their
family
members,
according
to
their
upbringing,
culture
and
background.
Active
listening
also
involves
customizing
your
style
and
language
to
match
that
of
your
patients
or
anybody
you
are
listening
to.
This
can
be
done
by
using
the
same
language
as
the
patient
wherever
possible.
Another
important
aspect
of
active
listening
is
respecting
the
pauses
and
silences
of
the
patient.
This
would
mean
not
immediatety
jumping
in
and
talking
whenever
the
patient
pauses
for
breath
or
reflects
silently.
iii)
Verbat
techniques.’
These
are
pivotal
in
making
the
communication
effective
and
thus
contribute
towards
the
therapeutic
process.
These
are
vital
skitls
for
the
doctors
and
can
be
mastered
through
practice.
Any
verbal
communication
in
a
clinical
setting
involves
the
following
components: Questions:
these
can
be
closed
or
open
ended.
Ctose
ended
questions
elicit
a
yes/no
or
a
fixed
response
e.g.
4What
is
your
name?”
“Are
you
married?”
5Do
you
get
nausea
after
taking
your
meals”?
These
questions
are
vital
at
the
start
of
an
interaction
both,
to
collect
data
as
well
as
establish
familiarity
and
comfort
with
the
patient.
The
open
ended
questions
do
not
elicit
a
particular
answer.
They
are
intended
to
encourage
patients
to
talk
more
about
their
story
or
to
expand
more
upon
their
issues.
Questions
are
usually
used
for
exploration
of
a
particular
aspect,
for
obtaining
further
information,
to
clarify
any
details
and
to
encourage
a
patient
to
talk.
E.g.
“What
brings
you
to
the
hospital
today”
or
5Kaisay
aana
hua?°
or
even
simply
5Jee,
kohiye.”
Fadorsthatrmptøv.
cotrimintcaUon

18. It
is
important
to
start
an
interaction
with
the
patient
or
his
family
members
with
an
open
ended
query,
such
as
What
brings
you
to
the
hospitaL?”
What
can
I
do
for
you”?
This
gives
the
patient
a
chance
to
open
the
conversation,
with
what
s/he
considers
most
significant.Leading
questions
are
those
that
prompt
the
patient
to
answer
in
a
certain
way.
These
lead
to
skewed
information
as
we
tend
to
give
the
answer
that
we
feet
the
person
is
looking
for.
These
should
be
avoided
as
should
value
laden
ones.
Some
examples
of
these
are
e.g.
Don’t
you
think
your
pain
radiates
into
the
left
arm?”
or
“Do
you
feet
ashamed
of
your
short
stature?”
Moreover
‘why’
questions
should
be
used
sparingly
e.g.
“Why
do
you
think
you
have
developed
shortness
of
breath?”
An
effective
communication
therefore
revolves
around
questions
starting
with
what,
when,
where
and
how
Funneling:
This
refers
to
the
use
of
questions
to
guide
the
conversation
from
a
broader
area
to
a
more
specific
one.
These
should
follow
open
ended
questions.
This
technique
hetps
the
interviewer
move
from
general
statements
by
the
patient
to
specific
areas
of
clinical
relevance
e.g.
“Now
that
you
have
described
your
complaint
of
feeling
weak
and
lethargic.
can
you
describe
which
specific
part
of
the
body
you
were
referring
to?”
Paraphrasing:
It
refers
to
the
process
of
repeating
the
last
few
words
the
patient
said
and
summarising
what
the
patient
has
communicated
so
far,
in
your
own
words,
and
then
ask
him
or
her
to
validate
if
you
have
understood
it
correctly,
e.g.
“you
have
told
me
about
the
weakness
in
your
legs
and
lethargy
that
you
feel
after
walking
for
only
few
yards.
Is
that
right?”
‘Aap
ne
bataya
k
aap
kal
maiday
mal
2
haftay
sejatan
ho
rahi
haijo
khanoy
k
baud
barhjaati
hai,
kya
also
he
hal?”
Setective
reflection:
Reflection
is
a
technique
to
bring
out
the
feelings
attached
to
various
symptoms
and
problems
that
a
patient
has
stated.
It
refers
to
the
method
of
repeating
back
to
the
client
a
part
of
something
s/he
said
that
was
emphasised
in
some
way
or
which
seemed
emotionally
charged.
e.g.
How
does
it
feel
when
you
start
to
feel
fatigued
only
walking
for
a
few
minutes?
You
told
me
earlier,
that
you
were
once
an
athlete
who
could
easily
run
a
mile.”Empathy
buitding:
This
refers
to
statements
made
by
the
doctor
that
make
the
patient
see
that
his
or
her
feelings
have
been
well
understood.
It
helps
the
patient
understand
that
his/her
feelings
are
valid
and
that
the
doctor
would
have
felt
the
same
if
s/he
was
in
the
patient’s
place.
It
is
important
here
to
refrain
from
expressing
sympathy
instead,
which
would
imply
that
the
doctor
feels
sorry
for
the
patient’s
plight.
can
imagine
how
difficult
it
must
be
for
you
to
live
with
your
pain
for
such
a
long
time”
is
an
empathetic
statement,
which
is
highly
desirable;
a
statement
such
as
“Poor
you,
really
feel
bad
hearing
your
story”
is
an
expression
of
sympathy
which
may
not
have
the

19. desired
therapeutic
effect
and
also
undermine
the
effectiveness
of
communication. Checking
for
understanding:
From
time
to
time
during
the
session
the
doctor
needs
to
summarise
patients
statements
or
ask
the
patient
to
comment
on
the
summary.
to
ensure
if
s/he
has
understood
the
problem
and
its
associated
feelings
correctly.
An
effective
communication
based
on
the
above
principles
is
bound
to
form
a
bond
and
a
relationship
between
the
patient
and
the
doctor
in
which
both
feel
understood
and
connected.
It
is
this
feeting
of
mutual
understanding
that
is
traditionally
described
by
patients
as
H
atf
my
ittness
was
retieved
after
tat
king
to
my
doctor.
WhiLe
the
principles
of
effective
communication
should
be
part
of
all
clinical
interactions
between
a
doctor
and
his
patient,
the
best
use
of
these
principles
is
in
counselling
individuals,
couples,
family
members
or
groups.
2.
Counsetting
Counselling
is
a
technique
that
aims
to
hetp
peopte
help
themselves
by
the
development
of
a
therapeutic
relationship
between
the
counsetlor
and
the
patient
or
family
member,
a
colleague
or
anybody
who
seeks
counsel.
The
process
aims
at
helping
a
person
achieve
a
greater
depth
of
understanding,
and
clarification
of’
the
problem
mobilises
personal
coping
abilities.
It
is
not
an
ordinary
every
day
conversation,
in
which
one
person
•
asks
the
other
for
advice
and
gets
the
other
person’s
opinion
on
what
to
do.
Counselling
is
a
limited
supportive
activity
aimed
at
developing
a
person’s
ability
to
decide
upon
and
initiate
a
constructive
change.
A
doctor
or
a
medical
student
may
come
across
a
variety
of
situations
in
clinical
settings
and
professional
interactions
in
which
they
may
require
counselling
skills.
Some
of
the
common
scenarios
where
this
skill
can
become
a
useful
intervention
include:
breaking
bad
news
to
patients
or
their
families,
or
resolving
professional
conflicts.
These
may
include
announcing
that
a
patient’s
biopsy
report
has
revealed
a
malignancy,
or
that
cardiopulmonary
resuscitation
has
failed
to
revive
the
patient.
It
may
be
required
as
part
of
sharing
the
news
of
a
baby
with
congenital
malformations
or
a
stillborn
baby
with
the
expectant
parents,
resolving
a
conflict
between
a
colleague
and
a
nurse
in
the
ward,
or
handling
a
relative
who
feels
that
his
patient
is
being
ignored
and
denied
a
particular
investigation
or
intervention.
A
coun
selling
session
aims
to:
a)
Establish
a
relationship
of
mutual
trust
and
care
in
which
patients
and/or
their
families
feel
secure
and
able
to
express
themselves
in
any
way
or
form
necessary.
b)
Give
patients
or
their
families
a
chance
to
seek
clarification
and
expLanation
of
terms,
issues
and
misgivings.
c)
Provide
an
opportunity
to
patients
or
whoever
is
being
counselled
to
freely
express
his
or
her
feelings
and
emotions.
d)
Provide
reassurance.

20. e)
Achieve
a
deeper
and
a
clearer
understanding
of
a
heatth
related
issue
based
on
scientific
and
evidence
based
data.
f)
Identify
the
various
choices
and
options
alongside
their
pros
and
cons
through
a
process
of
discussion
and
dialogue
between
the
counsetlor
and
the
patient.
g)
Help
the
person
make
a
decision
or
reach
a
solution
that
is
most
suitable
for
him/her.
h)
Seek
support
of
the
counsellor
i)
Mobilise
resources
required
to
implement
the
solution.
j)
Learn
the
necessary
skills
to
cope
or
deal
with
the
issue.
Under
no
circumstances
is
the
counsellor
expected
to
make
decisions
on
behalf
of
the
patient
or
the
one
counselled.
The
responsibility
of
the
consequences
of
the
proposed
solution
thus
always
rests
on
the
shoulders
of
the
patient
seeking
counsel
and
never
on
the
counsellor.
If
a
medical
student
or
a
doctor
opts
to
take
up
the
role
of
a
counsellor
s/he
needs
to
develop
and
exhibit
certain
attributes,
discussed
below.
What
traits
must
a
counsettor
have?
Unconditionat
positive
regard
This
involves
a
deep
and
positive
feeling
for
the
patient,
being
non-judgmental
and
trusting.
Empathic
understanding
This
is
the
ability
to
accurately
perceive
others’
feelings,
validating
them
and
communicating
this
understanding
to
them
effectively.
As
highlighted
above,
it
is
different
from
sympathy
which
implies
feeling
sorry
for
the
person.
Warmth
and
consideration
This
can
be
achieved
by
remaining
open-minded
and
non
judgmental.
Avoiding
over
emphasis
of
your
professional
role
and
being
consistent
in
behavior
helps
convey
that
you
are
genuinely
there
to
help.
Also
by
remaining
respectful
and
tactful,
the
counsel
tor
would
be
able
to
show
warmth
and
consideration
to
his
patient.
ClarityThe
counselling
relationship
should
remain
clear
and
without
mystery
to
the
patient.
As
a
counsellor
you
are
required
to
be
clear
and
explicit.
Encourage
the
person
being
counselled
to
be
similarly
explicit
in
his
requirements.
Use
of
the
techniques
of
paraphrasing
and
checking
for
understanding
described
above
can
ensure
successful
communication.
Here
and
now
thinhing
The
distressed
patients
would
like
to
talk
excessively
about
their
past
in
order
to
avoid
the
reality
of
the
present.
As
counsellor
you
need
to
help
identify
present
thoughts
and
feelings
to
enhance
problem
solving
attitude
on
the
basis
of
here
and
now’,
and
focus
on
the
present
day
issue(s).

21. Do
not
ask
why”
questions,
These
imply
interogatiorv
Does
not
involve
giving
direct
advice
to
patients
Do
not
say
should
ought
or
icarna
chahiye
tha.
Does
not
solve
people’s
problems
for
them
These
imply
moralisation.
Do
not
blame
the
patient
Does
not
challenge
a
patient’s
feelings
and
perceptions
t)o
not
compare
the
patient’s
experiences
witi,
Does
not
impose
the
counsellor’s
own
views
your
own,
or
gite
examples
from
your
life
onto
the
patient
The
patient
is
a
different
petson
from
you
and
has
different
life
experiences.
Does
not
make
people
less
emotional
Do
not
invalidate
the
patient’s
feelings,
Does
not
work
to
fulfil
the
counsellor’s
need
to
make
people
feel
better
3.
Informational
Care
(IC)
Memoirs
of
a
patient’s
son
I
took
my
etderly
mother
to
a
targe
hospitat
in
our
city
when
she
became
sick
She
was
very
embarrassed
to
go
to
the
doctor
because
she
said
that
he
would
examine
her
and
cause
bepardagi
but!
convinced
her
that
they
have
welt
trained
doctors
who
are
trustworthy
and
wilt
take
care
of
her
without
causing
her
any
embarrassment
We
went
to
the
outdoor
department
where
we
were
told
that
she
had
a
breast
lump
which
coutd
be
°a
tumOur.”
This
was
like
a
bolt
of
lightning
for
the
whole
family
as
we
had
heard
that
nobody
survives
from
cancer
I
borrowed
5000
rupees
from
a
friend
and
admttted
her
in
the
sUrgery
ward
in
the
big
hospitaL
We
were
hoping
that
through
these
doctors,
A(tah
would
help
us
through
this
trial,
A
junior
doctor
took
her
medical
history
and
started
some
medicines.
I
asked
him
whether
my
mother
woutd
be
okay,
but
he
said
he
didn’t
know
yet
and
we
needed
some
tests.
He
then
went
away
and
a
nurse
gave
us
a
slip
to
do
some
tests
but
nobody
told
us
how
much
the
tests
would
cost
woutd
it
be
painful
for
my
mother
how
long
would
the
results
take,
how
tong
would
we
need
to
stay
in
the
hospitat,
any
precautions
we
need
to
take
for
her
recovery?
When
the
test
results
came
the
junior
doctor
looked
at
the
results
and
told
us
that
the
senior
doctorsahib
wilt
decide
during
“the
round
I
thought
maybe
they
wilt
tell
us
when
they
decide
after
the
round
The
senior
doctor
sahib
came
for
the
round
but
he
discussed
something
in
English
with
the
other
doctors
and
moved
on
from
our
bed
without
telling
us
anything.
Later
on,
a
group
of
students
came
to
our
bed
and
said
that
they
needed
to
examine
my
mother’s
chest
My
mother
was
very
ashamed
but
they
sqid
that
it
was
necessary
for
her
treatment,
and
so
We
had
to
agree
Seven
of
them
examined
my
mothers
chest
turn
by
turn
and
we
were
constantly
worried
about
how
many
peopte
might
be
watching
her
like
this.
Later
on,
I
asked
for
the
senior
doctor
sahib
to
find
out
about
the
treat
ment
of
my
mother
and
the
questions
I
had
in
my
mind,
but
the
peon
said
that
he
was
in
a
meeting.
I
asked
for
the
junior
doctor
who
had
taken
our
history
but
he
had
left
after
his
duty
and
would
be
coming
back
the
next
day
I
asked
the
nurses
too
but
they
did
not
know
anything
about
my
mothers
treatment
plan.
A
newjunior
doctor
came
that
evening
on
Ucity
and
told
us
that
we
had
to
prepare
for
my
mothers
surgery
two
days
later,
and
that
we
also
needed
to
arrange
for3
units
of
blood
and
about
20,000
rupees
for
the
items
required
in
the
surgery.
We
were
very
confused,
as
no
one
had
discussed
anything
with
us
about
this
surgery.
When
I
asked
the
junior
doctor
about
how
much
money
we
needed
in
4otat
how
many
days
we
would
need
to
stay
in
the
hospital
caun4Ipon
7
MIsconcptfons
about
Counselling.

22. after
thaL
and
if
there
was
any
other
option
besides
the
surgery
he
got
angry
and
said
that
Don
tyou
trust
the
doctors
advice2
and
you
care
about
mon
eymore
than
your
mothers
health
57
was
very
hurt
and
embarrassed
bythese
comments
On
the
otherhand
my
mother
and
sisters
were
very
hopetess
as
they
had
heard
that
nobody
sunuves
from
5cancer
even
afterthe
surgery
Veiywomed
and
confused
we
were
totd
bya
neighbtur
that
a
local
pirsa
R2LJ
We
did
not
know
what
to
do
All
we
really
wanted
was
someone
to
listen
and
answer
some
of
our
quenes
in
this
confusion
and
desperation,
a
consultation
with
the
pirsahib
seemed
like
our
onty
ray
of
hope
So
the
next
morning
we
left
the
hospital
fora
meeting
with
the
pirsahTh’_..
Recommended
exercise
Read
this
case
scenario
once
before
studying
this
sectlonr
and
then
a
sec
ond
time
after
completing
the
section
Discuss
whythis
chath
of
events
ted
to
this
tonsequence
and
what
actions
could
have
been
taken
differently
by
the
health
care
team
to
avoid
such
an
unfortunate
outcome
LI
H
Informational
care
is
defined
as
provision
of
information
to
patients
using
principles
of
communication
regarding
the
disease,
the
drugs
and
the
doctor
(the
3
Ds).
This
helps
to
fill
the
gap
in
the
patient’s
knowledge
and
understanding
in
these
areas.
In
order
for
the
patient
to
fully
achieve
this
understanding,
informational
care
must
be
provided
using
Language
that
the
patient
understands.
During
ill
health,
the
patient
and
his
caregivers
feel
a
desperate
need
to
know
what
exactly
is
wrong,
how
it
is
being
or
will
be
managed,
who
will
deliver
the
care
and
how.
The
amount
of
information
provided,
timing,
Language
and
setting
in
which
informational
care
is
imparted
has
to
be
tailored
according
to
the
individual
needs
of
the
patient,
This
includes
considerations
such
as
what
stage
the
illness
or
recovery
is
at
and
what
questions
bother
the
patient
the
most.
Seven
ESSePtIIS
Ifl
iflformatlonal
Care:
The
physician
must
set
aside
time
within
a
consultation
to
give
a
reasonable
level
of
information
to
the
patient
and
his
family
about
the
disease
and
treatment.
The
IC
session
must
take
place
in
the
language
that
the
patient
can
understand.
it
must
start
with
patient’s
knowledge,
understanding
and
expectations.
Aap
apni
bemari
kal
baray
ma)
kya
Jantay
haln
The
doctor
must
than
remove
any
myths
and
misconceptions
that
the
patient
mentions
in
his
description.
These
misconceptions
must
be
clarified
and
replaced
with
evidence-based
information,
The
task
of
giving
intormation
should
be
professional,
evidence
based
facts
are
provided
without
fear
of
causing
a
negative
reaction
in
patient
and/or
family.
It
must
however
be
done
with
compassion,
empathy
and
sensitivity.
Vague
statements
and
building
false
hope
should
be
avoided.
Both
aspects
of
the
disease
and
treatment,
negative
and
posItive
should
be
communicated
to
th,
patient,
but
information
overload
is
to
b,
avoided,
Use
of
simple
figures,
diagrams
and
sketches
are
often
helpful
to
enhance
the
patient’s
understanding.
Most
patients
or
relatives
may
like
to
keep
the
sketches
at
the
end
of
the
session,
which
consolidates
their
interest
and
the
titility
of
the
IC
etetcise
in
the
therapeutic
process.
The
IC
session
ends
with
th.
patient
briefly
summerising
his
new
understanding
of
the
3
Os.
This
helps
to
evaluate
how
much
of
the
InformatIon
has
been
retained,
The
doctor
finally
reassures
that
any
future
concerns
and
clarifications
that
ar.
needed
will
also
be
addressed.

23. What
is
wrong
with
me
(diagnosis)?
Why
have
developed
this
disease
(aetiology)?
Is
there
an
effective
treatment
to
my
problem?
Is
the
treatment
safe?
Are
there
any
serious
or
danoerous
side
effects
(management)?
How
long
iIl
I
take
to
recover
(prognosis)?
Is
therea
‘Perhez’
(restrictions)?
Is
there
a
risk
of
illness
being
spread
to
those
APOUND
me
or
passing
It
onto
my
offspring
(transmission)?
How
will
the
illness
and
the
treatment
effect
or
influence
my
functioning?
(Can
I
continue
to
work
or
rest?
What
will
happen
to
my
sex
life,
sleep,
appetite
etc.?)
4.
Handling
Difficutt
Patients
and
their
Families
Health
professionals
find
certain
types
of
patients
and
their
families
exceedingly
difficult
to
deal
with.
These
include
individuals
who
•
have
long,
meaningless
and
repetitive
discussions
with
the
doctor
•
waste
precious
time.
•
become
too
dependent
and
clingy
ask
for
undue
favours
•
make
unprofessional
demands.
•
try
to
manipulate
the
doctor
•
become
angry
when
things
do
not
go
their
way
•
become
rude
or
behave
aggressively.
•
refuse
diagnostic
tests
and
treatment.
Other
patients
who
are
seen
as
difficult
are
those
with
medically
unexplained
symptoms
(MUS)
such
as
vgue
physical
complaints,
aches
and
pains,
mentat
health
problems
and
patients
who
may
be
drug
users,
are
obese
or
mute.
Management: It
is
important
to
be
aware
of
factors
operating
in
a
health
professional
that
can
give
a
false
feeling
that
the
patient
is
behaving
in
a
difficult
way.
These
commonly
include
having
a
heavy
work
load
and
what
time
of
the
day
the
interaction
with
the
patient
occurs,
as
health
professionals
tend
to
become
irritable
towards
the
end
of
the
day.
Inadequate
knowledge
and
skills
to
deal
with
a
demanding
clinical
situations
may
also
cause
the
health
pro
fessional
to
become
panicked
or
overly
sensitive.
Lack
of
training
in
com
munication
and
counselling
skills
may
worsen
this
situation.
Some
health
professionals
trained
in
a
biomedical
model
feel
that
addressing
patient’s.
psychosocial
and
spiritual
issues
is
not
their
job.
They
may,
therefore,
Seven
Questions
a
Patient
NeedsAnSwered
man
CSessian

24. become
irritable
when
a
patient
brings
up
these
aspects
for
discussion.
Whatever
ones
views
may
be,
as
a
heatth
professional
you
are
likely
to
come
across
at
Least
one
if
not
all
of
the
aforementioned
situations.
The
following
steps
may
help
in
dealing
with
a
difficult
patient
or
family
effectively:
a)
Have
an
understanding
of
the
biopsychosocial
model
and
integrated
health
care
model
and
believe
in
the
effectiveness
of
these
well
researched
models.
b)
Train
yourself
well
in
principles
of
effective
communication
and
counselling.
Seek
specialised
training
in
handling
of
difficult
patients
by
trying
to
form
a
relationship
or
bond
with
difficult
patients
in
the
ward.
Looking
at
videos
of
how
seniors
ideally
handle
such
patients
and
discussions
with
health
team
members
will
help
educate
you.
c)
Learn
relaxation
techniques
to
manage
your
own
anger
and
feelings
of
frustration.
d)
Approach
difficult
patients
with
tolerance,
patience
and
use
of
principles
of
active
listening
and
unconditional
positive
regard,
keeping
your
cool.
Concentrate
on
breathing
deeply
and
easily
while
listening
to
the
angry
patient
or
a
family
member.
e)
Do
not
take
remarks
being
passed
as
personal
insult’
or
challenge
to
your
integrity
or
authority.
Consider
them
a
different
viewpoint
of
an
individual
who
is
hurt
or
is
uninformed
and
unguided.
f)
Allow
the
patient
or
family
member
to
express
anger
and
validate
it
by
statements
such
as
“your
anger
is
understandable”,
“I
can
understand
your
feelings”,
“this
must
be
frustrating
for
you’.
“mujhe
andaza
hal
kaiye
aap
k
tiye
kitna
mushkft
waqt
hal”
g)
Offer
a
chair
and
a
calmer
setting
to
discuss
the
issue
at
hand
in
more
detail.
Offer
an
apology
or
an
explanation
for
any
unintended
offense
but
do
not
appear
defensive.
Stay
calm,
maintaining
an
open
body
posture,
a
safe
distance
and
always
keep
an
eye
at
the
emergency
exit.
Always
ask
for
assistance
from
colleagues
or
staff
at
the
earliest
signs
of
aggression
or
threatening
postures
by
a
patient
or
famity
members.
h)
For
difficult
pai.
its
in
particular,
define
the
objectives
and
duration
of
consultatio
ri
advance.
i)
Offer
referral
to
a
colleague
or
a
senior
consultant,
particularly
if
you
are
not
making
any
headway.
j)
Use
humour
while
collecting
further
data,
reassure,
undertake
detailed
physical
examination,
and
a
more
extensive
diagnostic
work
up.
or
seek
opinion
from
a
mental
health
professional.
k)
Involve
family
members,
friends
or
significant
others
in
the
life
of
the
patient
for
support
as
well
as
help
in
understanding
of
the
patient’s
issues.

25. 5.
Breaking
Bad
News
Any
news
that
adverseLy
and
seriously
affects
an
individual.’s
view
of
his
or
her
own
future
is
considered
bad
news.
There
are
many
clinical
situations
where
bad
news
has
to
be
communicated
to
patients
and/or
their
relatives,
e.g.
disctosing
the
diagnosis
or
relapse
of
cancer,
birth
of
mal
formed
baby
or
death
of
a
loved
one.
Breaking
bad
news
is
an
unpLeasant
task
and
can
be
learned
from
the
senior
physicians
or
through
own
profes
sional
experience.
Most
patients
and
families
expect
full
disclosure
delivered
with
empathy,
kindness
and
clarity.
There
are
five
different
schools
of
thought
regarding
the
provision
of
information
to
patients.
The
biopsychosocial
model
has
the
least
number
of
limitations
and
is
therefore
strongly
recommended
for
use
in
health
settings.
a)
Blo-Psycho-Sociat
Modet:
This
model
provides
clear,
crisp,
evidence
based
information
on
the
patient’s
condition
but
tailors
the
flow
and
amount
of
information
accord
ing
to
the
needs
of
the
patient.
A
vertical
flow
of
all
data
on
the
disease
(particularly
the
parts
that
the
patient
or
his
family
have
not
asked
for),
is
avoided.
The
bad
news
is
broken
using
principles
of
effective
communi
cation,
counselling
and
informational
care
discussed
earlier.
The
patient
is
encouraged
to
involve
his
family
members,
particularly
the
ones
who
can
provide
psychosocial
support,
during
the
session
as
well
as
in
the
long
run.
This
model
suggests
the
following
steps
for
a
session
that
aims
at
breaking
bad
news:
Step
1:
Seating
and
Setting
(Environment):
Exclusivity The
environment
where
bad
news
is
being
broken
can
have
serious
repercussions
on
the
outcome
of
the
interview.
A
patient’s
mistrust
and
antagonism
may
simply
result
from
a
poorly
chosen
location.
It
is,
therefore,
worth
trying
to
find
a
private
room
where
the
doctor
and
patient
can
focus
on
the
subject
attentively.
invoLvement
of
significant
others
Some
patients
like
to
have
family
members
or
friends
around
them
when
they
receive
bad
news,
while
others
prefer
to
hear
bad
news
alone.
Ask
the
patient
who
they
would
like
to
accompany
them.
If
there
are
more
than
a
few
people
supporting
the
patient,
ask
one
person
to
act
as
representative.
This
gives
the
patient
support
and
alleviates
some
stress
from
the
doctor
in
the
face
of
an
emotionally
charged
interview.
Seating
arrangements
It
is
advisable
for
the
interview
to
take
place
with
both
octor
and
patient
comfortabty
and
respectfully
seated
next
to
each
other,
preferably
at
a
distance
of
an
arm’s
length.
The
arrangement
should
never
impart
an
intimidating
image
of
the
doctor.
It
should
provide
an
appropriate
setting
for
discussions
and
any
emotional
outbursts
or
ventilation
of
feelings
that
may
arise.

26. Be
attentive
and
calm
Most
doctors
feet
anxious
when
breaking
bad
news
and
it
is
worth
spending
some
time
to
eliminate
any
signats
that
may
suggest
our
own
anxieties.
Maintain
eye
contact
and
show
your
attention.
If
the
patient
starts
to
cry,
try
shifting
your
gaze
because
nobody
Likes
to
be
watched
while
crying.
This
should
however
be
done
with
sensitivity
and
must
never
send
a
signal
that
you
do
not
realty
care
about
the
patients
feelings.
Listening
mode
SiLence
and
repetition
of
last
few
words
that
the
patient
has
said.
are
two
communication
skills
that
wiLt
send
across
the
message
that
you
are
Listening
weLl.
AvaitabitityIf
you
have
appointments
to
keep,
give
your
patient
a
cLear
indication
of
your
time
constraints
but
make
yourself
available
to
the
patient
for
all
his
queries
and
doubts
for
the
duration
that
you
are
with
him
or
her.
Step
2:
Patient’s
Perception:
Ask:
What
do
you
know?
“Aap
apni
bemoan
kai
baray
mai
kyajantay
ham?”
The
principle
involved
in
this
step
is
“before
you
tell,
ask.”
Before
you
break
the
bad
news
to
the
patient,
try
to
ascertain
as
accurately
as
possible
the
patient’s
perception
of
his
or
her
MEDICAL
condition.
Obtaining
this
information
depends
on
your
own
communication
style.
As
your
patient
responds
to
your
questions
take
note
of
the
language
and
vocabulary
that
s/he
is
using
and
be
sure
to
use
the
same
vocabulary
in
your
sentences.
This
alignment
is
very
important
as
it
hetps
you
assess
the
gap
between
patient’s
expectations
and
actual
medical
condition.
If
the
patient
is
in
denial,
try
not
to
confront
him
in
the
first
interview,
as
denial
is
an
unconscious
defense
mechanism
that
facilitates
coping.
Step
:
Invitation:
Ask:
What
would
you
tike
to
know?
“Aap
bemari
k
baray
mai
kyajanna
chahain
ge?”
Although
most
patients
want
to
know
all
about
their
illness
but
assumption
towards
that
should
be
avoided.
Obtaining
overt
permission
respects
the
patient’s
right
to
know
or
not
to
know.
Some
examples
to
address
this
are:
“Are
you
the
kind
of
person
who
likes
to
know
alt
the
details
about
what’s
going
on?”,
“How
much
information
would
you
like
me
to
give
you
about
your
diagnosis
and
treatment?”,
“Would
you
like
me
to
give
you
details
about
what
is
going
on
or
would
you
prefer
I
tell
you
about
the
treatments
I
am
prescribing
to
you?.”

27. Step
:
Knowledge:
Before
you
break
bad
news,
give
your
patient
a
warning
of
some
sort
to
help
him
prepare
e.g.
“Unfortunately
I
have
some
bad
news
for
you
Mr.
X”
or
“I
am
sorry
to
have
to
tell
you...”
When
giving
your
patient
bad
news,
use
Language
similar
to
his.
Avoid
scientific
and
technical
language.
Even
the
most
well
informed
patients
find
technical
terms
difficult
to
comprehend
in
that
state
of
emotional
turmoil.
Give
information
in
small
bits
and
clarify
whether
s/he
un
derstands
what
you
have
said
so
far,
e.g.
“Do
you
see
what
I
mean?”
or
“Is
this
making
sense
so
far?”
As
emotions
and
reactions
arise
during
the
interview,
acknowledge
them
and
respond
to
them.
Ask:
What
have
you
understood?
“Kya
mal
aap
ko
baat
theek
se
samjha
saka/saki
hoon?”
Step
5:
Empathy:
For
most
doctors
responding
to
our
patients’
emotions
is
one
of
the
most
difficult
parts
of
ourjobs.
In
our
effort
to
alleviate
our
own
discomfort
it
is
tempting
to
withhold
certain
information
or
give
a
more
hopeful
picture
than
actually
exists.
These
tactics
may
appear
to
help
in
the
short
term
but
seriously
undermine
aft
your
efforts
in
the
long
run.
It
is
much
more
useful
and
therapeutic
to
acknowl
edge
the
patient’s
emotions
as
they
arise
and
address
them.
The
technique
that
is
most
useful
is
termed
the
empathic
response.
An
empathic
response
involves
listening
and
identifying
the
emotion
or
mix
of
emotions
that
the
patient
is
experiencing
and
offer
an
acknowledgement
for
them.
Identify
the
source
of
that
particular
emotion
and
then
respond
by
showing
that
you
understand
the
emotional
expression
of
the
patient.
Statements
such
as
“mai
bhi
agar
aap
ki
jagah
hon
toh
aisa
he
mehsus
karoon”
reassure
the
pa
tient
that
you
understand
the
human
side
of
the
medical
issue
and
that
you
have
a
respect
for
his
feelings.
Step
6:
Summarise:
Before
the
discussion
ends,
recapitulate
the
information
in
a
short
summary
of
all
that
has
been
discussed
and
give
your
patient
an
opportunity
to
voice
any
major
concerns
or
questions.
Step
:
Ptan
of
Action:
You
and
your
patient
should
go
away
from
the
interview
with
a
clear
plan
for
the
next
steps
that
need
to
be
taken
and
the
role
you
both
would
play,
in
the
management
of
the
issues.
Also
allow
the
patient
to
have
a
way
of
contacting
you,
through
the
hospital
exchange
or
after
rounds
the
next
morning,
in
case
they
have
any
questions.

28. b)
Individuatised
Disclosure
Model:
In
this
model
the
amount
of
information
disclosed
and
the
rate
of
its
discLosure
are
tailored
to
the
desires
of
the
individual
patient
by
doctor-patient
negotiation.
First
the
doctor
and
patient
work
together
to
clarify
what
information
the
patient
wants.
The
doctor
then
imparts
that
information
in
a
way
that
the
patient
understands.
This
is
an
on-going
and
developing
process.
It
implies
a
tevel
of
mutual
trust
and
communication
that
takes
time
and
effort
to
develop.
The
distinguishing
features
of
this
model
are
that
it
takes
time
and
skills
and
its
assumptions
are
supported
by
evidence.
It
has
the
capacity
to
maximise
quality
of
life
for
the
patient.
The
underlying
assumptions
in
this
model
are
that
it
takes
each
individual
a
different
amount
of
time
to
absorb
and
adjust
to
bad
news.
A
partnership
between
the
doctor
and
the
patient
for
decision
making
is.
therefore,
in
the
patient’s
best
interest.
Its
disadvantages
are
that
it
is
a
time
consuming
process
that
might
be
difficult
for
a
busy
physician
to
undertake.
It
also
tends
to
drain
a
health
care
providers’
emotional
resources.
The
advantages
are
that
the
amount
of
information
given
and
rate
of
disclosure
is
taiLored
to
needs
of
the
individual
and
a
supportive
relationship
with
the
doctor
is
established.
c)
FuLL
Disclosure
Model:
This
model
involves
giving
full
information
to
every
patient
as
soon
as
it
is
known.
It
argues
that
this
promotes
doctor-patient
trust
and
communication
and
facilitates
mutual
support
within
the
family
unit.
The
underlying
assumptions
in
this
model
are
that
the
patient
has
a
right
to
full
information
about
himself
and
the
doctor
has
an
obligation
to
give
it.
It
assumes
that
all
patients
want
to
know
bad
news
about
themselves
and
that
patients
themselves
should
decide
what
treatment
is
best
for
them.
The
disadvantage
of
this
model
is
that
discussion
of
options
in
detail
may
frighten
and
confuse
some
patients.
The
doctor
insisting
on
providing
information
may
undermine
defenses
such
as
deniaL
which
are
otherwise
important
for
the
survival
of
the
patient.
The
provision
of
full
information
may,
also,
have
negative
emotional
consequences
for
some.
The
mod
el
holds
some
advantages
as
well,
such
as
promotion
of
doctor-patient
trust,
family
support
and
allowing
patients
time
to
put
affairs
in
order
in
case
of
a
poor
prognosis.
It
also
helps
those
patients
who
cope
better
with
their
diagnosis
by
having
the
maximum
amount
of
information
about
their
illness.
c)
PaternaListic
Disctosure
ModeL:
This
model
implies
that
information
about
the
patient’s
disease
is
the
right
of
the
doctor.
The
doctor
delivers
the
information
to
the
patient
as
and
when
s/he
deems
appropriate,
in
a
‘sugar
coating’
to
minimise
the
pain
and
distress
of
the
patient.
It
also
involves
the
expression
of
sympa
thy
and
a
sharing
of
emotions
on
the
part
of
the
doctor.
This
model
is
no
longer
recommended
for
use.
d)
Non-Disctosure
Modet:
This
model
is
based
on
the
view
that
under
no
circumstance
should
patients
be
informed
that
they
have
acquired
a
lethal
disease.
It
states
that
deception
should
be
used
if
necessary,
on
the
basis
that
the
patient
needs
protection
from
the
terrible
reality
of
terminal
illness.
This
model
has
been
traditionally
adopted
as
part
of
a
paternalistic
and
nurturing

29. attitude
of
doctors
towards
their
patients.
The
underLying
assumptions
in
this
modet
are
that
it
is
appropriate
for
a
doctor
to
decide
what
is
best
for
the
patient;
patients
do
not
want
to
hear
bad
news
and
they
need
to
be
protected
from
it.
This
model
has
obvious
disadvantages
such
as:
denial
of
the
opportunity
to
adjust
to
illness,
which
the
patient
is
ob
•
viousty
experiencing
•
trust
in
doctor
is
undermined
opportunities
for
helpful
interventions
are
lost
•
patient
compliance
is
less
tikely
•
patients
may
acquire
wrong
information
that
can
lead
to
avoidance,
isolation
and
a
perception
of
rejection
•
the
patient
may
experience
a
sense
of
loss
of
control
in
what
is
hap
pening
to
his
own
body
Advantages
of
following
this
model
are
that
it
is
easier
and
less
time
consuming
for
the
doctor
and
suits
those
people
who
prefer
not
to
know
their
condition.
This
model
s
fast
fatling
out
of
favour
and
is
now
widely
rejected
by
modern
day
doctors
as
welt
as
patients
and
their
families.
What
expectations
do
the
patient
and
[amity
have
when
receiving
bad
news? According
to
research,
the
most
important
factor
to
the
patient
and
family
receiving
bad
news,
is
the
attitude
of
the
health
professional.
The
heatth
professional
should,
thus,
be
knowledgeable,
empathetic
and
give
hon
est
and
clear
answers
in
simple
language.
The
second
most
important
factor
is
the
setting
in
which
the
news
is
broken.
A
quiet,
private
place
•
where
the
news
is
broken
in
an
uninterrupted
way
is
preferred.
What
are
the
common
reactions
that
a
patient
experiences
upon
receiv
ing
bad
news?
The
reactions
that
a
person
goes
through
when
they
hear
bad
news,
can
be
summarised
as
the
stages
of
denial,
anger,
bargaining,
depression
and
acceptance.
These
stages
are
rarely
clearly
delineated,
and
often
patients
go
through
one
or
more
stages
at
the
same
time
and
for
each
individual
the
length
of
time
each
stage
lasts
may
vary.
It
is
important
that
the
health
professional
empathise
with
and
provide
support
for
the
patient
during
each
stage.
What
are
the
common
reactions
in
a
heatth
professionaL
breaking
bad
news? Delivering
bad
news
can
be
equally
taxing
and
demanding
for
the
health
professional.
S/he
may
experience
strong
emotions
of
being
a
failure,
or
of
not
having
done
enough
for
the
patient.
Feelings
of
helplessness,
sad
ness
and
fear
that
they
may
harm
the
patient
emotionally
by
telling
them
the
truth
may
be
experienced.
Some
may
feel
shame
and
disiltusionment
with
their
profession,
and
others
may
experience
fear
of
their
own
death
and
disability.
These
feelings
are
essentially
normal
reactions
to
a
challenging
and
a
difficult
situation.
A
young
health
professional
is
advised
to
share
these
feelings
with
a
senior
colleague.
S/he
may
even
assist
in
a
few
situations
before
undertaking
this
specialised
communication
in
clinical
settings.

30. ChaLlenges
In
Non-pharmacological
Interventions
As
health
professionals
the
biggest
hurdle
we
face
in
the
administration
of
any
non-pharmacological
intervention
is
the
Lack
of
time.
In
busy
cLin
ics
and
overcrowded
wards
where
patients
go
from
being
humans
with
names
to
beds
with
numbers,
it
seems
impossible
to
find
the
time
to
give
someone
all
they
need.
It
seems
to
suffice
that
we
are
there
at
alt,
that
we
are
doing
the
bare
minimum
to
keep
afloat
in
the
never-ending
sea
of
patients
that
threatens
to
drown
us.
In
such
a
situation
we
must
keep
in
mind
two
things:
Research
shows
that
by
not
spending
the
required
amount
of
time
the
first
time
we
see
a
patient,
we
tend
to
misunderstand.
misdiagnose
and
mistreat.
The
inevitable
result
of
this
is
that
not
only
does
a
patient
not
improve,
s/he
may
return
to
a
different
doctor
in
a
worsened
condition.
This
means
that
for
the
majority
of
our
time,
we
are
redoing
work
that
a
colleague
has
done
improperly
(due
to
lack
of
time)
and
vice
versa.
There
are
millions
of
patients
stuck
in
this
loop,
who
keep
reappearing
for
consultations,
thereby
increasing
the
workload
of
heatth
professionals
as
a
whole.
Secondly.
it
is
important
to
understand
that
our
job
is
not
to
mistreat
the
most
number
of
people
in
a
day,
but
to
actuaLly
treat
the
minimum
number
of
people
we
can
to
the
best
of
our
abilities.
Using
non-pharmacological
interventions,
such
as
providing
informational
care
and
breaking
bad
news
saves
us
time
in
the
Long
term.
For
example,
if
we
are
able
to
take
the
time
to
explain
to
a
patient
that
the
true
mea
sure
of
whether
their
blood
glucose
levels
is
normal
is
fasting
btood
glu
cose,
or
an
HbAic,
they
will
not
waste
our
time
(and
that
of
the
path
lab)
by
getting
random
blood
glucose
Levels
done
and
showing
them
to
us.
Breaking
bad
news
is
another
time-consuming
procedure,
how
ever,
one
of
utmost
importance.
To
inform
an
individual
that
s/he
may
have
cancer
or
AIDS
is
to
inflict
a
major
psychological
trauma.
People
will
remember,
for
the
rest
of
their
lives,
the
details
of
the
occasions
when
important
news
was
broken.
No
surgeon
would
think
of
operating
without
booking
an
operating
theatre
and
setting
aside
sufficient
time
to
do
the
job
properly.
S/he
would
not
‘skip
the
anaesthesia”
just
because
it
takes
time.
The
procedure
for
breaking
bad
news
must
have
a
similar
importance.
A
health
pro
fessional
must
think
for
a
moment
how
they
would
feel
if
they
were
to
receive
such
news.
There
is
a
world
of
difference
between
the
doctor
who
breaks
this
news
in
relaxed
atmosphere
with
a
support
ive
attitude
and
the
caLlous
consultant
who
flings
bad
news
at
the
patient
in
a
public
ward.
Before
teLling
people
what
we
think
they
need
to
know,
we
should
find
out
what
they
already
know,
or
think
they
know,
about
the
situation
and
what
their
priorities
are.
If
they
use
words
like
cancer’
or
death’,
we
should
check
out
that
these
words
mean
the
same
to
them
as
they
do
to
us.
‘There
are
many
kinds
of
cancer,
what
does
the
word
mean
to
you?’.
‘Have
you
seen
anyone
die?
How
do
you
view
death?’
will
often
reveal
considerable
ignorance
and
open
the
door
to
positive
reassurance
and
explanation.
Too
often,
doctors
fail
to
invite
questions
and
miss
the
opportunity
to
help
people
with
the
issues
that
are
concerning
them
most.
The
patient
has
a
right
to
know
the
truth
about
an
illness,
but
we
must
respect
their
right
to
monitor
the
amount
of
new
and
painful
information
that
s/he
can
cope
with
at
any
given
time.
It
is
just
as
wrong
to
tell
people
too
much,
too
soon,
as
it
is
to
tell
them
too
little,
too
late.

31. •
Life-threatening
illness
can
undermine
our
confidence
and
trust
and
members
of
the
caring
professions
can
do
a
great
deal
to
help
peopte
through
these
psychosocial
transitions.
Accurate
informa
tion
is
essential
to
planning.
Many
patients
may
react
with
relief
when
they
are
told
they
have
cancer,
as
without
any
information
they
have
already
imagined
the
worst.
It
is
easier
to
cope
with
a
Le
gitimate
diagnosis
than
to
live
in
an
unplanned
state
of
uncertainty.
•
Many
of
the
different
ways
people
cope
with
threats
reflect
the
coping
strategies
that
have
been
found
to
minimise
stress
earty
in
life.
At
times
of
threat,
those
who
tack
confidence
in
their
own
resources
may
seek
help
of
others,
express
clear
signals
of
distress
and
cling
inappropriately.
Those
who
lack
trust
in
others
may
keep
their
problems
to
themselves,
bottle
up
their
feelings
and
blame
hea[thcare
providers
or
therapies
for
their
symptoms.
Their
tack
of
trust
makes
it
necessary
for
them
to
control
us
rather
than
be
controlled
by
us.
A
few,
who
lack
trust
in
themselves
and
others.
may
keep
a
low
profile,
turn
in
on
themselves
and
become
anxious
and
depressed.
To
those
who
lack
self-esteem
the
most
important
thing
we
have
to
offer
is
our
esteem
for
their
true
worth
and
poten
tial.
To
those
who
lack
trust
in
others
we
can
show
that
we
under
stand
their
suspicion
and
their
need
to
be
in
control
of
us.
Doctors
must
act
as
advisors
rather
than
instructors
and
show
that
they
accept
that
trust
must
be
earned:
and
that
‘it
is
not
our
right
to
be
trusted’.
SUMMARY
The
breaking
of
bad
news
is
a
difficult
situation
for
both
the
health
professional
and
patient
and
the
family
members.
The
task
should
be
undertaken
in
an
exclusive
and
an
uninterrupted
setting.
The
information
provided
should
be
based
on
what
the
patient
and
famity
wants
to
know.
The
information
should
build
on
what
is
already
known
to
them.
Opening
statement
should
be
on
the
lines
of
“I
have
to
share
information
that
may
be
unpleasant”
or
“I
know
it
may
be
tough
for
you
to
know.”
The
contents
may
be
broken
into
short
sentences
making
sure
that
the
patient
gets
adequate
chance
to
process
the
unpleasant
data.
Accept
and
respect
the
emotional
reactions
that
follow
the
sharing
of
the
information.
In
the
end
leave
enough
time
for
clarifications
and
questions.
Always
schedule
a
follow
up
meeting
and
mobilization
of
any
immediate
support
that
the
patient
or
the
family
may
need
after
learning
the
bad
news.
The
session
should
not
end
without
assessing
the
risk
of
the
individual
harming
them
selves,
and
putting
in
place
clear
preventive
interventions
in
this
regard.
Reassurance
that
you
as
a
health
professional
stand
committed
to
pro
vide
support
and
be
with
the
patient
during
these
trying
moments
is
a
source
of
comfort
for
the
patient
and
the
family.
This
is
a
safe
note
on
which
to
leave.
A
calm,
compassionate.
empathetic
health
profession
alwho
has
adequate
knowledge
of
the
patient’s
condition
can
leave
a
calming
effect
on
the
patient
and
the
family.
Young
health
professionals
need
to
be
aware
of
the
strong
emotional
reactions
that
they
themselves
may
experience
before,
during
or
just
after
breaking
the
bad
news.
These
feelings
are
normal
and
their
impact
can
be
reduced
significantly
by
sharing
them
with
a
more
experienced
colleague.

32. 6.
Crisis
Intervention
and
Disaster
Management
The
word
crisis
is
derived
from
a
Greek
word
meaning
decision
makkig.
Chinese
language
has
an
expression
for
it
in
two
words;
danger
and
opportunity.
A
crisis
is,
therefore,
a
situation
which
holds
potential
for
great
individual
growth
provided
that
the
appropriate
decisions
are
taken.
People
in
individual
crises
or
natural
disasters
find
themselves
in
situations
that
require
deep
and
insightful
decision-making
and
lead
to
a
permanent
change
in
their
lives.
Crises
are
periods
of
disorganization,
characterised
by
trial
and
error,
disequilibrium,
and
attempts
to
reduce
feelings
of
dis
comfort.
Resotution
of
a
crisis
can
result
in
either
an
increase
or
decrease
in
person’s
level
of
functioning
or
a
return
to
the
previous
baseline
of
functioning.
Individuals
and
communities
who
undergo
major
disasters
may.
however,
never
be
the
same
again.
At
a
psychological
tevel,
they
may
become
more
vulnerable
to
future
crises.
They
are
at
a
higher
risk
to
become
victims
of
a
variety
of
post
traumatic
conditions
such
as
post-traumatic
stress
disorder
(PTSD).
depression,
anxiety
and/or
dissociative
states.
They
may
become
resilient
and
battle-hardened’,
and
thus,
better
equipped
to
deal
with
challenges
of
life.
This
change
that
foltows
major
trauma
may
be
the
basis
of
the
positive
shifts
in
human
be
haviour
called
post-traumatic
growth
occur
in
response
to
stressful
periods
of
human
maturation
and
transition.
These
inctude
childbirth,
early
child
hood,
schooling,
adolescence,
marriage,
parenting,
divorce,
hospitalization,
death
of
a
loved
one
etc.
A
situational
crisis
is
where
a
person
is
faced
with
a
stressful
or
traumatic
event
which
could
be
a
natural
or
a
manmade
disaster
e.g.
ftoods,
earthquakes,
rape,
terrorist
attacks,
war,
murder
etc.
Ak.
GENERATE
AND
EXPLORE
ALTERNATIVE
RESOURCES
AND
COPING
SKILLS
EXPLORE
FEELINGS
AND
EMOTIONS
(USING
ACTIVE
LISTENING
AND
VAUDATION
SKILLS)
IDENTIFY
DIMENSION
OF
PRESENTING
PROBLEMS.
INCLUDING
CRISIS
PRECJPITANTS
ESTABLISH
RAPPORT
AND
COLLABORATIVE
RELATIONSHIP
PLAN
AND
CONDUCT
CRISIS
AND
BIOPSYCHOSOCIAL
ASSESSMENT
(INCLUDING
LETHALI1’!
MEASURES)
Roberts’
seven
stage
modet
of
crisis
intervention

33. Communication
Strategies
In
Crisis
intervention
Using
silence
gives
the
person
time
to
reflect
and
become
more
aware
of
feelings.
Silence
can
prompt
elaboration.
Simply
being
with
the
person
can
make
them
feel
supported.
Using
non-verbal
communication-
maintaining
eye
contact,
head
nodding,
caring
facial
expressions,
and
occasional
“uh-huhs
lets
the
person
know
that
you
are
in
tune
with
them
Paraphrasing,
expressing
understanding,
empathy
and
interest
are
conveyed
by
repeating
portions
of
what
the
person
said.
Paraphrasing
also
checks
for
accuracy
,clarifies
misunderstandings,
and
lets
people
know
that
they
have
been
heard.
You
could
say,
“So
you
are
saying
that..”,
or”Aap
k
kehne
ka
matlab
ye
hai
kaL.
1efiecting
feelings
helps
the
person
identify
and
articulate
emotions.
You
could
say.
“You
sound
angry...”
or
“You
look
scared...”
Allowing
the
expression
of
emotions
is
an
important
part
of
healing.
Venting
often
helps
the
person
work
through
feelings
and
helps
in
problem
solving
Disaster
Management:
A
crisis
involves
three
main
phases:
emergency
phase,
rehabilitation
phase,
and
recovery
phase.
Each
of
these
phases
has
its
unique
characteristics.
The
common
factors
for
a
medical
student
to
remember
regarding
disasters
include:
a)
The
consequent
trauma
is
never
surgical
and
medical
atone:
nearly
all
those
affected
suffer
psychosocial
changes.
b)
Most
psychosocial
consequences
of
trauma
are
essentially
normal
reactions
to
the
overwhelming
nature
of
the
disaster.
More
people
dont
get
PTSD
than
do
get
PTSD.
c)
Groups
most
vulnerable
to
deyeloping
post
traumatic
conditions
include
women,
children
and
the
elderly,
but
young
adults
and
males
are
not
immune
to
developing
psychological
reactions.
d)
Provision
of
early
psychosocial
support
by
trained
professionals
prevents
long
term
psychiatric
morbidity.
It
also
enhances
the
impact
of
surgical
and
medical
interventions
and
promotes
early
recovery
from
the
physical,
psychological
and
socioeconomic
effects
of
trauma.
e)
All
medical
and
psychosocial
care
should
be
part
and
parcel
of
the
larger
disaster
relief
in
form
of
food,
shelter,
clothing
and
security.
Psychosocial
and
mentat
health
care
should
be
made
an
integral
part
of
medical
and
surgical
care.
This
will
help
to
prevent
stigma
of
mental
and
psychosocial
issues.
It
also
helps
to
ensure
a
holistic.
biopsychosocial
model
of
health
care
delivery
fl
Traumatised
individuals
and
communities
best
recover
through
pro
viding
psychological,
social
and
economic
support
to
each
other
(rather
than
relying
on
outside
help
alone).
An
early
return
to
their
homes
or
shelters
close
to
home
and
active
participation
in
social,
educational,
economic,
and
reconstructive
activities
ensure
a
quicker
rehabilitation.

34. g)
The
use
of
psychotropics,
particularly.
the
benzodiazepines
should
be
avoided
and
simple.
evidence-based,
culturally
rooted,
non-phar
macological
interventions
are
preterabte.
Only
short-term
use
of
up
to
two
weeks
for
morbid
anxiety
and
insomnia
may
be
advised.
h)
Rescue
workers
and
health
professionals
involved
in
provision
of
relief
work
require
psychosocial
support.
They
need
adequate
rest
and
recreation
as
well
as
constant
appreciation
and
patronage.
They
should
work
using
the
buddy
system,
which
involves
individuals
teaming
up
and
caring
for
and
monitoring
each
others
psycholog
ical
and
physical
wellbeing.
Preferably
they
should
remain
in
touch
with
their
families
and
friends
back
home.
This
prevents
early
fatigue.
burn
out
and
long
term
psychosocial
complications.
j)
Up
to
one
third
of
the
affected
population
may
develop
long
term
post
traumatic
conditions
characterised
by
disabling
flashbacks
of
the
trauma,
autonomic
hyper-arousal.
avoidance
(of
cues,
settings
and
circumstances
that
are
[inked
in
anyway
with
the
traumatic/di
saster
event),
anxiety,
depression
and
dissociative
states.
A
second
disaster
wave
hits
soon
after
the
first.
This
is
largely
in
the
form
of
epidemics,
wound
infections,
malnutrition,
death
and
dis
ease
due
to
exposure
to
extremes
of
temperature.
7.
Conftict
Resolution
Conflict
is
a
state
where
two
forces
oppose
each
other.
Conflicts
arise
in
situations
where
individuals
and
groups
are
not
getting
what
they
want
or
need.
This
includes
marital
conflict,
conflict
amongst
colleagues,
the
attendant
of
a
patient
and
the
nursing
staff,
medical
students
on
a
clini
cal
rotation
in
conftict
with
hospital
staff,
or
the
college
administration
etc.
Conflicts
are
inevitable
situations
and
are
usually
seen
where
there
is
poor
communication,
power
seeking.
dissatisfaction
with
management
style.
weak
leadership.
lack
of
openness
and
change
in
leadership.
Conflict
has
the
quality
to
divert
attention
from
the
main
activity,
undermine
morale,
polarise
people
and
groups,
reduce
cooperation,
sharpen
differences
and
thus
Lead
to
irresponsible
or
harmful
behaviour.
It
is,
therefore,
important
to
understand
that
at
times
the
individuals
involved
may
be
unaware
of
their
needs
or
wants.
Conflicts
have
the
potential
to
be
constructive
when
they
are
raised
in
the
spirit
to
clarify
and
solve
problems.
In
these
circumstances
conflict
and
timely
resolution
may
help
relieve
tension
and
pent
up
emotion
as
well
as
help
build
cooperation
through
learning
more
about
each
other.
a)
Common
Causes
of
Conflict
in
Heatthcare
Settings:
Assumptions
are
being
made
e.g.
the
doctor
assumes
that
the
patient
knows
that
his
absence
from
the
ward
is
on
account
of
an
unavoidable
academic
commitment
like
attending
an
international
conference.
The
patient
instead
may
not
be
aware
of
the
activity
or
may
not
attach
the
same
importance
to
it
as
the
doctor.
ii)
Knowledge
is
minimal
e.g.
the
family
has
inadequate
information
on
the
indication
of
biopsy
in
a
patient
and
may
see
it
as
a
suspicion
of
malignancy
in
the
patient.
H
i)
i)
‘St
Las/a
Zombie

35. iv)
Knowledge
is
minimal
e.g.
the
family
has
inadequate
information
on
the
indication
of
biopsy
in
a
patient
and
may
see
it
as
a
suspicion
of
malignancy
in
the
patient
v)
Expectations
are
too
high:
e.g.
the
patient
believes
that
a
course
of
chemotherapy
should
have
completely
cured
him
of
his
lympho
ma,
when
instead
s/he
develops
a
complication
of
the
treatment
and
deteriorates.
vi)
Personality,
race,
gender
or
social
class
differences
exist
e.g.
a
trainee
nurse
may
have
a
tow
frustration
tolerance
and
take
offence
of
an
innocent
remark
by
a
patient;
a
visitor
or
a
medical
student
or
the
janitorial
staff
goes
on
a
strike
for
being
poorly
paid.
vii)
Needs
and
wants
are
not
being
met
e.g.
a
patient
dissatisfied
with
food,
bedding
or
facilities
in
the
ward.
viii)
Values
are
being
tested
e.g.
a
welt-clad
female
patient
reluctant
to
allow
a
male
student
to
examine
her.
ix)
Perceptions
are
being
questioned
e.g.
a
confident
medical
student
distressed
about
not
being
given
a
chance
by
the
surgical
resident
to
undertake
an
incision
and
drainage
procedure
independently.
b)
Methods
of
Conflict
Resotution:
The
underlying
emotion
in
all
conflicts
is
bottled
up
anger,
frustration
and/or
an
impression
of
being
ignored,
or
of
being
‘taker
for
granted’.
The
most
common
underlying
cause
is
often
not
a
clash
of
interests
but
a
faulty
communication
or
unfounded
concerns.
The
worst
ways
of
dealing
with
conflicts
is
to
brush
them
under
the
carpet,
or
to
ignore
or
postpone
their
resolution.
A
formalised
strategy
to
resolve
conflicts
is
called
Organised
Conflict
Management
(0CM).
The
following
steps
of
0CM
help
resolve
most
conflicts
readily:
i)
Meet
conflicts
head
on.
/
CAUSES
OF
CONFLiCT
IN
NEALTHCARE
SETTINGS
HEALTH
OUTCOMES
PERFORMANCE
iii)
Assumptions
are
being
made
e.g.
the
doctor
assumes
that
the
patient
knows
that
his
absence
from
the
ward
is
on
account
of
an
unavoidable
academic
commitment
like
attending
an
international
conference.
The
patient
instead
may
not
be
aware
of
the
activity
or
may
not
attach
the
same
importance
to
it
as
the
doctor.
P.ERK5ANOPPWEXGE
qUA#voPuFg
V
V
ii)
Show
mutual
respect
by
separating
the
person(s)
from
the
problem.
Do
not
try
to
corner,
attack
or
undermine
the
individual(s)
involved
in
the
conflict.
iii)
Set
goals
that
lead
to
a
win-win
situation
for
both
the
parties
in
conflict
rather
than
a
victory
of
one
party
at
the
expense
of
the
other.
iv)
Resolve
the
conflict
through
free
communication.
_____________
VV._
VV1

36. v)
Be
honest
about
concerns
and
reservations
and
verbalise
them
as
early
as
possible.
vi)
Agree
to
disagree.
as
healthy
disagreements
lead
to
better
decisions.
vii)
Leave
individual
egos
out
of
negotiations,
and
avoid
serving
or
pleasing
one
individual.
Aim
at
satisfaction
of
the
group,
rather
than
the
leader
alone.
Exploitative
and
deceptive
methods
of
resolving
confticts
can
succeed
temporarily
but
are
Likely
to
generate
bigger
issues
in
future.
viii)
If
you
are
the
one
coordinating
the
dialogue,
tet
the
negotiating
team
create
solutions
rather
than
handing
over
the
solutions
-
people
support
what
they
create.
ix)
Discuss
differences
in
values
openly.
x)
Undertake
a
deeper
anaLysis
of
the
situation
that
generated
the
conflict.
Conftict
resolution
based
on
a
superficial
analysis
is
likely
to
result
in
a
bigger
conflict
in
future.
A
conflict
arising
out
of
hurt
feelings,
and
emotional
reasons
is
likely
to
settle
on
its
own
with
passage
of
time
and
an
improved
communication
between
the
parties.
A
conflict
that
arises
out
of
morality
issues,
religious
differences,
or
cultural
differences
is
unlikely
to
resolve.
Here
the
two
parties
can
agree
for
a
peaceful
co-existence
in
spite
of
the
conflict.
Realistic,
fact
based
conflicts
can
be
best
resolved
through
creative
solutions
put
forth
by
the
parties
themselves.
The
best
method
of
dealing
with
conflicts
is,
however,
by
preventing
them.
A
sound
management
system
in
medical
colleges.
departments,
wards
and
hospitals
helps
to
ensure
this.
It
involves
mechanisms
of
quali
ty
control,
free
horizontal
interactions
and
sharing
of
information.
Leader
ship
should
be
based
on
principles
of
following
a
middle
path
rather
than
extreme
measures.
Ensuring
equity
and
justice
and
imparting
feelings
of
security
and
predictability
can
prevent
the
rise
of
conflicts
as
welL
as
ensure
their
early
resolution.Do’s
and
Dont’s
In
Crisis
Intervention
Do
Say:
Dont
Say:
These
are
normal
reactions
to
ft
could
have
been
worse
an
abnormal
situation
It
Is
understandable
that
you
i
this
W8
You
can
always
get
another
car/house
or
have
another
child
It
was
not
your
fault;
you
did
the
best
you
could
It
is
best
if
you
just
stay
busy
lam
sorry
that
this
happened
I
know
just
how
you
feel
Things
will
get
batter,
and
you
will
I
feel
better,
although
things
may
You
need
to
get
on
with
your
life
never
be
the
same
again
I

37. Empathy The
single
thread
that
tinks
alt
the
above
non-pharmacological
interven
tions
is
the
demand
on
the
doctor
to
empathise
with
the
patient
and
the
family.
The
most
important
step
in
building
a
therapeutic
bond
is
the
doc
tors
ability
to
experience
the
feelings
of
his
patients
and
to
gain
a
deeper
understanding
of
their
distress,
disease
or
disability.
Most
medical
students
start
their
career
in
medical
college
with
a
huge
capacity
to
empathise.
Alt
that
they
have
to
learn
is
to
communicate
it
effectively.
The
biomedical
modeL
with
its
emphasis
on
the
disease,
rather
than
the
person
experiencing
it
provides
few
opportunities
to
develop
and
use
this
skill.
Medical
students,
eager
to
perform
well,
are
rewarded
for
their
abiLity
to
memorise
anatomical
and
biochemical
facts,
causes
of
diseases
and
classification
systems.
Their
ability
to
empathise
or
relate
with
patients
at
a
human
level
is
not
marked,
rewarded
or
appreciated.
As
a
resu[t
of
this,
slowly
but
surely
they
start
to
focus
more
on
acquiring
knowledge,
with
their
skill
at
treating
patients
as
humans
and
empathis
ing
with
them
fading
into
the
background.
The
best
time
to
learn
how
to
empathise
is
in
your
relationships
with
each
other
as
medical
students.
The
first
step
in
this
direction
is
to
opt
to
study
in
a
group
rather
than
alone.
Once
you
are
part
of
a
group,
try
and
under
stand
the
reactions
of
a
fellow
student
who
is
struggling
with
language.
or
a
concept;
who
fails
in
a
class
test,
a
sub-stage
or
a
viva.
Sitting
next
to
someone
who
has
failed,
or
is
in
pain,
and
thinking
of
how
s/he
is
feeling
is
an
important
exercise
by
which
you
can
eventually
learn
to
empathise
with
patients.
Let
the
person
you
are
trying
to
empathise
with,
express
their
feetings.
The
best
technique
in
this
pursuit
is
to
share
their
silence.
Sit
quiet.
Listen
actively:
let
the
person
know,
that
you
care
and
it
is
ok
for
them
to
share
feelings
with
you.
This
effort
on
your
part
to
empathise
with
your
colleagues
in
the
first
couple
of
years
in
medical
college
will
make
you
comfortable
with
your
own
world
of
emotions.
It
is
this
import
ant
ability
in
a
human
to
stay
in
touch
and
be
aware
of
one’s
own
feelings
that
helps
them
to
relate
with
feelings
of
others
and
thus
enhances
their
ability
to
empathise.
During
clinical
years,
try
and
sit
with
patients,
even
after
you
have
taken
the
history
and
have
completed
the
clinical
exam-.
nation.
Encourage
them
to
talk
about
how
they
feel
in
reaction
to
their
illness,
hospitalisation,
and
treatments
being
offered
to
them.
Share
their
fears,
disappointments
and
sorrow
without
trying
to
take
sides
of
the
health
professionals
and
hospitaL
authorities.
Ask
questions
about
the
influence
of
the
disease
and
the
treatment
on
their
life
at
home,
at
work
and
in
general.
These
apparently
irrelevant”
steps
will
take
you
ctoser
to
your
patients
and
thus
increase
the
chances
of
empathising
with
them.
It
is
this
ability
to
bond,
and
eventually
feel
the
way
your
patients
feet,
that
wilt
help
you
have
an
insight
into
how
patients
think.
i

38. 1.
A
patient
from
a
vilLage
in
ChoListan
desert
presents
to
a
health
professionat
in
Lahore.
He
appears
to
be
suffering
from
diabetes
mettitus,
according
to
his
HbAic
and
fasting
bLood
glucose
reports.
The
heaLth
professional
does
not
speak
or
understand
his
tanguage.
The
best
way
to
provide
informational
care
would
be:
a)
Drawing
pictures
b)
Using
sign
language
to
communicate
effectively
c)
Seeking
help
from
a
colleague
who
partially
knows
the
patient’s
language
d)
Exclude
medical
jargon
from
communication
and
state
essentiat
facts
through
an
interpreter
e)
Make
an
attempt
to
learn
patient’s
Language
and
then
communicate
effectively
2.
During
a
counseLling
session,
the
most
important
aspect
is:
a)
Charismatic
personality
b)
Asking
why
the
patient
feels
the
way
they
do
c)
Speaking
to
the
patient
in
their
language
U)
Unconditional
positive
regard.
e)
Empathising
with
the
patient’s
situation
3.
Active
Listening
is
best
accomptished
by
the
doctor
understanding
and
using:
a)
Body
language.
b)
Paralinguistic
aspects
c)
Active
prompting
d)
Adequate
eye
contact.
e)
Responses
to
open
ended
questions.
4.
White
deaLing
with
a
patient
who
is
fearfuL
about
not
waking
up
from
anaesthesia
for
her
hysterectomy,
an
empathic
response
is:
a)
I
assure
you
that
your
concerns
are
not
scientific,
everybody
wakes
up
from
anaesthesia
b)
I
do
understand
your
concern,
in
your
situation
I,
too
may
have
felt
the
way
you
are
feeling
c)
I
know
that
you
are
scared
but
you
are
a
brave
person
who
can
face
this
d)
We
are
experts
in
the
field;
we
will
make
sure
that
nothing
happens
to
you.
e)
Please
relax,
everything
will
be
fine
SAMPLE
MCQ
FOR
SECTION
A

39. 5.
Effective
communication
skills
are
considered
essentially
important
for
a
doctor.
The
most
important
reason
for
a
doctor
to
develop
effective
communication
with
his
patients
is:
a)
It
is
a
vital
tooL
in
clinical
settings.
b)
It
forms
the
basis
of
the
interaction
between
the
doctor
and
patient.
C)
It
is
used
in
informationat
care
sessions
with
the
patient
and
their
famiLies.
d)
Doctors
can
convey
their
message
on
various
health
topics
better.
e)
Doctors
will
gain
respect
and
popularity
with
the
public.
Sampte
Short
Essay
Question
For
Section
A
Qi.
Briefly
describe
the
seven
questions
that
need
to
be
answered
in
an
informational
care
session.
Q2.
What
are
the
steps
invoLved
in
breaking
bad
news
to
a
patient?
Answers l.a 2.d 3.b 4.b 5.b For
answers
to
short
essay
questions
see
Chapter
3,
Non-pharmalog
ical
interventions.

40. b
ECTION
B
edical
Ethics,
Professionalism
and
Doctor-Patient
elationship
I
sb,ear
[‘p
scuLapus,
Lpgeta.
anb
anacra.
anb
3
take
to
b%tite%%
all
tfje
gobs,
all
d
gobbeaea,
to
keep
arcorbing
to
mp
aWftp
anti
nip
ubgmeiu,
tt
(otLobng
atfj.
to
con%iber
bear
to
me
aS
mp
parentS
tdm
to(io
taug
me
tl.ü
art:
to
Cibe
m
cmnmmt
it
im
anti
if
nws%arp
to
sbare
nip
goats
tnittj
m:
to
took
upon
his
cljilbrcn
aS
nip
aton
.—c
beatberL
to
teach
tm
this
art
it
tfrp
so
bcsirr
k%tfjmd
fee
or
britten
omt%e;
to
Impart
to
nip
sans
anb
tbe
SonS
of
ttje
master
[‘ibjo
taughi
me
anti
tk
bisnptes
bfjo
babe
enrotkb
ttjemwetbes
anti
babe
agreeb
to
tlje
rute%
of
the
profeSSion,
but
to
these
atont
the
prtce5
anti
tljt
instruction.
I
UnIt
prescribe
rtgimtns
tar
the
goat
of
nip
patients
,,
acarbingtompabititpanbmpiumeiUanbneberboarmloanpcnc
r
to
please
no
one
tofU
I
prescribe
a
beatitp
brug
nor
gibe
abbece
Wijicfj
map
cause
$S
tieatlj.
lor
bsI(
I
gibe
a
boman
a
pessarp
to
prorure
abortion.
ut
I
bitt
preSerbe
the
puritp
of
nip
(itt
anti
nip
art.
I
bill
nof
cut
tar
Slant,
tUtu
for
patients
in
bhom
the
tüea%t
is
manitt%t
I
bill
(taUt
tts
operation
to
be
performeb
[‘p
practitioners,
sptclat&s
arLInebtrpbousebfrrticome)bstt.tronlptrxdgxb
at
mp
patients.
keeping
mp%elt
far
tram
alt
intentional
Ilt-boing
anti
Th
altsebwtionanbesptdaltptromtttp(easureso((bstfjbionietiorbeth
men,
be
the?
fret
or
stabes.
Alt
that
map
come
to
mp
knobeebgey
tn
the
exercise
of
mp
profession
or
In
baitp
commerce
bath
mni
Wjlcfj
ongljnoftobesprtabaheoab,3bittkeepftcrtianbbellntbertebeaL
-
It
I
keep
(tO
oath
taithtuttp.
map
3
tnwp
nip
tite
anti
practice
nip
..
art.
etsptcteb
bp
alt
men
anti
In
alt
times;
but
it
I
s’wtrbe
(rain
U
I
map
the
reberft
be
mp
tnt.”
-
-.
--—
.-
7
_____
Retevance
of
Ethics
in
the
Life
of
a
Doctor
Medical.
Ethics
Ethical.
Omissions
in
Medical.
Practice
Ethical.
Dil.emmas
in
a
Doctor’s
Life
Doctor-Patient
Rel.ationship
Ptofessiona[ism
in
Heal.th
Care

41. After
ordering
a
hot
cup
of
Doodh
Patti,
the
tocat
preferred
version
of
English
tea
Ahmed,
Fazat,
Javed
and
Safdar
started
their
evening
chat.
The
topic
today
was
not
pot
itics
but
the
attitude
of
doctors.
Ahmed
remarked
‘The
new
Doctor
Saheb
who
has
opened
his
ctinic
is
very
different
from
Dr
Raheem
who
died
tast
year
after
serving
the
community
as
a
generat
practitioner
for
thirty
years.
Dr.
Khatid
has
a
neon
sign
of
his
name
and
qualifications
outside
the
clinic.
He
runs
his
clinic
more
like
a
‘health
shop
He
asks
his
patients
to
deposit
a
fixed
amount
with
him
prior
to
the
con
sultation,
irrespective
of
their
financial
status.
The
other
day
Dr
Khatid
insisted
that
I
shoutd
get
the
Hepatitis
vaccine
whether
I
like
it
or
not
without
giving
me
a
choice
to
do
so.”
Safdar
quickly
added:
“Dr.
Saheb
removed
my
appendix
in
surgery,
a
few
weeks
ago,
after
telling
me
that
the
appendix
would
burst
if
I
did
not
get
it
operated
there
and
then.”
Javed
recalled
the
differences
between
the
two
doctors:
“Dr
Raheem
was
a
very
kind
man.
He
never
charged
the
poor
He
always
discussed
matters
with
his
patients.”
He
cited
Dr
Raheem’s
gesture
of
explaining
atl
the
advantages
and
disadvantages
of
contraceptives
to
his
wife
and
then
asking
her
to
make
a
choice,
before
he
put
heron
the
contraception
pilL
Javed
then
came
to
Dr
Khalld’s
rescue
and
remarked,
“Yaar,
everything
and
everybody
has
changed,
how
can
doctors
be
the
same?!
Dr.
Khatid
needs
a
much
larger
amount
of
money
than
Dr
Raheem
to
run
his
home
and
family
His
family
sold
a
large
piece
of
land
to
afford
his
medical
education
and
is
still
under
debt,
while
Dr
Raheem
went
to
a
medical
college
with
hardly
any
expenses
involved.
He
is
a
fine
surgeon
and
knows
much
more
than
us
about
illness;
why
should
he
ask
us
about
medical
matters
as
long
as
he
means
well?”
Fazal
had
another
story
to
telL
“Dr
Khatid
gladly
accepted
a
new
mobile
phone
from
a
female
patient
so
that
she
could
call
him
for
telephonic
advice.
He
also
went
on
a
holiday
to
Bhurban
with
his
family
and
a
friend,
with
all
expenses
paid
by
the
pharmaceutical
company
where
lam
emptoyed.”
Javed
again
came
to
Dr
Saheb’s
rescue,
“But
then
he
never
charges
any
fee
from
the
medical
students
and
his
colleagues
and
recently
appeared
on
the
television
channel
and
gave
free
advice
on
important
health
matters.”
Ahmed
concluded
the
discussion
by
saying
“Dr
Khatid
is
like
all
of
us;
he
has
his
positives
and
has
some
negatives
too.
Hebannot
be
compared
with
Dr
Raheem
as
the
ethics
of
the
medicat
profession
may
have
changed
over
the
last
three
decades.”
Safdar
remarked
on
his
way
out
of
the
tea
bar,
“Let
us
wait
and
watch
Dr
Khalid’s
progress.”
Medical
Ethics
and
Professionalism
F—
-

42. ReLevance
of
Ethics
in
the
Life
of
a
Doctor
The
discussion
at
the
tea
bar
shows
how
doctors
are
regularly
viewed
and
critiqued
in
terms
of
their
vaLue
systems
and
behaviour
by
the
community.
It
also
shows
that
doctors
vary
in
their
practice
of
ethical
and
moral
issues.
This
hightights
the
need
for
clear
guidelines
on
how
doctors
are
expected
to
behave
to
be
considered
ethicat
professionaLs’.
The
community
puts
doctors
on
very
high
pedestals.
They
are
expected
to
be
kind,
caring,
and
hetpfu[.
They
are
expected
to
be
committed
to
heaLth
provision
and
keep
the
interests
of
their
patients
above
their
own.
They
must
never
harm
anybody,
be
just
and
equitable
and
show
character
and
resilience.
They
must
also
be
able
to
communicate
effectively,
compassionately
and
fearlessly.
They
are
supposed
to
respect
the
laws
of
confidentiality
when
it
comes
to
their
patients’
data.
Alongside
these
expectations
are
the
set
of
laws
of
the
state
governing
medical
profession,
and
the
regulations
of
the
Pakistan
Medical
and
Dental
Council,
that
a
doctor
must
adhere
to.
The
behaviour
of
doctors
is
called
upon
to
reflect
the
traditions
and
values
associated
with
them
over
centuries
of
the
history
of
their
profession.
Doctors
face
various
ditemmas
and
difficult
choices
in
their
daily
practice
such
as
taking
consent
from
patients
and
families
with
low
literacy
and
inadequate
understanding
of
health
issues.
They
come
across
controver
sies
such
as
abortion,
euthanasia,
human
rights,
and
gender
issues.
They
atso
deal
with
powerful
sections
of
society
while
compiling
medico-legal
reports.
Their
relationship
with
their
patients,
their
families,
the
pharmaceu
tical
industry,
media
and
the
challenges
posed
by
the
internet
and
modern
technologies
and
treatment
options
all
raise
ethical
concerns.
ALL
in
atl,
ethical
principles
are
required
for
good
medical
practice
and
come
into
play
in
almost
all
ctinical
decisions
that
a
doctor
makes.
They
remain
under
scrutiny
even
in
their
personat
and
private
life.
A
good
doc
tor
is
one
who
adheres
to
ethicat
principles,
regulations
and
customs
of
his
profession
under
all
circumstances.
S/he
must,
therefore,
have
a
clear
understanding
of
what
medical
ethics
are
and
what
their
scope
is.
1.
Scope
and
Meaning
of
Medicat
Ethics
MedicaL
ethics
is
the
study
of
moral
aspects
of
a
doctor’s
professional
life
The
two
branches
of
ethics
relevant
to
a
medical
professional
are:
ETHICS
I
DES
IVE
Whatwas,isorwllb
,
What
Is
at
I
NORMATIVE
What
ought
to
or
shoId
happen
What
Is
ideal

43. Normative
Ethics:
What
heatth
professional
should
do?
Normative
ethics
refers
to
what
actions
are
right
and
wrong
in
principle,
i.e
what
the
norms
are.
It
serves
to
create
moral
standards
that
people
should
foLlow.
These
provide
the
theoretical
and
ideaL
framework
that
can
guide
a
doctor
dealing
with
a
practical
problem
e.g.
Should
a
doctor
be
required
to
take
consent
for
surgery
from
an
iLLiterate
man,
with
the
fear
that
the
pa-
tient
may
make
the
wrong
choice?
(As
was
the
case
in
the
tea
bar
dialogue,
when
Dr.
Khalid
choe
to
remove
Ahmeds
appendix
without
his
consent)
Should
public
money
be
used
to
treat
patients
of
drug
abuse
and
AIDS?
Should
the
Population
Control
Division
pay
the
bills
of
an
employee
seeking
a
test-tube
baby
or
in-vitro
fertilization
(IVF)?
Descriptive
Ethics:
What
health
professionals
actually
do?
Descriptive
ethics
are
concerned
with
researching
the
morals,
be[iefs
and
behaviours
people
actually
have.
It
is
a
study
of
the
behaviours
of
health
professionals
and
what
sort
of
moral
values
they
follow.
This
involves
var
ious
medical
issues
and
ethical
dilemmas
e.g.
Should
Dr.
Khalid
charge
a
large
consultation
fee
irrespective
of
the
patients
paying
capacity?
2.
Guiding
PrincipLes
of
MedicaL
Ethics
The
guiding
principles
of
medical
ethics
in
the
practice
of
a
health
profes
sion,
also
known
as
the
‘four
pillars”
are
autonomy,
beneficence,
non-maleficence,
and
justice.
a.
Autonomy:
This
implies
that
it
is
the
patients
right
to
choose
whether
or
not
to
undergo
a
certain
treatment.
The
doctor
must
give
full
information
such
as
therapeutic
effects,
risks,
side
effects,
positives
and
negatives
to
the
patient.
The
patient
should
then
be
allowed
to
make
a
meaningful
decision
without
any
external
influence
or
compulsion.
In
the
tea-bar
example,
Dr.
Khalid
should
have
explained
the
risks
and
benefits
of
undergoing
an
appendectomy
to
Ahmed.
He
should
have
then
let
him
make
a
choice
about
undergoing
the
surgical
intervention.
The
underlying
principle
of
this
approach
is
called
informed
consent
(explained
in
more
detail
later
in
this
chapter).
b.
Beneficence:
This
calls
for
all
medical
professionals
to
do
good
for
all
patients
under
all
circumstances,
the
same
way
as
ordinary
citizens
are
required
to
do
good
for
their
parents
and
children
alone.
Doctors,
therefore,
have
a
special
relationship
with
their
patients
as
they
demand
care
from
them
as
a
duty
and
an
obligation.
(Javed’s
objection
to
Dr.
Khalid’s
choice
of
charging
the
poor
was
based
on
the
norm
of
beneficence).
c.
Non-
maleficence:
This
refers
to
the
obligation
a
doctor
has
to
do
no
harm
(or
minimise
it
as
much
as
possible)
to
his
patients.
It
is
an
exten
sion
of
the
principle
of
beneficence.
This
requires
the
doctor
to
protect
his
patient
against
all
forms
of
harm
and
always
act
in
his
best
interest.
Dr.
Khalid’s
decision
to
protect
Ahmed
from
the
risks
of
an
inflamed
appendix
by
operating
on
him
even
without
his
consent
was
an
expression
of
this
principle. The
three
principles
listed
above
are
accepted
in
legal
terms
as
prima
fcicie
(assumed
to
be
correct
until
proven
otherwise).
They
form
the
basis
for
all
other
ethical
guidelines,
but
none
of
those
guidelines
can
be
in
contradic
tion
to
them.

44. 3.
Common
EthicaL
Issues
in
MedicaL
Practice
a.
Informed
Consent
and
Confidentiatity
The
two
commonest
ethical
concerns
for
a
physician
are
consent
and
confldentiaUty.
These
are
also
the
two
paramount
norms
that
are
most
often
ignored
by
physicians.
Consent
is
omitted
by
most
doctors
on
account
of
two
reasons.
Firstly.
the
paternalistic
attitude
of
doctors
thinking
they
know
what
is
best
for
the
patient.
Secondly,
the
common
folly
of
thinking
that
an
illiterate
or
an
ignorant
patient
may
miss
out
on
a
cure
if
‘crucial”
time
is
wasted”
in
obtaining
their
approvaL
There
is
also
a
fear
that
the
patient
may
say
no’
when
data
on
the
risks/hazards
of
intervention
is
communicated.
Confidentiality
of
patient
is
also
regutarly
compromised
when
we
share
the
details
of
the
patient’s
condition
and
clinical
details
with
his
relatives,
friends
and
‘well-wishers’,
without
the
patient’s
prior
permission.
The
practice
of
undertaking
interventions
and
heatth
decisions
without
informed
consent,
as
well
as
sharing
a
patient’s
clinical
data
with
anybody
without
his
or
her
prior
permission,
are
unethicat.What
is
Informed
Consent?
Consent
is
the
agreement
by
the
patient
to
undergo
an
examination,
procedure,
or
treatment.
It
can
be
given
orally,
by
signing
a
form
or
a
written
statement
or
simply
agreeing
by
a
gesture
e.g.
offering
to
pull
up
the
shirt
for
letting
the
doctor
examine
the
abdomen.
It
must
always
be
obtained
in
advance.
In
order
for
the
consent
to
be
valid,
the
patient
should
be
competent,
that
is.
should
have
the
capacity
to
make
a
decision
(free
of
a
defect
of
mind
or
judgment
and
not
be
a
minor).
The
patient
must
give
consent
freely
and
voluntarily
(without
coercion
or
threat).
S/he
must
also
be
given
options
to
choose
from
and
not
fear
rejection
or
neglect
by
the
doctor
in
case
he
or
she
re
fuses
to
agree.
The
patient
must
be
offered
all
the
information
that
a
reasonable
professional
should
have
(prudent
professional
standard)
and
as
much
as
a
patient
would
like
to
know
(prudent
patient
stan-
dard).
The
minimum
information
required
is,
the
risks
involved,
likely
success
rate,
the
side
effects,
and
a
comparison
with
other
options.
In
Ahmed’s
case,
Dr.
Khalid
should
have
informed
him
of
the
risks
of
an
aesthesia,
and
abdominal
surgery.
The
doctor
must
also
ensure
that
the
information
has
been
clearly
understood.
The
whote
process
of
seeking
informed
consent
must
be
made
after
building
a
trusting
re
lationship
with
a
patient.
The
patient
should
be
able
to
see
the
doctor
as
caring,
competent
and
reliable.
Exceptions
to
the
rule
of
informed
consent
are
patients:
brought
into
emergency
and
accident
departments
unconscious
and
alone
requiring
life-saving
measures,
children
under
16
years
of
age
(the
parents
have
the
right
to
provide
informed
consent)
with
an
impaired
capacity
to
give
consent.
Consent
is
a
reflection
of
the
norm
of
autonomy
highlighted
above
as
the
foremost
pillar
of
medical
ethics.

45. by
Peachy
Keen
Birth
Services
taceboak.com/Peachyteen6irth
Use
your
B.R.A.I.N.S.
When
trying
to
decide
if
a
precedure
is
right
for
you
and
your
baby,
here
ore
the
questions
to
ask
to
make
sure
you
hove
cii
of
the
information
necessary
to
make
an
informed
choke.
D
Benefits
—
What
are
the
benefits
of
this
procedure?
What
are
we
hoping
U
to
achieve?
R
Risks—What
are
the
risks
or
side
effects?
What
other
interventions
will
go
along
with
this?
Alternatives
—
What
are
our
other
options?
I
intuition—
Doesthe
informationyou’rereceiving
make
sense.
Doyou
I
need
additional
info,
or
a
second
opinion?
[%J
Nothing
—
What
if
we
do
nothing,
or
wait
a
while
before
deciding?
S
‘Scuse
Me
—
Can
we
please
have
some
time
alone
to
discuss
and
decide?
Informed
consent
shoutd
answer
these
questions
for
patients
Confidentiatity:
How
much?
When
can
it
be
breached?
It
is
the
common
law
duty
of
a
doctor
to
respect
the
confidence
that
a
patient
has
in
him,
Doctors
are
expected
to
preserve
absoLute
con
fidentiality
on
all
that
they
know
about
their
patient.
This
applies
not
only
during
the
treatment
but
also
after
it
and
even
after
the
patients
death.
This
is
a
means
of
expressing
respect
for
the
patients
right
to
privacy
and
hetps
the
patient
speak
freely
to
the
doctor.
Confiden
tiality
is
the
foremost
part
in
the
traditional
Hippocratic
Oath
that
alt
doctors
are
committed
to.
A
doctor’s
registration
with
PMDC
can
be
cancelled
and
misconduct
charges
in
a
court
of
Law
can
be
pressed
if
found
responsible
for
an
unauthorised
breach
in
confidentiaLity.
There
are
instances,
however,
in
which
breaches
of
confidentiality
can
be
made:
•
When
a
patient
authorises
it
in
situations
such
as
while
seeking
medical
fitness
to
gain
employment
or
getting
a
medical
report
prepared
for
a
second
opinion.
Patient
has
the
right
to
ask
for
a
copy
of
the
medical
report.
They
must
always
be
explained
the
contents
of
the
report
and
should
always
understand
what
they
have
consented
to.
•
When
information
is
to
be
shared
within
the
health
care
team
What
you
say
in
here
stays
in
here.
Unions:
•
Someone
In
honing
yons
•
You
want
to
hurt
samson.
•
You
ssant
to
hmtyosrsatt
•
You
glue
nsa
pornsi.sionto
sCans
with
a
trusted
adult
Questions
for
Informed
Consent
•
When
the
disclosure
is
in
the
best
interest
of
the
patient,
as
in
the
case
of
physical
or
sexual
abuse,
where
confidentiality
would
mean
a
continuation
of
a
perpetual
hazard.
In
case
of
a
terminally
ill
patient
who
does
not
wish
to
know
the
prognosis
fully,
the
doctor
may
make
the
family
or
next
of
kin
aware
of
the
outcome,
with
the
patients
consent.

46. •
When
the
disclosure
is
in
public
interest
and
the
doctor’s
attempt
at
holding
back
information
may
harm
members
of
the
society.
This
includes
instances
such
as
reporting
the
matter
to
ticensing
authorities
when
a
patient
is
unfit
to
drive,
or
has
a
sexually
transmitted
disease
e.g.
is
HIV
positive
and
the
wife
is
at
risk.
In
all
such
circumstances.
the
patient
should
first
be
persuaded
and
counseLed
to
report
the
matter
themselves.
•
In
case
of
a
Legislative
requirement.
This
refers
to
matters
of
Laws
on
Public
Health
and
control
of
diseases
such
as
chotera,
small
pox,
plague
or
venereal
diseases.
•
For
research
purposes
and
case
reporting
as
anonymous
data,
or
if
the
identity
of
the
patient
may
be
surmised
from
it,
after
the
patient’s
consent.
Medicat
Students
and
the
Issues
of
Consent
and
Confidentiality:
Medical
students
may
only
be
called
to
observe
a
clinical
interac
tion
after
the
permission
of
the
patient
has
been
sought
in
advance
and
not
after
a
patient
walks
into
a
setting
where
the
students
are
already
seated.
A
medical
student
may
onty
undertake
a
procedure
after
an
informed
consent
has
been
taken.
The
patient
must
be
briefed
about
the
training
level
and
status
of
the
student.
Adequate
safeguards
should
always
be
put
into
place
in
all
such
settings
and
the
patient
duly
informed
about
them.
As
regards
confidenti
ality,
medical
students
have
the
same
duty
as
the
treating
doctor.
They
must
adhere
to
the
same
principles
as
those
outlined
for
the
members
of
the
health
team.
Medical
students
may
themselves
be
required
to
give
informed
consent
if
they
opt
to
serve
as
healthy
volunteers
in
research
projects.
The
Dean/Principal
of
their
medical
cotlege
must
be
kept
informed
in
all
such
matters.
b.
Decision-Making
Capacity
Capacity
in
health
ethics
refers
to
the
ability
of
the
individual
to
understand
the
nature
of
their
illness,
the
treatment
options
and
the
consequences
of
the
decision.
All
adults
are
assumed
to
have
the
capacity
to
make
decisions
about
their
health
and
treatment
options.
This
capacity
may
be
impaired
in
certain
conditions.
A
psychiatric
consultation
is
not
necessary
to
estabUish
capacity
of
every
adult.
It
is
incorrect
to
assume
that
alt
patients
with
psychiatric
disorders
lack
this
capacity
at
all
times.
Patients
with
psychiatric
disorders
or
head
injury
must
be
clearly
shown
to
have
impaired
judgement
and
inability
to
weigh
options
at
the
time
of
decision
making.
Patients
with
neurological
illnesses
like
dementia
do
not
automatically
lack
this
capacity
till
late
in
the
progression
of
their
disease.
They
can
make
informed
decisions
in
early
stages
of
their
illness
and
should
be
encouraged
to
do
so
by
the
family
and
the
treating
doctor.
Next
of
kin
may
make
decisions
about
a
patient
in
a
coma
or
veg
etative
state.
The
decision
of
continuation
of
life
support
in
a
brain
dead
patient,
however,
needs
to
be
made
by
the
medical
authorities
in
collaboration
with
(but
not
necessarily
with
the
consent
of)
the
family
of
the
patient.

47. With
regards
to
minors,
parents
have
the
right
to
make
decisions
on
behalf
of
their
children.
It
may
be
inappropriate
to
have
the
same
rute
for
teenagers.
The
physician
should,
however,
encourage
teen
agers
to
participate
in
the
decision
making
process
and
have
a
say
along
with
their
parents.
Religious
beliefs
of
an
individual
cannot
be
trespassed
in
informed
decision
making.
All
due
respect
should
be
shown
to
a
decision
of
refusal
of
treatment
on
the
basis
of
a
religious
belief.
An
organ
transplant
or
transfusion
may
be
refused
by
a
patient
on
the
basis
of
his
beliefs.
Parents
do
not,
however,
automatically
have
the
right
to
use
their
belief
system
in
decisions
about
their
children’s
health
and
treatment
options.
A
court
can
authorise
a
decision
in
their
place
in
situations
where
a
conflict
arises
on
this
basis.
Can
an
individual
make
advance
directives
regarding
health-related
decisions?
The
answer
is
yes.
This
can
be
done
by
making
a
Living
witt.
In
this
the
individual
makes
their
own
decisions
regarding
treat
ment
choices
they
would
or
would
not
want
in
case
their
capacity
becomes
impaired.
This
option
is
particularly
useful
in
decisions
related
to
resuscitation,
organ
transplant,
dialysis
or
organ
donation.
Patients
may
Leave
specific
instructions
regarding
cardiopulmonary
resuscitation
as
Do
Not
Resuscitate
(DNR),
Comfort
Care
(a
general
withdrawal
of
life
prolonging
care
in
favour
of
the
patients
care),
and
Palliative
Care.
This
can
also
be
done
by
proxy,
where
the
individual
nominates
a
person
who
will
decide
on
his
or
her
behalf
once
he
or
she
loses
capacity
to
do
so.
Legally
this
is
referred
to
asa
power
of
attorney). The
ethical
dimension
to
be
kept
in
mind
is
to
give
maximum
control
to
the
patients
during
the
times
when
they
can
make
sane,
rational,
and
objective
decisions
about
their
life
and
death.
c.
Euthanasia Euthanasia
is
when
a
physician
administers
a
Lethal
drug
to
a
patient,
with
the
patient’s
futl
consent
and
voluntary
cooperation.
Euthanasia
must
be
distinguished
from
Physician
Assisted
Suicide.
Physician
assisted
suicide
refers
to
where
the
physician
dispenses
(but
does
not
administer)
a
lethal
drug
to
a
patient
with
intact
capacity
for
the
purpose
of
they
themselves
bringing
an
end
to
their
life.
Both
are
considered
illegal
and
unethical
in
our
setting.
Certain
Western
societies
have
sanctioned
voluntary
euthanasia
with
strict
controls
in
ptace.
U.
Malpractice In
order
to
state
that
a
health
professional
has
indulged
in
mal
practice,
it
must
be
established
through
adequate
and
sustainable
evidence
that
the
physician
has
wronged
a
patient
and/or
harmed
them.
It
must
be
shown,
however,
that
the
physician
had
known
better.
It
implies
that
the
health
professional
was
negligent
and
did
not
meet
the
required
standards
of
practice.
This
includes
failure
to
undertake
informed
consent.

48. e.
Inclusion
of
Patients
in
CtinicalTriaLs
ClinicaL
tria[s
may
only
be
started
after
approval
of
institutional
eth
ica[
committees.
Patients
can
give
informed
and
written
consent
to
participate
in
clinical
trials
after
being
provided
due
explanation
of
details
of
the
triaL
Patients
must
have
the
option
to
opt
out
of
the
tri
al
at
any
stage.
It
is
obtigatory
for
the
principal
investigator
to
predict.
be
aware
of,
and
inform
the
patient
of
any
dangerous
consequences
of
the
triaL
4.
Common
Ethical
Ditemmas
in
a
Heatth
Professional’s
Life
On
account
of
their
unique
position
in
society,
doctors
have
access
to
the
most
intimate
areas
of
peopLe’s
lives.
They
are,
therefore,
likely
to
come
across
unusual
social
situations.
The
doctor
is
not
expected
to
respond
to
these
situations
like
other
members
of
the
society
and
a
minor
stumble
on
their
part
may
compromise
their
position.
Some
of
the
common
situations
where
he
needs
to
show
prudence
and
not
take
the
obvious
course
are
discussed
below.
a.
EuthanasiaEuthanasia
or
physician
assisted
suicide
is
considered
one
of
the
most
prevalent
problems
when
dealing
with
the
ethics
of
patient
management.
A
worldwide
debate
continues
to
rage
on
the
subject
of
the
‘right
to
die.”
Should
people
have
the
right
to
end
their
own
tives
when
prolonging
it
will
only
cause
them
more
pain?
Should
families
who
love
someone
so
much
that
they
don’t
want
to
lose
them
continue
to
cause
them
more
pain
by
keeping
them
alive?
From
the
Greek
term
for
“good
death”,
euthanasia
means
com
passionately
allowing,
hastening
or
causing
the
death
of
another.
Generally
someone
resorts
to
euthanasia
to
relieve
suffering,
main
tain
dignity
and
shorten
the
process
of
dying
when
death
appears
inevitable.
Euthanasia
can
be
voluntary
if
the
patient
has
requested
it
or
involuntary
if
the
decision
is
made
without
the
patient’s
consent.
Euthanasia
can
be
passive
—
simply
withholding
heroic
life
saving
measures
or
active
—
deliberately
taking
a
person’s
life.
Euthanasia
assumes
that
the
intent
of
the
physician
is
to
aid
and
abet
the
pa
tient’s
wish
to
die.
Most
of
the
medical,
religious
and
legal
groups
in
both
the
United
States
and
UK
are
against
euthanasia.
The
World
Medical
Associa
tion
issued
the
following
declaration
on
euthanasia
in
October
1987:
‘Euthanasia,
that
is
the
act
of
deliberately
ending
the
life
of
a
patient,
even
at
his
own
request
or
at
the
request
of
his
close
relatives,
is
un
ethical.
This
does
not
prevent
the
physician
from
respecting
the
wilL
of
a
patient
to
allow
the
natural
process
of
death
to
follow
its
course
in
the
terminal
phase
of
sickness.”
It
should
be
noted
that
the
Pakistan
Medical
and
Dental
Council
also
holds
the
same
view
on
euthanasia.
Practice
of
euthanasia
by
a
doctor
is
considered
a
criminal
act.

49. b.
Accepting
gifts
from
patients
Sharing
of
gifts
as
an
expression
of
gratitude
is
a
common
norm
in
nearly
all
societies,
especially
ours.
In
certain
subcultures,
in
fact,
the
gift
giver
may
feel
insulted
if
his
offerings
are
not
accepted.
A
clear
set
of
guidelines
should
therefore
be
fottowed
by
health
•
professionals
which
may
then
become
a
well-known
custom
of
the
medical
community
in
the
society.
Citizens
would
then
also
gradually
start
to
follow
these
customs.
A
safe
recommendation
in
this
regard
is
to
accept
a
parting
gift
at
the
end
of
a
successful
treatment,
as
long
as
it
is
in
form
of
a
bou
quet
of
flowers,
a
box
of
sweets
or
chocolates.
You
may
accept
this
graciously.
Patients
who
bring
gifts
during
the
treatment
may
cause
problems.
It
may
be
an
expression
of
the
patients
need
for
“more
than
usual”
attention.
They
may
be
interested
in
developing
a
per
sonal
friendship,
or
being
part
of
your
non-professional
life.
Extrav
agant
and
expensive
gifts
must
never
be
accepted.
This
is
because
they
signify
that
the
patient
is
putting
you
under
a
heavy
obligation
or
has
elevated
you
to
an
extraordinary
pedestal.
Both
scenarios
can
land
the
doctor
into
serious
trouble
in
the
long
run.
If
a
patient
does
so
it
is
safe
to
return
the
gifts
saying
“I
will
not
be
able
to
accept
this
gift,
as
it
is
against
my
professional
ethics.
I
assure
you
that
my
care
and
concern
for
your
health
wilt
continue
to
remain
the
same.”
In
the
scenario
discussed
previously,
the
patient
who
brought
a
mo
bile
phone
for
Dr.
Khalid
may
have
an
agenda
beyond
the
obvious
meaning
of
taking
medical
advice
readily.
Dr.
Khalid
should
have
politely
refused
the
gift
and
reassured
the
patient
of
his
availability
as
and
when
required
to
provide
professional
advice,
preferably
in
person.
c.
SexuaL
boundaries
violation:
sexuat
retationships
in
medicaL
setting
Doctors
operate
in
odd
hours,
in
close
and
sometimes
intimate
settings
for
long
hours
and
without
clearly
defined
boundaries
of
age,
gender
and
social
class.
They
work
with
fellow,
senior
and
junior
colleagues,
nurses,
paramedics,
patients
and
their
families,
and
visitors.
They
may
also
become
associated
with
professionals
from
departments
of
sociology,
social
work,
psychology,
NGO5,
the
pharmaceutical
industry,
and
other
related
organizations.
Alt
forms
of
liaisons
and
relationships
involving
personal
intimacy
of
a
sexual
nature
in
hospital
settings
are
considered
unethical
and
illegaL
This
is
to
protect
the
sanctity
of
the
medical
profession
and
the
hospital.
A
sexual
liaison
between
a
patient
and
his
or
her
doctor
is
prohibited
by
law
and
the
regulations
governing
the
profession,
the
world
over.
At
a
psychotogical
level
such
a
relationship
is
considered
at
par
with
incest.
The
same
rule
applies
to
a
medical
student
or
any
health
pro
fessional
working
with
a
patient.
Patients
are
vulnerable
to
develop
ing
an
erotic
attachment
with
their
doctor,
a
medical
student
or
any
health
professional
involved
in
their
care
and
may
even
declare
their
passion.
This
can
be
handled
by
explaining
in
no
uncertain
terms
that
it
is
impossible
for
you
to
continue
as
their
care
provider
in
such
a
situation.
Medical
students
themselves
run
the
risk
of
being
ex
ploited
by
senior
professionals
and
even
teachers
in
the
hospital
and
college
settings.
They
must
always
report
the
matter
to
the
Dean
or
Principal
and
to
do
so
with
immediate
effect,

50. without
fear
and
prejudice.
It
is
useful
to
remember
that
a
predator
or
exptoiter
who
threatens
dire
consequences
if
you
inform
a
concerned
authority
is
essentially
a
coward.
Never
feel
fearful
or
overwhelmed
by
such
an
individual
or
a
group.
d.
Charges
and
Fee:
Patients,
CoLleagues,
Teachers,
Medical
Students
The
medical
profession
has
traditionally
been
a
service
with
no
pri
mary
commercial
interests.
With
the
privatization
of
health
services
and
involvement
of
health
insurance
in
some
capitaList
countries,
the
delivery
of
service
is
nearly
always
associated
with
financial
transactions,
atbeit
not
always
directly
at
the
point
of
delivery.
It
is
not
unethical
to
charge
a
fee
for
a
consultation,
procedure
or
an
intervention:
it
is
against
the
customs
and
norms
to
base
the
doc
tor-patient
relationship
on
their
capacity
to
pay.
The
charges
should
never
be
extravagant,
or
vary
from
one
set
for
the
poor
and
another
for
the
rich.
A
simpLe
ethical
rule
is
to
determine
a
fee
structure
that
does
not
render
a
doctor,
a
procedure
or
an
intervention,
beyond
the
reach
of
an
average
citizen.
Traditionally,
doctors
are
not
expected
to
charge
their
coLleagues,
teachers,
medical
students
or
the
extreme-
ly
poor.
e.
Retationship
with
the
Pharmaceuticat
Industry
Doctors
and
the
pharmaceutical
industry
need
to
have
a
congenial
but
professional
relationship.
This
must
be
aimed
at
mutual
pooling
of
resources
to
promote
welfare
of
health
institutions
and
patients
and
investment
in
research.
The
use
of
this
relationship
for
personal
gains
or
profiteering
is
unethicaL.
It
is
unethical
for
doctors
to
seek
financial
assistance
from
the
pharmaceutical
industry,
for
travels
abroad,
material
benefits
for
themselves
or
their
families.
They
may,
however,
seek
support
in
scientifically
valid
research
pursuits
provid
ed
the
research
is
not
aimed
at
promoting
a
particular
product
of
the
sponsor.
They
may
also
receive
travel
grants
from
the
sponsor
if
they
are
traveling
to
present
findings
of
this
research
on
an
academic
forum.
Grants
from
the
pharmaceutical
industry
towards
setting
up
or
improving
a
health
facility,
or
a
service
exclusively
for
the
welfare
of
patients
are
a[so
acceptable.
Prudent
use
of
pharmaceutical
human
and
material
resources
to
improve
health
literacy
amongst
patients
and
the
community
could
be
an
ethical
and
useful
pursuit.
The
pharmaceutical
industry
human
resource
and
customised
software
may
be
useful
in
improving
treat
ment
adherence.
A
doctor
in
particular
and
all
health
professionals
in
general
must
always
guard
against
becoming
biased
by
the
promotional
literature
distributed
by
the
pharmaceuticaL
representatives.
The
preferred
resource
for
information
regarding
a
particular
drug
should
always
be
peer
reviewed
medical
literature.
Health
professionals
must
aLso
refrain
from
luncheons,
dinners
and
meetings
held
at
holiday
resorts
or
hotets
under
the
cover
of
academic
activities
such
as
panel
discussions’
and
lectures
etc.
Dinner
and
Lunches
with
sponsored
educational
talks,
or
for
the
inclusion
of
patients
in
clinical
triaLs,
are
not
unethical:
however
a
professional
needs
to
use
his
or
her
own
prudence
as
regards
the
reaL
agenda
of
such
a
sponsorship.

51. Medication
samples
can
be
accepted
only
for
the
exclusive
use
of
deserving
patients
on
the
basic
ethics
principle
ofjustice.
These
samples
are
not
for
the
use
of
physician’s
family
and
friends.
Health
professionals
walk
a
tight
rope
in
their
relationship
with
the
pharmaceutical
industry.
If
used
prudently
this
relationship
can
en
hance
the
image
of
the
medical
profession
and
bring
great
advan
tages
for
research
and
patient
welfare.
A
minor
slip
on
the
doctor’s
part
or
an
overenthusiastic
nonprofessional
interaction
can,
however,
cause
him
great
harm.
The
single
driving
force
for
doctors
when
they
prescribe
drugs
has
to
be
the
benefit
of
their
patient.
The
doc
tor
under
all
circumstances
must
prescribe
those
drugs
and
inter
ventions
that
are
the
most
efficacious,
cost
effective
and
supported
by
most
evidence-base.
f.
Media
and
Medicine
The
last
two
decades
have
witnessed
a
rapid
growth
of
print
and
electronic
media.
This
has
resulted
in
our
excessive
dependence
on
the
media
for
all
kinds
of
information.
Whether
it
is
the
latest
development
in
politics
or
the
day’s
weather,
the
addictive
nature
of
media
technology
keeps
most
people
glued
to
their
TV
or
computer
screens
for
considerable
lengths
of
time
each
day.
The
news
media
are
also
an
important
source
of
information
on
health
and
medical
therapies.
There
is,
however,
widespread
concern
that
some
media
coverage
of
scientific
issues
may
be
inaccurate
and
over-enthusias
tic.
Journalists
and
media
managers
have
been
criticised
by
scien
tists
and
physicians
for
misleading
the
public
over
important
medi
cal
issues.
A
1997
survey
of
scientists
found
that
the
majority
of
them
believed
that
reporters
do
not
understand
statistics
wetl
enough
to
explain
new
scientific
findings,
do
not
understand
the
nature
of
science
and
technology
and
are
more
interested
in
sensationalism
than
in
scientific
truth.
For
instance,
sensationa[ised
reports
on
the
hazards
of
calcium
channel
blockers
may
have
led
some
patients
to
stop
taking
their
prescribed
antihypertensive
medications,
while
op
timistic
coverage
of
stem
cell
therapy
resulted
in
patients
requesting
this
unproven
treatment.
Similarly
the
internet
hosts
thousands
of
web
pages
offering
all
kinds
of
medical
advice
to
the
vulnerable
user.
\5Vhere
e-medicine
and
e-consultations
have
effectively
by
passed
the
hurdLe
of
distance,
they
still
remain
vutnerabte
to
ex
ploitation
by
quacks
and
impersonators.
Despite
the
controversy,
an
effective
and
judicious
use
of
electronic
and
print
media
along
with
internet
can
be
made
in
regard
to
prevention
of
illnesses
and
promotion
of
health.
The
concept
of
e-Health
offers
many
opportu
nities
for
prevention,
choice,
home
based
care,
and
chronic
disease
management,
and
it
has
the
potential
to
widen
access
to
health
care
for
most
patients.
Continuous
Medical
Education
fCME)
is
being
effectively
imparted
to
a
wide
section
of
medical
professionals
through
authentic
medical
websites
such
as
‘Medscape’
and
video
teleconferencing
is
an
effective
tool
for
sharing
information
through
long
distances
today.
Artist
Laura
Zomt
The
use
of
electronic
and
print
media
to
improve
health
literacy
is
a
noble
public
health
pursuit.
Such
opportunities
do,
however,
run
the
risk
of
misinformation.
They
also
have
the
potential
to
be
used

52. ?‘
for
personal
projection
by
hea[th
professionals.
Patients
and
their
families
may
expLoit
such
opportunities
for
seeking
free
advice
with
adverse
and
dangerous
consequences.
Health
Literacy
programmes
cannot
be
used
for
advertising
a
particular
drug
or
intervention
or
for
provision
of
specific
advice
to
viewers
or
callers
on
the
show.
The
use
of
internet
and
eHealth
can
be
brought
to
ethical
use
through
organizing
health
promotion
seminars
and
video
conferencing
to
run
CME
(contipuous
medical
education)
and
CPD
(continuous
profes
sional
development)
activities.
g.
E-Consuttations
and
Tetemedicine
E
-consultations
and
telemedicine
has
become
a
reality.
Telemed
icine
is
currently
linking
far
flung
areas
and
cities
like
Gilgit
and
Skardu
with
Islamabad.
The
phenomena
of
telemedicine
is
being
practiced
without
boundaries
around
the
world,
and
with
video
call
ing
features
available
in
every
social
media
app,
it
is
likely
to
spread
even
more.
Surgical
interventions
can
now
be
monitored
by
experts
in
the
field
from
a
distance
through
video
links,
especially
in
war
torn
areas.The
appearance
of
doctors
on
television
channels
is
an
important
way
to
promote
health
Uteracy.
It
is,
however,
unethical
to
attempt
to
diagnose
and
treat
patients
during
these
interactions.
Medicat
advice
should
not
be
given
out
to
peopte
cat[ing
in”
to
television
shows.
It
is
also
not
ethically
correct
to
attempt
to
diagnose
and
treat
patients
on
video
calls.
h.
TechnoLogy-assisted
Medicat
services
E
-consultations
and
telemedicine
has
become
a
reality.
Telemed
icine
is
currently
linking
far
ftung
areas
and
cities
like
Gilgit
and
Skardu
with
Islamabad.
The
phenomena
of
telemedicine
is
being
practiced
without
boundaries
around
the
world
and
with
video
call
ing
features
available
in
every
social
media
app,
it
is
likely
to
spread
even
more.
Surgical
interventions
can
now
be
monitored
by
experts
in
the
field
from
a
distance
through
video
links,
especially
in
war
torn
areas.The
appearance
of
doctors
on
television
channels
is
an
important
way
to
promote
health
literacy.
It
is,
however,
unethical
to
attempt
to
diagnose
and
treat
patients
during
these
interactions.
Medical
advice
should
not
be
given
out
to
peopLe
“calling
in’
to
television
shows.
This
is
ethically
incorrect.
i.
Declaration
by
a
Medicat
Student
or
a
Trainee
Heatth
Professional
It
is
mandatory
for
all
medical
students
and
trainee
health
profes
sionals
to
declare
their
exact
role
and
identity.
It
is
unethical
for
medical
students
to
pose
as
junior
doctor’
or
doctor
on
duty’
in
front
of
an
ignorant
patient
or
a
family
member.
Trainee
psychologists,
clinical
psychologists
and
other
health
professionals
working
in
hospital
settings
can
be
mistaken
for
doctors.
They
often
do
not
object
when
addressed
by
the
patients
or
their
families
as
‘doctor.
This
tendency
must
be
curbed,
in
favour
of
revealing
your
exact
identity
and
role
in
the
health
team
and
taking
pride
in
it.
Most
patients
enjoy
talking
to
medical
students
and
trainees
from
other
health
disciplines
as
they
have
more
time
for
them
and
are
more
interested
in
their
condition

53. Eysenbach
G,
]adadAR
Evidence-based
Patient
Choice
and
Consumer
heatth
inform
at/cs
in
the
Internet
age
]
Med
Internet
Res
2001,3t2):e19
URL:
http://wwwjmit
org/2001/2/e19
DOl:
lo.2196/jmir.3.2.e19 PMID:
11720961
PMCID:
PMC1761898
5.
Doctor-Patient
Relationship
If
you
have
come
to
hetp
me
You
are
wasting
your
time
But
if
you
hove
come
because
Your
tiberation
is
bound
up
with
mine
Then
let
us
work
together
-
An
Australian
Aborigine’s
statement
to
a
Doctor
The
basis
of
the
unique
relationship
between
doctor
and
patient
is
the
capacity
of
the
doctor
to
appreciate
the
complexity
of
human
behaviour.
A
doctor
must
be
sensitive
to
the
effects
of
history,
culture,
and
environment
on
his
patients.
At
the
center
of
this
therapeutic
retationship
is
the
trust
that
a
patient
has
in
the
doctor,
This
trust
is
built
on
the
unconditionaL
positive
regard
that
the
doctor
holds
for
the
patient,
irrespective
of
their
gender,
social
class,
caste,
colour
or
creed.
The
bond
that
forms
in
the
relationship
can
take
three
forms:
The
vertical
model,
where
the
doctor
completely
takes
over
the
process
of
care
with
the
patient
having
virtually
no
role
e.g.
when
a
patient
is
unconscious,
immobilised
or
in
an
altered
state
of
con
scious,
or
is
incapacitated.
The
teacher-student
model,
where
the
doctor
plays
a
roLe
similar
to
that
of
an
authority
figure
(such
as
a
teacher
or
a
parent),
who
dom
inates,
controls
and
guides
the
patient
e.g.
in
the
case
of
a
patient
-
recovering
from
a
surgical
intervention.
The
mutual
participation,
horizontal
modeL
where
the
doctor
and
the
participation
behave
as
partners
in
the
process
of
healing
and
care.
Each
augments
and
supports
the
other’s
effort.
The
patient
in
this
is
fully
aware
and
informed
and
plays
an
active
role
in
the
treat
ment
process
e.g.
a
patient
of
diabetes
metlitus
who
understands
the
nature
of
his/her
illness
and
undertakes
lifestyle
changes
to
manage
it
with
the
doctor’s
cooperation.
is
an
active
partner
in
the
management
process.
C
‘4(1’-”
/ -j
F,b
/
ZL:Z
;
2
48

54. It
is
important
to
note
that
the
relationship
between
doctor
and
patient
should
be
based
on
empathy,
not
on
friendship
or
affection
and
love.
Such
a
model
is
not
always
unethicaL
but
may
turn
the
relationship
into
an
unprofessional
one
with
obvious
repercussions
and
dangers.
The
major
dangers
in
this
relationship
include:
The
doctor
assuming
the
role
of
a
savior
and
fantasizing
that
only
they
can
reEscue
the
patient
from
all
the
troubles
of
the
world
The
doctors
inability
to
switch
off
and
leave
behind
the
patients
problems
when
away
from
the
clinical
setting.
A
need
to
control
everything
in
the
patients
life
and
to
try
and
pre
vent
death,
which
may
not
be
possible
in
all
cases.
A
doctor
visualising
his
or
her
own
complexes
and
difficulties
in
the
patients
issues
e.g.
a
doctor
having
a
disturbed
relationship
with
his
father,
assuming
that
the
patient
must
also
be
going
through
such
difficulties
or
a
doctor
avoiding
discussion
of
such
an
issue
with
their
patient
even
when
it
is
of
clinical
significance.
The
doctor
becoming
judgmental
in
the
relationship
with
the
pa
tient
and
starting
to
determine
what
he
or
she
ought
and
ought
not
to
do.
An
enthusiastic
medical
student
handing
over
financial
or
material
help
to
a
patient
or
seeking
them
from
a
patient.
Both
transactions
are
against
the
norms
of
professionalism.
Rights
and
Responsibilities
of
Patients
and
Doctors
a.
Rights
of
the
Patient
It
is
useful
to
have
a
list
of
rights
that
medical
ethics
grant
to
a
patient.
Doc
tors
have
a
duty
to
communicate
and
assist
patients
in
protecting
these
rights.
Patients
have
the
right
to:
•
have
informed
consent
taken
from
them.
This
is
after
they
have
been
educated
about
the
illness
and
its
treatment,
alternative
treatment
options
and
side-effects
involved.
Costs
of
the
proposed
treatment
and
any
further
costs
associated
with
rehabilitation
and
details
of
support
services
must
alo
be
communicated
to
the
patient.
withdraw
consent
at
any
time.
refuse
experimental
or
research
treatment.
•
obtain
a
second
opinion.
•
confidentiality
regarding
details
of
a
condition
and
treatment
being
maintained
by
medical
and
hospital
staff.

55. be
treated
with
care,
consideration
and
dignity.
•
request
medical
files
from
the
doctor.
•
obtain
legal
advice
regarding
any
matter
arising
from
the
treatment.
•
contact
friends,
relatives,
soLicitors,
members
of
the
religious/faith
group
or
his
or
her
wards
if
he
or
she
is
the
parent
or
guardian.
•
ask
to
stay
with
a
child
at
all
times
except
where
separation
is
necessary
for
medical
reasons.
•
inform
nursing
staff
if
he
or
she
wants
to
or
does
not
want
to
see
or
speak
to
a
visitor.
b.
ResponsibiLities
of
the
Patients
Besides
their
rights,
patients
have
certain
responsibilities,
such
as
to:
•
Know
their
own
medical
history
including
medications
taken
•
Keep
appointments
or
advise
/
inform
those
concerned
if
they
are
unable
to
do
so.
•
Comply
with
the
treatment
advised
/
supplied.
•
Inform
the
doctor
if
they
are
receiving
treatment
from
another
health
professional
•
Know
how
their
charges
of
treatment
are
best
covered.
•
Conduct
themselves
in
a
manner
which
will
not
interfere
with
the
welt-being
or
rights
of
other
patients
or
staff.
c.
Rights
of
the
Doctor
A
doctor
has
the
right
to
refuse
to
undertake
an
action,
a
procedure
or
an
intervention
which
is
against
his/her
personal
ethics
or
beliefs.
S/he
also
has
the
right
to
refuse
to
treat
a
certain
individual
(provided
the
individual
is
not
in
any
immediate
Life
threatening
danger).
In
such
an
eventuality
the
physician
is
under
obligation
to
refer
the
patient
to
another
professional.
d.
ResponsibiLities
of
the
Doctor
•
leave
a
hospital
at
any
time
(except
in
the
cases
of
infectious
disease
or
certain
psychiatric
conditions).
If
the
patient
leaves
against
medical
advice,
however,
s/he
is
liable
for
any
injury
or
illness
caused,
or
ag
gravated
by.
the
action.
‘!
L’1’
Z/—
Whon
14t
WSflI
.‘c—
cJon,
wtflQ,nfl
ID
rDu.
It
is
a
doctor’s
responsibility
to
provide
scientific
information
on
disease,
diagnostics
and
treatment
options
available
to
the
patient.
S/he
is
also
re
sponsible
for
addressing
a
patient’s
concerns
and
taking
informed
consent
for
all
therapeutic
actions.
Doctors
must
respect
the
patient’s
decisions
even
when
they
are
in
disagreement
with
them.
They
must
uphold
the
interest
of
their
patient
above
their
own
(fiduciary).
They
must
also
never
use
their
authority
in
any
cause
other
than
the
best
interest
of
the
patient.

56. Miss
X,
a
twenty
year
old
student
from
the
local
intermediate
cottege,
was
admitted
in
a
long
stay
medical
ward
undergoing
treatment
for
pulmonary
tubercutosis.
Mr
K
a
third
year
medical
student
was
assigned
to
take
a
de
tailed
medicat
history
and
examination.
During
the
course
of
history
taking,
Mr
Ynoticed
that
only
after
a
few
minutes
of
interaction,
Miss
Xsat
up
in
the
bed
and
became
cheerfuL
Even
while
describing
the
details
of
her
cough,
toss
of
weight
and
night
sweats
she
woutd
smile.
At
the
end
of
forty
minutes
assignect
for
taking
the
aacount,
Mls.XinsistecTthdt
Mr.
Yshould
tal?e
a
bite
from
the
fruit
basket
or
else
take
a
cup
of
tea
with
her
She
mentioned
that
some
of
the
important
details
of
the
history
have
not
been
yet
covered
and
asked
the
medical
student
to
come
in
the
evening
and
she
wilt
be
glad
to
furnish
further
details.
Mr
Ywas
impressed
by
the
‘unusuat’friendly
attitude
of
the
patient
He
turned
up
in
the
evening,
to
find
that
Miss
X
was
waiting
for
him.
She
not
onty
gave
a
detailed
account
of
her
iltness
but
also
reported
‘feeling
much
better”since
her
morning
interaction
with
Mr
Y.
She
told
him
how
impressed
she
was
with
the
‘kind
and
pleasant
personatity”
of
Mr
Yand
that
she
had
never
seen
such
a
wonderful
‘doctor.”
She
asked
for
Mr
Y’s
mo
bite
number
so
that
she
could
talk
to
him
when
she
felt
distressed
or
unwelL
Mr
Ygtadly
agreed.
On
his
way
back
from
the
ward,
Mr
Ywas
thinking
about
the
“positive
impact”
that
he
had
on
his
patient
He
decided
that
he
should
visit
her
regularly
during
his
clinical
rotation
to
“assist
her
feel
better”
Next
day
he
bought
fruits,juices
and
chocolates
for
the
patient
He
did
so
secretively,
so
that
the
ward
staff
and
his
batch
mates
should
not
‘make
stories’
or
‘get
ideas
The
gesture
went
down
very
well
with
Miss
X
In
a
few
days,
Ywas
a
regular
visitor
to
Miss
X
even
after
his
batch
moved
on
to
the
surgical
rotation.
Miss
X
would
regularly
call
on
his
cell
phone
to
seek
advice.
She
started
to
share
her
unhappiness
and
her
arguments
with
her
mother
and
how
much
she
missed
her
kind
and
affectionate
father
whom
she
had
lost
as
a
child.
Yin
the
meanwhile
start
ed
to
advise
her
on
social
and
domestic
issues,
how
to
deal
with
her
“cruel
mother”
He
started
to
feel
like
the
only
‘saviour’
and
‘friend’
in
X’s
“miserable”
life.
When
the
ward
staff
began
to
object
to
his
visits,
Mr
Ystarted
to
get
into
arguments
with
them
and
insisted
that
he
was
doing
so
to
keep
the
patient
happy
and
healthy.
In
a
few
days,
Miss
X
was
discharged
from
the
hospitaL
One
evening
Mr
Yresponded
to
a
knock
at
his
hostel
room’s
door
to
find
Miss
Xstaning
there
with
a
bag
in
her
hand.
She
told
him
that
she
had
left
the
home
and
her
callous
mother
who
wanted
to
marry
her
off
to
a
cousin
against
her
wilL
She
stated
that
Mr
Ywas
the
only
one
whom
she
thought
“really
understood
and
cared”for
her
and
could
save
her
from
the
wrath
of
her
mother
Mr
Ywas
flabbergasted
and
did
not
know
what
to
do.
He
hurried
ly
made
her
sit
in
the
WRoom
and
started
to
insist
that
she
return
home.
He
categorically
stated
that
he
could
not
really
take
responsibility
of
Miss
X
Miss
Xbroke
down
into
tears
initially
and
then
started
to
shout
and
cry,
accusing
Y
of
misguiding
her,
and
saying
he
was
“no
different
from
the
rest
of
the
unkind
world.”
Word
started
to
spread
in
the
hostel
and
the
warden
arrived.
Miss
X’s
famity
was
contacted
and
she
was
returned
home
with
great
difficulty.
Mr
Y
was
severely
reprimanded
and
for
many
weeks
became
the
laughingstock
of
his
class.
Miss
X
was
admitted
in
the
psychiatry
ward
with
an
attempt
at
de
liberate
self-harm
as
she
took
an
overdose
of
her
anti
TB
drugs
and
slashed
her
wrists.
Mr
Ywas
called
by
the
treating
psychiatrist,
where
he
learned
of
the
psychological
reactions
that
had
led
to
his
and
Miss
X’s
ordeaL
It
took
many
weeks
of
intense
psychotherapeutic
work
for
the
mental
health
team
to
work
through
the
issues.
In
the
course
of
Miss
X’s
treatment
and
Mr
Y’s
coun
selling
sessions,
the
phenomena
of
transference,
counter-transference
and
resistance
became
clear
to
Mr
K

57. Psychological
Reactions
in
Doctor-Patient
Relationship
The
primary
expectation
of
patients
from
their
doctor
is
that
they
show
empathy,
that
is,
understand
their
feelings,
show
kindness,
interest,
and
a
non-judgmental
approach.
They
also
expect
to
be
considered
active
partners
in
care.
In
Pakistan
the
doctor
is
given
the
status
of
someone
who
always
makes
the
better
decision
for
you
in
matters
of
health.
This
leads
to
either
feelings
of
sympathy
(feeling
and
experiencing
the
emotions
of
the
patient)
and
over-identification
with
the
patient,
or
distancing
and
isolation
from
the
patient.
Both
reactions
on
the
part
of
the
physician
can
make
the
relationship
complicated
or
take
a
turn
that
undermines
professionalism.
There
are
a
variety
of
social
and
psychological
reactions
in
a
typical
sus
tained
doctor-patient
relationship.
These
phenomena
are
most
intense
in
psychotherapeutic
interactions
but
can
occur
in
any
helping
relationship
in
a
milder
or
a
somewhat
modified
form.
They
are:
•
social
bonding
•
dependence
•
transference
•
counter-transference
•
resistance
•
physician
burn-out
These
reactions
occur
in
the
mind
of
the
patient
as
well
as
the
doctor
without
one’s
normat
awareness.
They
can
help
a
doctor
understand
why
a
certain
patient
is
reacting
in
a
particular
way
or
why
they
themselves
are
behaving
differently
with
a
certain
patient.
a.
Social
bonding
Pakistan
is
a
unique
mix
of
urban,
rural,
semi
urban,
modern,
pagan,
east
ern
and
western
cultures.
Its
Islamic
heritage
and
connection
with
the
Arab,
Central
Asian
and
Persian
tradition
further
defines
the
nature
and
form
of
its
relationships.
The
modern
doctor
who
practices
allopathic
medicine
is
linked
with
the
British
Raj.
Fotlowing
the
independence
in
1947,
the
tertiary
care
hospitals
were
run
by
doctors
trained
in
Britain.
The
traditional
rela
tionship
that
the
common
man
has
with
the
doctor
is
similar
to
his
bond
with
the
ruling
elite
in
the
19th
and
20th
century.
which
was
heavily
under
the
Western
influence.
The
common
man,
therefore,
has
an
urge
to
form
a
closer
social
bond
with
the
doctor,
who
is
seen
as
part
of
the
elite.
The
doctor
in
his
own
need
to
be
part
of
the
elite
makes
constant
efforts
to
socia[ise
with
high
ranking
government
officials,
miLitary,
politicians,
and
others
in
power.
This
arrangement
grossly
undermines
the
professional
nature
of
the
bond
that
should
ideally
exist
in
an
ethical
health
setting.
It
results
in
the
so-called
VIP
culture
in
hospitals,
and
grossly
undermines
the
•
founding
principle
ofjustice
in
medical
ethics.
The
quality
and
nature
of
social
bonds
between
doctors
and
their
patients
is
expected
to
take
a
new
shape
with
the
advent
of
social
media.
All
at
tempts
at
forming
social
bonds
that
can
challenge
the
professional

58. nature
of
doctor
patient
reLationship
must
be
guarded
against.
This
in
c[udes
befriending
patients
on
sociaL
networks
or
making
them
privy
to
doctors
personaL
Lives.
This
is
because
this
shifts
the
focus
of
the
doctor
patient
reLationship
to
the
doctor,
instead
of
remaining
on
the
patient
and
their
treatment.
It
also
transforms
the
doctor
patient
relationship
from
a
therapeutic
to
a
social
one.
This
may
also
lead
to
serious
issues
of
trans
ference
and
counter
transference.
b.
Dependence
The
vertical
nature
of
the
existing
relationship
between
doctors
and
their
patients
puts
health
professionals
on
a
higher
pedestal,
where
they
are
asked
to
make
crucial
health
decisions
concerning
the
Life
of
their
pa
tients.
Traditional
family
physicians
even
have
a
say
in
personal
and
family
decisions
of
the
community
that
they
serve.
This
unique
status
gener
ates
strong
psychological
dependence
of
patients
on
their
doctors.
If
the
patient
has
dependent
personality
traits,
this
dependence
can
become
counter
therapeutic
and
lead
to
negative
heaLth
outcomes.
A
dependent
patient
can
start
to
tax
health
resources,
a
doctor’s
time
and
energies.
They
may,
then,
translate
their
dependence
into
hostility
and
anger
towards
the
health
profession.
An
ethical
doctor
ensures
earty
detection
and
management
of
this
psychological
reaction.
If
there
is
a
failure
to
manage
this
state
it
is
safe
to
refer
the
patient
to
a
colleague
for
further
management
after
briefing
them
on
the
issue.
c.
Transference
Transference
is
when
feelings,
attitudes
and
desires
originatly
linked
with
a
significant
figure
in
a
patient’s
life
(usually
childhood)
are
projected
or
transferred
onto
the
doctor.
Transference
may
be
positive
or
negative.
The
significant
figure
may
be
a
patient’s
parents,
sibling
or
someone
that
the
patient
was
close
to.
Depending
on
the
nature
of
the
relationship
of
the
patient
with
that
person
in
childhood,
the
feelings
for
the
doctor
can
be
positive
or
negative.
In
the
case
mentioned
above,
Mr.
Y,
was
seen
as
a
kind
and
compassionate
repLacement
of
the
Miss
X’s
[ate
father.
___
CIii1c
______
___
114e
D€TO
Tht
TO
-::.--J1

59. When
a
patient
is
seen
showing
aggression
towards
a
doctor,
with
no
ob
vious
cause
in
the
present,
this
may
be
an
expression
of
negative
transfer
ence.
A
doctor
unaware
of
the
phenomenon
of
transference,
may
find
this
behaviour
threatening
and
offensive.
Similarly,
positive
transference
feelings
amongst
patients
commonly
occur
on
long
stay
wards
for
the
female
nurses
attending
them.
The
femate
doc
tor
or
nurse
may
remind
them
of
a
mother
or
a
caring
elder
sister.
Patients
in
such
a
state
may
openly
express
their
desire
to
bond
with
the
nurse
or
a
doctor
as
a
sister,
brother,
mother,
father,
uncle
or
aunt.
Due
to
the
patient
experiencing
this
transference,
s/he
may
give
the
doctor
an
elevated
sta
tus,
and
start
to
compliment
them
unduly.
It
is
important
for
the
doctor
or
other
health
professional
in
this
situation
to
reaLise
that
the
patient
knows
next
to
nothing
about
them
personally
and
is
merely
identifying
them
with
•
someone
they
knew
intimately.
This
may
become
difficult,
as
the
show
of
this
emotion
may
be
quite
flattering,
especially
if
coming
from
the
opposite
sex.
$
Unresolved
and
unaddressed
transference
can
tead
to
prolongation
of
the
patients
stay
in
the
ward.
Patients
may
begin
to
ask
for
personal
phone
numbers
and
home
addresses
of
the
carer.
They
may
also
begin
to
invite
the
doctor
or
the
nurse
to
meet
outside
clinical
settings
(as
in
the
case
of
Mr.
Y
and
Miss
X).
The
ethical
dilemmas
that
may
follow
this
behaviour
call
for
a
constant
awareness
and
understanding
of
the
phenomenon
of
trans
ference. d.
Counter-transference
If
an
adult
patient
in
a
medical
ward
wants
to
be
examined
by
one
partic
ular
doctor,
wishes
the
doctor
comes
to
their
bed
first
and
spend
longer
time
in
their
company,
it
may
be
on
account
of
a
paternal
transference.
The
doctor,
on
account
of
his
physical
appearance,
mannerism,
or
personal
ity,
may
remind
the
patient
of
their
father.
The
feelings
for
the
father
that
the
patient
felt
as
a
child
and
were
tong
forgotten,
may
come
to
the
sur
face
during
their
admission.
This
often
happens
as
patients
in
a
ward
feel
dependent
and
cared
for,
the
same
as
children.
This
behaviour
amongst
grown-up
patients
of
reverting
to
child-like
behaviour
is
catted
regression.
In
this
state
they
start
to
feel
a
strong
bond
for
the
doctor,
similar
to
one
they
once
had
with
a
parent
figure
as
a
child.
In
countertransference
the
emotional
responses
of
the
doctor
are
directed
towards
the
patient.
Similar
to
transference,
countertransference
may
also
be
negative
or
positive.
The
patient
in
such
situations
reminds
the
doctor
of
a
welt-loved
or
hated
individual
from
the
past.
and
fulfils
an
unfulfilled
psychological
need.
In
the
case
of
Mr.
Y,
(mentioned
before)
his
deep
Poctor,
I
had
a
dfficuIt
childhood.

60. I
seated
desire
to
feel
like
a
rescuer
was
fuLfilled
by
Miss
Xs
reaction.
In
another
setting,
a
young
doctor
during
his
house
job
began
spending
long
hours
in
the
care
of
a
60
year
old
patient
with
hemiplegia.
He
would
miss
his
ward
rounds,
emergency
duties
and
even
his
rest
hours
to
be
on
the
bedside
of
the
patient
when
there
was
no
cLinical
need
to
do
so.
A
deeper
took
into
the
situation
revealed
that
the
patient’s
looks
greatly
resembled
the
doctor’s
deceased
father,
who
died
of
stroke
many
years
ago,
and
who
the
young
doctor
had
failed
to
took
after.
In
this
case,
the
doctor
experi
enced
countertransference
towards
the
patient.
Unaddressed
counter-
transference
can
greatly
jeopardise
the
professional
life
of
a
doctor
anci
compromise
the
quality
of
the
doctor-patient
relationship.
How
can
transference
and
countertransference
issues
be
dealt
with?
The
most
important
measure
in
all
health
care
settings
is
to
have
a
con
stant
awareness
of
transference
and
countertransference.
A
conscious
understanding
of
the
feelings,
positive
or
negative,
that
a
doctor
or
their
patient
is
having
can
make
behaviour
clinicat
and
prudent.
Transference
or
countertransference
may
become
overpowering
and
adversely
affect
the
doctor’s
ctinicatjudgment
or
progress
of
the
patient.
In
such
a
case,
care
of
the
patient
should
be
shifted
to
a
more
experienced
colleague.
It
may
become
necessary
to
report
the
matter
to
the
consultant
or
head
of
department
to
make
alternative
arrangements.
This
is
an
action
that
Mr.
Y
should
have
undertaken
at
the
very
onset
of
his
discovery
of
the
phe
nomena
of
transference
and
countertransference;
Mr.
Y
instead
kept
it
a
secret
as
he
was
unaware
of
the
psychological
reactions
setting
in.
In
case
there
are
repeated
episodes
of
transference
and
counter-trans
ference
with
a
particular
doctor,
it
is
appropriate
for
them
to
seek
psycho
therapeutic
advice
from
a
mental
health
professional.
It
is
also
important
to
work
towards
ensuring
the
therapeutic
relation
ship
is
strictly
professionaL
Making
statements
to
a
patient
such
as
“you
remind
me
of
my
mother”,
or
referring
to
patients
as
Uncle,
Amma
or
Cha
cha
is
not
helpfuL
The
use
of
titles
such
as
Mr.,
Ma’am,
or
Bibi
or
Sahab
to
refer
to
patients
is
respectful
and
culturally
appropriate.
e.
Resistance
Some
patients
may
be
seen
constantly
defying
a
doctor’s
instructions
in
spite
of
repeated
warnings
of
the
serious
consequences.
An
example
of
this
is
a
patient
of
coronary
artery
disease
who
refuses
to
give
up
smok
ing,
eats
red
meat
regularly,
finds
evening
walks
“boring”
and
makes
no
attempt
to
shed
weight.
This
patient
is
exhibiting
what
is
referred
to
as
resistance
in
the
doctor
patient
relationship.
Resistance
is
a
result
of
use
of
unhealthy
defense
mechanisms
such
as
denial,
avoidance,
rationaliza
tion
and
suppression
(discussed
in
detail
in
section
E).
The
patient
is
often
unaware
of
this
and
it
may
be
useful
to
discuss
these
in
a
therapeutic
interaction.
This
will
help
to
make
the
patient
conscious
of
the
basis
of
their
faulty
behavior
and
work
towards
improving
it.
Resistance
can
seriously
disrupt
the
doctor
patient
relationship.
A
doc
tor
who
is
unaware
of
it
may
gradually
start
to
withdraw
from
the
care
of
such
a
patient
or
refuse
to
treat
him
at
alL
The
patient
may
become
even
more
resistant
to
treatment
following
or
develop
hostile
feelings
towards
the
doctor.
Resistance
may
be
a
transitory
stage
in
the
treatment
process.

61. gradually
receding
on
its
own.
It
may
be
resolved
with
a
couple
of
sessions
addressing
the
issue
in
a
meaningful
discussion
with
the
patient.
Clinical
ty,
resistance
may
present
as
or
non-adherence
to
treatment
on
part
of
the
patient.
When
a
patient
is
repeatedly
seen
to
do
so,
it
is
important
to
consider
it
a
psychological
reaction
that
needs
a
deeper
insight
and
un
derstanding. f.
UnweLL
Physician
/
Burn-out
With
increasing
personal
and
professional
demands.
there
is
a
proportion-
‘
I
.
ate
rise
in
stress
experienced
by
health
professionals.
This
increased
stress
-
‘-
may
lead
to
maladaptive
methods
of
dealing
with
the
situation,
causing
the
,.
.
‘
heaLth
professional
to
burn
out.”
Burnout
refers
to
a
form
of
psychological
stress
caused
by
mental
and
physical
exhaustion.
It
leads
to
an
increase
..
in
the
number
of
health
professionals
who
develop
depression,
become
suicidal,
indulge
in
drug
abuse,
alcoholism
and
other
risk
taking
behav-
Arfist
Laura
Zombie
ior
patterns.
This
adversely
affects
their
professional
and
ethical
standing.
These
health
professionals
are
a
risk
to
themselves,
their
patients
and
their
own
family
and
community.
Early
signs
of
burnout
in
physicians
include
the
following:
•
Long
working
hours
without
any
time
for
exercise,
healthy
family
life,
and
interaction
with
friends
•
Loss
of
temper
and
anger
outbursts
at
work
and
at
home
•
Chaotic
family
life
•
Impaired
clinical
decision-making
and
deteriorating
performance
•
Frequent
job
changes
•
Un-prescribed
use
and
misuse
of
painkillers,
tranquillisers,
smoking,
alcohol
abuse
It
is
ethical
tooffer
and
provide
help
to
a
colleague
who
is
showing
early
signs
of
impairment
in
performance
due
to
burnout.
In
case
they
refuse
to
seek
help
and
continue
to
see
patients,
the
matter
may
need
to
be
report
ed
to
PM&DC
or
the
employers.

62. Professionalism
in
Health
Care
A
healthy
doctor-patient
relationship
is
dependent
on
the
professional
excellence
of
a
doctor.
Professional
excellence
is
based
on
the
knowledge,
skills
and
attitude
of
the
physician,
who
is
expected
to
treat
both
the
psy
che’
(mind)
and
the
‘soma’
(body).
The
following
attributes
of
knowledge,
skills
and
attitude
are
essential
for
any
doctor
to
be
considered
a
professional.a.
KnowLedge
i.
Distinguish
normality
from
abnormality
from
a
medical.
social
and
psychological
perspective
ii.
Relate
biological
factors
with
psychosociaL
factors
in
health
and
disease
iii.
Learn
the
use
principles
of
behavioural
sciences
in
clinical
interviews,
assessments
and
management
plans
iv.
Request
and
justify
not
only
laboratory,
radiological,
and
electrophysiological
investigations
but
also
make
social
and
psychological
inquiries
v.
Use
pharmacological
as
well
as
non-pharmacological
interventions.
vi.
Apply
evidence-based
research
findings
to
clinical
situations
b.
SkiLLs
Written
Communication
ShiLLs:
i.
Demonstrate
competence
in
medical
writing
ii.
Write
a
comprehensive
history
of
the
patient
iii.
Update
medical
records
clearly
and
accurately
iv.
Write
management
plans,
discharge/transfer
summaries
and
referral
notes
VerbaL
Communication
ShiLls:
i.
Establish
professional
relationships
with
patients
and
their
caregivers
to
obtain
a
history,
a
physical
examination
and
make
an
appropriate
management
plan
ii.
Demonstrate
usage
of
appropriate
Language
in
bedsiçfe
sessions,
outpatients,
E-communication,
seminars,
iii.
Demonstrate
the
ability
to
communicate
clearly
and
sensitively
with
patients,
relatives,
other
health
professionals
and
the
public
iv.
Demonstrate
competence
in
presentation
skills
v.
Provide
informational
care
and
counsel
patients
f.
Use
principles
of
effective
communication
(section
A)
in
all
his/her
clinical
interactions.

63. Patient
Management
Skitts:
i.
Interpret
the
history
and
examination
findings
and
arrive
at
an
appropriate
differential
diagnosis
and
final
diagnosis
ii.
Demonstrate
competence
in
cLinical
problem
identification,
analysis
and
management
of
the
probtem
using
appropriate
resources
üi.
Prioritise
cLinical
probtems
for
interventions
iv.
Use
evidence-based
pharmacological
and
psychosocial
interventions
v.
Independently
undertake
counselling
and
informational
care
sessions
Skitts
in
Research:
i.
Undertake
relevant
literature
searches
and
collect
evidence
based
guidelines
for
use
in
clinical
practice
ii.
Interpret
and
use
resuLts
of
peer
reviewed
and
standard
articles
to
improve
clinical
practice
(and
learn
to
not
rely
on
data
published
by
groups
with
a
vested
interest)
iii.
Organise
and
actively
participate
in
educational,
training
and
research
activities
c.
Attitudes
Towards
Patients:
i.
Establish
a
therapeutic
and
ethical
relationship
with
all
patients
ii.
Demonstrate
commitment
to
the
biopsycho-’social
model
in
the
assessment
and
management
of
patients
iii.
Demonstrate
sensitivity,
empathy
and
understanding
while
performing
physical
and
mental
state
examinations
iv.
Consistently
show
consideration
towards
the
interests
of
the
patient
and
the
community
and
place
them
above
personal
interest
v.
Adhere
to
principles
of
medical
ethics
under
all
circumstances
vi.
Exhibit
highest
standards
of
professionalism
through
the
practice
of
integrity,
compassion.
honour.
humanism
and
respect
for
patients.
colleagues,
seniors
and
juniors,
vii.
Demonstrate
ability
to
work
as
a
team
member
as
well
as
a
leader
Towards
Setf
Development:
i.
Demonstrate
consistent
respect
for
every
human
being
irrespective
of
ethnic
background.
culture.
soclo-economic
status
and
religion.
ii.
Dealwith
patients
in
a
non-discriminatory
and
prejudice
free
manner.
iU.
Deal
with
patients
with
honesty,
equity
and
compassion.
iv.
Demonstrate
flexibility
to
adjust
appropriately
to
changing
circumstances.

64. v.
Foster
principles
of
self-education
and
reflection
in
order
to
constantly
update
and
refresh
knowledge
and
skills
vi.
Recognise
stress
in
self
and
others.
vii.
Deal
with
stress
and
support
colleagues
and
allied
health
workers.
viii.
Handte
criticism
by
colleagues
or
patients
constructively.
ix.
Obtain
and
value
a
second
opinion
on
clinical
matters.
x.
Demonstrate
effectiveness
as
a
member
as
well
as
a
leader
of
the
health
team
Towards
Society:
i.
Exhibit
sensitivity
towards
the
social,
ethical
and
legal
aspects
of
health
care
provision
ii.
Offer
cost
effective
professional
services
In
addition
to
the
above
attitudes
s/he
must
demonstrate
a
commitment
towards
following
measures
of
professionaL
character
deveLopment.
These
measures
can
be
used
by
the
trainers
of
medical
students
and
post-graduate
trainees
to
measure
professionalism
for
assessment
and
feedback.ProfessionaL
Attire:
A
medical
student
or
a
doctor
is
expected
to
dress
in
serious,
non-
provoking
and
non-offending
attire.
The
bearing
of
the
health
professional
should
help
patients
become
comfortable.
It
should
not
in
any
way
give
an
image
of
self-neglect
or
non-concern.
Respect
for
time
and
punctuatity:
A
doctor
is
expected
to
be
punctual
and
prepared
for
ward
rounds,
lec
tures,
and
procedures
for
patients.
This
attitude
affects
the
morale
of
patients,
colleagues
and
students
as
it
reflects
commitment
towards
the
profession.
A
lack
of
this
attitude
marks
lack
of
discipline,
structuring
and
organizing
capabilities
of
the
doctor.
Grasp
and
knowtedge
about
patients
under
care:
A
doctor
is
expected
to
have
a
grasp
and
knowledge
of
the
patients
s/he
interviews
and
should
be
equipped
with
basic
literature
about
the
patients’
illness.
S/he
is
also
expected
to
present
the
patient’s
history
to
the
consul
tant
the
next
day
of
hospitalisation.
An
expression
of
this
pattern
is
viewed
as
a
positive
professional
attitude.
Lack
of
this
indicates
poor
work
ethic
and
insufficient
intellectualstamina.
Conscientiousness:Taking
responsibility
in
carrying
out
clinical
assignments
reflects
interest
in
learning
and
efficient
patient
care.
A
doctor
is
expected
to
have
a
responsi
ble
attitude
about
his/her
patients,
which
profiles
them
as
a
conscientious
professional.
Inconsistency
of
this
attitude
indicates
health
problems,
am
bivalence
towards
career,
and
inability
to
become
a
real
professional.

65. A
doctor
or
a
medical
student
is
expected
to
adhere
to
the
basic
human
value
of
understanding
detaits
of
a
patient’s
clinical
findings
and
reporting
them
with
accuracy,
integrity
and
confidentiality.
A
failure
to
acknowledge
one’s
mistakes
and
omissions
in
reference
to
patient’s
clinical
information
qualifies
for
serious
professional
dishonesty
and
merits
dismissal
from
training. Avaitabitity
to
the
patients:
Doctors
are
expected
to
be
available
to
their
patients
on
a
daily
basis
through
appointments,
and/or
telephone.
When
on
leave
or
out
of
station
on
duty,
they
must
be
available
on
telephone
to
the
patients
they
consider
need
attention.
They
must
inform
the
patient
of
this
in
advance
and
intro
duce
them
to
another
doctor
who
has
been
briefed
about
their
condition
and
will
care
for
them
in
their
absence.
Relationships: Relationships
with
patients,
hospital
staff,
fellow
students,
colleagues
and
faculty
member
are
expected
to
be
of
mutual
support.
respect,
and
professional
honesty.
Difficulties
in
dealing
with
or
failure
to
cooperate
with
any
one
or
more
of
these
people
may
reflect
health
problems
or
serious
personality
issues.
Integrity
in
reporting
patients’
findings:
Assessment
of
Attitudes
(Professionalism)
Score
in
Doctors
Professional
attire!
demeanour
•1I
Iactf9rumeand
puncwky::
-.
-
7 3
Grasp
and
knowledge
of
awn
patients
L
Integrity
in
reporting
patient
findings
Relatbnsblps
with
colleagues,
hospital
staff
and
patients
*
Score
7-70
-.

66. I
SAMPLE
MCQ
FOR
SECTION
B
1.
A
young
man
undergoes
a
three
month
tong
treatment
by
a
femate
doctor.
Upon
his
recovery,
to
show
his
gratitude
he
brings
her
an
expensive
gift.
Themost
ethicaL
way
to
respond
wouLd
be:
a)
Report
the
matter
to
the
head
of
department.
b)
Ask
the
patient
to
leave
immediatety,
or
you
will
call
security.
C)
Tell
the
patient
you
will
be
right
back
and
send
in
a
male
colleague
to
manage
the
situation
d)
Take
the
gift
but
tell
the
patient
to
never
bring
you
anything
ever
again
e)
Politely
refuse
to
take
the
gift
and
explain
to
the
patient
that
it
is
against
medical
ethics
to
do
so.
2.
A
25
yr
old
male
presents
to
you
in
emergency,
after
a
road
traffic
accident.
On
examination
he
is
seen
to
have
had
profuse
blood
toss,
has
low
BR
and
cotd
clammy
skin
and
he
is
drowsy.
What
is
the
most
appropriate
action:
a)
Try
to
wake
him
up
so
he
can
give
consent
to
proceed
further.
b)
Wait
for
the
patient’s
brother
to
arrive
so
he
can
give
consent
c)
Start
Life
saving
measures
immediately
as
the
situation
is
an
emergency
and
does
not
require
informed
consent.
d)
To
refuse
treatment
without
available
consent.
e)
Ask
your
senior
to
decide.
3.
A
patient
recently
diagnosed
with
Type
II
Diabetes
mellitus
refuses
to
cut
back
on
the
use
of
sugary
drinks
and
sweets,
despite
being
given
informational
care
by
his
doctor,
and
warned
of
the
serious
consequences.
He
is
displaying
the
phenomenon
of:
a)
Transference
b)
Resistance
c)
Counter-transference
d)
Non-compliance
e)
Emotional
instability.
4.
You
have
been
asked
to
taLk
to
a
patient
who
has
refused
diaLysis
for
renal
failure.
The
most
appropriate
strategy
would
be
to:
a)
Provide
detailed
informational
care
in
an
exclusive
setting
b)
Listen
and
empathise
with
unconditional
positive
regard
c)
Explain
the
pros
and
cons
of
her
decision
and
then
leave
the
choice
of
dialysis
to
her
d)
Explain
to
the
patient’s
family
the
importance
of
dialysis
and
ask
them
to
convince
her
e)
Take
the
patient
for
dialysis
without
telling
her

67. 5.
A
young
man
reports
to
the
medicat
OPD
with
swotten
tymph
gtands,
genital
uLcers,
and
chronic
fatigue.
He
is
admitted
and
upon
testing
is
found
to
be
H
IV-Positive.
According
to
the
principtes
of
medical
ethics,
the
most
suitable
action
is
to:
a)
Not
give
any
one
the
information
to
protect
confidentiaLity
b)
Tell
the
patients
family
to
tell
everyone
he
has
been
in
contact
with
C)
Inform
the
patients
wife
immediately.
U)
Convince
the
patient
to
keep
the
information
quiet,
to
protect
him
from
the
stigma
e)
Counsel
the
patient
regarding
the
transmission
of
HIV,
and
persuade
the
patient
to
tetl
his
wife
himself.
Inform
him
of
your
responsibility
to
teLl
her
yourself,
in
case
he
refuses
to
do
so.
Sample
Short
Essay
Question
For
Section
B
01.
What
are
the
essentiaL
principles
of
medical
ethics?
HighLight
the
two
most
commonly
ignored
ethical
norms
in
medical
practice.
02.
Differentiate
between
transference
and
counter-transference.
Answers i.e 2.
c
3.
b
4.
c
5.
e

68. ECTION
C
sychology
in
Medical
Practice
OUTLINE
•
Role
of
Psychology
in
Medical
Practice
Principles
of
Psychology
•
Learning
•
Metacognition
Memoty
•
Perception
•
Thinking
.
Emotions
•
Motivation
Intettigence
Personatity
Neurobiological
Basis
of
Behaviour
Chapter
1
Psychology
in
Medical
Practice
Human
thought,
behaviour
and
interactions
follow
a
set
of
psychological
processes
and
principles.
The
role
of
these
principles
and
factors
in
the
main
tenance
of
health
and
illness
is
of
crucial
importance.
Some
of
the
hea[th
and
disease
situations
influenced
by
psychological
factors
are
as
follows:
a.
Rote
of
psychoLogicaL
factors
in
the
aetioLogy
of
heaLth
probLems
There
are
many
habituaL
patterns
of
behaviour
that
can
adversely
affect
one’s
health
and
increase
ones
susceptibility
to
illness.
There
is
ample
ev
idence
that
chances
of
developing
a
heart
disease
are
increased
amongst
those
who
smoke,
consume
a
fatty
diet
and
adopt
sedentary
lifestyles.
Obesity,
misuse
and
abuse
of
tranquillisers,
alcohol,
street
drugs
like
cannabis,
heroin
and
stimulants,
risk-taking,
and
thrill
seeking
behaviour,
are
all
known
to
lead
to
diseases
and
consequences
that
include
diabetes
meltitus,
cirrhosis
of
liver,
psychiatric
disorders,
and
road
traffic
accidents
with
obvious
morbidity
and
mortality.
Public
health
interventions
to
address
these
unhealthy
lifestyLe
factors
and
promote
healthy
behaviours
in
the
community
can
decrease
the
subsequent
risk
of
the
illnesses
mentioned
above.b.
Rote
of
psychotogicat
factors
in
the
precipitation
(triggering)
of
iLLnesses
Physiological
processes
in
humans
are
directly
affected
by
psychological
stress,
e.g.
the
immune
system.
the
endocrine
system,
and
the
sympathet
ic
and
parasympathetic
systems
in
the
body
etc.
There
is
scientific
evidence
that
traumatic
life
events
(called
critical
incident
stress)
and
persistent
high
stress
situations
(called
cumutative
stress)
can
trigger
either

69. the
first
episode
or
a
repeat
episode
(called
recurrence)
of
a
variety
of
dis
eases.
Some
common
examples
incLude
ischemic
heart
disease,
asthma,
allergies,
acid
peptic
disease,
migraine
etc.
c.
RoLe
of
psychotogicat
factors
in
the
management
of
iLLnesses:
Even
after
a
disease
process
has
started,
psychological
and
social
fac
tors
ptay
an
important
role
in
the
course
of
iLlness,
both
in
aggravating
it
or
recovering
from
the
illness.
For
example,
positive
behavioural
changes
are
an
integral
part
of
the
management
of
diseases
like
diabetes
meWtus,
hypertension,
and
ischemic
heart
disease.
Similarly
social
support
ptays
a
vital
role
in
the
management
of
serious
illnesses
like
drug
dependence
and
schizophrenia,
among
many
others.
d.
Rote
of
psychoLogicaL
and
sociaL
factors
in
diseases
causing
disabiLity,
handicap
and
stigma
ALL
illnesses
which
resuLt
in
temporary
or
permanent
disability
or
handicap
give
rise
to
serious
psychological
reactions
in
patients
and
their
carers
e.g.
despair,
hopelessness,
guilt,
anger,
frustration,
and
Loss
of
motivation
etc.
Similarly,
illnesses
associated
with
social
stigma.
e.g.
HIV/AIDS,
are
also
as
sociated
with
various
psychological
and
social
challenges,
and
addressing
these
issues
is
an
integral
part
of
the
management
of
such
illnesses.
e.
Rote
of
psychotogicaL
factors
in
patients’
reactions
to
iLLness
A
persons
attitude
towards
his/her
illness
can
play
a
vital
role
in
determin
ing
a
person’s
future
health.
Poor
compliance
with
the
doctor’s
prescrip
tion
continues
to
beone
of
the
major
hurdles
towards
the
success
of
any
treatment.
This
non-adherence
to
treatment
is
often
on
account
of
exces
sive
and
inappropriate
use
of
psychological
defence
mechanisms.
Some
people
develop
a
liking
towards
some
aspects
of
their
sickness,
such
as
the
excessive
attention
they
get
from
everybody
while
they
are
ill
and
thus
develop
sick-roles,
which
can
detay
their
recovery,
and
return
to
work.
A
positive
psychological
reaction
to
illness
on
the
other
hand
can
hasten
the
recovery
and
the
healing
process.
f.
Medicatty
UnexpLained
Physicat
Symptoms
(MUPS)
MUPS
include
a
wide
variety
of
apparently
physical
illnesses
that
have
been
shown
to
have
a
psychological
causation.
These
are
seen
in
most
medical
and
surgical
specialties
and
include
disorders
Like
irritable
bowel
syndrome,
non-utcer
dyspepsia,
temporo-mandibular
joint
dysfunction,

70. 8.
Intelligence
9.
Personality
Chapter
2
Principles
of
Psychology
1.
Learning
Master
A,
an
8
year
old
boy,
used
to
wet
his
bed
almost
every
night
He
was
ashamed
of
this
and
was
ridiculed
by
his
cousins.
His
parents
became
worried
and
took
him
to
a
doctor
who
referred
him
to
a
psychiatrist.
A’s
therapist
decided
to
teach
him
to
remain
dry
during
the
night
by
using
a
number
of
basic
learning
principles.
He
was
given
a
buzzer
which
would
sound
the
moment
he
passed
urine
in
bed
at
night,
thus
waking
him
up.
The
idea
was
to
associate
the
stimuli
from
a
full
bladder
and
the
urge
to
urinate
with
waking
up.
If
Master
A
woke
up
in
time,
he
could
go
to
the
bathroom
before
he
could
wet
his
bed.
In
addition
to
this
device,
A
and
his
mother
were
explained
a
behavioural
technique
by
which
A
had
to
change
the
sheets
himself
with
no
help
when
the
bed
was
wet
On
the
other
hand
when
the
bed
was
dry,
A
was
given
a
chocolate.
After
21
consecutive
dry
nights
the
buzzer
would
be
removed,
but
the
behavioural
method
of
rewarding
a
‘dry
night’
with
a
chocolate
would
remain
in
place.
A
review
after
two
months
of
the
start
of
A’s
treatment,
his
buzzer
was
removed,
since
he
had
remained
dry
for
21
consecutive
nights.
He
wet
his
bed
twice
after
this
but
that
was
all.
In
the
next
18
months,
MasterA
stopped
wetting
his
bed.
How
in
your
view
did
he
overcome
his
bed
wetting
problem?
writer’s
cramp,
atypical
facial
pain,
chronic
fatigue
syndrome
etc.
Besides
the
psychological
causation,
their
management
also
involves
various
psy
chologicl
interventions.
A
list
of
psychological
phenomena
that
shape
human
behaviour
in
health
and
disease,
therefore,
needs
to
be
analysed.
A
study
of
these
processes
of
normal
human
psyche
can
help
a
medical
student
to
enhance
under
standing
of
their
own
behaviour
as
well
as
assist
in
developing
a
deeper
insight
into
t[e
behaviour
of
cotleague,
other
professionals
and
most
importantly,
patients
and
the
individuals
around
them.
These
include:
1.
Learning
2.
Metacognition
3.
Memory
4.
Perception
5.
Thinking
6.
Emotions
7.
Motivation
The
psychological
principle,
that
formed
the
basis
of
Master
A’s
treatment,
is
called
the
Learning
theory.
Learning
is
the
process
by
which
new
be
haviour
patterns
are
acquired,
This
is
a
key
process
in
human
behaviour.
It
plays
a
central
role
in
our
language,
customs,
personality
traits
and
even
our
perceptions.
Humans
have
instinctual
patterns
similar
to
those
of
an
imals
but
their
complex
behaviour
patterns
are
a
result
of
their
advanced
learning
capacity.
Learning
is
a
relatively
permanent
change
in
behaviour,
for
better
or
worse.

71. a.
Operant
Conditioning
Learning
theory
implies
that
learning
new
behaviours
or
changes
in
behaviour
occur
on
the
basis
of
the
environmental
conditions
or
responses
to
it.
This
is
known
as
operant
conditioning
or
instrumentaL
conditioning.
Operant
conditioning
was
established
by
the
work
of
BE
Skinner.
Operant
conditioning
occurs
when
a
behaviour
that
is
not
a
part
of
persons
naturaL
responses
is
learned
(or
unlearned)
by
consequenc
es
in
the
form
of
reward
and
punishment.
Operant
conditioning
explains
the
learning
of
voluntary
behaviour,
such
as
motor
actions.
The
famous
Skinner
Box
demonstrated
operant
conditioning
by
placing
a
rat
in
a
box
in
which
the
pressing
of
a
small
lever
produc
es
food.
Skinner
showed
that
the
rat
eventually
learns
to
press
the
bar
regu[arty
to
obtain
food
(reward).
If,
however,
the
rat
pressed
the
[ever
and
received
an
electric
shock
or
nothing
at
aLl,
(punishment
or
[ack
of
reinforcement)
it
stopped
pressing
the
lever.
Skinners
work
showed
that
operant
conditioning
works
on
the
princi
ples
of
reinforcement.
Reinforcement
refers
to
any
event
that
increas
es
the
chance
that
a
response
will
occur
again
or
a
behaviour
will
be
repeated.
There
are
three
types
of
reinforcement:
Positive
reinforce
ment
(reward),
negative
reinforcement
and
punishment.
Positive
reinforcement
is
when
one
receives
a
reward
for
a
behaviour,
which
results
in
the
behaviour
being
reinforced,
and
thus,
repeated.
This
reward
may
be
in
the
form
of
attention,
praise,
success,
a
mate-
nat
gain.
An
example
is
a
child
who
consistently
gets
a
praise
or
hug
for
picking
up
his
toys.
after
playing
with
them
will
learn
to
be
neat
and
orderly.
Operant
Conditioning
Reinforcement
Punishment
Increase
Behavior
Decrease
Behavior
I
I
I
Positive
Negative
Positive
Negative
A.d
appetatrve
stimulus
nordous
stimuli
gggg
appetative
stimulus
following
correct
behavior
following
behavior
following
behavior
Gn,,,g
hrdwus
rxioog
Escape
Active
Avoidance
Bcmv
noxious
stimuli
Behavior
avoids
noxious
following
correct
behavior
stimulus
.,.,
,*,,,,
dorr
xywn,..,
vwwco6,d,*
,frw
.,,no.6Avn
Postive
presence
of
a
stimulus
Negative
absense
of
a
stimulus
Reinforcement
increases
behavior
Punixhment
decreases
behavior
Escape
removes
a
stimulus
Avoidance
prevents
a
stimulus

72. Punishment
is
when
a
behaviour
is
followed
by
a
painfuL
stimulus,
resutting
in
the
behaviour
being
stopped,
and
not
repeated.
If
a
child
puts
her
finger
into
an
electric
socket
and
gets
electrocuted
(punish
ment),
she
is
not
likely
to
do
this
again.
Negative
reinforcement
is
not
the
same
as
punishment.
Negative
re
inforcement
is
when
a
negative
stimulus
is
stopped
only
when
a
de
sired
behaviour
occurs.
This
is
experienced
commonly
as
a
person
in
the
car
behind
you
constantly
pressing
the
horn
until
you
move
your
car
out
of
the
way.
In
this
case
the
noise
of
the
loud
horn
is
the
nega
tive
stimulus.
The
desired
behaviour
is
moving
the
car.
The
lever
bbx
experiment
by
Skinner
mentioned
above
proved
that
a
behaviour
will
occur
more
frequently
if
given
positive
reinforcements
and
witl
decrease
in
frequency
by
punishment.
Master
A,
described
in
the
beginning
of
the
section
was
instrumentally
conditioned
to
re
main
dry
by
the
use
of
the
buzzer.
The
reward
that
he
got
in
the
form
of
a
chocolate
was
a
positive
reinforcement
whereas
the
act
of
get
ting
up
and
washing
his
clothes
was
a
negative
reinforcement.
The
various
types
of
reinforcement
and
punishments
are
summarised
in
the
table
below.
An
important
consideration
in
changing
and
manipuLating
behaviour
is
the
relative
effectiveness
of
the
various
types
of
reinforcement.
Positive
reinforcement
is
the
most
effective
method
in
changing
be
haviour,
while
punishment
is
the
worst.
This
is
why
you
may
notice
that
a
person
has
to
be
punished
many
times
before
his/her
unde
sired
behaviour
is
stopped.
Another
factor
to
keep
in
mind
with
children
is
their
need
for
attention
which
acts
as
-positive
reinforcement,
even
if
the
attention
involves
being
yelled
at
or
punished.
A
child
who
is
repeatedly
scolded
for
nail
biting,
or
thumb-sucking
may
persist
with
these
habits
beyond
chitdhood.
Feature
Effect
on
behaviour
Example
Comments
Positive
Behaviour
is
increased
Child
increases
his
Reward
or
reinforcement
Reinforcement
by
reward
kind
behaviour
increases
desired
behaviour.
towards
his
younger
Master
A
got
chocolate
brother
to
get
praise
whenever
he
succeeded
in
keeping
dry
at
night
-
VV
VV
-
-.
-
V.
.
-
,Chlnc,ees*hte
t1veavoIdanceofan
P.inem.ntt.t
or
escape
kind
beheviour
stimulus
increases
-
towsids
hbyouj
áed
beha6ourThect
brtoavd%w.ehinghIsclothes
___
E
Punishment
Behaviourisdecreased
Childdecreaseahis
D.ilve,yofanaversive
by
suppression
hitting
behaviour
stimulus
decreases
after
his
mother
unwanted
behaviour
rapidly
scolds
him
but
not
permanently.
The
buzzer
was
th.
aversive
stimulus
in
A’s
case
V
-
V•_V
VV•V
VV_VV_
-
V_VVVV
VV_VV_
liminated
C
Iopehlg
kxtInctlefl
I.
meN
cement
V
-
Iviau’
,h5iIlIhm.nt
-
Vii
rnothe#
V
V
V
mwanted
b.hevloUt.
V
V
S.V;VV!V
VV
V
Conditioning
Principles
in
reot
tile
‘iSt
Hijab
Zainab
,nish,nent
or
Negative
Hi
if
‘i

73. Shaping
and
Mode[ting
Shaping
and
modelling
are
also
theories
of
learning
derived
from
the
aforementioned
principtes.
Shaping
involves
rewarding
closer
and
closer
approximations
of
the
wanted
behaviour
until
the
correct
behaviour
is
achieved.
An
example
of
this
is
when
a
child
learning
to
write,
starts
with
writing
on
a
paper
with
straight
lines
and
is
rewarded
with
a
star’
for
doing
so.
He
then
learns
to
write
in
straight
lines
on
a
plain
paper,
or
a
medical
student
who
starts
to
learn
stitching
of
wounds,
makes
mistakes
and
then
at
tains
perfection
by
shaping’.
Modelling
is
a
type
of
observational
[earning.
This
is
what
occurs
when
a
student
starts
to
talk,
dress
and
behave
in
a
manner
similar
to
that
of
an
inspiring
teacher;
ivhen
someone
gets
a
haircut
to
took
the
same
as
their
favourite
film
star
or
a
medical
student
decides
to
be
a
surgeon,
after
doing
a
rotation
with
an
excellent
surgical
specialist.
b.
Ctassical
Conditioning
Classicat
conditioning
is
another
principle
of
the
learning
theory.
It
involves
three
factors:
A
neutral
stimulus,
a
stimulus
that
causes
a
biological
response,
and
the
biological
response
itself.
It
is
a
form
of
learning
that
occurs
when
these
two
stimuli
are
paired.
The
neu
tral
stimulus
is
known
as
the
conditioned
stimulus.
This
is
usually
a
neutral
object
such
as
a
bell,
a
picture
or
a
smell.
The
other
stim
ulus
is
known
as
the
unconditioned
stimulus.
The
unconditioned
stimulus
is
one
that
is
inherently
capable
of
producing
a
biological
response
such
as
food
or
increased
room
temperature.
The
biolog
ical
response
is
known
as
the
unconditioned
response.
Salivation,
piloerection,
sweating
and
autonomic
arousal
are
types
of
biological
responses. When
a
biological
response
is
elicited
with
a
stimulus
that
causes
it,
such
as
food
causing
salivation,
this
is
known
as
an
unconditioned
response. When
a
biological
response
is
coupled
with
a
stimulus
that
would
not
normalty
cause
it,
such
as
a
belt
causing
salivation,
this
is
known
as
a
conditioned
response.
Classical
conditioning
Operant
Conditioning
Developed
lntheUsbysldnner
V ne..
Classical
conditionin
Unconditioned
stimulus:
light
butt
Conditioned
stimutus:
cheese
Biologicot
response:
seen
in
the
mous
Stimulus
is
provided
before
reflex
Stimulus
is
provided
after
reflex
Deve’oped
in
luuia
by
Pavlov
Relies
on
association
between
stimulus
and
response
lnvolufltaiy,
automtlc
A
Relies
on
reinforcement
Voluntaty,opemtes
on
environment
Passive
learning
Active
learning

74. —
___________
-,-t-.
-,.
-/.-.—....
Ivan
Pavlov,
a
Russian
physiologist
in
the
1890’s
established
many
of
the
basic
principles
of
classical
conditioning.
He
designed
an
appa
ratus
that
coutd
measure
the
amount
of
saliva
being
produced
in
a
dog’s
mouth
in
response
to
food
(unconditioned
response).
Pavlov
noted
dogs
salivated
when
presented
with
food.
He
also
saw
that
dogs
did
not
do
this
when
he
rang
a
bell.
He
then
trained
the
dog
by
sounding
the
bell
and
shortly
afterwards
presenting
food.
After
the
sound
of
bell
had
been
paired”
with
food
a
few
times,
he
tested
the
effects
of
training
by
measuring
the
amounts
of
saliva
when
he
rang
the
bell
but
did
not
present
food.
He
discovered
that
some
saliva
was
produced
in
response
to
the
sound
of
the
bell
(conditioned
stimulus)
alone.
This
is
a
conditioned
response.
Similarly,
people
in
many
parts
of
the
world
have
learnt
to
associate
the
golden
letter
M
of
McDonald’s
with
tasty
fast
food
and
have
developed
a
con
ditioned
response
(of
salivation
or
the
smell
of
the
‘Big
Mac’,
to
the
mere
sight
of
the
large
golden
arches).
Extinction
is
the
process
by
which
conditioned
responses
decreases
if
the
conditioned
stimulus
is
never
again
paired
with
the
uncondi
tioned
stimulus.
For
example
if
only
the
bell
is
rung
but
no
food
is
presented,
the
salivation
in
response
to
the
ringing
of
the
bell
will
eventually
stop,
i.e.
become
extinct.
r.
Learning
principLes
in
Clinical
Settings
Use
of
Operant
Conditioning
against
bad
habits
How
can
we
use
learning
principles
to
discontinue
bad
habits?
The
following
techniques
derived
from
the
above
mentioned
principles
of
the
learning
theory
could
offer
some
hetpful
possibitities:1.
Try
to
discover
what
is
reinforcing
a
bad
habit,
and
remove,
avoid
or
delay
the
reinforcement
Exampte:
Asif
is
a
medical
student
who
developed
the
habit
of
taking
longer
and
longer
breaks
when
studying.
He
realised
that
the
breaks
were
usually
lengthened
by
watching
TV.
The
pleasure
of
watching
TV
was
also
reinforcing
more
frequent
breaks.Solution:
To
improve
his
study
habits,
Asif
should
either
resolve
to
stay
out
of
the
TV
room
untilwork
is
done
(avoid
reinforce
ment),
or
else
complete
2
hours
of
study
for
half
an
hour
of
TV
watching
(delay
reinforcement).
Example:
Farah,
another
medical
student,
has
a
different
prob
lem.
When
she
reads
in
the
evening,
her
periods
of
concentra
tion,
last
only
about
15
minutes.
They
are
usually
followed
by
a
trip
to
the
kitchen
for
a
snack.
In
addition
to
falling
behind
in
her
studies,
she
is
gaining
weight.
Solution:
Taking
snacks
are
rewarding
her
impulse
to
avoid
read
ing.
Firstly
she
should
do
her
reading
at
school
or
at
a
library,
so
that
there
is
a
delay
between
the
impulse
to
eat
and
the
reward
of
snacking.
At
home
she
should
only
keep
foods
that
require
preparation,
so
that
a
separate
trip
to
the
market
is
required
for
the
snack.
Requiring
a
walk
to
the
market
will
also
help
her
in
weight
control.

75. 2.
Avoid
or
narrow
down
cues
that
elicit
the
bad
habit.
Exampte:
Mr
Javed
is
not
ready
to
give
up
smoking
but
would
like
to
reduce
it.
He
has
taken
many
smoking
cues
out
of
his
daily
routine
by
removing
ashtrays,
matches
and
extra
cigarettes
from
his
house,
car
and
office.
He
has
also
been
making
an
effort
to
stay
away
from
smokers,
take
a
walk
after
meals
(leaving
his
cigarettes
at
home)
and
put
chewing
gum
in
his
mouth
whenever
he
feels
nervous.
Solution:
To
further
improve
his
controt
of
smoking
MrJaved
should
try
narrowing
cues.
He
could
begin
by
smoking
only
inside
the
building,
never
outside
or
in
his
car.
He
could
then
limit
his
smoking
to
his
home
and
then
to
only
one
room
at
home
and
then
to
one
chair
in
that
room.
If
he
succeeds
in
getting
this
far,
he
may
want
to
limit
his
smoking
to
one
uninteresting
place
such
as
a
bathroom,
basement
or
garage.
3.
Make
an
incompatible
response
in
the
presence
of
stimuti
that
usuatty
precede
the
bad
habit.
ExampLe:
Maryam
bites
her
nails
so
much,
that
they
are
painful
and
unsightly
to
look
at.
She
has
identified
several
situations
in
which
she
is
most
likely
to
bite
her
naiLs
and
would
Like
to
break
the
connection
between
these
and
her
habit.
Solution:
Maryam
should
make
a
list
of
incompatible
behaviours
she
can
engage
in,
when
she
has
the
urge
to
bite
her
nails.
These
can
include
putting
her
hands
in
her
pockets,
taking
notes
in
her
class,
sketching
pictures,
crossing
her
arms,
chewing
gum
or
combing
her
hair.
4.
Use
negative
practice
to
associate
a
bad
habit
with
discomfort.
Exampte:
Hassan
has
a
facial
tic
that
appears
when
he
is
nervous
or
tired.
The
tic,
which
looks
like
a
wink
with
his
right
eye
often
leads
to
social
embarrassment.
SoLution:
In
negative
practice
a
response
is
repeated
until
it
becomes
boring,
painful
or
produces
fatigue.
This
increases
the
awareness
of
the
habit
and
tends
to
discourage
its
recurrence.
Hassan
could
stand
in
front
of
a
mirror
and
repeat
the
tic
until
the
muscles
used
become
quite
uncomfortable.
He
could
also
wear
a
rubber
band
on
his
wrist
and
stretch
it
to
rebound
on
to
the
skin
causing
a
mild
pain
each
time
he
winks.
Similarly
if
you
have
a
habit
of
saying
“you
know”
or”muttab
hai”
“uh”
or
“like”
too
often
when
speaking,
set
aside
15
minutes
a
day
and
repeat
the
error
over
and
over
while
thinking
“I
hate
the
way
this
sounds.
5.
Utitise
feedback
to
change
bad
habits.
Atmost
any
habit
wiLl
benefit
from
simply
keeping
a
score.
Keep
track
of
the
number
of
times
daily
that
you
arrive
late
to
class,
smoke
a
cigarette,
waste
time
during
studying,
bite
your
finger
nails.
swear
or
whatever
other
response
you
are
interested
in
changing.
This
will
serve
as
a
‘feedback’.
You
will
soon
find
the
frequency
of
these
bad
habits,
going
down.

76. Uses
of
Classical
Conditioning
in
CLinical
Settings
Since
much
of
medical
practice
involves
behaviour
and
changing
behaviour,
the
principles
outlined
above
can
be
seen
in
clinical
settings.
A
few
examples
will
be
discussed
here.
i.
Acquisition
of
fear
and
anxiety
about
hospitats
Children,
as
well
as
many
adults
have
a
great
dislike
of
doc
tors
and
hospitals.
Children,
in
particular,
are
known
to
cry
and
scream
at
the
sight
of
the
doctor’s
white
coat
and
at
the
smell
of
the
antiseptic,
after
they
have
received
injections
or
intrave
nous
drips
in
hospital
settings.
It
is
quite
likely
that
they
associ
ate
(pair”)
neutral
stimuli
such
as
white
coats
with
nasty,
painful
events
(injections,
drips),
It
is
for
this
reason
that
many
paediatri
clans
these
days
do
not
wear
the
traditional
‘uniform’
associated
with
the
medical
profession.
so
that
the
“paired”
response
may
not
take
place.
After
a
few
visits
to
such
a
doctor
the
classical
conditioning
that
occurred
between
the
white
coat
and
injections
witl
undergo
‘extinction’.
The
child
will
discover
that
the
uncon
ditioned
stimulus
and
the
conditioned
stimulus
are
not
“paired
anymore.ii.
Chemotherapy
for
treating
cancer
Chemotherapy
for
treating
cancer
is
a
highly
unpleasant
expe
rience
for
patients.
It
usually
involves
a
series
of
weekly
injec
tions
of
powerful
cytotoxic
drugs
that
have
marked
side
effects.
The
patient’s
hair
falls
out,
they
feel
nauseous
and
sick,
and
are
unable
to
eat.
It
is
a
common
observation
that
conditioned
anticipatory
nausea
and
vomiting
occurs
in
these
patients
simply
at
the
sight
of
the
medical
staff
and
smell
of
the
hospital
setting.
Recently,
attempts
to
use
the
principles
of
classical
condition
ing
have
been
tried
to
help
children
overcome
specific
dislikes
of
food
which
have
been
induced
by
cancer
chemotherapy.
Frequently
children
have
been
found
to
associate
feelings
of
being
sick
with
the
last
food
they
ate
before
their
treatment
and
so
were
refusing
it
afterwards.
The
children
were
given
a
strong
tasting
sweet
after
their
last
meal
but
before
the
chemotherapy.
The
investigators
found
that
children
given
the
sweet
ate
more
of
proper
nutritionally
good
food
afterwards
than
children
given
no
such
intervention.
iü.
Treatment
of
Phobias
A
phobia
is
defined
as
an
intense,
irrational
fear
of
an
on
object,
animal,
or
a
situation,
leading
to
its
avoidance
in
fLiture.
It
is
per
fectly
reasonable
to
feel
intense
fear
at
the
sight
of
a
poisonous
snake.
It
is
unreasonable,
however,
to
feel
intense
fear
of
ele
vators,
lizards,
heights,
thunder
etc.
A
form
of
therapy
known
as
Systematic
Desensitization
based
on
classical
conditioning
can
be
beneficial
in
treating
patients
whose
lives
have
become
dysfunctionat
and
miserable
because
of
their
phobia.
The
method
involves
firstly
getting
the
patient
to
relax
fully,
through
the
use
of
specific
relaxation
techniques.

77. After
that,
the
patient
is
asked
to
imagine
a
picture
only
remote
ty
associated
with
the
feared
object,
or
situation,
In
the
case
of
someone
frightened
of
dogs,
for
example.
the
patient
wilt
imag
ine
a
simple
outLine
drawing
of
the
dog.
Whenever
the
patient
feeLs
any
sign
of
anxiety,
he
is
asked
to
signal
it
by
raising
a
little
finger.
When
that
happens.
s/he
is
instructed
again
to
fully
relax
using
relaxation
methods.
Eventually,
the
images
are
brought
closer
and
closer
to
the
real
phobic
stimulus
and
continue
into
real
life
so
that
finally
s/he
is
able
to
maintain
a
relaxed
state
of
mind
firstly
in
imagination
and
lafer
in
the
presence
of
a
dog
in
real
tife.
The
principle
invotved
is
to
associate
a
calm,
relaxed
state
of
mind
with
something
which
once
instilled
terror,
and
irrational
fear.
2.
Metacognition
Metacognition
is
defined
as
thinking
about
how
we
think.
It
refers
to
knowl
edge
people
have
about
their
own
thought
processes.
It
is
not
uncommon
for
many
medical
students
to
take
notes
of
only
those
aspects
of
a
lecture
that
they
consider
difficult.
Sirnitarty,
often
while
studying
we
notice
that
we
are
having
trouble
learning
a
certain
chapter
but
are
able
to
learn
another
chapter
by
mistake.
This
understanding
of
our
own
learning
processes
is
V
metacognition.
The
examples
illustrate
a
student’s
awareness
of
their
cog-
V
V
V
nition
and
hints
at
a
strategy
for
managing
learning
based
on
this
aware-
:“
V
-
ness.
VVV2
Metacognitive
awareness
is
not
seen
in
children
as
it
develops
later
in
life.
V
It
may
compensate
for
tower
levels
of
ability.
It
enables
students
to
coordi
nate
the
use
of
extensive
knowledge
and
develop
many
separate
strate-
Metocnition-HitingA
gies
to
accomplish
complex
learning
goals.
Medical
students
are
expected
to
learn
complex
concepts
and
a
rote
learning
of
these
is
neither
possible,
nor
required
Metacognitive
techniques
can
help
achieve
this
task.
Efficient
learners
are
highly
aware
of
their
own
thinking
and
memory
and
use
this
V
information
to
regulate
their
learning.
Their
knowLedge
includes
the
how,
why
and
when
of
learning.
The
degree
of
metacognitive
ability
varies
from
person
to
person
and
some
basic
level
of
automaticity
comes
only
through
regular
practice.
One
way
to
practice
is
to
use
monitoring
checklists
in
which
students
can
check
off
component
steps
in
monitoring
their
learning.
Metacognitive
strategies
for
medical
students
tive
reading
Involves
you
In
a
process
of
actively
questioning
the
matedaIu
read.
Befor.you
n
address
the
questions
of
is
It
any
good?
and
“what
does
It
meanr
you
must
understand
whatycu
are
reading.
Here
are
acme
helpful
tipw
1.
Quickly
read
the
title
page
prefuce
or
abstract
to
get
an
Idea
of
the
topic
of
the
article
or
book
and
cetego
rize
It
In
your
mind.
Is
It
really
a
report
of
research
findings
or
Is
It
an
anecdotal
account
of
somebody’s
Isolat
edexperlencei Z.
Study
the
table
of
contents
or
the
headings
In
the.ardcle
to
get
a
sense
of
Its
stmcture.Thls
alerts
you
In
advance
about
what
to
expect
3.
Read
any
boldface
excerpts
or
boxed
summaries
(like
this
one)
to
ascertain
the
maIn
points
or
Ideas.
4.
Leaf
through
the
whole
article
dipping
Inhere
and
there
to
follow
the
logic.
5.
FInd
the
Important
and
unfamiliar
words
and
use
racoure
like
a
glossary
or
dictionary
to
determine
their
meaning. 6.
HIghlight
key
points
or
conclusions
by
underlining
or
puWng
notes
In
the
margins.
7.
Be
able
to
say
with
certainty
that
you
understand
what
you
have
read
before
you
crltidze
It
8.
Compare
what
you
have
read
in
one
study
with
whatyotW
have
read
cwnulatlveiyon
a
topic.

78. There
ate
three
main
phases
in
Learning:
1.
PLanning
2.
Monitoring
3.
EvaLuation
1.
PLanning
phase
This
is
the
phase
in
which
the
Learner
is
preparing
to
tackle
what
is
to
be
Learnt.
In
the
planning
phase,
Learners
may
ask
themseLves
the
folLowing
questions:
•
Why
do
I
need
to
know
this?
Write
down
Learning
outcomes
of
the
chapter
to
be
read
or
the
task
assigned.
•
What
do
I
know
aLready
about
this
topic?
Before
reading
the
chapter,
write
down
a
few
facts
or
concepts
that
you
aLready
know
about
it.
•
How
wiLL
I
Learn
it?
Use
Learning
strategies
such
as
mnemonics.
watch
a
video
reLated
to
the
subject
or
reLate
the
disorder
being
described
in
the
chapter
to
a
patient
you
have
recently
seen.
2.
Monitoring
phase
WhiLe
going
through
the
materiaL
to
be
Learnt,
Learners
can
monitor
their
Learning
by
asking
the
foLlowing
questions:
•
How
am
I
doing
in
grasping
these
concepts?
Do
I
understand
what
am
I
studying?
Think
or
repeat
the
important
points
in
the
mind
after
reading
a
few
paragraphs.
3.
Evatuating
phase
During
this
phase,
after
completing
what
was
to
be
Learnt,
[earners
can
ask
themseLves
the
foLlowing:
•
How
weLL
did
I
do
Learning
this?
•
Is
there
anything
I
do
not
understand?
•
How
shouLd
correct
my
errors?
•
Were
there
any
distractions
or
behaviours
that
were
Limiting
my
concentration
while
studying?
•
Have
I
accomplished
the
goals
I
set
for
myself?
Assess
yourself
on
the
basis
of
the
objectives
that
you
listed
at
the
start.
•
Is
there
a
practicaL
appLication
for
what
I
have
learnt?

79. 3.
Memory
Zahra
was
considered
one
of
the
brightest
students
in
her
ctass.
Her
peers
were
envious
of
the
ease
with
which
she
managed
to
remember
every
sin-
gte
detait
by
quickLy
skimming
through
her
textbooks.
Now,
as
a
doctor
her
performance
is
phenomenat
as
she
knows
the
name
of
every
patient
and
their
family
member
and
is
able
to
recall
their
medical
histories
with
ease.
Her
friends
often
commented
that
her
memory
was
“photographic”
and
that
“her
mind
works
like
a
computer.”
Memory
is
one
of
the
extraordinary
phenomena
of
the
natural
world.
Our
sensory
experiences,
perceptions
and
actions
change
us
continuously
and
determine
what
we
are
later
abte
to
perceive,
remember,
understand,
and
become.
Human
memory
is
unique
in
its
characteristic
ability
to
store
visual
recordings.
aLong
with
associated
emotions
and
feelings.
A
subsequent
re
call
of
various
memories
includes
reliving
the
associated
emotions.
It
is
this
quality
that
makes
our
memories
pleasant
and
unpleasant.
Higher
mental
functions
such
as
speech,
thinking,
perceptions,
moods,
psychomotor
skills
and
consciousness
of
surroundings
are
based
on
memory.
Without
memory
there
can
be
no
mind.
(For
details
on
the
neurobiological
basis
of
memory,
refer
to
Chapter
7)
a.
Stages
in
Memory
Human
memory
resembLes
a
computer,
consists
of
an
information
pro
cessing
system
in
three
separate
stages:
i.
Encoding:
Sensory
information
is
received
and
coded
or
trans
formed
into
neural
impulses
that
can
be
processed
further
or
stored
for
later
use.
Just
as
a
computer
changes
keyboard
entries
into
binary
digits
that
can
be
stored
on
a
disk,
sensory
information
is
transduced,
so
that
it
can
be
used
and
stored
by
the
brain.
Apart
from
transduction
a
great
deat
of
encoding
process
appears
to
be
devoted
to
rehearsing
or
repeating
the
input.
ii.
Storage:
Like
a
computer
program,
the
encoded
information
must
be
stored
in
the
memory
system.
Atthough
some
bits
of
information
are
stored
briefly
or
used
only
once,
and
then
discarded,
others,
like
certain
telephone
numbers,
are
used
frequently,
and
are
therefore
stored
on
a
more
permanent
basis.
iii.
Retrieval:
Once
a
file
has
been
named
and
stored
on
a
computer,
we
can
call
it
up
by
its
name
and
use
it
again.
Human
memory
works
in
much
the
same
way.
When
we
recall
or
bring
a
memory
into
consciousness,
we
have
retrieved
it.
This
recall
process
is
known
as
memory
retrieval.

80. Sensory
Memory
(1sec)
Episodic
Memory
(events.
experiences)
Human
Memory
Short-term
Memory
tVrkIng
Memory)
t1
miii)
Procedural
Memory
(skIlls.
tasis)
b.
Types
of
Memory
I.
Sensory
Memory:
Sensory
memory
is
a
memory
or
storage
of
sensory
events
such
as
sights,
sounds
and
tastes
with
no
further
processing
or
interpreta
tion.
Sensory
memory
provides
us
with
a
very
brief
image
of
all
the
stimuti
that
were
present
at
a
particular
moment
and
therefore
has
the
potential
to
be
quiet
large.
Sensory
memory
appears
to
Last
only
briefly,
about
one
half
to
one
second,
depending
on
which
senso
ry
system
is
involved.
For
instance
if
you
see
an
object,
an
image
persists
for
about
one-half
second
afterwards.
Similarly
information
you
hear
is
held
as
a
brief
echo
in
sensory
memory
for
up
to
two
seconds.
ii.
Short-term
Memory
fSTM):
Not
everything
seen
or
heard
is
kept
in
memory.
Lets
say
a
TV
com
mercial
is
running
in
the
background
as
your
friend
reads
you
his
notes
on
pharmacology.
Do
you
remember
the
words
of
the
TV
ad?
Probably
not,
because
selective
attention
determines
what
informa
tion
moves
on
to
short-
term
memory.
Short
term
memories
are
also
brief,
but
longer
than
sensory
memories.
Attending
to
your
friend’s
narration
will
place
his
technicaljargon
in
your
short-term
memory
(while
allowing
you
to
ignore
the
voice
on
TV
saying
‘talk
shawk”).
Short-term
memories
can
be
stored
as
images,
but
more
often
they
are
stored
as
sounds,
especiatly
in
recalling
words
and
letters.
Short-
term
memory
acts
as
a
temporary
storehouse
for
small
amounts
of
information.
Unless
the
information
is
important,
it
is
quickly
dumped
from
STM
and
is
lost
forever.
Short-term
memory
prevents
our
minds
from
collecting
useless
names,
dates,
telephone
num
bers
and
other
trivia.
At
the
same
time
it
provides
a
working
memory
where
we
do
much
of
our
thinking,
dialling
a
phone
number,
doing
mental
arithmetic
and
remembering
a
shopping
list.
iii.
Long-term
Memory
(LTM):
nformation
that
is
meaningful
and
important
is
transferred
to
the
third
memory
system
called
long-
term
memory.
In
contrast
to
SIM,
long-term
memory
([TM)
acts
as
a
permanent
storehouse
for
infor
mation.
[TM
contains
everything
you
know
about
the
world
and
yet
there
appears
to
be
no
danger
of
running
out
of
room
in
LTM,
Long-term
Memory
IL
ft
Explicit
Memory
(.i)flsCiOU(
implicit
Memory
(unconsdousl
Declarative
Memory
(facts,
even(s)I
Semantic
Memory
(fads.
concepts)

81. Type
Description
Examples
Implicit!
Memories
used
In
making
responses
Remembering
how
to
dissect
Procedural
and
skilled
actions.
pass
a
nasogastrlc
tube,
play
tennis
or
drive
a
car.
Semantic
Our
store
of
general
and
specific
Vt.r
balls
at
700
C,
Paklstanl
knowledge
fri
Asia,
and
heart
leon
the
left,
.
‘
motorco.kInthemedlel frontal
lobe
Episodic
Memories
of
personal
events.
Your
first
day
of
college,
birthday,
your
patient’s
clinIcal
state
which
is
considered
to
have
a
Limitless
storage
capacity.
In
formation
in
the
LTM
is
stored
on
the
basis
of
meaning
and
importance
and
not
by
sound
or
image.
When
new
information
enters
STM,
it
is
related
to
knowledge
stored
in
LTM.
This
gives
the
new
information
mean
ing
and
makes
it
easier
to
store
it
in
LTM.
It
is
therefore
important
to
buiLd
new
information
on
what
you
atready
know
(stored
in
your
LTM).
The
hippocampus
is
of
particular
importance
in
LTM.
Recent
research
in
human
memory
has
revealed
that
there
is
more
than
one
type
of
LTM.
The
type
of
information
being
processed
influences
the
nature
of
the
stored
memory.
Three
major
categories
of
LTM
have
been
proposed,
as
iLlustrated
in
the
above
table.
iv.
Rehearsal.: The
process
of
rehearsal
consists
of
keeping
items
of
information
in
the
centre
of
attention,
by
repeating
them
silently
or
aLoud.
The
amount
of
rehearsal
given
to
items
is
important
in
the
transfer
of
information
from
short
term
memory
to
tong
term
memory.
Ex
periments
have
indicated
that
the
sheer
amount
of
rehearsal
may
be
tess
important
than
the
ways
in
which
information
is
rehearsed.
Just
going
over
and
over
what
is
to
be
remembered
(maintenance
rehearsal)
does
not
necessarily
succeed
in
transferring
it
to
tong
term
memory.
What
reatly
works
is
eLaborative
rehearsaL
which
is
an
active
process
involving
giving
the
material
organization
and
mean
ing
as
it
is
being
rehearsed.
hiomIng
Information
SensoTy Memoly
+
Forgotten
Forgotten
t4r’ti
niy
is
thougnt
to
invotve
at
least
three
steps.
Incoming
intormation
is
first
hetd
far
a
second
or
t&o
by
sensory
memory.
Information
selected
by
attention
is
then
transferred
to
short
term
memory.
If
new
information
is
not
rapidly
encoded,
or
rehearsed,
it
is
forgotten.
If
it
is
transferred
to
tang
term
memory,
it
becomes
ret
ativety
permanent,
alt
haugh
retrieving
it
may
be
a
problem.

82. Forgetting:Forgetting
is
the
inability
to
recall
information.
This
means
that
much
of
what
we
think
as
forgotten
is
not
reatly
forgotten
because
it
was
never
encoded
and
stored
in
the
first
ptace.
The
information,
due
to
tack
of
attention,
may
not
have
reached
short
term
memory
from
the
sensory
register.
Alternatively
due
to
inadequate
encoding
and
rehearsaL
the
information
may
not
have
been
transferred
from
the
short
term
memory
to
the
tong
term
memory.
How
much
of
the
information
is
forgotten
depends
on
the
following
factors:
•
Interference:
Experimental
evidence
as
well
as
everyday
experi
ence
indicates
that
learning
new
things
interferes
with
our
mem
ories
of
what
we
learned
earlier
and
prior
learning
interferes
with
our
memory
of
things
learned
later.
•
Retrieval
problems:
Finding
information
in
the
organised
long
term
memory
store
is
aided
by
retrieval
cues,
or
reminders
which
direct
the
memory
search
to
the
appropriate
part
of
the
tong
term
memory
Ubrary.
Without
the
retrievat
cues,
the
sought
for
item
stored
in
LIM
may
not
be
found
and
seem
forgotten.
While
we
often
cannot
recall
something
while
actively
searching
for
it,
we
may
later
recall
the
sought
for
information,
when
we
have
given
up
the
search
and
are
doing
something
else.
The
new
activity
in
which
we
are
engaged
gives
us
another
set
of
appropriate
re
minders
or
retrieval
cues.
Perhaps
the
new
situation
leads
us
to
search
through
portions
of
our
LTM
store
not
examined
before.
It
is
therefore
a
good
idea
to
ask
the
examiner
to
go
to
the
next
question
in
viva
voce,
rather
than
continuing
to
retrieve
an
answer.
It
will
come
to
you
in
a
while,
when
you
are
answering
another
question.Motivated
forgetting:
The
theory
of
motivated
forgetting
was
in
troduced
by
Sigmund
Freud
when
he
described
a
key
concept
of
psychoanalysis
viz,
repression.
Repression
refers
to
the
tenden
cy
of
people
to
have
difficulty
in
retrieving
anxiety-
provoking
or
threatening
information.
This
helps
to
explain
why
people
gener
ally
remember
pleasant
events
more
often
than
they
do
unpleas
ant
ones:
the
unpleasant
memories
have
been
repressed.
This
aspect
should
encourage
to
make
ones
learning
a
lot
of
fun,
en
joying
your
studies
and
clinical
work
rather
than
making
it
painful
and
a
burden.
This
will
happen
if
you
will
leave
your
exam
prepa
ration
to
the
few
days
before
the
exam.
c.
The
Anatomy
and
Biochemistry
of
Memory
The
study
of
organic
memory
disorders
has
ted
researchers
to
identify
brain
structures
that
appear
to
mediate
short
term
and
long
term
memory
processes.
Two
of
the
key
parts
of
the
limbic
system,
the
hippocampus
and
the
amygdata
embedded
under
the
temporal
lobes
are
essential
in
receiving
new
information
and
storing
it.
The
diencephalon
also
contains
a
number
of
structures,
the
most
important
for
memory
being
the
mam
mitlary
bodies,
thalamus
and
hypothatamus.
Lesions
to
these
structures
generally
result
in
problems
with
encoding
of
new
information.
Although

83. CyIic-Anp
lIly
UodiflUonof
(mk,pl
pu’
DNAnter.tn
—..
Undtory
Ue.,on,
Nw
pt.n
fo.mtion
F,,,tjo,of
NewSynpti
IrVb
Connoton
FormaUon
of
Long
Term
Memory
no-one
has
yet
found
the
exact
physical
changes
in
a
cell
that
accounts
for
a
memory,
many
new
discoveries
have
been
made
about
the
physiologicat
basis
of
learning
and
memory.
One
of
these
findings
is
the
role
that
Long
term
potentiation
fLTP)
may
play
in
memory
formation.
Studies
reveal
that
repeated
electrical
stimulation
of
nerve
cells
in
the
brain
can
lead
to
a
sig
nificant
increase
in
the
likelihood
that
a
celt
will
respond
strongly
to
a
future
stimulation.
This
effect
can
tast
for
a
long
time
and
may
be
a
key
mech
anism
in
the
formation
of
memories.
Studies
also
indicate
that
a
specific
type
of
receptor
viz.
NMDA
receptor
is
extremely
active
in
Long
term
poten
tiation
as
is
the
role
of
catcium.
An
important
part
of
memory
formation
is
an
increase
in
the
sensitivity
of
certain
nerve
cells
to
acetytchotine.
U.
Methods
to
Improve
Memory
•
The
example
of
Zahra
given
in
the
beginning
of
the
section
clearLy
indi
cates
that
some
individuals
have
specific
techniques
through
which
they
facilitate
there
memory
and
learning
of
new
information.
Some
of
these
are
as
follows:
•
Know[edge
of
resuLts:
Learning
occurs
most
effectively
when
feed
back
or
knowledge
of
resuttsãLtows
you
to
check
and
see
if
you
are
teaming.
Feedback
also
helps
you
identify
material
that
needs
extra
practice,
and
it
can
be
rewarding
to
know
that
you
have
answered
or
remembered
correctly.
•
Attention:
A
setting
that
enhances
your
focus
while
studying,
and
ensures
minimal
distraction
will
turn
your
attention
to
the
memory
job
at
hand.
•
Recitation
and
rehearsat:
This
means
repeating
to
yourself
what
you
have
Learned.
If
you
are
going
to
remember
something,
eventually
you
will
have
to
retrieve
it.
Recitation
forces
you
to
practice
retrieving
information
as
you
are
learning.
When
you
are
reading
a
textbook,
you
should
stop
frequently
and
try
to
remember
what
you
have
just
read
by
summarizing
it
aloud.
-
Organise:
Assume
that
you
must
memorise
the
following
tist
of
words;
north,
man,
red,
spring,
woman,
east,
autumn,
yellow,
sum
mer,
boy,
blue,
west,
winter,
girl.
green,
south.
This
rather
difficult
list
could
be
organised
into
chunks
as
follows:
north-east-south-
west,
spring-summer-autumn-winter,
red-
yellow-green-blue,
man-worn
an-boy-girl.
Similarly
by
making
up
stories
using
tong
list
of
words
to
be
memorised
makes
remembering
the
list
much
easier.

84. •
Selection:
The
Dutch
scholar
Erasmus
said
that
a
good
memory
is
like
a
fisherman’s
net.
It
should
keep
all
the
big
fish
and
let
the
little
ones
escape.
If
you
boil
down
the
paragraphs
in
your
textbooks
to
one
or
two
important
terms
or
ideas,
you
will
find
memorizing
more
manageable.
Practice
careful
and
setective
marking
in
your
text
books
and
marginal
notes
to
further
summarise
ideas.
Most
students
mark
their
texts
too
much
instead
of
too
little.
If
everything
is
under
lined,
you
haven’t
been
selective.
Seriat
position:
Whenever
you
must
learn
something,
be
aware
of
the
serial
position
effect.
This
is
the
tendency
to
make
most
errors
in
remembering
the
middle
of
a
list.
If
you
are
introduced
to
a
long
line
of
people,
the
names
you
are
likely
to
forget
will
be
those
in
the
middle,
so
you
should
make
an
extra
effort
to
attend
to
them.
The
middle
of
a
list,
poem
or
speech
should
therefore
be
given
special
attention
and
extra
practice.
•
Mnemonics:
A
mnemonic
is
any
kind
of
memory
system
or
aid.
People
demonstrating
extraordinary
feats
with
their
memories
are
actually
using
mnemonics
to
perform
this.
Mnemonic
techniques
rely
on
the
linking
or
association
of
to-be-remembered
material
with
a
systematic
and
organised
set
of
images
or
words
that
are
already
firmly
established
in
long
term
memory
and
can
therefore
serve
as
retrieval
cues.
Similarly
medical
students
often
invent
mnemonics
for
memorizing
the
names
of
cranial
nerves;
amino
acids
etc.
and
can
remember
these
lists
for
lengthy
periods.
The
basic
principles
in
the
formation
of
mnemonics
are:
-
Use
mental
pictures
-
Make
things
meaningful
-
Make
information
familiar
-
Form
bizarre,
unusual
or
exaggerated
mental
associations.
Attach
emotions,
feelings
or
link
up
with
an
event.
We
hardly
ever
forget
what
is
emotionally
significant
in
our
lives.
Senior
citizens
continue
to
recall
events
of
emotional
significance
even
when
their
short-term
memory
is
grossly
impaired.
•
Using
mental
pictures
or
visuaL
imagery
to
enhance
retention.
One
way
is
to
simply
imagine
an
unusual
scene
that
includes
the
various
elements
you
want
to
remember,
For
instance
on
your
way
home,
you
have
to
shop
for
a
newspaper,
notebook,
pen
and
shaving
cream.
To
remember
this
list
of
items,
you
have
to
make
up
a
men
tal
image
of
something
funny
and
bizarre
such
as
you,
opening
up
the
front
page
of
a
newspaper
to
find
a
picture
of
a
person
reading
a
notebook
with
one
hand
and
using
a
pen
to
wipe
off
the
shaving
cream
on
his
face
with
the
other
hand.
•
Overtearning:
Many
studies
indicate
that
memory
is
greatly
im
proved
when
study
is
continued
beyond
bare
mastery.
In
other
words
after
you
have
learned
material
well
enough
to
remember
it
without
error,
you
should
continue
to
study
the
material.
Overlearn
ing
is
your
best
insurance
against
going
blank
on
a
test
because
of
anxiety.

85. Spaced
practice:
Spaced
practice
generally
is
superior
to
massed
practice.
Three
20
minutes
study
sessions
can
produce
more
learn
ing
than
one
hour
of
continuous
study.
•
Whote
versus
part
learning:
Generally
it
is
better
to
practice
learn
ing
whole
packages
of
information
rather
than
smaller
parts.
Try
to
study
the
largest
meaningful
amount
of
information
possible
at
one
time.
This
means,
reading
a
textbook
is
better
than
reading
con
densed
notes.
The
only
notes
that
will
benefit
you
will
be
the
ones
that
you
make
yourself
based
on
steps
listed
above
(selection).
•
Steep:
Sleeping
after
study
is
helpful
and
reduces
the
interference.
Similarty
breaks
and
free
times
in
a
schedule
are
as
important
as
the
study
periods.
Staying
awake
the
whole
night
before
your
exams
is
not
the
smart
thing
to
do
•
Review:
Reviewing
shortly
before
an
examination
is
helpfuL
though
one
should
avoid
the
tendency
to
memorise
new
information
at
that
point.
This
review
should
take
about
an
hour
not
the
whole
night
prior
to
the
exam
e.
Pathological
Changes
in
Memory
Codu
Normal
Brain
Brain
with
Alzheimer’s
‘I-

86. Before
considering
the
pathological
basis
of
memory
toss,
it
is
important
to
run
simple
tests
of
a
person’s
cognitive
functions
such
as
attention,
con
centration.
registration
and
motivation
(see
table
of
MMSE
on
next
page).
In
case
of
an
impairment
of
one
or
more
of
these
higher
mental
functions,
the
function
of
memory
does
not
come
into
play.
People
with
tow
mood,
poor
motivation
and
consequent
Lack
of
attention
and
concentration
my
there
fore
complain
of
Loss
of
memory.”
This
state
is
catted
pseudodementia.
Another
situation,
in
which
people
sometimes
experience
a
significant
al
teration
in
their
memory
or
identity,
occurs
on
account
of
loss
of
integrative
function
of
the
brain
due
to
an
emotional
challenge
or
a
stress
that
could
be
sociaL
psychological
or
structurat.
Such
stress
can
interrupt
learning
new
information,
recalling
old
information,
or
change
the
ability
to
think
and
process
information.
This
results
in
disruption
of
memory
and
identity.
These
alterations
in
memory
(and
or
of
identity.
or
consciousness)
some
times
lack
a
clear
physical
cause
and
are
called
dissociative
disorders.
The
principle
symptom
in
such
situations
is
an
inabitity
to
recall
important
personal
events
and
information
of
personal
significance.
Disturbances
in
memory
and
identity
that
have
clear
physical
causes
inctude
amnestic
disorders
and
dementias.
Amnestic
disorders
affect
a
person’s
memory
exclusively,
either
for
events
before
an
amnesia
inducing
trauma
or
for
information
learned
after
it
or
both.
They
are
caused
by
med
ical
conditions,
such
as
thiamine
deficiency,
hypothyroidism,
hypogtycae
mia,
chronic
alcohot
or
substance
abuse,
head
injury
or
other
problems
that
can
adversely
affect
the
physical
functioning
of
the
brain.
Dementias
involve
mote
than
just
memory
ate
characterised
by
deficits
in
other
areas
of
cognitive
functioning.
such
as
reasoning
and
problem
solving.
These
kinds
of
dementia
are
caused
primarily
by
degenerative
diseases
that
af
fect
specific
areas
of
the
brain.
The
most
common
amongst
them
is
Alzhei
mer’s
disease.
4.
Perception
I
never
woutd
hove
dreamed
that
ye/tow
is..
soyettow.
I
don’t
have
the
words,
I’m
amazed
byyettow.
But
red
is
my
favourite
colour
Ijust
can’t
believe
red.
I
can’t
wait
to
get
up
each
day
to
see
what
I
can
see.
And
at
night
I
took
at
the
stars
in
the
sky
and
the
flashing
tights.
You
coutd
never
know
how
wonderfut
everything
is.
Isaw
some
bees
the
other
day,
and
they
were
magnificent.
Isaw
a
truck
drive
in
the
rain
and
throw
a
spray
in
the
air
It
was
marvellous.
And
did
I
mention.
i
saw
a
fatting
tea
fjust
drifting
through
the
air”
Bob
Eden,
who
had
his
sight
restored
after
being
btind
for
four
decades.
Perception
is
the
process
of
making
sense
of
the
stimuli
in
our
environ
ment.
To
activate
a
particular
receptor.
a
specific
type
of
energy
must
be
present:
light
waves
for
vision,
movement
of
air
molecules
for
hearing.
molecules
in
a
liquid
solution
for
taste,
and
so
forth.
You
cannot
shine
a
flashlight
in
your
ear
and
expect
to
have
a
visual
response
since
there
are
no
light-sensitive
receptors
there.
Neurons
operate
on
the
basis
of
changes
in
their
electrical
charge
and
the
release
of
neurotransmitters.
Physical
energies
of
light.
sound,
odour
and

87. taste
molecules
must
be
changed
into
etectrochemical
forms
that
the
nervous
system
can
process.
This
conversion
of
stimuli
from
the
recep
tors
into
etectrochemical
energy
that
can
be
used
by
the
nervous
system,
is
catted
transduction.
Continued
presentation
of
the
same
stimutus
can
cause
receptors
to
become
tess
sensitive
to
that
particular
stimulus.
This
process,
known
as
adaptation,
occurs
very
rapidLy
when
odours
and
tastes
are
involved.
To
understand
perceptual
processes,
we
focus
on
visual
per
ception.
Many
of
the
processes
we
wilt
discuss
also
apply
to
other
senses.
a.
Motivation
and
Perception:
We
do
not
perceive
everything
in
our
environment.
Our
motives,
needs,
drives,
and
even
prejudices
may
distort
or
determine
what
we
perceive.
A
thirsty
traveller
lost
in
a
desert
is
bound
to
experi
ence
a
mirage,
a
false
perception
of
water,
influenced
by
his
motiva
tion
to
search
for
a
water
body.
A
patient
in
a
ward
waiting
for
visitors
in
the
evening,
would
from
a
distance
misperceive
a
stranger
as
a
relative.
A
medical
student
may
hear
his
name
called
(erroneously)
while
waiting
for
his
turn
for
the
viva
voce.
Similarly.
certain
stimuli
are
more
likely
to
attract
our
attention
than
others.ing
is
your
best
insurance
against
going
blank
on
a
test
because
of
anxiety.
b.
Attention
and
Perception:
We
cannot
possibly
attend
to
and
process
all
the
stimuli
that
our
sensory
systems
receive
at
any
one
moment;
some
of
them
must
be
filtered
out.
A
good
example
of
the
need
to
filter
information
is
a
typical
healthcare
situation
in
our
settings.
You
might
be
running
a
busy
medical
OPD
with
many
patients
surrounding
you,
white
you
desperately
try
to
focus
on
the
information
being
given
by
the
pa
tient
you
are
examining.
If
you
try
to
listen
to
the
shouting
and
crying
of
the
patient
waiting
for
the
turn
and
one
in
front,
you
will
probably
find
yourself
switching
your
attention
back
and
forth
between
them
and
becoming
quite
confused.
This
is
why
it
is
important
to
not
have
more
than
one
patient
by
your
desk
or
examination
table.
Having
pa
tients
wait
outside
the
room
will
help
to
limit
the
amount
of
sensory
input
and
focus
your
attention
better.
c.
Basic
Perpetual
Abitities:
i.
Patterns
and
Constancies:
We
perceive
objects
in
our
environ
ment
as
having
features
such
as
pattern,
constancy,
depth.
and
movement.
Our
perception
of
these
objects
and
their
features
is
so
automatic
that
we
often
take
them
for
granted.
They
are,
how
ever,
crucial
components
of
perception.
ii.
Pattern
Perception:
Among
the
most
basic
perceptual
abilities
is
the
ability
to
perceive
patterns.
To
survive
in
modern
society,
we
must
be
able
to
perceive
a
staggering
numbor
of
shapes
and
fig
ures.
A
few
of
the
patterns
we
perceive
everyday
are
the
letters
of
the
alphabet,
traffic
signs,
friends
facial
features,
food
items
in
the
grocery
store.
the
buildings
in
an
apartment
complex,
and
cars
in
a
parking
lot.
The
ability
to
discriminate
among
different
shapes
and
figures
is
known
as
pattern
perception.
iii.
Perceptuat
Constancies:
Once
you
have
identified
an
object,
you
continue
to
recognise
it
even
if
it
changes
its
location
and
distance

88. r
and,
therefore,
casts
a
different
image
on
your
retina.
A
change
in
the
retinal
image
does
not
signal
a
change
in
the
object.
This
ten
dency
to
perceive
objects
as
relatively
stable
is
called
perceptual
constancy.
The
importance
of
perceptual
constancies
should
be
obvious;
they
allow
us
to
deal
with
our
environment
as
relatively
stable
and
unchanging.
We
do
not
have
to
treat
every
perceptual
change
as
if
our
environment
had
changed
completely
different
positions.
iv.
Shape
Constancy:
Shape
constancy
means
that
your
perception
of
the
shape
of
an
object
does
not
change
even
though
the
image
projected
on
your
retina
does.
In
other
words,
the
shape
of
an
ob
ject
is
perceived
independently
of
the
image
it
casts
on
the
retina.
This
phenomenon
is
easy
to
demonstrate.
Look
at
this
book
from
a
number
of
angles.
You
see
nothing
but
a
book
being
held
in
dif
ferent
positions.
The
same
coutd
be
said
for
the
opening
and
clos
ing
of
a
door
or
the
image
of
a
car
making
a
left
turn
in
front
of
you.
The
image
on
your
retina
changes
drastically,
yet
the
object
you
perceive
does
not.
Almost
any
moving
object
displays
the
prin
ciple
of
shape
constancy.
For
the
perception
of
shape
constancy
to
occur,
however,
the
object
must
be
famitiar
and
must
be
seen
in
an
identifiable
context.
If
there
is
no
context
or
background
to
whfr-h
the
object
can
be
related,
it
appears
to
float
in
space.
and
you
cannot
judge
its
correct
orientation.
Shape
constancy.
thus,
disappears.
v.
Size
Constancy:
Size
constancy
also
helps
us
maintain
consis
tency
in
our
perceptual
environment.
As
objects
move
toward
us,
their
retinal
images
enlarge;
as
they
move
farther
away,
their
reti
nal
images
diminish.
We
do
not
perceive
those
objects
as
chang
ing
their
size,
we
perceive
them
as
moving
toward
or
away
from
us.
Size
constancy
depends
on
the
familiarity
of
the
object
and
the
ability
to
judge
distance,
When
we
are
dealing
with
familiar
objects
and
can
easilyjudge
distances,
we
are
more
likely
to
per
ceive
the
objects
as
having
a
constant
size.
When
we
are
dealing
with
unfamiliar
objects
and
our
ability
to
estimate
distance
is
poor.
the
objects
may
appear
to
change
size.
Size
and
shape
constan
cy
may
seem
rather
simple
because
they
are
automatic
process
es,
but
these
constancies
involve
a
great
deal
of
processing.
We
use
familiar
background
objects
for
purposes
of
comparison
(size
constancy)
and
to
anchor
our
perceptions
(shape
constancy).
Au
ditory
constancies
are
another
important
aspect
of
perception.
We
perceive
words
as
the
same
when
they
are
spoken
by
various
individuals
with
different
voices.
Similarly
a
melody
is
recogniz
able
even
when
it
is
played
on
different
instruments
and
in
differ
ent
keys.
vi.
Depth
Perception:
In
addition
to
a
world
of
constancies,
we
ex
perience
a
third
dimension:
depth
perception.
The
surface
of
the
retina
is
two-dimensional
(top
to
bottom,
side
to
side).
yet
we
are
able
to
judge
distances
and
locate
objects
in
space
(three-di
mensionalty)
quite
well.
Two
main
types
of
cues,
binocular
and
monocular,
are
used
to
create
our
perception
of
depth.
Binocular
cues
involve
the
use
of
both
eyes,
whereas
monocular
cues
are
processed
by
only
one
eye.

89. viii.
Monocular
Cues:
Monocular
cues,
which
can
be
perceived
by
ei
ther
eye,
also
help
determine
depth.
For
example,
when
the
cii
lary
musctes
change
the
shape
of
the
lens
in
accommodation,
the
muscle
adjustments
are
sensed
and
used
to
help
determine
distance.
Artists
use
numerous
monocular
cues,
including
super
position
(the
fact
that
neat
objects
partialty
obscure
mote
distant
objects),
texture
gradient
(that
the
texture
of
a
surface
becomes
smoother
with
increasing
distance),
linear
perspective
(that
paral
lel
lines
appear
to
converge
as
they
recede
into
the
distance),
and
relative
brightness
(that
brighter
objects
appear
closer)
to
create
the
illusion
of
depth.
These
cues
also
operate
in
our
day-to-day
environment.
*
ix.
Perception
of
Movement:
We
often
come
across
messages
on
electronic
signs
that
has
letters
and
words
that
appear
to
move
across
it.
Our
perception
of
separate
words
is
created
because
of
the
proximity
of
the
letters
that
make
up
each
group
(word)
and
the
spaces
between
successive
groups
of
letters.
Unlike
the
let-
ters
you
are
reading
in
this
text,
the
letters
on
the
electronic
sign
are
made
up
of
separate,
unconnected
points
we
complete
them
using
closure.
This
sign
adds
another
dimension
to
our
consider
ation
of
perception:
although
the
words
do
not
really
move
across
the
sign,
they
appear
to
do
so.
Apparent
motion
is
the
illusion
of
movement
created
by
turning
the
lights
on
and
off
in
a
particular
sequence.
The
same
phenomenon
is
seen
in
movies,
television,
and
videocassettes.
All
of
these
forms
of
entertainment
rely
on
the
brain’s
ability
to
create
the
perception
of
motion
from
a
series
of
still
pictures.
L vii.
Binocular
Cues:
Among
the
most
important
binocular
cues
are
adjustments
of
the
eye
muscles
and
binocular
disparity.
The
mus
cles
that
move
the
eyeball
to
get
the
best
possible
view
provide
feedback
for
judging
distance.
When
objects
are
near,
the
eyes
rotate
toward
a
centre
point.
You
can
feel
the
muscle
tension
when
you
look
at
objects
that
are
very
close.
To
experience
this
sensation,
focus
on
this
sentence
and
move
the
book
closer
to
your
eyes.
The
closer
the
book
gets,
the
more
eye
muscle
strain
you
feel;
the
farther
away
the
object
is,
the
less
eye
muscle
strain
you
experience.
It
is
important
for
a
medical
student
who
spends
long
hours
reading
to
place
the
book
at
a
distance
which
causes
minimal
or
no
strain
on
the
eyes.
D
.)
d.
AbnormaLities
of
Perception
i.
Illusions: An
illusion
is
a
misperception
of
a
real
external
stimulus.
Percep
tion
involves
the
brain’s
attempt
to
interpret
and
make
sense
of
the
stimuli
we
receive
from
our
environment.
Most
of
the
time
our
perceptual
hypotheses
are
quite
accurate,
but
sometimes
they
can
be
wrong.
For
example,
how
often
could
you
have
sworn
that
your
professor
had
said
an
exam
was
next
Thursday,
not
next
Tuesday?
Have
you
ever
been
absolutely
sure
that
a
traffic
light
was
green.
not
red?
It
is
easy
to
trick
our
senses
into
developing
an
incorrect
perceptual
hypothesis.
Such
incorrect
perceptual
hy
potheses
form
the
basis
for
perceptual
illusions.
These
illusions
are
misperceptions
or
interpretations
of
stimuli
that
do
not
follow
rF
i
i
‘4::
I
Artist:
Hj/ab
ZaTha
The
influence
of
mThd-.cet
on
perceptio
Who
do
you
see
in
these
pictures?
Th
Ilustrates
how
a
pat
vnt
a
doctor
and
family
member
may
peicewe
the
sam
problem
dit’erentt

90. atiucinationstist
Lam
Zombie
Thinking:
The
talking
of
the
soul
with
itself
the
sensations
received
by
the
eye.
Illusions
are
often
seen
in
pa
tients
in
Intensive
Care
Units,
such
as
those
in
a
toxic
confusional
state
or
delirium,
as
well
as
people
under
the
effect
of
alcohol
and
drugs
such
as
LSD.
ii.
Hattucinations:Hallucinations
are
perceptions
without
any
stimulus.
They
can
be
in
any
of
the
five
senses
but
the
most
common
hallucinations
are
of
auditory
and
visual
type.
They
are
seen
most
commonly
in
pa
tients
with
serious
mentat
illnesses
such
as
schizophrenia.
These
patients
may
hear
voices
talking
about
them
or
doing
a
running
commentary
on
their
actions.
These
abnormal
perceptions
are
real
to
the
patient,
which
is
why
s/he
can
be
seen
to
be
in
con
versation
with
the
imaginary
voices.
The
most
common
cause
of
visual
hallucinations
is
delirium
tremens.
e.
Extrasensory
Perception
(ESP):
This
refers
to
the
occurrence
of
experiences
or
behaviours
in
the
absence
of
an
adequate
stimulus.
Such
occurrences
are
considered
to
be
paranormal
or
beyond
our
normal
sensory
abilities
and
are
studied
in
parapsychology.
ESP
includes
the
phenomena
of:
•
Clairvoyance:
The
ability
to
perceive
events
or
gain
information
in
ways
that
appear
unaffected
by
distance
or
normal
physical
barriers.
•
Tetepathy:
Extrasensory
perception
of
another
person’s
thoughts
or
in
other
words
the
abitity
to
read
someone’s
mind.
•
Precognition:
The
ability
to
perceive
or
accurately
predict
future
events.
Thus
prophecies
and
prophetic
dreams
about
the
future
are
included
in
precognitions.
•
Telekinesis:
This
phenomenon
studied
by
parapsychologists
is
basically
the
ability
to
exert
influence
over
inanimate
objects.
In
other
words
“mind
over
matter.”
To
date
there
is
little
scientific
evidence
to
prove
the
existence
of
extrasensory
perceptions.
5.
Thinking
During
most
of
our
waking
hours,
and
even
when
we
are
asleep
and
dreaming,
we
think.
Thinking
is
a
mental
process
invotving
the
manipula
tion
of
both
information
from
the
environment
and
the
symbols
stored
in
tong
term
memory.
Thinking
is
evident
when
we
solve
a
problem
or
make
a
decision.
Thinking
can
take
the
form
of
images
or
concepts.
Visuat
imagery.
the
experience
of
seeing
even
though
the
event
or
object
is
not
actually
viewed,
can
activate
brain
areas
responsible
for
visual
perception,
such
as
the
occipital
lobe.
Imagery
does
not
have
to
be
visual,
however;
it
can
be
auditory
or
olfactory.
Visual
images
allow
us
to
scan
information
stored
in
memory,
answer
questions
and
help
us
plan
a
course
of
action.
Suppose
we
need
to
describe
the
size
of
an
acre.
How
might
we
convey
this
infor
mation?
We
could
say
that
there
are
43,560
square
feet
in
an
acre.
Would

91. that
hetp
you
understand
how
large
an
acre
is?
Perhaps
not.
If
we
used
a
visual
image,
however,
and
said
that
an
acre
is
about
the
size
of
a
football
field,
this
woutd
probably
make
it
much
more
meaningful.
Similarly,
a
consultant
listening
to
a
house
officer
describe
a
patient
on
the
telephone
would
rely
on
her
capacity
to
build
visual
images
of
the
clinical
picture,
before
she
can
give
some
urgent
instructions.
a.
Concepts What
would
life
be
like
if
we
had
to
deal
separately
with
each
indi
vidual
animal,
event,
object,
and
person
in
our
environment?
How
could
we
learn
the
names
of
all
of
them?
We
avoid
such
problems
by
using
concepts
or
mental
representations
of
a
class
(students,
nurses,
chairs,
politicians).
A
concept
is
a
symbolic
construction
rep
resenting
some
common
and
general
feature
of
objects
or
events.
Concepts
lighten
the
load
on
memory
and
enhance
our
ability
to
communicate.
They
also
allow
us
to
make
predictions
about
ani
mals,
events,
objects,
and
people.
Much
of
what
we
learn
in
school,
especially
primary
school,
involves
concepts
such
as
colours,
letters,
species
of
living
organisms,
whole
numbers
and
fractions,
time,
and
distance.
The
use
of
such
concepts
makes
communicating
a
great
deal
of
information
possible
with
relative
ease.
Concepts
are,
therefore,
an
important
class
of
language
symbols
used
in
thinking.
b.
Problem
Sotving
Every
day
we
encounter
a
variety
of
minor
problems;
occasionally
we
face
major
ones.
You
may
find
that
your
computer
has
fallen
prey
to
a
virus,
your
shirt
button
has
fallen
off,
or
your
motorbike
won’t
budge.
Some
problems
are
easy
to
solve,
others
require
great
effort,
and
some
may
be
unsolvable.
The
problems
we
must
solve
can
differ
along
several
dimensions.
One
way
problems
differ
is
that
some
of
them
are
well
defined
and
others
are
ill
defined.
Well-de
fined
problems
have
all
their
components
specified.
as
in
algebraic
equations;
the
goal
of
the
problem
is
quite
clear.
Ill-defined
prob
lems
have
a
degree
of
uncertainty
about
the
starting
point,
needed
operations
and
final
product.
A
well-defined
problem.
for
example.
might
take
the
form
of
How
should
I
use
the
word
processor
to
fit
a
500-word
essay
on
two
pages%’
An
ill-defined
question
might
take
the
form
of
How
can
I
write
the
type
of
paper
that
will
get
me
a
higher
percentage
of
marks?”
Problem-Solving
Methods:
When
you
recognise
that
a
problem
ex
•
ists,
you
can
remember
whether
you
faced
a
similar
problem
in
the
past.
If
so,
you
can
retrieve
the
solution
from
memory
and
appLy
it
to
the
current
problem.
If
the
problem
is
new
and
there
is
no
solution
in
long-term
memory
tLTM),
you
can
use
several
strategies
to
attack
the
problem.
Computers
have
provided
scientists
with
a
model
that
can
be
used
to
understand
human
thinking.
However,
to
use
the
computer
as
a
model
of
human
thought,
researchers
need
to
know
what
human
beings
do
when
they
solve
problems.
We
use
two
gen
eral
approaches
to
solving
problems
and
these
can
be
programmed
into
a
computer:
algorithms
and
heuristics.

92. i.
Algorithms:
An
algorithm
is
a
recipe
or
rule
for
solving
a
problem
that
guarantees
a
solution
if
there
is
one.
A
simple
example
of
an
algorithm
is
the
mathematical
formula
used
to
determine
the
area
enclosed
by
a
rectangle:
length
multiplied
by
width
gives
the
answer,
Algorithms
cannot,
however,
provide
answers
when
the
probleni
is
not
clearly
specified.
There
are
no
procedures
that
can
be
set
up
in
advance
to
guarantee
a
solution
for
sLich
problems.
Moreover,
some
problems
are
so
vast
that
algorithms
are
simpty
out
of
the
question.
For
example,
chess
players
could
not
rely
on
algorithms
because
it
would
take
centuries
to
examine
all
possi
ble
arrangements
of
the
chess
pieces,
even
if
the
players
could
evaluate
them
at
a
rate
of
several
million
per
second.
Computers
playing
chess
are,
however,
capable
of
doing
so.
ii.
Heuristics:
Heuristics
are
educated
guesses
or
rules
of
thumb
that
are
used
to
solve
a
problem.
The
use
of
heuristics
does
not
guarantee
a
solution
but
it
makes
more
efficient
use
of
time
than
algorithms.
For
instance,
a
doctor
looking
to
obtain
informed
con
sent
prior
to
a
surgicat
intervention
may
heuristically
solve
this
problem.
There
exists
no
international
standard
for
information
disclosure
for
a
medical
or
psychiatric
situation
but
as
a
rule
of
thumb,
five
areas
of
information
are
generally
provided:
diagnosis,
treatment,
consequences,
alternatives
and
prognosis.
Obstacles
and
Aids
to
Probtem
Sotving
Researchers
comparing
the
problem
solving
techniques
of
experts
and
novices
and
found
that
experts
have
more
information
that
they
can
use
to
solve
problems.
Experts
know
how
to
collect
and
orga
nise
information
and
are
better
at
recognizing
patterns
in
the
infor
mation
they
gather.
As
health
professionals
we
often
come
across
situations
that
challenge
us
and
expose
the
limits
of
our
clinical
experience.
Such
situations
merit
a
consultation
from
our
senior
colleagues,
and
are
considered
a
norm
in
medical
practice.
At
times
the
strategies
used
to
solve
problems
may
become
obstacles
in
problem
solving.
Some
examples
of
this
are:
•
Functional
fixedness
or
rigidity
•
Mental
set
•
Assumptions
•
Misleading
information
•
Transfer
Mentat
set
According
to
Sternberg
and
Sternberg
(2012),
a
mental
set
consists
of
a
frame
of
mind
involving
an
existing
model
for
representing
a
problem,
a
problem
context,
or
a
procedure
for
problem
solving.”
In
most
cases,
it
is
helpful
in
problem
solving
to
use
a
solution
that
has
worked
before.
It
may,
however,
become
a
problem
if
you
insist
on
using
a
particular
strategy
to
solve
a
problem
(even
if
it
does
not
work)
and
cannot
think
of
any
other
way
to
do
it
because
this
was
a
strategy
that
had
worked
in
the
past.
Mental
sets
can
make
it
difficult
for
a
doctor
to
determine
the
cause
of
an
illness.

93. Functionat
fixedness
Functionat
fixedness
is
a
particular
kind
of
mental
set
that
only
allows
objects
to
have
a
fixed
functionality.
This
refers
to
the
ten
dency
to
try
and
solve
problems
only
in
one
particular
way.
It
occurs
when
we
are
unable
to
recognise
that
an
object
or
thinking
tool
may
be
used
for
something
other
than
its
intended
use.
This
prevents
us
from
creatively
solving
a
problem.
A
clothes
hanger,
for
example,
is
an
object
intended
to
hang
clothes
in
a
cupboard.
Functional
fixed-
ness
is
the
mental
block
that
dictates
this
is
its
only
use.
This
would
prevent
one,
for
example,
from
using
the
hanger
to
unlock
a
car
door
when
the
keys
have
been
left
inside.
Misteading
information
In
a
complicated
problem
there
may
be
large
amounts
of
data
avail
able,
which
may
distract
from
the
information
required
to
arrive
real
solution.
This
may
occur,
for
example
when
we
are
unabLe
to
arrive
at
a
diagnosis
for
a
patient
with
pyrexia
of
unknown
origin,
C
PUO)
be
cause
s/he
has
been
tested
for
everything
under
the
sun,
with
some
reports
having
positive
findings
but
none
seemingly
indicating
the
cause
of
the
infection.
It
is
important,
therefore,
to
be
able
to
sepa
rate
information
with
respect
to
relevance
when
solving
a
problem.
This
is
especially
the
case
with
admitted
patients
who
have
under
gone
many
investigations.
Assumptions We
may
at
times
be
unable
to
solve
a
problem
because
we
may
he
assuming
that
certain
obstacles
to
the
solution
exist
when
this
is
not
the
case.
Transfer Transfer
refers
to
“the
extent
to
which
knowledge
and
skills
acquired
in
one
situation
affect
a
person’s
learning
or
performance
in
a
subse
quent
situation.
(Ormrod,
2014)
This
is
obviously
an
important
prob
lem
solving
technique,
but
can
cause
obstacles
as
welL
Negative
transfer
occurs
when
one
attempts
to
solve
a
second
problem
with
the
same
strategy
as
the
first
one.
An
example
of
negative
transfer
is
when
one
switches
from
driving
a
manual
transmission
car
to
an
automatic
one
and
keeps
trying
to
switch
gears.

94. Problems
Involving
Transfer,
a
method
of
problem
solving
The
Radiation
Problem
imagine
you
are
a
doctor
treating
a
patient
with
a
malignant
stomach
tumor.
You
cannot
operate
on
the
patient
because
of
the
severity
of
the
cancer.
But
unless
you
destroy
the
tumour
somehow,
the
patient
will
die.
You
could
use
high-intensity
X-rays
to
destroy
the
tumour.
Unfortunately.
the
intensity
of
X-rays
needed
to
destroy
the
tumour
will
also
destroy
healthy
tissue
through
which
the
rays
must
pass.
X-rays
of
lesser
intensity
will
spare
the
healthy
tissue
but
they
will
be
insufficiently
powerful
to
destroy
the
tumour.
What
kind
of
procedure
could
you
employ
that
will
destroy
the
tumour
without
also
destroying
the
healthy
tissue
surrounding
the
tumour?
The
Military
Problem
A
general
wishes
to
capture
a
fortress
located
at
the
centre
of
a
country.
All
of
them
are
minefleldi
Although
small
groups
of
men
can
pass
over
the
road
sally.
any
large
armyof
soldiers
will
detonate
the
mines.
A
futl-scale
direct
attack
is,
therefore,
Impossible.
What
should
the
general
do?
Think
about
this:
What
are
the
commonaifties
between
the
two
problems.
and
what
is
an
elemental
strategy
that
can
be
derived
by
comparing
the
two
problems?
Correspondence
between
the
Radiation
and
the
Military
Problems
What
are
the
commonalities
between
the
two
problems,
and
what
is
an
elemental
strategy
that
can
be
derived
by
compared
the
two
problems?
(After
Gick
&
Holyoak
1983)
Military
Problem
Radiation
Problem
Initial
State
Coal:
Use
army
to
capture
fortress
Resources:
Sufficiently
large
army
Constraint:
Unable
to
send
entire
army
along
one
road
Solution
Plan:
Send
small
groups
doing
multiple
toads
simultaneously
Outcome:
Fortress
captured
by
army
Initial
State
Goal:
Use
X-raysto
destroytumour
Resources:
Sufficiently
powerful
rays
Constraint:
Unable
to
admInister
high-intensity
rays
from
one
direction
only
Solution
Plan
mister)
densfty
rays
from
pie
directions
simultaneousty
Outcome:
Tumour
destrcted
by
rays
initial
State
Goal:
Use
force
to
overcome
a
central
target
Resources:
Sufficiently
great
force
Constraint:
Unable
to
apply
full
force
along
one
path
alone
Solution:
Apply
weak
forces
along
multiple
paths
simultaneously
Outcome:
Central
target
overcome
by
force
M.L
Cick
and
K.
3
Holyoak
fl983),
schema
induction
and
Analogical
Trans
fer’
Cognitive
Psychology.
Vol
l5pp
7-38.
Convergence
Schema
I

95. A
c.ction/d.clsion
COflsqLeficei
a
chofrr
A
I
The
Seven
Step
Decision
Making
Process
c.
Decision
making
Each
day
we
make
dozens,
perhaps
hundreds,
of
decisions
on
every
aspect
of
Life:
what
to
wear,
eat,
say,
do.
Some
decision
making
involves
choosing
among
proposed
solutions
to
a
problem.
Some
of
these
decisions
are
easy:
others
are
not.
How
do
we
make
such
decisions?
The
human
brain’s
prefrontaL
cortex,
through
its
vast
connectivity
with
the
rest
of
the
brain,
enables
us
to
process
vast
amounts
of
information
quickty
and
accurately.
Heuristics
is
one
method
of
doing
so.
Decision
making
is
a
seven
step
process,
as
seen
in
the
diagram
above.
d.
Creative
Thinking
As
a
medical
student,
you
may
have
noticed
that
a
few
of
your
peers
or
teachers
deal
with
probLems
in
a
unique
and
extraordinary
way.
They
are
able
to
visuaLise
and
understand
difficult
and
boring
sub
jects
in
a
fresh
and
new
way.
Perhaps
you
are
one
of
those
peopLe
who
think
and
act
creatively.
The
creative
thinker
whether
artist,
stu
dent
or
scientist
is
trying
to
create
something
new.
Creative
thinking
involves
a
new
and
unique
way
of
conceptuaLising
the
worLd
around
us. Creativity
ProfiLe
Creative
people
possess
the
following
qualities:
•
Unusual
awareness
of
people.
events
and
problems.
•
High
degree
of
verbal
fluency.
•
Ftexibility
with
numbers
and
concepts
•
Flexibility
in
social
situations.
•
OriginaLity
of
ideas
and
expression.
•
Sense
of
humour.
•
Ability
to
abstract,
organise
and
synthesise.
•
High
energy
and
activity
Level.
•
Persistence
in
tasks
of
interest.
•
Lmpatience
with
routine
or
repetitive
tasks.
Willingness
to
take
risks,
•
Vivid
and
spontaneous
imagination
in
childhood.

96. A
-
,
Verification
A
Illumination
-
Incubation
______________
Preparation
Orientation
Five
step
procs
of
crcitit’e
thinking
Stages
of
creative
thinking
Creative
thinking
is
a
five
stage
process:
i.
Orientation:
The
problem
must
be
defined
and
important
dimensions
identified.
ii.
Preparation:
In
this
stage
creative
thinkers
saturate
themselves
with
as
much
information
related
to
the
problem
as
possible.
iii.
Incubation:
Most
major
probLems
produce
a
period
when
all
attempted
solutions
appear
futile.
At
this
point
problem
solving
may
proceed
on
a
sub-conscious
tevel
for
some
time.
iv.
Illumination:
The
stage
of
incubation
is
often
followed
by
a
wave
of
insight
and
produces
the
Aha!’
or
eureka”
experience.
v.
Verification:
The
final
step
is
to
test
and
critically
evaluate
the
solution
obtained
during
the
stage
of
illumination.
Common
barriers
to
creative
thinking
There
are
three
types
of
barriers
that
impede
creative
thinking
and
problem
solving:
Emotional,
cultural
and
perceptual
barriers.
Emotional
barriers:
O
Inhibitions
‘Fear
of
failure.
Inability
to
tolerate,
‘Ambiguity•
Excessive
self-criticism.
Cultural
barriers:
•
Value
systems
that
consider
fantasy
and
imagination
a
waste
of
time.
•
Being
taught
that
playfulness
is
an
exclusive
domain
of
children.
•
Categorisation
tat
home
and
as
a
society)
of
reason
and
logic
as
good
but
feelings,
intuition,
pleasure
and
humour
as
bad
Perceptual
barriers
include
habits
leading
to
a
failure
to
identify
important
etements
of
a
problem.

97. 6.
Emotions
Being
the
first
in
his
pharmacotogy
class
to
detiver
a
presentation,
Sha
hid
was
feeling
terrified
on
the
podium
with
the
microphone
in
his
hand.
Though
the
lecture
hail
was
nicely
air
conditioned,
he
felt
hot
As
he
began
to
speak,
he
could
feel
a
strange
sense
of
having
a
lump
in
his
throat
and
a
feeling
of
discomfort
in
his
stomach.
He
tried
to
clear
his
throat
but
his
dry
mouth
and
trembling
hands
were
making
the
task
too
difficult
“Is
this
the
same
tecture
hall
where
I
have
been
attending
classes
every
day
and
had
fun
with
my
friends:
he
thought
The
growing
restlessness
and
sarcastic
expressions
on
the
audiences
faces
was
not
a
real
threat
but
Shahid
felt
as
if
it
was.
His
heart
was
now
beating
at
the
rate
of
140
bpm
and
his
ctothes
were
drenched
with
sweat
The
rationat
part
of
his
mind
totd
him
that
his
imagination
was
running
wild
but
he
remained
unable
to
shake
the
fear
and
dread
that
had
taken
over
the
control
of
his
body.
Life
would
be
dull
and
colourless
without
emotions.
Feelings
and
emo
tions
add
pleasure
and
excitement
to
our
lives.
Have
you
ever
waited
untit
someone
was
in
a
good
mood
to
ask
for
a
favour?
If
so,
you
are
aware
that
emotions
have
a
powerful
influence
on
everyday
behaviour.
It
is
a
common
observation
that
it
is
easier
to
make
decisions
when
you
are
in
a
good
mood,
People
who
are
happy
are
more
likely
to
help
others
in
need.
Similarly
we
are
all
aware
of
the
importance
of
love,
optimism,
acceptance
and
joy
in
human
relationships.
However
emotions
also
have
their
negative
effects
as
we
saw
in
Shahid’s
case.
Definition The
word
emotion
is
derived
from
the
Latin
word
which
means
“to
move”
and
emotions
do
indeed
move
us.
An
emotion
is
a
feeling
with
its
dis
tinctive
thoughts,
psychobiological
states,
and
range
of
propensities
to
behave.
Human
emotions
can
be
disruptive
(as
in
Shahid’s
case
who
was
experiencing
“stage
fright)
but
often
they
aid
survival.
This
seems
to
be
why
emotional
reactions
were
retained
in
evoLution.
For
details
on
the
neurobiology
of
emotions,
refer
to
Chapter
3,
The
Neurobiological
Basis
of
Behaviour.
a.
Types
of
Emotions
There
are
two
types
of
emotions:
innate
(primary)
emotions
and
mixed
(secondary)
emotions.
Innate
or
primary
emotions:
The
concept
of
primary
emotions
was
first
given
by
Robert
Plutchik
(ig8o)
who
believed
that
there
were
eight
primary
or
innate
emotions:
fear,
surprise,
sadness,
disgust,
an
ger,
anticipation,joy
and
acceptance.
A
baby
by
the
end
of
first
year
can
express
most
of
the
primary
emotions.
Secondary
or
mixed
emotions:
Primary
emotions
can
be
mixed
to
give
rise
to
the
secondary
or
mixed
emotions.
For
instance
the
emo
tion
of
love
results
from
a
combination
ofjoy
and
acceptance.
The
mixture
of
disgust
and
sadness
gives
rise
to
the
secondary
emotion
of
remorse.
Jealousy
can
be
considered
as
a
mixture
of
love,
anger
and
feat.
Most
secondary
emotions
are
acquired.
Greed,
lust,
preju
dice,
paranoia,
hatred,
and
shame
are
some
examples
of
acquired
emotions.

98. b.
Expression
of
Emotions
Facial
expressions
appear
to
be
central
to
the
expression
of
emo
tions
and
have
been
retained
through
the
evolutionary
process.
Body
gesture
and
movements
(body
Language)
also
express
feel
ings,
mainly
by
communicating
emotionaL
tone
rather
than
specific
messages.
While
the
language
we
use
to
express
ourseLves
verbaLly
may
vary
with
race
and
geography,
body
language
and
faciaL
ex
pressions
are
Largely
universaL
C.
PhysioLogicat
Differences
amongst
Emotions
U.e.
It
is
usually
difficult
to
differentiate
one
emotion
from
the
other
on
the
basis
of
physiological
changes
but
some
differences
provide
important
cues.
For
example.
people
cry
when
they
are
sad,
some
times
even
when
they
are
happy,
but
almost
never
when
they
are
angry
or
disgusted.
Establishing
the
physiological
specificity
of
emotions
does
not
require
that
every
emotion
have
a
unique
phys
iological
signature,
only
that
some
emotions
differ
from
others
in
consistent
ways.
Finding
such
evidence
has
not
been
easy
because
emotions
are
generally
short
lived,
tasting
for
only
a
short
white.
Over
the
years,
research
suggests
that
there
are
several
reliable
differences
amongst
various
emotions.
One
of
the
most
consistent
findings
is
the
tendency
for
anger
to
be
associated
with
cardiovascu
lar
changes.
The
heart
rate
increases
with
anger,
fear,
and
sadness,
it
decreases
with
disgust.
Compared
to
anger.
fear
is
associated
with
lower
blood
pressure.
cooler
surface
temperature
and
less
blood
ftow
to
the
periphery
of
the
body.
Our
language
reflects
some
of
these
physiological
differences.
We
use
phrases
such
as
“blood
boil
ing”
when
we
talk
about
anger
but
not
when
talking
about
disgust.
happiness
or
sadness.
The
description
“white
with
fear”
reflects
the
cooler
skin
temperature
associated
with
the
emotions
EmotionaL
Intettigence
Most
people
may
find
it
difficult
to
identify
what
emotion
they
are
experiencing
and
when.
For
instance,
if
a
student
has
failed
a
sub
stage.
he
may
be
feeling
a
myriad
of
different
emotions:
shame,
em
barrassment,
hopelessness,
fear
of
the
future.
Now
if
his
best
friend
topped
this
exam,
this
may
complicate
his
feelings
even
further.
In
this
entire
scenario,
however,
if
asked,
how
he
is
feeling,
he
may
only
respond
with:
“bad.”
Recognizing
what
particular
emotions
we
are
feeling
is
a
key
element
of
the
concept
of
‘emotional
inteLLigence’.
The
abitity
of
an
individuat
to
recognise
their
own
and
other’s
emotions,
reason
through
them
and
use
them
to
their
advantage
is
referred
to
as
emotionat
intelligence.
This
is
measured
as
emotional
intettigence
quotient
or
EQ.
This
will
be
further
discussed
in
the
section
on
‘Inteltigence.
Lack
of
Emotions
Not
all
of
us
possess
the
capacity
to
express
our
emotions
to
the
same
degree.
Some
individuals
feet
a
great
difficulty
in
expressing
their
emotions
and
understanding
those
of
others.
This
may,
inevi
tably.
lead
to
a
difficulty
in
maintaining
relationships.
This
emotional
difficulty
is
called
alexithymia.
People
with
alexithymia
are
not
aware
of
their
own
feelings
and
may
even
lack
the
words
needed
to
____

99. .4,:.
communicate
their
emotions.
A
common
example
in
clinical
practice
is
that
of
patients
who
are
unable
to
express
their
distress,
depres
sion
or
anxiety.
They
describe
these
feetings
in
terms
of
physical
symptoms
such
as
headache,
gas
or
‘gala’.
These
patients
more
often
than
not
are
silent
sufferers
of
atexithymia.
presenting
with
a
somatoform
disorder.
7.
Motivation
We
alt
seek
different
goals,
some
more
vigorously
than
others,
The
same
goat
may
be
pursued
for
different
reasons.
While
alt
of
us
may
want
to
be
good
doctors,
our
motivation
for
this
may
differ.
Some
may
want
this
because
they
would
like
to
treat
their
patients
welL
Others
may
be
inter
ested
in
getting
famous
and
stilt
others
are
concerned
with
becoming
rich.
Our
behaviour
is
driven
and
pulled
towards
goats.
The
driving
force
which
results
in
persistent
behaviour
directed
towards
particular
goats
is
called
‘motivation’. Motives
cannot
be
observed
directly
and
are
in
fact
inferred
by
us
after
we
have
observed
people
working
towards
certain
goals.
n
other
words,
motives
are
inferences
from
behaviour.
They
are
powerful
tools
for
the
explanation
of
behaviour
and
allow
us
to
make
predictions
about
future
behaviour. BiologicaL
motivation:
The
biological
motives
are
rooted
in
the
physiologi
cal
state
of
the
body.
There
are
many
such
motives
including
hunger,
thirst,
sexuat
desire,
temperature
regutation,
steep,
pain-avoidance
and
a
need
for
oxygen.
As
regards
the
biological
motives,
the
body
tends
to
maintain
a
state
of
equilibrium
called
homeostasis.
Sexual
motivation:
This
depends
to
a
large
degree
on
sex
hormones.
These
hormones
organise
the
brain
and
body
of
developing
humans
so
that
they
have
male
or
female
characteristics.
The
activation
of
sexual
motivation
in
humans,
however,
seems
to
be
controlled
more
by
external
stimuli
and
learning
than
by
sex
hormones.
SociaL
motivation:
Social
motives
are
learned
motives
that
involve
other
people.
Examples
of
social
motives
include
the
need
for
achievement,
need
for
approval
and
need
to
attain
power.
Power
motivation
is
when
the
goal
is
to
influence,
control,
persuade,
lead
and
charm
others
and
enhance
one’s
own
reputation
in
the
eyes
of
other
people.
A
special
form
of
power
motivation
with
negative
objectives
is
termed
Machiavettianism.
It
is
char
acteristic
of
people
who
express
their
motivation
to
become
powerful
by
exploiting
others
in
a
deceptive
and
unscrupulous
fashion.
Self-actuaLization
motivation:
This
was
first
described
by
Abraham
Maslow,
who
spent
most
of
his
life
studying
healthy
people.
Self-actualiza
tion
refers
to
an
individual’s
need
to
do
what
he
or
she
is
capable
of
doing.
Setf-actuatisers’
are
people
who
make
the
most
use
of
their
capabilities,
and
are
able
to
maximise
their
potentiaL
The
goals
may
vary
from
per
son
to
person.
According
to
Maslow,
self-actualization
is
considered
the
topmost
in
a
hierarchy
of
needs
or
motives
in
life.
Esteem
needs
include
the
need
for
prestige,
success
and
self-respect.
Betongingness
and
love
includes
the
need
for
affection,
affiliation
and
identification.
Safety
needs
include
the
need
for
security,
stability
and
order.
The
basic
physiological
needs
include
hunger,
thirst
and
sex.
The
order
in
which
these
are
listed
are
important
since
the
physiotogical
needs
must
be

100. White
the
provision
of
food,
drugs,
bedding
and
a
comfortable
ward
setting
by
the
paramedics
in
the
hospital
caters
for
the
basic
physiotogicat
needs,
hospitat
administrators
provide
for
the
second
tier
of
needs
i.e.
security
The
need
for
betongingness
and
tove
isjeopardised
once
the
patient
is
so
lated
from
home,
famity
and
significant
others.
The
nursing
staff
is
uniquely
placed
to
fulfil
this
need.
They
can
provide
a
surrogate
environment
that
gives
unconditional
regard
and
respect.
so
the
patient
does
not
feet
aban
doned
with
respect
to
this
third
tier
of
needs.
Addressing
the
patient
by
their
preferred
name,
rather
than
bed
number
12
or
13
(which
undermines
the
sense
of
belongingness
and
need
for
bonding).
greeting
patients
with
a
smite,
staying
by
their
side
when
they
are
in
distress
or
pain,
and
com
forting
them
are
aLl
gestures
that
a
sensitive
nursing
staff
ensures
in
their
interaction
with
patients.
A
patient’s
illness,
its
correlates
and
consequent
disabilities,
undermines
their
self-respect
and
setf-esteem.
The
steps
of
making
him/her
wear
a
patient’s
uniform,
taking
away
alt
tiberties
of
movement,
food,
and
choices,
confinement
to
a
bed
or
a
room
and
frequent
examinations
of
body
parts
(by
medicaL
students,
trainees,
residents
and
consultants)
conducted
in
groups
can
be
embarrassing
for
the
patient.
This
take
away
the
fourth
tier
of
needs
of
esteem
and
recognition,
as
described
by
Maslow.
As
leader
of
the
health
team,
the
doctor
should
take
charge
of
this
most
vital
need.
A
healthy
doctor-patient
relationship
based
on
mutual
participation
and
in
formed
consent
can
enhance
the
self-esteem
of
the
patient.
A
doctor
who
greets
his/her
patients
on
arrivat;
addresses
the
patient
with
his/her
pre
ferred
name
and
adds
sahib’
or
‘soft/ba’
(or
culturally
appropriate
phrase
of
respect);
seats
them
respectfully;
takes
permission
before
undertaking
an
examination
or
a
procedure
and
looks
after
them
using
the
bio-psychoso
ciat
model
of
health
care,
not
only
adequately
provides
for
the
self-esteem
needs
of
the
patient
but
also
enhances
adherence
to
treatment,
and
the
chances
of
recovery
from
itlness.
Mastows
Hierarchy
of
Needs
in
HospitaL
satisfied
before
any
of
the
others
can
be
met
A
starving
man
is
preoccu
pied
with
the
search
for
food.
He
is
not
bothered
about
what
happens
to
morrow
as
only
today’s
meat
counts.
Once
he
is
assured
of
eating
today,
he
can
begin
to
worry
about
his
safety
needs
and
thus
climb
up
the
hierarchy
by
one
step.
Most
of
us
do
not
make
it
to
the
top
of
the
pyramid
partly
be
cause
of
the
state
of
the
society
in
which
we
live.
It
is
only
when
our
basic
needs
are
met,
that
energy
is
available
to
strive
for
greater
understanding
of
ourselves
and
our
surroundings.
The
patient
in
a
hospital
environment
in
the
grip
of
an
illness,
experiences
a
fall
to
the
baseline
step
of
Maslow’s
hierarchy
of
needs.
S/he
is
concerned
solely
with
fulfilling
their
basic
physiological
needs
and
restoring
physical
or
mental
health.
A
comprehensive
health
care
plan
should,
therefore,
not
only
focus
on
the
management
of
the
disease
but
also
make
an
attempt
to
facilitate
the
patient’s
upward
ascent
on
the
hierarchy
of
needs.
The
diseased
state,
amongst
other
influences,
also
limits
a
person’s
social
and
occupational
functioning.
The
need
to
setf-actuatise
and
realise
one’s
full
potential
is,
thus,
also
obstructed
by
illness
and
hospitalisation.
The
ideal
health
system
caters
for
social
and
occupational
rehabilitation
of
pa
tients
during
hospitalisation
as
well
as
following
discharge.
The
concept
of
tertiary
care
and
rehabilitation
following
injury
and
disease
augments
the
process
of
self-actualisation.
Adding
psychological
and
spiritual

101. dimensions
to
the
care
plan
can
enhance
it
further.
This
goat
is
only
possi
ble
through
the
implementation
of
the
bio-psycho-social
model
of
health
care.
It
is
the
responsibility
of
health
policy
makers
and
pubtic
heatth
pro
fessionals
to
develop
and
implement
a
health
system
that
ensures
fulfiL
ment
of
unique
potentials
of
the
citizens
and
helps
them
become
self-actualisers. Profite
of
a
setf-actualiser
•
A
doctor
has
the
unique
opportunity
to
achieve
his/her
own
self-actual
ization
as
well
as
make
a
contribution
towards
the
achievement
of
self-ac
tualization
in
others.
Maslow
found
that
self-actualisers
shared
a
number
of
characteristics
irrespective
of
whether
they
were
rich
or
poor.
famous
or
unknown,
academically
distinguished
or
uneducated.
These
are:
•
Efficient
perceptions
of
reality:
Most
of
Maslows
subjects
could
judge
situations
correctly
and
honestly.
•
Comfortable
acceptance
of
self,
others
and
nature:
SeIf-actuatisers
were
able
to
accept
their
own
shortcomings
as
well
as
those
of
others.
•
Spontaneity:
Maslow’s
subjects
extended
their
creativity
into
everyday
activities.
They
tended
to
be
unusually
energetic.
engaged
and
spontaneous.
•
Task-centring:
Most
subjects
had
a
mission
in
life
that
they
vigorously
pursued.
•
Autonomy:
Subjects
were
free
from
dependence
on
external
authority
and
tended
to
be
resourceful
and
independent.
../
(
Maslow’s
hierarchy
of
needs
•
Fellowship
with
humanity:
SeIf-actuatisers
felt
a
deep
identification
with
others
and
the
human
situation
in
general.
•
Profound
interpersonal
relationships.
They
were
able
to
form
meaningful
and
sustained
mutually
beneficial
interpersonal
relationships.

102. •
Non-hostile
sense
of
humour:
Self
actuatisers
have
a
wonderful
capacity
to
laugh
at
oneself.
•
Peak
experiences:
AtI
of
Mastow’s
subjects
reported
the
frequent
occurrence
of
peak
experiences.
These
are
experiences
that
are
marked
by
feelings
of
euphoria,
harmony
and
deep
meaning.
8.
Intettigence
Intelligence
is
hard
to
define.
It
can,
generally,
be
described
as
the
glob
al
capacity
of
the
individual
to
act
purposefully,
think
rationatly,
and
deal
effectively
with
the
environment.
In
essence,
intelligence
is
the
prob
tem-sotving
ability
of
an
individuaL
The
Wechs[er
Adult
InteLligence
Scale
(WAISR)
and
the
Wechster
Intelli
gence
Scale
for
Children-Ill
IWISC-llI)
are
the
two
most
common
methods
of
assessing
the
IQ
of
adults
and
chitdren,
respectively.
Assessment
of
IC
includes
the
assessment
of
mathematical,
verbal,
spatial,
and
mechanical
proficiency.The
measure
of
intelligence
is
the
Intelligence
Quotient
CIQ)
which
is
ob
tained
by
dividing
a
child’s
mental
age
with
his/her
chronological
age
and
multiplying
it
with
100.
IQ
mental
age/chronological
age
x
100.
Extremes
of
Intelligence
Individuals
who
enter
the
medical
profession
have
been
found
to
harbour
an
IQ
score
higher
than
the
average
10
of
the
population
which
ranges
from
go
to
110.
Scores
below
70
or
above
130
occur
in
only
about
5
per
cent
of
the
popuLation.
Individuals
with
such
statistically
rare
scores
are
considered
exceptionaL
Those
with
scores
below
70
may
be
diagnosed
as
mentally
handicapped
if
they
also
exhibit
significant
deficits
in
adaptive
behaviour
such
as
self-care,
sociaL
skills,
or
communication.
The
diagnosis
of
a
mental
handicap
also
requires
that
the
condition
begin
before
age
18.
In
many
cases,
deficits
that
occur
after
age
18
are
the
result
of
brain
dam
age
from
traumatic
injury
to
the
head
and
brain.
Individuals
with
10
scores
about
140
and
above
may
be
identified
as
gifted.
Savant
Syndrome:
In
1887,
J.
Langdon
Down
described
a
group
of
mental
ly
handicapped
children
who
exhibited
speciaL
abiLities.
Down
eventually
became
known
for
his
description
of
Down
syndrome
but
in
a
book
enti
tled
Qn
Some
of
the
MentatAffections
of
Childhood
and
Youth,
he
offered
a
description
of
Savant
syndrome.
Savant
syndrome
occurs
in
individuaLs
who
are
severely
handicapped
in
overaLt
intelligence
yet
demonstrate
exceptional
ability
in
a
specific
area
such
as
aft,
memory,
or
music.
These
individuals
are
often
atso
gifted
with
extraordinary
memories.
For
example.
despite
very
Low
scores
on
tests
of
inteLligence,
one
of
Down’s
patients
had
memorised
a
large
number
of
historicaL
facts.

103. Emotionat
IntelLigence
Emotional
intelligence
is
defined
as
the
capacity
to
identify,
understand
and
control
the
expression
of
emotions.
Emotional
intelligence
abilities
can
be
divided
into
four
areas:
i.
The
capacity
to
accurately
identify
emotions.
ii.
The
capacity
to
use
emotions
to
facilitate
thinking.
iii.
The
capacity
to
understand
emotional
meanings.
iv.
The
capacity
to
manage
emotions.
To
be
emotionally
intelligent
is
to
have
interpersonal
skills
that
characterise
a
rich
and
balanced
personality.
Emotional
intelligence
includes,
as
Aris
totle
put
it.
the
rare
ability
“to
be
angry
with
the
right
person,
to
the
right
degree,
at
the
right
time,
for
the
right
purpose,
and
in
the
right
way.”
The
measure
of
emotional
intelligence
is
known
as
Emotionat
quotient
(EQ.)
Components
of
Emotional
Intelligence
One
commonly
used
version
of
Peter
Salovey
and
John
Mayer’s
1990
defi
nition
of
emotional
intelligence
includes
abilities
in
five
main
areas:
i.
Self-awareness:
Recognizing
one’s
own
feelings
as
they
occur
is
the
crux
of
emotional
intelligence.
The
ability
to
monitor
feelings
from
moment
to
moment
is
key
to
insight
and
understanding
one’s
own
self.
Being
aware
of
one’s
emotions
makes
one
more
confident
when
making
important
life
decisions
such
as
what
career
path
to
follow,
or
whom
to
marry.
ii.
Managing
emotions:
Having
appropriate
emotional
reactions
is
a
capacity
that
builds
on
self-awareness.
The
ability
to
modulate
negative
expressions
of
emotions
such
as
anxiety,
anger,
and
depression
is
a
crucial
emotional
skill.
Emotional
resilience
helps
one
to
prevail
over
life’s
inevitable
setbacks.
Those
who
lack
emotionat
self-regulation
are
continualLy
overcome
by
feelings
of
distress.
iii.
Motivating
oneself:
Being
able
to
focus
on
a
goal
is
essential
for
a
range
of
accomplishments.
Emotional
self-control
such
as
delaying
gratification
or
controlling
impulsivity
is
crucial
in
working
towards
such
life
goats.
Individuals
who
can
harness
their
emotions,
and
maintain
hope
and
optimism
despite
frustrations,
are
generally
more
productive
and
effective.
iv.
Recognizing
emotions
in
others:
Empathy,
another
skill
based
in
emotionat
self-awareness,
is
fundamental
to
interpersonal
effectiveness.
Those
who
are
well
attuned
to
subtle
social
cues
that
indicate
what
others
feel
are
more
successful
in
personal
and
professional
settings.
v.
Handling
relationships:
The
art
of
relationships
requires
skill
in
managing
others’
emotions.
Social
competence
underlies
popularity.
leadership,
and
interpersonal
effectiveness.

104. EQ
EQ
Measures
emoIion
Intetigence:
abtrry
to
manage
emotions
Flexible
skiT
can
be
learned
and
ImprovedUmbic
stem
Street
smort
Manages,
resolves
conflict
Effeciiie
dung
times
of
stress
EmotionaL
InteLligence
and
I.Q.
In
a
sense
the
human
brain
contains
two
minds
and
two
different
kinds
of
intelligence:
rationaL
and
emotionaL.
These
two
fundamentally
different
modes
of
consciousness
interact
to
constitute
our
mental
life.
The
emo
tional
and
rational
minds
are
semi-independent
faculties,
each
reflecting
the
operation
of
distinct,
but
interconnected,
circuitry
in
the
brain.
The
complementary
relationship
and
working
of
limbic
system
and
neocortex,
particutarly
of
the
amygdala
and
prefrontal
lobes,
means
each
is
a
full
partner
in
mental
life.
The
emotionaL
and
rational
minds
operate
in
tandem
for
the
most
part.
Emotions
contribute
to
and
inform
the
operations
of
the
rational
mind,
and
the
rational
mind
refines
and
sometimes
vetoes
the
input
of
the
emotions.
When
these
partners
interact
welt,
both
emotional
intelligence
and
intellectual
ability
are
enhanced.
There
is,
at
best,
a
slight
correlation
between
1.0.
and
certain
facets
of
emotional
intelligence,
small
enough
to
make
it
ctear
that
these
are
large
ty
independent
entities.
When
people
with
high
1.0.
struggle
in
life,
and
those
with
modest
I.Q.
do
surprisingly
wett,
the
difference
often
may
be
attributable
to
emotional
intelligence.
Those
with
an
extremely
high
1.0.
but
low
emotional
intelligence-or
low
1.0.
and
extremely
high
emotionat
Intel
Ugence
are
relatively
rare.
Unlike
the
familiar
tests
for
1.0.
there
is
as
yet
no
corresponding
test
that
measures
emotional
intelligence,
although
there
is
ample
research
on
each
of
its
components.
Some
aspects
of
emotional
intelligence
are
best
tested
by
studying
an
individual’s
ability
at
the
task.
Empathy
can
be
evaluated,
for
example,
by
testing
an
individual’s
accuracy
at
interpreting
another’s
feelings
from
their
facial
expressions.
Measures
conttlv1ntece;
ability
to
problem
soIre1ea,Mm
10gbPermanent,
fixed
at
birth
Neocortex
—
Confronts
threats
head
on

105. How
to
Improve
Emotional
InteLligence
While
I.Q
is
targely
under
genetic
inftuence,
emotional
intelligence
is
a
set
of
skills
that
can
be
learnt
and
enhanced.
just
like
any
other
skills.
Below
are
a
few
guidelines
to
help
a
person
get
started
with
improving
their
emotional
intelligence:
Observe
how
you
react
to
people.
Do
you
rush
to
judgment
before
you
know
all
of
the
facts?
Do
you
stereotype?
Look
honestly
at
how
you
think
and
interact
with
other
people.
Try
to
put
yourself
in
their
place,
and
be
more
open
and
accepting
of
their
perspectives
and
needs. Look
at
your
work
environment.
Do
you
seek
attention
for
your
accomplishments?
Humility
can
be
a
wonderful
quality,
and
it
doesn’t
mean
that
you’re
shy
or
lack
self-confidence.
When
you
practice
humility,
you
say
that
you
know
what
you
did,
and
you
can
be
quietly
confident
about
it.
Give
others
a
chance
to
shine
-
put
the
focus
on
them,
and
don’t
worry
too
much
about
getting
praise
for
yourself.
Do
a
setf-evatuation.
What
are
your
weaknesses?
Are
you
willing
to
accept
that
you’re
not
perfect
and
that
you
could
work
on
some
areas
to
make
yourself
a
better
person?
Have
the
courage
to
look
at
your
self
honestly
-
it
could
change
your
Life.
•
Examine
how
you
react
to
stressful
situations.
Do
you
become
upset
every
time
there’s
a
delay
or
something
doesn’t
happen
the
way
you
want?
Do
you
blame
others
or
become
angry
at
them,
even
when
it’s
not
their
fault?
The
ability
to
stay
calm
and
in
control
in
difficult
situations
is
highly
valued
in
alL
professional
and
non-professional
settings.
Keep
your
emotions
under
control
when
things
go
wrong.
•
Take
responsibility
for
your
actions.
If
you
hurt
someone’s
feelings.
apologise
directly
—
don’t
ignore
what
you
.did
or
avoid
the
person.
People
are
usually
more
willing
to
forgive
and
forget
if
you
make
an
honest
attempt
to
make
things
right.
•
Examine
how
your
actions
will
affect
others
-
before
you
take
those
actions.
If
your
decision
will
impact
others,
put
yourself
in
their
place.
How
will
they
feel
if
you
do
this?
Would
you
want
that
experience?
If
you
must
take
the
action,
how
can
you
help
others
deal
with
the
effects?

106. i.
Sensorimotor
stage
(0-2
years):
The
child’s
inteLtectua[
development
is
targety
nonverbal
in
this
stage
and
is
mainly
concerned
with
[earn
ing
to
coordinate
purposeful
movements
(such
as
neck
holding.
crawling
and
walking)
with
sensory
input,
After
the
age
of
18
months
the
concept
of
object
permanence
begins
to
emerge.
This
refers
to
the
child’s
ability
to
recognise
the
permanence
of
objects.
For
instance
ifs/he
is
playing
with
a
ball
and
it
rolls
under
the
sofa,
they
would
not
Look
for
it
as
they
think
it
no
longer
exists.
For
the
very
young
child
out
of
sight
can
literally
mean
out
of
mind,”
This
is
why
playing
peekaboo
(“taa)
amuses
infants,
as
they
think
that
if
you
are
hidden,
you
do
not
exist
and
when
you
reappear.
they
ate
surprised.
The
development
of
object
permanence,
therefore,
is
the
under
standing
that
the
ball
stilt
exists
and
now
the
child
will
search
for
it.
I
NW@,
9.
Personatity
DeveLopment
PersonalityThe
word
personality
originates
from
the
Latin
persona”,
which
means
mask.
Personatity
can
be
defined
as
the
deeply
ingrained
and
relativety
enduring
patterns
of
characteristics,
behaviour,
motives,
beliefs,
attitudes
and
cognitions
that
an
individual
possesses.
Awareness
of
our
personality
and
our
ability
to
recognise
ourselves
separately
from
the
environment
is
the
only
thing
that
separates
us
from
artificial
intelligence.
While
the
exact
nature
of
personality
is
a
topic
of
intense
academic
de
bate,
general
consensus
states
that
aspects
of
personality
start
to
devetop
during
childhood
and
are
then
strengthened
and
moulded
tilt
adulthood.
This
chapter
sheds
light
on
multiple
theories
of
personality
development.
As
alt
chiLdren
develop
differentty
and
each
has
their
own
complex
cog
nitions
and
characteristics,
no
single
theory
can
account
for
it.
Thus,
it
is
helpful
to
have
a
broader
appreciation
of
personality
development
than
any
one
theory.
a.
Piaget’s
Theory
of
Cognitivó
Development
The
Swiss
psychologist,
Jean
Piaget
believed
that
alt
children
pass
through
a
series
of
distinct
stages
in
intellectual
development.
He
believed
children
construct
knowledge
for
themselves
as
‘little
scientists’.
His
theory
hypothesised
that
children
advance
through
four
stages
of
cognitive
development
with
each
stage
building
on
the
previous
one.
ü.
Preoperational
stage
(2-7
years):
During
this
stage
the
child
devel
ops
the
ability
to
think
symbolically
and
use
language.
The
use
of
language
is
not
sophisticated,
however,
and
they
tend
to
confuse
words
with
the
object
they
represent.
The
child
is
also
egocentric
(they
feel
everything
is
about
“Me!”)
and
unable
to
take
the
point
of
view
of
other
people.
During
this
stage
chiLdren
also
make
conserva
tion
errors.
where
they
believe
that
simply
changing
the
appearance
of
objects
can
change
their
quantity.
iii.
Concrete
Operational
stage
(7-11
years):
An
important
development
during
this
stage
is
mastery
of
the
concept
of
conservation
as
well
the
ability
to
reason
logicalLy.
Children
have
learned
that
pouring
liquid
from
a
talL
narrow
glass
into
a
shallow
dish
does
not
reduce

107. the
amount
of
fluid.
During
this
stage,
a
child’s
thought
starts
to
grasp
the
concept
of
time,
space
and
numbers.
The
child
starts
using
categories
and
principles.
iv.
Format
Operationat
stage
(12
years
onwards):
After
the
age
of
ii.
the
child
begins
to
break
away
from
concrete
objects
and
specific
examples.
Thinking
is
based
more
on
abstract
ideas
and
the
child
becomes
tess
egocentric.
This
stage
represents
the
attainment
of
full
adult
intellectual
ability.
The
older
adoLescent
is
capable
of
reasoning
and
can
conceptualise
mathematics,
physics,
and
phi
losophy.
Piaget
argued
that
attainment
of
this
stage
is
not
universal
and
may
depend
on
quality
of
education,
the
environment
and
the
society
that
the
adolescent
is
living
in.
b.
Freud’s
Psychoanatyticat
Theory
of
Personality
Devetopment
Sigmund
Freud
proposed
that
an
individual’s
personatity
develops
through
a
series
of
five
stages
stretching
from
infancy
to
adulthood.
These
stages
are
called
psychosexual
stages
because
each
is
characterised
by
efforts
to
obtain
pleasure
centred
on
one
of
several
parts
of
the
body
catted
erogenous
zones.
According
to
Freud,
the
five
stages
of
psychosexual
development
are
the
oral,
anal,
phallic,
latency,
and
genital
stages.
I
Oral
Stage:
Pleasure-seeking
behaviour
in
the
oral
stage
focuses
on
the
baby’s
mouth.
Young
children
can
often
be
seen
biting,
sucking.
or
placing
objects
in
their
mouths.
Freud
hypothesised
that
if
oral
needs
such
as
the
need
for
food
are
delayed,
the
child’s
personality
may
become
arrested
or
fixated.
An
individual
whose
development
is
arrested
at
this
stage
will
disptay
behaviours
as
an
adult
that
are
associated
with
the
time
of
life
during
which
the
fixation
occurred.
For
example,
fixation
at
the
oral
stage
may
manifest
in
behaviours
such
as
chewing
on
pencils,
smoking
or
overeating
and
in
person
ality
characteristics
such
as
excessive
dependency,
optimism,
and
gullibility.
ii.
Anal
Stage:
From
about
18
months
until
about
3
years
of
age,
the
child
is
in
the
anal
stage.
As
the
child
gains
muscular
control,
the
erogenous
zone
shifts
to
the
anus,
and
the
child
derives
pleasure
from
the
retention
and
expulsion
of
faeces.
The
key
to
this
stage
is
toilet
training.
The
way
parents
approach
toilet
training
can
have
lasting
effects
on
their
children.
If
the
parents
are
strict
and
demand
ing,
the
chitd
may
rebel,
and
the
result
will
be
fixation
at
this
stage.
Individuals
who
are
fixated
at
this
stage
may
be
overly
rigid,
obses
sional
and
orderly
as
adults
and
are
referred
to
as
anat
-retentive.
People
who
have
obsessional
traits
in
personality
tend
to
be
per
fectionists.
These
people
can
become
easily
distressed
and
anxious
when
their
orderliness
or
time
tables
are
disturbed.
iii.
Phattic
Stage:
The
phallic
stage,
which
begins
at
about
age
4
to
5.
is
ushered
in
by
another
shift
in
the
erogenous
zone
and
the
child’s
pleasure
-
seeking
behaviour,
During
this
stage,
children
derive
pleasure
from
fondling
their
own
genitals.
Children
also
begin
to
differentiate
between
males
and
females.
It
is
during
this
stage
that
children
begin
to
identify
with
the
same
sex
parent
and
compete
with
them
for
the
other
parent’s
attention.
This
is
also
the
stage

108. where
boys
devetop
a
feeling
of
wanting
to
possess
the
mother
and
the
desire
to
replace
the
father
—
what
Freud
called
the
Oedipus
complex.
Conversely
girls
develop
a
simitar
set
of
feelings
but
for
the
father
in
what
is
referred
to
as
the
Etectra
complex.
A
disturbed
phallic
stage
is
seen
in
adults
in
the
form
of
disturbed
relationships
with
either
the
opposite
gender
or
both.
iv.
Latency
and
Genitat
Stages:
At
about
age
6,
children
enter
a
peri
od
when
their
sexual
interests
are
suppressed.
This
period,
which
lasts
until
the
beginning
of
adotescence,
is
called
the
latency
stage.
Sexual
interests
are
reawakened
at
puberty
and
become
stronger
during
the
genital
stage.
In
this
stage,
sexual
pleasure
is
derived
from
heterosexual
relationships.
At
the
beginning
of
the
genital
stage,
most
adolescents
have
difflculty
developing
true
affection
and
caring
for
others:
they
still
experience
the
narcissistic
qualities
of
earlier
stages
of
development.
As
they
mature,
they
develop
greater
ability
to
establish
such
relationships,
thus
setting
the
foundation
for
adult
relationships.
Although
Freud’s
psychosexual
stage
theory
of
personality
development
was
fascinating
and
audacious
given
the
conservative
era
of
its
concep
tion,
it
was
based
upon
case
studies
and
hence
lacked
repeatability
and
reliability.
The
theory
was
based
predominantly
on
male
development
and
there
was
little
mention
of
the
psychosexual
development
of
females.
It
can
also
not
be
verified
through
empirical
research,
as
constructs
utilised
in
the
theory
cannot
be
measured.
c.
Erikson’s
Stages
of
Psychosociat
Development
Erik
Erikson
added
to
Freud’s
theory
by
concentrating
on
human
develop
ment
beyond
puberty.
He
concluded
that
human
personality
is
determined
not
only
by
childhood
experiences,
but
also
those
of
adulthood.
denlity
nerfi’iky
INFANT
IDD([R
PR[-
cUIOUI..-
AllcttJ
YOUNG
MI[[
WR
(WOOt[A
A[R
A11T
A[
Afl
GvIt
tnf€iatil
https//sites.googte.com/site/hool?appsychotogy;a/

109. He
described
8
stages
of
the
life
cycle
fsee
table
below)
I.
Infancy.
The
first
of
Erikson’s
stages
is
“trust
versus
mistrust”
and
occurs
from
birth
to
1
year.
The
child
devises
either
a
trusting
or
mis
trusting
relationship
with
the
world
around
it
based
on
whether
its
immediate
needs
are
met.
These
needs
are
generally
concerned
with
physical
cravings
(food,
sleep,
and
comfort)
and
feelings
of
attachment.
ii.
Early
Childhood:
The
second
stage
of
development
Erikson
is
“autonomy
versus
shame
and
doubt”
which
occurs
between
1
to
3
years
of
age.
During
this
stage
children
learn
to
be
independent
but
only
if
they
are
sufficiently
encouraged
to
explore
their
world
and
given
freedom
to
do
so.
Children
with
overly
restrictive
or
anxious
parents
who
restrict
their
children’s
creativity
and
independent
exploration
of
their
environment,
start
to
self-doubt
and
become
tess
confident.
iii.
Late
Childhood:
From
the
age
of
three
to
six,
children
pass
through
the
stage
Erikson
refers
to
as
“initiative
versus
guitt.”
During
this
period
of
development,
children
take
the
initiative
to
further
explore
their
environment
and
gain
new
experiences.
The
aspect
of
guilt
comes
about
when
there
are
unforeseen
consequences
involved
in
these
explorations.
iv.
Shool
Age.
The
final
stage
of
childhood
development
is
called
“industry
versus
inferiority,”
and
it
lasts
from
age
six
to
12.
In
this
stage
children
learn
to
read
and
write
and
learn
specific
skills.
Children
seek
to
win
approval
by
demonstrating
skills
that
are
valued
by
the
society
and
develop
a
sense
of
accomplishment.
Mastery
in
these
skills,
with
adequate
support
from
parents,
teachers
and
peers,
brings
about
a
sense
of
overall
competence.
Failure
brings
about
a
sense
of
inferiority
in
the
child.
v.
Adolescence.
During
the
years
of
12
to
18,
the
stage
of
identity
versus
rote
confusion
occurs
as
the
vital
transition
from
childhood
to
adulthood
takes
place.
This
is
the
time
when
the
child
evaluates
his/her
identity
and
decides
the
role
he
wiLl
occupy
as
an
adult.
Erikson
claimed
that
some
uneasiness
would
be
felt
as
the
adult
tries
to
feel
comfortable
in
their
changing
body
and
success
during
this
stage
wilt
lead
to
fidelity.
This
is
because
the
individual
will
only
be
able
to
accept
others
who
may
be
ideologically
different
once
s/he
becomes
comfortable
with
whom
they
are
themselves.
vi.
Occurring
in
young
adulthood
(ages
i8
to
40
yrs.),
in
this
stage
of
intimacy
versus
isolation”
individuals
become
more
intimate
with
each
other
and
explore
retationships
that
lead
to
long
term
commitments
with
people
who
are
not
family
members.
Success
during
this
stage
leads
to
a
sense
of
commitment
and
healthy
relationships
whereas
resistance
to
intimacy
may
lead
to
isolation.
vii.
During
mid
adult
years
(40-85)
individuals
reach
the
stage
of
“generativity
versus
stagnation.”
They
become
established
in
society
and
their
careers
as
well
s
give
back
to
their
society
by
educating
their
children
and
working.
Failure
in
this
stage
by
not
playing
an
accommodating
role
in
society
can
tead
to
stagnation
and
feelings
of
worthlessness.

110. Child
begins
to
view
his/her
Overprotective
self
as
an
individual
In
their
parenting
can
lead
own
right
apart
from
their
to
selFdoubt
in
parents
but
still
dependant
the
chIld.
on
them,
Toilet
training
and
Conditions
that
I
controlling
temper
lead
to
the
child
tantrums
begIns
feeling
inadequate
or
learning
skills
like
walking
or
talking
are
S
hazard
In
this
stage
Oaedy
strict
Phallic
stage
disdplinv
bythO
3-6
years
parents
can
PISxJrB
suppress
the
become
child’s
pleasure
zones.
Gender
identity
forms.
Oedipus.
Electra
complex
occurs
viii.
The
last
and
final
stage
of
integrity
versus
despair”
occurs
after
65
years
of
age
where
productivity
deteriorates
and
individuals
reflect
on
their
roles
in
life
and
their
accomplishments.
Erikson
believed
that
people
who
do
not
feel
satisfied
with
what
they
have
achieved
through
their
role
in
society
have
a
tendency
to
become
depressed
and
feet
helpless.
Although
one
of
the
most
influential
theories
of
development.
Eriksons
work
was
rather
vague
in
the
description
of
factors
that
may
affect
each
stage
and
of
the
behaviours
that
would
lead
to
successfuL
completion
of
each
stage.
Trtrst
In
others
and
feelings
of
security
based
on
how
th
infant
is
trgated
by
the
parents/caretakers.
AGE
PEflIOD
ERIKSONS
EASIC
DEVELOPMENTAL
DEVELOPMENTAL
FREUD’S
COMPONENTS
TASKS
HAZARDS
psycHosExuAl.
STAGES
infanqv
-
-
Trust
Biahtol8
months
vs
-
Mistrust
Early
Childhood
Autonomy
l8monthstothree
-
vs
years
Shame
Abuse.
neglect
in
Infancy.
premature
or
harsh
weaning
Oral
stage
Pleasure
focused
on
mouth
-
chewng.
sucking
and
biting
Anal
stage
Pleasure
is
focused
on
bowel
and
bladder
emptying
Late
Childhood
initiative
Child
feels
g
sense
initiative
3-Sysars
-.
vs
toundarsl.andtheworld.
-
-
Guilt
and
their
main
word
goes
-
-
from
7’JoI
to
whyT
-.
I
ftation
of
adult
behaviOur
•
r
occurs.
The
child’s
-
imagination
starts
to
develop.
-
-
.
-
Reality
testing
begins
School
Age
6-lZyeere
Adolescence
12-20
years
Latency6
years
puberty
Playing
with
the
same
gender.dormant
sexual
feelings
Industry
vs
inferiority
Identity
vs
Role
Confusion
Young
Adulthood
Intimacy
18-25
years
-
vs
latIon
Generetivigr
vs
Stagnation
--
Old
age
integrity
6syearstOdeeth
vs
-
Despair
Child
feels
accomplishment
in
learning
and
masteringnow
skills.
Identity
development
of
who
one
is
Capacity
for
love,
mutual
dafdoliort
commitment
to
workand’telatlonships:
impdrsohal
reiationshlps.
Creativity,
productivity.
concern
for
others,
self-
indulgence.
impoverishment
Of
self
Acceptance
Of
the
worth
and
uniqueness
of
oneg
llfe
sense
orioss.
contempt
tor
Qthers
--
Genital
Stage
Pubertyonwards
Seauci
interests
mature
Failure
due
to
personal
limitations
or
extreme
competition
leads
to
sense
of
inferiority
and
poor
work
habits
Society
fails
to
pfoeide
well
defined
roles
or
roles
are
undesirable
leading
to
contusion
isolation
or
lack
of
personal
relations
FaIlure
to
perfect
and
master
developmentaltasks,
leading
to
stagnation
Ineblityto
find
Meaning
in
life
Adulthood25’65
years

111. Determinants
of
Personality
The
study
of
personality
cannot
only
be
based
on
how
it
is
manifested
and
changed
overtime
but
rather
what
factors
determine,
or
affect
personality.
Charles
Darwin
in
his
‘Origin
of
Species’
proposed
that
a
person’s
person
ality
originates
in
the
mother’s
womb
with
genetic
and
hereditary
factors
contributing
to
our
primal
personality
traits.
Scholars
like
John
Locke
argued
that
the
human
psyche
and
psychological
traits
are
formed
pri
marity
due
to
the
environment
and
surroundings
that
the
person
is
raised
in.
Angyat
(1941)
believed
that
the
determinants
of
personality
are
neither
exclusively
organismic
nor
environmental
but
rather
a
combination
of
both.
When
studying
the
development
of
personality,
therefore,
one
must
take
a
holistic
approach
and
consider
biologicaL
psychological
and
social
factors.
Biotogical
factors
Biological
determinants
of
personality
include
inherited
traits
and
characteristics
as
well
the
workings
of
the
nervous
system.
glands
and
blood
chemistry
(Kumar,
2015).
Factors
such
as
heredity
are
de
termined
at
birth
and
can
be
referred
to
as
physical
structure,
mus
cle
density,
facial
structure,
attractiveness
that
one
inherits
from
the
biological
makeup
of
their
parents.
Basically.
the
way
we
look
plays
an
important
role
in
how
others
treat
us
and
how
we
in
turn,
treat
others.
Krueger
and
Johnson
(2008)
found
that
genes
contributed
to
individual
differences
in
alt
of
five
of
the
Big
Five
personality
fac
tors.
As
we
grow
older
we
acquire
different
aspects
of
our
parents’
personalities.
Siblings
may
differ
in
their
appraisals
of
situations
as
well
as
in
their
overall
outlook
on
life.
Proponents
of
lhe
nature
over
nurture
argument
would
suggest
that
these
personality
differenc
es
are
due
to
the
differences
in
the
children’s’
observation
of
their
parents’
behaviour.
Sociat/Environmetita[
factors
Factors
such
as
social
structure
and
the
environment
play
a
vital
role
in
the
formation
of
a
child’s
personality.
Numerous
studies
have
shown
that
a
constructive
learning
environment,
social
support
and
a
nurturing
family,
all
positively
affect
the
development
of
personal-
ity.
Environmental
factors
may
include
the
culture
that
children
are
raised
in
and
the
societal
norms
that
guide
behaviour.
Environmental
factors
can
be
used
to
manipulate/suppress
the
genetic
predisposi
tion
to
express
undesirable
emotional
and
behavioural
responses
of
individuals.
In
2000,
Collins
et
at
found
that
factors
such
as
parent
ing
and
other
early
life
experiences
affect
the
expression
of
genetic
personality
traits.
Personality
Types:
Relevance
to
Clinicat
Conditions
Many
readers
would
have
observed
that
it
is
a
common
tendency
for
peo
ple
to
categorise
others
on
the
basis
of
their
personal
characteristics.
Even
in
your
class
there
are
bound
to
be
‘shy’
students
and
the
‘sociable
out
going’
type.
Classifying
people
into
types
is
one
device
by
which
we
try
to
make
sense
out
of
others’
behaviour
and
anticipate
how
they
wilt
act
in
the
future.
The
notion
that
people
can
be
classified
into
certain
types
is
one
of
the
oldest
ideas
about
personality
Personatity
classifications
date
back
to
400
BC.
Hippocrates,
a
Greek
physician
grouped
people
into
four
types
on
the
basis
of
their
temperaments.
These
were
sanguine
(cheerful,
vigorous,

112. Type
A
persons
are
driven
and
competitive.
They
tive
under
constant
pressure,
which
is
usually
setf-created.
They
also
take
on
multiple
activities
with
rigid
deadLines
to
meet.
These
people
may
function
weU.
most
of
the
time
and
may
be
competent
and
efficient.
Under
stress,
however,
they
are
likely
to
become
hostile,
anxious
and
disorganised.
They
may
feeljittery
and
irritable
prior
to
examinations
and
are
constantLy
in
a
hurry’.
The
underlying
cause
of
an
increased
incidence
of
heart
disease
in
Type
A
personality
is
the
constant
outflow
from
the
sympathetic
nervous
system
in
response
to
stressors.
Type
B
persons
are
easy-going,
non-competitive,
placid
and
cooL
They
remain
calm
and
composed
under
stressful
states.
Given
a
task
to
do,
Type-A’s
usually
perform
near
their
maximum
capacity
no
matter
what
the
situation
is.
Type
B
persons
only
work
hard
when
given
a
deadline.
Interestingly,
when
placed
in
Long
lasting
stressfuL
situations
over
which
they
have
little
controL
Type
A
personalities
tend
to
give
up.
They
exhibit
he[p[essness
and
be
come
less
responsive
than
Type
B
personalities.
PersonaLity
types
that
can
influence
heatth
personnel:
There
are
distinct
personatity
types
that
doctors
and
medical
students
may
come
across
in
hospitals
and
in
their
personaL
lives.
KnowLedge
and
under
standing
of
personality
profiles
can
help
them
dealwith
these
individuals
more
effectively.
The
foremost
amongst
personality
types
that
may
be
difficult
to
handte
are
those
with
histrionic
or
sociopathic
personatity
traits
or
types.
These
individuals
have
the
following
characteristics;
•
manipulative
behaviour
superficiaL
charm
•
loud
in
their
expression
(both
in
language
as
well
as
dressing
and
demeanour),
•
tell
fantastic
stories
(mostly
false),
Personality
types
and
heart
disease
optimistic),
metancholic
(depressed).
choteric
(hot-
tempered)
and
phlegmatic
(slow
moving.
unexcitable).
According
to
the
Type
theory
of
personality,
people
can
be
divided
into
extroverts
and
introverts.
Extroverts
share
a
tendency
to
be
outgoing,
friendly
and
talkative
whereas
introverts
can
be
described
as
people
who
share
characteristics
such
as
shyness.
sociaL
withdrawal
and
a
preference
to
spend
time
alone,
Heart
disease
has
traditionally
been
linked
to
smoking,
obesity,
diabetes
and
inactivity.
In
recent
years,
however,
a
link
between
heart
disease
and
personality
types
has
emerged.
Two
specific
behaviour
pattern
types
are
now
known
to
be
associated
with
increase
and
decrease
chance
of
coro
nary
artery
disease;
Type
A
and
Type
B.
•
exaggerate
their
symptoms,
•
take
advantage
of
naive
medicaL
students
(asking
for
uncalled
for
investigations,
petty
cash,
small
time
favours,
drugs.
cigarettes).
•
prefer
to
be
treated
by
junior
doctors
(for
fear
of
being
discovered
or
identified).

113. The
common
ploys
used
by
such
patients
include
stories
of
being
mal
treated
by
their
own
family,
work
setting,
or
the
society
in
generaL
These
individuals
readily
share
sob
stories
of
being
‘cheated”
or
‘abandoned”
in
life.
They
may
say
they
are
in
dire
need
of
money
to
pay
for
a
lifesaving
procedure
or
drug.
A
dangerous
strategy
they
use
is
appearing
to
develop
‘strong
feelings
of
love”
for
the
doctor
or
the
medical
student.
The
story
of
Miss
X
in
section
on
psychological
reactions
in
doctor
patient
relationship
in
Section
2,
revealed
that
she
had
histrionic
traits.
The
case
report
goes
on
to
reveal
the
complications
that
can
arise
if
a
medical
student/doctor
is
caught
unaware.
While
it
is
crucial
to
be
wary
of
such
personalities
and
to
be
constantly
on
the
lookout,
it
is
equally
important
not
to
judge,
pun
ish
or
prosecute
them.
These
individuals
have
deep
rooted
psychological
conflicts
and
complexes
and
require
professional
psychiatric
help.
This
help
should
be
offered
to
them
at
the
earliest.
It
is
always
better
to
hand
over
the
care
of
patients
with
such
attributes
to
the
senior
members
of
the
health
team.
Clinicat
descriptions
of
their
behaviour
must
be
entered
in
their
case
histories,
for
future
reference.
The
table
briefty
describes
the
important
features
of
the
various
types
of
personality
disorders.
Chapter
3
Neurobiological
Basis
of
Behaviour
The
evolution
of
our
understanding
of
the
mechanisms
of
human
be
haviour
has
undergone
many
different
stages
(see
table).
The
most
recent
and
perhaps
the
most
dependable
expLanation
is
the
neurobiological
basis
of
behaviour.
While
we
study
exhaustive
texts
on
iow
the
brain
works
in
terms
of
our
most
basic
functions,
we
as
students
tend
to
gloss
over
the
anatomy.
biochemistry
and
neurology
of
what
makes
us
who
we
are.
The
purpose
of
this
chapter
is
to
shed
light
on
some
of
these
areas.
It
is,
however
beyond
the
scope
of
this
book
to
go
intodetails
of
neurobiolo
gy
and
cognftive
neuroscience
for
which
the
reader
must
consult
a
more
exhaustive
text
and
ongoing
research
articles
on
the
subject.
It
must
be
brought
to
the
reader’s
attention
that
the
human
brain
is
not
like
a
house
with
rooms,
in
which
certain
functions
take
place
only
in
certain
areas.
It
is,
in
fact,
the
connectivity
between
various
areas
of
the
brain
that
leads
to
this.
The
following
text
works
to
highlights
some
of
these
connections,
and
should
work
to
create
awareness
that
such
connections
exist.”
We
do
not
h’now
everything,
and
not
alt
of
what
we
betieve
we
know
is
correct,”
-
Anon
Religion ch
Neurosdence
-
-,,---_j
Ge
Progression
of
our
understanding
of
human
behaviour
Cluster
A
CMad”)
Paranoid:
Distrustful,
preoccupi
with
conspIracy
theones
Schizotypal:
socially
odd,
magica
thinking
Cluster
B
(“Bad”)
Histrionic:
provocative,
dramatic
shallow
emotionally
fri’—I
[
I
Nardssisstic:
Grandiose,
self
loving
lack
empathy,
sense
of
entitlement
Borderline
(emotionally
unstable):
Impu
swe.
unstable
intense
relationships.
proni
to
deliberate
self-harm,
drug
abuse
Obsessive
compulsive:
perfectionist
inflexible
morals,
preoccupied
with
rules/orderliness
Dependant:
submissive,
helpless,
clingy,
excessively
needy
Personatity
disorder

114. EmotionEmotion
may
be
defined
as
a
feeling
with
its
set
of
unique
thoughts,
elec
trical
and
biochemical
changes,
and
the
range
of
behaviours
it
can
Lead
to
(See
Section
C,
Chapter
2).
There
are
two
different
kinds
of
emotions:
inher
ent
and
learnt.
Inherently
found
emotions
include
those
that
all
human
be
ings
are
born
with
the
capacity
to
experience.
These
can
range
from
anger,
sadness,
fear,
love
and
amazement.
These
emotions
are
derived
primarily
from
our
basic
human
drives
such
as
hunger,
thirst,
sex
and
the
need
for
social
interaction.
The
Learnt
emotions
include:
envy,
pride,
guilt,
pity.
resentment
and
af
fection,
alt
of
which
are
housed
in
the
frontal
cortex.
The
more
complex
emotions
like
jealousy,
greed,
paranoia,
and
lust
are
a
mix
of
the
inborn
and
learnt
emotions.
There
is
Less
known
about
the
neurobiology
of
these
highly
complex
emotional
states
but
there
is
a
fair
amount
of
research
on
the
inborn
and
learnt
emotions.
Neuroanatomy
of
Emotions
The
neuroanatomical
site
for
the
manufacturing’
of
emotion
is
the
limbic
system.
The
range
of
behaviour
patterns
that
may
result
from
a
given
emo
tion
is
decided
by
the
frontal
cortex.
The
frontal
cortex
is
the
smart”
part
of
the
brain
where
planning
for
the
future,
decision
making
and
executive
functions
are
carried
out.
It
is
the
chief
executive
of
the
brain,
and
what
makes
us
“ashraf-ut-mahhtooqaat”
(The
Superior
Species).
The
prefrontal
cortex
is
what
allows
us
to
behave
in
a
civilised
fashion
even
when
our
emotions
urge
us
to
do
otherwise.
This
is
essentially
what
it
means
to
be
human,
as
animals
have
a
limited
capacity
to
perform
these
functions.
These
functions
are
performed
specifically
in
the
prefrontal
cortex
which
can
be
divided
into
3
parts:
Dorsotateral,
Ventromedial
and
OrbitofrontaL
The
dorsolateral
prefrontal
cortex
is
primarily
involved
in
managing
cognitive
processes.
moral
decision
making.
inhibition
of
emotion,
altruism
and
telling
the
truth
(or
tying!).
It
allows
the
individual
to
have
the
ability
to
entertain
multiple
ideas
at
the
same
time
and
plan
for
the
future.
It
is
also
involved
in
motivation,
attention
and
the
drive
to
complete
tasks.
It
is
par
ticularly
active
in
tasks
that
require
deductive
and
syllogistic
reasoning.[3;1
It
also
plays
a
role
in
the
behavioural
response
an
individual
has
to
anxiety
and
works
to
prevent
in
behaviour
likely
to
be
harmful
to
the
individual.
[61
The
ventromedial
prefrontal
cortex
has
a
role
in
emotional
regulation
and
decision
making
involving
morality.
[31
This
was
famously
seen
in
the
case
of
Phineas
Gage
who
suffered
damage
to
his
ventromedial
prefrontal
cortex.
[41
It
is
the
part
of
the
prefrontal
cortex
that
allows
one
to
[earn
from
their
mistakes.
It
also
allows
people
to
detect
irony,
sarcasm
and
detect
tying
in
other
people.
The
ventromedial
prefrontal
cortex
allows
people
to
use
emotions
to
make
moraljudgements.
This
can
be
explained
using
the
Trolley
dilemma
(Thomson,1g86),
in
which
a
person
is
asked
to
save
five
people
from
certain
death
by
a
trolley
crashing
into
them
by
pulling
a
switch
redirecting
the
trolley
to
kill
only
one
person.
The
majority
of
people
felt
that
it
was
moral
to
let
one
person
die
and
save
five
people.
If,
howev
er,
people
were
asked
to
physically
push
one
person
in
front
of
the
trolley
to
save
the
five
people,
they
refused,
despite
the
end
goal
of
both
being
the
same.
The
ventromediat
prefrontal
cortex
used
the
emotions
telt
in
the
situation
to
come
to
a
decision,
as
seen
by
Green
et
al.
(2011).
When
the
amygdala
becomes
active
in
situations
causing
anger
the
ventromedial
prefrontal
cortex
is
able
to
control
the
urge
to
act
impulsively.
[51

115. The
orbitofrontal
cortex
(so
called
because
it
represents
the
area
above
the
orbits)
plays
an
important
role
in
emotional
regulation,
specifical
ly
anger
management.
It
functions
to
associate
possible
outcomes
of
a
certain
behaviour
by
weighing
pros
and
cons
based
on
reward
and
pun
ishment
and
makes
a
decision.
Iii
In
one
study
people
with
more
outgoing
personalities
were
found
to
have
higher
volume
orbitofrontal
cortex,
while
more
introverted
people
were
found
to
have
a
higher
volume
ventromediat
prefrontal
cortex.
[2]
A
part
of
the
cingulate
cortex,
the
anterior
cingulate
cortex
(ACC)
is
the
area
where
the
integration
of
emotional
input
with
attention
occurs.
It,
therefore,
controls
emotional
arousal
and
emotional
self-controL
It
is
involved
in
gen
erating
empathy
and
social
awareness
and
becomes
active
when
individu
als
indulge
in
acts
of
bravery.
[41
To
summarise,
the
prefrontal
cortex
(the
smart’
part
of
the
brain),
takes
into
account
the
emotions
elicited
and
decides
the
most
logical
and
rational
action
to
take
in
a
situation.
171
The
limbic
system,
specifically
the
amygdala,
works
to
integrate
inputs
from
the
thalamus
and
frontal
cortex
with
outputs
involving
the
endocrine
and
autonomic
nervous
systems.
This
results
in
the
expression
of
emotion.
•
The
amygdala
is
the
main
mediator
of
the
fight,
flight
or
freeze
response.
It
is
invo[ved
in
the
mediation
of
aggression,
fear,
sexuaL
orientation
and
social
interaction,
including
the
number
and
kind
of
people
one
is
friends
with
and
interacts
with
in
a
social
context.
It
also
regulates
personal
space,
in
that
it
is
stimulated
when
another
human
being
gets
“uncomfortably
close.”
[81
The
right
lobe
of
the
amygdala
houses
negative
emotions
such
as
fear
and
anxiety.
The
left
lobe,
on
the
other
hand,
mediates
and
stores
both
positive
emotions
such
as
pleasure
and
happiness
and
negative
emotions
such
as
fear.
In
one
study,
poLitical
conservatism
was
linked
to
increased
volume
of
the
right
amygdala.
[9]
Distinct
gender
differences
have
been
seen
in
the
male
and
female
amyg
data.
The
mate
amygdata
has
a
larger
right
lobe,
while
the
female
amygda
Ia
has
a
larger
left
lobe.
As
the
right
lobe
is
associated
with
negative
emo
tions
and
action,
men
are
more
likely
to
react
physically
in
situations
that
are
emotionally
stressful.
The
left
lobe
is
important
in
the
recall
of
emotion
ally
charged
memories
and
details,
leading
to
more
intense
thought,
which
may
explain
why
women
are
more
likely
to
not
react
in
physical
ways
to
emotional
stress.
The
amygdaLa
also
mediates
the
formation
of
memories
that
have
an
emo
tional
content.
When
sensory
input
is
received,
it
is
relayed
by
the
thalamus
to
both
the
frontal
cortex
and
the
amygdata.
The
amygdala
then
checks
with
the
hippocampus
to
see
if
there
is
an
emotional
memory
of
a
similar
experience.
If
one
is
found,
we
tend
to
react
in
a
similar
fashion,
if
not;
the
prefrontal
cortex
kicks
in
to
make
something
of
the
novel
experience
and
forms
a
new
response.
Activity
of
the
amygdala
has
been
linked
to
clinical
depression,
anxiety
disorders,
and
posttraumatic
stress
disorder.
liD]
Despite
the
tact
that
the
prefrontal
cortex
is
the
smart
part
of
the
brain,
the
amygdala
exerts
far
more
control
over
it
than
the
prefrontal
cortex
does
over
the
amygdata
This
can
be
understood
it
the
amygdata
is
equated
with
the
moon
which
despite
its
size
may
eclipse
the
sun.
This
“limbic
eclipse”
is
th
reason
that
“love
is
blind”
“ghussa
akal
ko
khaajaata
hai”

116. (anger
makes
you
irrational)
and
durr
se
behosh
hona”
(fainting
with
fright)
occur.
As
seen
in
each
of
these
expressions,
an
emotion
that
is
essentially
less
‘smart”
completely
clouds
the
judgement
of
the
smarter
higher
centre,
the
frontaL
cortex.
Neurochemistry
of
Emotions
Biochemically,
certain
neurotransmitters
have
been
[inked
to
feeling
spe
cific
emotions.
Amongst
the
most
highty
researched
of
these
are
serotonin,
dopamine,
oxytocin
and
norepinephrine.
Serotonin
has
been
hailed
as
the
feet
good”
neurotransmitter
in
the
brain.
It,
among
other
things,
leads
to
a
feeling
of
well-being
and
satisfaction
liii.
Lower
than
normal
levels
have
been
linked
to
clinical
depression.
This
is
evidenced
by
the
improvement
of
symptoms
of
depression
with
the
use
of
serotonin
reuptake
inhibitors
tSSRIs
&
SNRIS)
h21
[131.
Dopamine
is
the
main
neurotransmitter
released
in
anger,
aggression
and
excitement.
Dopamine
levels
also
increase
when
an
individual
experiences
complex
emotions
[Ike
paranoia
and
jealousy.
Dopamine
is
also
the
primary
neurotransmitter
in
the
reward
pathway.
The
reward
pathway
is
activated
by
drugs
that
lead
to
increased
dopamine,
gambling
(where
winning
leads
to
dopamine
release),
and
playing
video
games.
This
is
also
why
all
of
these
activities
are
addictive.
Dopamine
is
responsible
for
the
kick”
that
normal
people
experience
in
moments
of
excitement
and
anticipation
when
they
are
looking
forward
to
something.
Higher
than
nor
mal
levels
of
dopamine
can
lead
to
difficulties
in
impulse
control,
aggression
and
eventually,
psychosis
[‘41
[151.
Oxytocin
is
the
neurotransmitter
of
love
and
bonding.
It
exists
in
the
body
both
as
a
hormone
and
a
neurotransmitter.
It
was
previously
studied
as
being
released
in
targe
amounts
during
childbirth,
and
immediately
after,
for
breastfeeding.
In
newer
research
it
has
been
hailed
by
many
as
ihe
propagator
of
the
human
species.”
This
is
not
only
due
to
its
role
in
child
birth
and
reproduction
(large
amounts
are
released
during
sexual
inter
course)
but
also
due
to
its
ability
as
a
neurotransmitter,
to
cause
‘pro-
social”
behaviour
1161.
Higher
levels
of
oxytocin
have
been
found
t
make
humans
more
likely
to
make
decisions
that
promote
the
well-being
of
a
group
rather
than
the
individuaL
The
bond,
kinship
and
love
that
any
two
human
beings
share
is
mediated
by
the
presence
of
oxytocin,
which
is
why
it
has
been
called
the
love
hormone.
It
has
also
been
known
to
decrease
stress
and
anxiety
and
lead
to
a
greater
degree
of
trust,
altruism
and
feel
ings
of
safety
between
people.
In
a
study
published
in
the
2013
in
the
Proceedings
of
the
National
Academy
of
Sciences
of
the
USA
Journal
(PNAS),
administration
of
oxytocin
was
revealed
to
cause
greater
fidelity
between
couples,
making
men
more
likely
to
be
monogamous
and
more
sensitive
to
other
people’s
emotions
t171.
It
is
thus
helpful
to
see
dopamine
as
the
neurotransmitter
released
when
one
first
becomes
intrigued
by
a
mysterious
stranger,
oxytocin
as
released
when
one
falls
in
love
and
serotonin
as
causing
the
sense
of
satisfaction
and
well-being
when
we
live
“happily
ever
after.”

117. —-—
-
5ota*
-Oytocm
Progression
otour
understanding
of
human
behaviour
Corpus
callosum
COMPONENTS
IN
THE
DIENCEPHALON
Anterior
group
of
thalamic
nuclei
Hypothalamus Mamillary
body
COMPONENTS
IN
THE
CEREBRUM
Cingulate
gyrus
Parahippocampal
gyms
Hippocampus
I
I
Lepreon
ftorFit
a’n
The
Limbic
System

118. Referencesi.Kringelbach,
M.
L.
(2005)
“The
orbitofrontal
cortex:
Unking
reward
to
he
donic
experience.
Nature
Reviews
Neuroscience
6:
691-702.
2.
Schoenbaum
G,
Takahashi
Y,
Liu
T,
&
McDannatd
M
(2011).
“Does
the
orbi
tofrontat
cortex
signal
vaLue?”
Annals
of
the
New
York
Academy
of
Sciences
1239:
87-99
3.
Hu,
C;
Jiang,
X
(2014).
“An
emotion
regulation
role
of
ventromedial
pre
frontal
cortex
in
moratjudgment.”
Front.
Hum.
Neurosci
8:
873.
doi:10.3389/
fnhum.2o14.oo873.4.
Nicolle,
A.
&
Goet,
V.
(2013).
What
is
the
role
of
ventromedial
prefrontal
cortex
in
emotional
influences
on
reason?
In
I.
Btanchette
(Ed.),
Emotion
and
Reasoning.
Psychology
Press.
5.
Schwartz,
Carl
E.,
et
aL
“Structural
differences
in
adult
orbital
and
ventro
medial
prefrontal
cortex
predicted
by
infant
temperament
at
4
months
of
age.”Archives
of
general
psychiatry
67.1
(2010):
78-84.
6.
Carlson,
N.
(2012).
Physiology
of
Behaviour
filth
Ed.).
Hartow:
Prentice
Hall..
Chan,
R.
C.
K.,
Shum.
D.,
Tou[opoutou,
T.
&
Chen,
E.
Y.
H.,
R:
Shum,
D:
Tou
lopoulou,
I;
Chen,
E
(2008).
“Assessment
of
executive
functions:
Review
of
instruments
and
identification
of
critical
issues.”
Archives
of
Clinical
Neuro
psychology.
2
23
(2):
201-216.
8.
Kennedy,
Daniel
P.,
et
al.
“Personal
space
regulation
by
the
human
amyg
data.”
Nature
neuroscience
12.10
(2009):
1226-1227.
9.
Kanai,
Ryota,
et
at
“Political
orientations
are
correlated
with
brain
struc
ture
in
young
adults.”
Current
biology
21.8
(201;):
677-680.
10.
Sheune,
Yvette
I.,
et
at
“Increased
amygdata
response
to
masked
emo
tional
faces
in
depressed
subjects
resolves
with
antidepressant
treatment:
an
fMRI
study.”
Biological
psychiatry
50.9
(2001):
651-658,
ii.
Peirson
AR,
Heuchert
JW.
Correlations
for
serotonin
levels
and
measures
of
mood
in
a
nonctinica[
sample.
Psychot
Rep
2000:87:707-16,
12.
Flory
JD,
Manuck
SB,
Matthews
KA.
et
at.
Serotonergic
function
in
the
central
nervous
system
is
associated
with
daily
ratings
of
positive
mood.
Psychiatry
Res
2004:129:11-9.
13.
Muldoon
MF,
Mackey
RH,
Williams
KV,
et
at.
Low
central
nervous
sys
tem
serotonergic
responsivity
is
associated
with
the
metabolic
syndrome
and
physical
inactivity.
]
Clin
Endocrinol
Metab
2004:
89:266-71.
14.
Schultz
W
(2007).
“Multiple
dopamine
functions
at
different
time
cours
es.”
Annual
Review
of
Neuroscience
30:
259-88.
15.
BjOrktund
A,
Dunnett
SB
(May
2007).
“Dopamine
neuron
systems
in
the
brain:
an
update.”
Trends
in
Neurosciences
30
(5):
194—202.
i6.
Lee
HJ,
Macbeth
AH,
Pagani
JH,
Young
WS
(Jun
2009).
“Oxytocin:
the
great
facilitator
of
tite.”
Progress
in
Neurobiology
88
(2):
127-51.
17.
01ff,
M..
FrUling.
J.
L.,
Kubzansky,
L.
D.,
Bradley,
B.,
Ettenbogen.
M.
A.,
Car
doso,
C
&
van
Zuiden,
M.
(2013).
The
role
of
oxytocin
in
social
bonding,
stress
regulation
and
mental
heatth:
an
update
on
the
moderating
effects
of
context
and
interindividuat
differences.
Psychoneuroendocrinotogy,
38(9),
1883-1894.

119. Motor
and
Sensory
Regions
of
the
Cerebral
Cortex
Language Language
forms
a
quintessential
part
of
what
it
means
to
be
human.
Human
language
is
unique
compared
to
the
communication
techniques
used
by
other
animals.
Other
animats
communicate
using
a
finite
num
ber
of
ideas
that
can
be
expressed.
Human
language.
on
the
other
hand,
is
open-ended
and
productive
meaning.
Humans,
can,
thus
produce
an
infinite
range
of
expressions
from
a
finite
set
of
elements
to
create
new
words
and
sentences.
[ii
Speaking
is
the
default
mode
for
language
in
all
human
cultures.
Humans
produce
language
using
control
of
the
lips,
tongue
and
the
rest
of
the
vo
cal
apparatus.
They
are
able
to
differentiate
spoken
sounds
white
attaching
contextual
meaning
to
the
sounds.
In
other
words
we
can
understand
what
is
being
said,
and
what
it
means
in
a
certain
situation.
These
abilities
are
[inked
to
a
neurological
apparatus
to
acquire
and
produce
language.
12]
While,
language
is
processed
in
various
areas
in
the
human
brain,
the
two
areas
that
are
mainly
involved
in
language
processing
are
Wernicke’s
area,
located
in
the
posterior
section
of
the
superior
temporal
gyrus,
(temporal
lobe)
and
the
Broca’s
area,
located
in
the
posterior
inferior
frontal
gyrus
(frontal
lobe)
of
the
dominant
hemisphere.
Wernicke’s
area
is
used
for
lan
guage
comprehension
and
Broca’s
area
is
responsible
for
language
artic
ulation.
Language
is
the
only
human
behavior
that
has
two
controlcentres.
thus
the
famous
idiom
pehte
tolah
phir
boto’
(think
before
you
speak).
Primary
motor
cortex
(precentr&
gyms)
Somatic
motor
association
area
(premotor
cortex)\
Prefrontal
cortex
Sri
Broca’s
area—
(production
of
speech)
Primary
sensory
cortex
(postcentml
gyms)
/
Somatic
sensory
association
area
Visual
association //_
area
Visual
cortex
Auditory
association
area
/
-
--
I
Wemicke’s
area
Auditory
cortex
(understand
speech)

120. Language
comprehension
is
known
to
consist
of
three
distinct
steps.
The
first
step
known
as
phonological
processing,
takes
place
in
the
frontat
lobes,
where
individual
sounds,
such
as
vowels
are
recognised.
The
sec
ond
step
is
known
as
texicat
processing
and
is
localised
in
the
left
temporal
lobe.
Lexical
processing
matches
heard
sounds
with
words
or
sounds
that
already
exist
in
the
individuat’s
memory.
In
the
third
step,
known
as
seman
tic
processing.
words
recognised
during
the
lexical
processing
step
are
connected
to
their
meaning.
Semantic
processing
activates
the
middle
and
superior
gyri
of
the
left
temporal
lobe.
Brain
areas
required
for
the
under
standing
of
the
conceptual
content
ot
words
are
distributed
all
over
the
cortex,
as
been
in
brain
imaging.
Language
production
occurs
in
the
opposite
direction
from
language
comprehension.
This
basically
means
that
it
proceeds
from
the
cortical
semantic
processing
to
the
teft
temporat
lexical
processing,
finally
going
to
the
phonologicat
processing
area
(for
speech)
or
the
graphomotor
system
(for
writing).
Prosody,
the
emotional
and
ffective
component
of
language.
or
‘body
language.”
appears
to
be
[ocalised
in
the
right
hemisphere.
Linguistic
functions
such
as
intonation,
tone,
stress,
and
rhythm
form
part
of
pros
ody.
Prosody
provides
information
on
the
various
non-semantic
aspects
of
communication,
such
as
the
emotional
state
of
the
speaker,
the
nature
of
what
is
being
said
as
welt
as
the
presence
of
irony
or
sarcasm.
These
nonverbat
elements
are
created
using
motor
operations
of
the
face,
mouth,
tongue,
and
throat
and
are
associated
with
Broca’s
area
in
the
left
frontal
lobe.
The
processes
needed
to
understand
these
nonverbal
elements
oc
cur
in
the
right-hemisphere
perisylvian
area,
particularly
Brodmann
area
22.
Language
exhibits
a
high
degree
of
hemispheric
lateralisation.
Damage
to
the
right
inferior
frontal
gyrus
diminishes
an
individual’s
ability
to
use
the
nonverbal
aspects
of
communication
such
as
conveying
emotion
or
emphasis
by
voice
or
gesture.
Damage
to
the
right
superior
temporal
gyrus
diminishes
an
individual’s
ability
to
understand
the
nonverbal
meaning
of
the
voices
and
gestures
of
others.
In
summary,
as
is
largely
known,
the
left
hemisphere
is
the
part
of
the
brain
that
is
mathematical,
calculating
and
analytical.
To
put
it
in
terms
of
an
unfair
stereotype
the
left
hemisphere
is
the
‘accountant”,
while
the
right
hemisphere
is
the
“artist’
where
lies
the
appreciation
of
art,
music
and
literature.
In
other
words.
while
the
Wernicke’s
area
that
processes
lan
guage
is
in
the
left
hemisphere
(in
most
right
handed
individuals),
the
right
hemisphere
is
where
the
processing
of
the
context,
sarcasm,
irony,
body
tanguage,
facial
expression
and
intonations
occurs.
In
any
given
spoken
sentence,
therefore,
the
left
hemisphere
hears
what
is
said
while
the
right
understands
how
it
is
said.
References1.
Hockett,
Charles
F.
(1960).
‘Logical
considerations
in
the
study
of
animal
communication.”
In
W.E.
Lanyon:
W.N.
Tavolga.
Animal
sounds
and
animal
communication.
pp.
392-430.
2..
Trnsk,
Robert
Lawrence
(1999).
Language:
The
Basics
(2nd
Ed.).
Psychology
Press.

121. Memory Memory
is
defined
as
the
mental
capacity
to
encode,
store,
and
retrieve
information.
[ii
Clinically
we
are
concerned
with
three,
testable
periods
of
memory
which
have
distinct
anatomical
correlates:
Immediate
memory
functioning
over
a
period
of
seconds:
recent
memory
applicable
over
a
scale
of
minutes
to
days:
and
remote
memory
ranging
over
time
periods
spanning
months
to
years. Immediate
memory
can
be
understood
as
the
ability
to
follow
a
train
of
thought.
It
is
divided
into
phonological
and
visuospatial
components.
The
phonological
component
is
localised
in
the
left
hemishphere
and
the
visuospatial
in
the
right..
Immediate
memory
is
often
related
with
recent
memory
using
the
concept
of
working
memory.
Working
memory
is
defined
as
the
ability
to
store
information
for
several
seconds
while
other
cognitive
operations
take
place
using
this
information.
The
dorsolateral
prefrontal
cortex
is
required
for
working
memory
along
with
the
certainty
with
which
the
information
is
known.
[2]
Some
researchers
locaUse
working
memory
predominantly
to
the
left
frontal
cortex.
Three
brain
structures
are
critical
to
the
formation
of
memories:
the
medial
temporal
lobe,
certain
diencephalic
nuclei,
and
the
basal
forebrain.
The
hippocompus
is
part
of
the
medial
temporat
tobe.
Adjacent
to
the
ante
rior
end
of
the
hippocampus
is
the
amygdata.
The
amygdala
and
the
hip
pocampus
work
in
tandem
to
store
emotional
experiences.
The
amygdala
rates
the
emotional
importance
of
an
experience
and
activates
the
level
of
hippocampal
activity.
This
phenomenon
is
called
the
memory
enhance
ment
effect
and
is
the
reason
why
emotionally
intense
experiences
are
etched
in
memory.
This
is
why
most
of
us
would
find
it
hard
to
recall
what
we
had
for
lunch
last
Tuesday,
but
remember
in
great
detail
what
the
menu
for
a
close
family
wedding
three
years
ago
was
or
the
exact
sequence
of
events
when
vie
were
in
a
car
accident.
The
amygdata
also
plays
a
role
in
the
formation
of
long-term
memory
by
moduLating
synaptic
plasticity,
which
helps
to
retain
a
memory.
It
helps
to
visuaLise
memory
as
a
grassy
path,
that
when
used
repeatedly
becomes
a
place
of
common
fare.
Long-term
memory
for
learning
events
is
not
formed
immediately.
These
memories
are
slowly
made
over
time,
through
a
process
called
tong
term
potentiation
These
are
enhanced
and
made
permanent
when
they
are
potentiated
by
experiences.
This
is
also
why
you
don’t
remember
last
minute
cramming
after
a
few
weeks.
It
is,
therefore,
imperative
for
a
medi
cal
student
to
ensure
that
all
forms
of
knowledge
are
enriched
by
seeing
a
patient
or
dealing
with
a
relevant
clinical
experience
in
real
Life
settings
of
a
hospital.
The
lesser
the
gap
between
studying
and
clinical
experience,
the
higher
the
chance
that
the
knowledge
will
remain
in
memory
for
the
long
term. The
association
areas
are
required
for
the
formation
of
memory
for
motor
acts.
The
performance
of
a
new
action
requires
feedback
from
the
sensory
cortex
and
association
areas.
Neuroimaging
has
shown
activation
of
the
large
parts
of
the
cortex,
during
performance
of
unskilled
acts.
When
per
forming
repeated
activities
initially
the
medial
temporal
lobe
is
activated,
however
with
time
the
performance
of
the
act
results
only
in
the
activation
of
the
premotor
and
left
parietal
cortex.
This
phenomenon
is
known
as
the

122. corticalisation
of
motor
commands,
The
repeated
acts
of
[earning
how
to
pass
a
catheter
or
intravenous
injection
ensure
perfection
and
thus
the
idiom
practice
mal?es
perfect!
Within
the
diencephaton.
the
dorsal
medial
nucleus
of
the
thatamus
and
the
mamillary
bodies
appear
necessary
for
memory
formation.
References1.
Gerrig,
Richard
J.
&
Philip
G.
Zimbardo.
Psychology
And
Lite,
;6/e.
Pub
tished
by
Allyn
and
Bacon.
Boston,
MA.
Copyright
(c)
2002
by
Pearson
Education.
Reprinted
by
permission
of
the
publisher.
2.
Sadock,
Benjamin
J.,
and
Virginia
A.
Sadock.
Kaplan
and
Sadock’s
synop
sis
of
psychiatry:
Behavioral
sciences/clinical
psychiatry.
Lippincott
Wit
hams
&
Wilkins,
2011.
ArousaLArousal
is
defined
as
the
physiotogicat
and
psychological
state
of
being
reactive
to
stimuli.
While
there
are
many
different
neural
systems
involved
in
the
establishment
and
maintenance
of
this
state,
research
has
shown
the
involvement
of
mainly
five
systems.
each
originating
in
the
brainstem.
These
systems
are
based
on
five
neurotransmitters:
norepinephrine,
ace
tylchoUne,
dopamine,
histamine,
and
serotonin.
The
noradrenergic
system.
originating
in
the
locus
coeruleus
causes
wake
fulness
by
the
release
of
norepinephrine.
The
cholinergic
system
based
in
the
pons
and
basal
forebrain
causes
cortical
activity
and
alertness.
Both
the
dopaminergic
system
and
the
serotonergic
system’s
neurons
project
into
the
limbic
and
prefrontal
cortex
and
are
important
for
mood
control
and
regulating
motor
movements.
The
histaminergic
system
neurons
proj
ect
into
the
cerebral
cortex,
thalamus,
and
the
basat
forebrain,
stimulating
the
release
of
acetytchohine
into
the
cerebral
cortex.
All
these
systems
are
related
to
the
development
of
a
feedback
mechanism
to
establish
and
maintain
arousal.
-
(,rW\
\
I
Image
is
taken
from
Christof
Koch
((20
p4)
“Figure
5.1
The
Chotinergic
Enabling
System”
in
The
Quest
for
Consciousness;
A
Neurobiological
Approach,
.
Roberts
&
Co.,
p.
91
ISBN.’
0974707708.
with
permission
from
the
author
under
license

123. There
have
been
attempts
to
explain
different
temperaments
in
humans
by
examining
variations
in
a
person’s
brain
stem,
Umbic
system,
and
thatamo
cortical
arousal
system
using
Electroencephalogram
(EEG).
[1]
Limbic
sys
tem
activation
has
been
[inked
to
neuroticism,
with
high
activation
showing
high
neuroticism.[2]
High
cortical
arousal
has
been
shown
to
be
associated
with
introversion.
People
with
high
extraversion
and
low
neuroticism
have
been
shown
to
have
the
towest
overa[[
levels
of
internal
arousat.
Converse
ly
people
with
high
extraversion
and
high
neuroticism
have
been
shown
to
have
the
lowest
intrinsic
thatamocortical
excitation.
References 1.
Robinson,
David
(6
November
2000).
UH0w
brain
arousal
systems
de
termine
different
temperament
types
and
the
major
dimensions
of
per
sonality.”
Elsevier.
Personality
and
Individual
Differences
i:
1233—1259.doi:
10.1016/s0191-8869(oo)0o2;1-7. 2.
Robinson,
David;
Gabriet,
Katchan
(22
February
1993).
Personality
and
Second
Language
Learning(PDF).
Personality
Individual
Differences
i6
(1):
143—157.dOi:10,1016/0191-8869(94)90118-x.
Retrievedl2
November
2012.
Steep Steep
is
a
recurring
state
of
altered
consciousness,
imperative
to
nor
mal
brain
and
body
function.
Approximately
one
third
of
our
lives
is
spent
asleep.
Steep
is
characterised
by
decreased
awareness
and
interaction
with
surroundings,
lowered
sensory
activity
and
inhibition
of
voluntary
muscles. The
awake
state
is
characterised
by
beta
and
alpha
waves
on
the
electro
encephalogram.
Beta
waves
are
commonly
seen
during
active
mental
con-
centration
whereas
alpha
waves
are
seen
when
a
person
c[oses
their
eyes
and
relaxes.
Each
stage
of
the
sleep
cycle
is
characterised
by
a
specific
wave
form
on
EEG.
Mapping
the
transition
of
sleep
from
one
stage
to
another
is
known
as
sleep
architecture
and
this
changes
with
age.
The
normat
sleep
cycle
is
divided
into
rapid
eye
movement
(REM)
steep
and
non-rapid
eye
movement
(NREM
steep).
REM
sleep
is
a
period
of
high
levels
of
activity
in
the
brain
and
a
level
of
physiological
activity
similar
to
when
the
person
is
awake.
During
NREM
sleep,
physiological
activity
is
less
than
when
an
individual
is
awake.
NREM
has
four
stages
(1-4).

124. Hypnograrn
,,•.Jlri4’1
.dnhiig
MIiiighi
11311
By!,
RazerM,
CC
BY-SA
3.0,
https://commons.wikimedia,org/w/index.
php?curid=;7745252
Stages
of
Steep
When
we
ñrst
fall
asleep,
we
enter
into
a
NREM
cycle
which
lasts
forgo
minutes.
These
go
minutes
are
composed
of
the
following
four
stages:
Stage
1
is
the
lightest
stage
of
sleep
with
theta
waves
on
EEC
and
is
char
acterised
by
a
sense
of
calmness,
slow
pulse,
respiration
and
a
decrease
in
blood
pressure.
This
constitutes
5%
of
the
sleep
cycLe.
Stage
2
shows
sleep
spindles
and
K
complexes
on
an
EEG.
This
stage
constitutes
about
45%
of
the
sleep
cycle
making
it
the
largest
portion
of
sleep
time.
Stage
3
and
4
are
characterised
by
the
delta
waves
or
slow
wave
steep
and
is
the
deepest
and
most
relaxed
stage
of
sleep.
Sleep
disorders
such
as
nightmares,
night
terrors,
sleep
walking
and
bed
wetting
occur
during
this
stage.After
about
90
minutes,
the
NREM
cycle
is
followed
by
REM
sleep.
Rapid
Eye
Movement
(REM)
steep
is
characterised
by
a
saw-tooth
EEG
showing
beta,
alpha
and
theta
wave
patterns.
Dreaming
occurs
during
this
part
of
sleep
along
with
an
increase
in
pulse,
respiration
and
blood
pressure.
REM
periods
of
10-40
minutes,
occur
about
every
90
minutes
throughout
the
night.Sleep
disorders
The
quantity
and
quality
of
steep
changes
with
age.
The
elderly
show
more
frequent
awakenings
during
the
night
white
teenagers
tend
to
remain
awake
alt
night
and
steep
during
the
day.
Changes
in
steep
are
believed
to
be
due
to
changes
in
internal
body
rhythm,
(catled
Circadian
Rhythm),
emotional
stress,
physical
illness
and
drugs.
The
chronic
use
of
sedatives
and
hypnotic
is
not
known
to
improve
steep.
On
the
contrary
they
are
implicated
in
many
of
the
dyssomnias.
Due
to
stow
metabolism
the
elderly
tend
to
accumulate
more
of
the
sedatives
in
their
bodies
which
may
lead
to
delirium,
daytime
drowsiness
and
loss
of
equilibrium.
w
\:St1ge
234

125. IF
Primary
Sleep
Disorders
Dyssomnias
Primary
Insomnia
Difficulty
falling
asleep,
staying
asleep,
or
sleeping
but
feeling
as
if
one
has
not
rested
during
sleep
sle.p1n.ss
lp)ng
q
.
Sleep
attacks
during
daytime.
Daytime
naps
relieve
sleepiness
“••-•
i
RNathlng
,alated
.
Abnormal
breathing
during
si.ep
sleepdIiorder
r
1.ads
tesi
pdIsuptlonvid
diytlme
sleepiness
,
-
-______
Circadian
rhythm
Disturbance
of
sleep
due
to
a
mismatch
between
a
persons
sleep
disorder
intrinsic
circadian
rhythm
and
external
sleep
wake
demands
Parasomnias Nightmare
disorder
Repeated
episodes
ofscary
dreams
that
wake
one
from
sleep
usually
during
REM
sleep
d.pb’
rdungslee
en
bslMdusl
may
sit
up
or
scream
end
appear
extremely
frightened.
Occurs
during
delta
sleep
Recurrent
sleep
walking
often
coupled
to
other
complex
motor
activity
There
are
two
types
of
sleep
disorders:
primary
and
secondary
steep
disorders.
Primary
disorders
occur
as
a
direct
result
of
disturbances
in
the
steep-wake
cycle.
Secondary
steep
disorders
occur
as
a
consequence
of
other
disorders
such
as
depression
or
due
to
a
general
medical
condition
(e.g.
pain)
or
substance
abuse.
Sleep
hygiene
The
following
factors
contribute
to
improvement
of
sleep:
•
Sleeping
and
waking
up
at
around
the
same
time
daily
(even
on
weekends!)
•
Increased
physical
activity
in
the
afternoon
and
early
evening
hours
•
Cooler
room
temperatures
are
more
conducive
to
sleep
than
warm
temperatures
•
Light
bedtime
snacks
that
have
calcium
and
small
amounts
of
sugar
•
Evening
relaxation
routines
such
as
progressive
muscular
relaxation
and
evening
prayers.
•
Avoidance
of
long
naps,
especially
during
the
later
part
of
the
day.
Narcolepsy Sleep
walking
disorder
Making
and
cleaning
your
bed
every
day.

126. •
Getting
into
bed
only
when
ready
for
sleep.
•
Eating
at
reguLar
times
daily
and
avoiding
large
meals
near
bedtime.
•
Avoidance
of
sensory
stimulation
at
night
by
substituting
TV
and
cellphone
usage
with
light
reading.
•
Avoidance
of
caffeine
and
fizzy
drinks
in
the
evenings.
Avoidance
of
excessive
smoking
in
the
evenings
(as
nicotine
is
a
stimulant).
•
Avoidance
of
stimulant
drugs
such
as
amphetamines,
cocaine
and
MDMA.
Steep
induction
Sleep
control
is
a
mental
technique
that
you
can
use
to
enter
normal
physi
ologicaL
sleep
any
time
without
the
use
of
drugs,
using
the
following
steps
•
Lie
down
in
bed.
ctose
your
eyes
and
graduatty
guide
your
mind
to
visualise
a
chat
kboard.
You
witt
mentatty
have
chatk
in
one
hand
and
an
eraser
in
the
other.
Mentatty
draw
a
targe
circte
on
the
chat
kboard
Then
draw
a
big
X
within
the
circle,
You
witt
then
proceed
to
erase
the
Xfrom
within
the
circte
starting
at
the
centre
of
the
X
and
erasing
towards
the
inner
edges
of
the
circte.
Be
care
fut
not
to
erase
the
circle
in
the
teast.
•
Once
you
erase
the
Xfrom
within
the
circle,
to
the
right
and
outside
of
the
circle
write
the
word
“deeper.”
Every
time
you
write
the
ward
“deeper”
you
will
enter
a
deeper
level
in
the
direction
of
healthy
sleep.
Write
a
big
number
100
within
the
circle.
Proceed
to
erase
the
number
100
being
careful
not
to
erase
the
circle
in
the
least.
Once
the
number
100
is
erased
to
the
right
and
outside
of
the
circle
you
wilt
go
over
the
word
“Deeper”
•
Every
time
you
go
over
the
word
“Deeperyou
wilt
enter
a
deeper
healthier
level
of
mind
going
in
the
direction
of
normal
natural
healthy
steep.
You
will
continue
using
numbers
within
the
circle
on
a
descending
scate
until
you
enter
a
normal
natural
healthy
physiological
sleep.
Whenever
you
enter
sleep
with
the
use
of
steep
control
you
wilt
awaken
at
your
customary
time
or
you
can
remain
asleep
for
as
long
as
you
desire.
When
you
wake
up,
you
will
feet
well-rested
and
refreshed.
Attention
to
detail
It
is
important
that
you
mentally
draw
a
large
circle
not
a
small
one,
You
shoutd
make
the
numbers
in
the
circle
large
enough
to
reach
the
edges.
Then
erase
them
carefully
paying
attention
to
details.
If
you
are
paying
close
attention
to
details
like
this
you
will
not
be
thinking
of
the
day’s
prob
lems
and
letting
them
keep
you
awake.
In
fact
what
you
will
be
doing
wilt
be
boring,
so
boring
that
you
will
go
to
sleep
rather
then
keep
doing
it.
If
your
attention
wanders
and
you
forget
what
number
you
are
on,
just
start
again
with
any
number.
If
you
feel
that
the
technique
may
not
be
working
properly
for
you,
review
the
instructions
and
make
sure
you
are
doing
it
exactly
as
instructed.
Perhaps
you
are
not
erasing
completely,
for
instance.

127. Coping
with
Insomnia
In
primary
insomnia
it
is
useful
to
encourage
regular
habits
and
exercise
and
discourage
indulgence
in
tobacco,
caffeine
and
alcohoL
If
insomnia
is
secondary
to
another
condition,
this
should
be
treated
and
general
mea
sures
to
promote
sleep
(discussed
above)
should
be
advised.
The
use
of
short
term
hypnotics,
such
as
benzodiazepines,
shoutd
be
avoided
due
to
their
high
addictive
potential.
Hypnotics
may
be
prescribed
for
a
few
days,
in
severe
cases
only.
Withdrawal
of
hypnotics
can
lead
to
insomnia
that
is
as
distressing
as
the
originat
sleep
disturbance.
Prolonged
use
can
lead
to
the
development
of
dependence,
tolerance
(needing
ever
increasing
dos
es
to
achieve
the
same
effect)
and
impaired
performance
during
the
day.
Effects
of
Sleep
deprivation
-
Irritability
-
Cognitive
impairment
-
Memory
lapses
or
loss
-
-
Increased
heart
rate
variability
-
Impaired
moral
-
Risk
of
heart
disease
judgement
-
Severe
yawning
-
Hallucinations
-
Symptoms
similar
t0ADHD
p.
Once
you
are
successful,
you
can
start
experimenting
to
see
if
you
can
find
a
variation
that
works
better
for
you.
At
first
you
may
need
to
go
through
quite
a
few
numbers
before
you
go
to
sleep
but
the
next
night
you
wilt
go
to
steep
more
quickly.
Eventually
you
will
be
able
to
fall
asteep
in
only
a
few
moments
with
this
technique.
It
witt
become
very
effective
if
you
persist
until
you
succeed.
I-
-
Impaired
immune
system
-
Increased reaction
time
-
Decreased
accuracy
-
Tremors
-Aches
-
Risk
of
diabetes
Type
2
-
-
Growth
suppression
-
Risk
of
obesity
-
Decreased temperature
i-

128. 1.
A
medical
student
who
has
just
failed
his
Anatomy
viva
returns
to
his
room
in
the
hostet
and
sees
that
his
roommate
is
watching
a
movie.
He
immediately
starts
yelling
at
him
for
making
too
much
noise.
This
reaction
is
most
likely
due
to
use
of
the
defense
mechanism
of:
a)
Suppression.
b)
Displacement.
C)
Identification.
U)
Reaction
formation.
e)
Repression.
2.
A
14
month
otd
has
to
be
taken
to
the
hospitat
for
her
vaccination.
As
soon
as
she
enters
the
hospitat,
injection
is
even
brought
in,
she
sees
a
doctor
and
smetts
the
antiseptics:
This
is
an
example
of:
a)
Systematic
desensitisation
b)
Classical
conditioning.
c)
Operant
conditioning.
d)
Shaping.
e)
Modelling
.
A
first
year
medical
student
reports
to
a
psychiatrist
saying
that
she
faints
with
fear
at
the
sight
of
the
cadavers
and
therefore
cannot
attend
her
anatomy
lectures.
She
even
has
troubLe
walking
by
the
anatomy
lab
atone.
The
psychiatrist
determines
that
she
has
a
phobia.
The
best
way
to
treat
her
phobia
would
be:
a)
Anxiotytics
prescribed
for
the
first
two
years
of
medical
coLlege
b)
To
ask
her
to
consider
giving
up
medicine
as
a
career
c)
Write
her
a
report
excusing
her
from
attending
the
Anatomy
lab,
for
medical
reasons
d)
Systematic
desensitization.
e)
Reassurance
4.
What
kind
of
memory
involves
the
recatt
of
the
indications
for
endoscopy?
Iniplicit
memory.
Semantic
memory.
Explicit
memory.
Episodic
memory.
Procedural
memory.
I
-
-.-—
SAMPLE
MCQ
FOR
SECTION
C
a)b)c)U)e)

129. 5.
Which
of
the
following
can
be
used
to
make
a
clinical
assessment
of
dementia?
a)
History
taking
and
physical
examination
b)
Mini
mental
state
examination
(MMSE)
C)
Blood
CP
and
Urine
RE
d)
MRI
Brain
e)
CT
Scan
Brain
SampLe
Short
Essay
Question
For
Section
C
Qi.
Briefly
describe
the
stages
in
the
formation
of
memory.
What
type
of
memory
is
required
to
remember
how
to
suture?
Q2.
What
are
the
different
stages
of
sleep?
How
do
they
appear
on
EEG?
Answers i.
b
2.
b
3.
U
4.
b
5.
b
I

130. _____________________________________________
ECTION
D
ciology
and
Anthropology
—
OUTLINE4
Chapter
1
Sociology
and
Anthropology
IntroductionSociology
and
anthropology
form
an
important
knowledge
base
in
the
understanding
and
practice
of
holistic
medicine
(Section
A).
It
is
necessary
to
understand
the
social
and
cultural
setting
as
welt
as
the
person
and
the
physician
to
have
a
holistic
view
of
health,
or
its
absence
resulting
in
dis
ease.
This
includes
culture,
values,
norms
and
health
belief
models.
These
factors
are
important
for
a
health
professional
to
study
as
they
influence:
•
rates
of
spread
of
diseases,
•
preventive
strategies,
•
pathways
to
health
care
facilities,
•
choices
and
options
of
treatment,
•
chitd
rearing
practices
•
social
barriers
to
health
care
•
compliance
or
treatment
adherence,
•
cultural
understanding
of
the
disease
•
illness
behaviour
•
utilisation
of
health
services.
The
study
of
sociology
and
anthropology
can
help
a
health
professional
in
making
a
sound
psychosocial
assessment
(at
par
with
biomedical
mea
sures)
to
determine
a
comprehensive
list
of
determinants
of
health
and
disease. Sociology
and
Health
•
Famity
Social
groups
Social
class
Gender
•
Child
Rearing
Practices
Roles
Sociot
Support
•
Religion
•
Stigma
•
Sich
Rote
Death
and
Dying
Comptiance
Anthropology
and
Health
Culture
Culture
and
Public
Health

131. Case
ILlustration
Muhammad
idrees
was
a
security
guard
who
was
severety
injured
white
guarding
a
government
office
in
Pakistan
which
was
attacked
by
mititants
Both
his
Legs
were
fractured
and
his
spinal
cord
was
injured
His
treatment
costs
were
covered
by
his
brothers
pooting
their
monetary
resources
dona
tions
by
his
emptoyers
and
Zakat
from
his
neighbours
His
fractured
Legs
were
operated
upon
successfully
but
he
became
paratyzed
due
to
his
spinat
cord
injury
As
he
could
no
longer
continue
working
as
a
security
guard
his
brothers
and
parents
set
up
a
smalL
cornershop
in
his
village
His
etdest
son
stopped
his
education
after
Matricut
ation
to
assist
his
father
in
the
shop.
He
had
to
rely
on
his
famiLy
and
friends
to
help
with
his
tong
term
medical
care
as
there
was
minimal
organisational
and
government
support
A
local
NGO
provided
him
with
crutches
and
Later
a
wheel
chair
He
went
through
a
period
of
grief
and
depression
after
the
incident
but
finally
recovered
with
the
support
of
his
famity
and
friends
When
asked
how
he
had
coped
with
the
trauma
and
the
permanent
disability
he
responded
that
he
had
accepted
Allahs
will
and
considered
himself
fortunate
to
have
the
opportunity
to
save
so
many
innocent
tives
that
could
have
been
tost
in
the
attack
Greg
Martin
was
a
fire
fighter
from
Belgium,
who
sustained
injuries
to
his
spinal
cord
while
rescuing
people
from
a
high
nse
building
which
was
on
fire
His
wife
and
two
children
lived
with
him
at
the
time
As
he
was
medically
insured,
he
received
very
good
medical
care
and
a
motorised
wheel
chair:
His
family
and
fnends
initially
prowded
emotional
cnd
moral
support
but
were
constrained
by
their
own
responsibilities
and
obtigations
He
retired
from
the
fire
department
with
futt
financiat
benefits
and
received
physical
rehabilita
tion
and
counselling
services
to
help
him
with
adjustment
after
the
accident
He
also
joined
a
comm
unity
group
of
retired
fire
service
veterans
to
help
him
cope
with
this
life
change
His
wife
and
chiLdren
were
very
supportive
and
caring
He
felt
proud
that
he
had
been
abte
to
hetp
so
many
peopte
during
his
work
as
a
fire
fighter
and
this
helped
him
cope
with
the
disability
His
wife
had
to
take
care
of
the
home
and
the
children
mostly
by
herself
now
as
wetl
as
look
after
his
increased
medical
needs
after
this
accident
She
also
re
ceived
counselling
to
help
her
deal
with
this
added
stress
Greg
went
through
a
phase
of
depression
andrecei
ved
psychotherapy
for
the
problem
At
three
years
follow
up
he
was
receiwng
treatment
for
alcohol
dependence
that
he
developed
after
the
accident
and
his
marital
ret
ationship
had
become
strained

132. 1.
SocioLogy
and
HeaLth
Sociology
is
the
scientific
study
of
patterns
and
systems
of
human
inter
action.
It
is
undertaken
by
focusing
on
the
social
structure
of
a
society
and
social
interactions
amongst
its
inhabitants.
The
role
of
sociology
in
behavioural
sciences
is
to
study
social
determi
nants
of
health
and
disease.
The
following
are
some
of
the
important
sociat
determinants
of
health
and
disease:
FamilyFamily,
as
the
basic
unit
oa
society,
is
the
building
block
upon
which
a
society
is
constructed.
Family
constitutes
two
or
more
people
related
by
blood,
marriage
or
adoption
living
together.
The
traditional
joint
family
where
grandparents,
parents,
siblings
and
cousins
lived
together
is
be
coming
increasingly
rare
in
Pakistan.
A
more
common
form
now
is
the
extended
family,
where
parents,
grandparents
(mostly
paternal),
and
oc
casionally,
unmarried
aunts
and
uncles
live
in
the
same
household,
There
is
a
growing
trend
to
tive
as
a
nuctear
famity.
where
the
husband
and
wife
live
with
their
children.
The
single
parent
family,
where
one
parent,
often
the
mother,
resides
alone
with
her
children,
is
as
yet
a
rarity
in
Pakistan
but
may
not
remain
so
in
future.
Famity
structure
and
functioning
is
the
way
a
family
is
organised
in
terms
of
its
boundaries,
emotional
bonding
and
inter
actions
outside
the
family.
These
parameters
greatly
influence
health
and
disease
patterns
and
reactions
to
both.
A
family
that
has
cLosed
boundaries
allowing
minimal
or
no
interaction
with
other
units
of
the
society.
leads
to
enmeshment
or
loss
of
boundaries
within
the
family.
This
consequently
results
in
serious
mental
and
physical
health
issues.
A
family
with
open
boundaries,
with
strong
ties
to
each
other
forms
the
basis
of
healthy
inter
actions
as
well
as
better
physical
and
emotional
health
in
its
members.
The
way
we
respond
to
symptoms.
cope
with
stress,
follow
health
ad
vice,
or
tet
our
illness
affect
our
close
relationships,
points
to
the
central
role
family
has
in
influencing
health
and
disease.
[[ness
does
not
exist
in
a
socially
neutral
environment.
An
ill
member
of
the
family
changes
the
structure
and
functioning
of
this
basic
unit.
This
influence
is
maximally
seen
in
psychiatric
disorders,
chronic
illnesses,
head
injuries,
stroke,
and
cancer.
The
influence
of
infectious
diseases
like
hepatitis,
tuberculosis,
sexually
transmitted
diseases,
HIV-AIDS,
skin
diseases
and
neurological
disorders
can
be
equally
severe.
In
our
social
settings
(with
minimal
or
no
govern
ment
social
services
available
for
health
care),
the
entire
burden
of
care
fatls
on
one
or
all
members
of
the
family.
A
sensitive
health
professional
is
familiar
with
the
concept
of
‘carer’s
burden’
and
its
impact
on
the
health
of
the
carer.
Another
influence
that
family
exerts
on
a
member’s
disease
is
the
role
it
plays
in
decision
making
as
regards
pathways
to
care,
choice
of
treatment
and
even
adherence
to
treatment.
Health
professionals
should
regularly
draw
genograms
(family
trees)
of
the
patients
family
to
familiar
ise
themselves
with
the
structure
and
functioning
of
the
family.
A
health
professional
aware
of
this
immediately
wins
over
the
key
mem
ber
in
the
family.
They
will
then
include
him/her
in
the
decision
making
process
to
ensure
their
positive
input.
A
typical
example
of
this
process
is
the
role
that
a
pregnant
lady’s
mother
plays
during
the
pregnancy
and
throughout
the
reproductive
health
process.
A
similar
role
is
played
by
the
reactions
of
the
in-laws
towards
the
pregnant
mother.
Supportive
handling
by
the
husband
and
in-laws
can
yield
huge
benefits
in
improving
the

133. PYGENDEP
1I
IMPLICATiONS
FOP
EXTENT
OF
URBANISATION
F.NMLVPELAONS
FAULT
STASIUTYI
INDMDUAL
Conceptuat
framework
for
understanding
the
rote
of
family
as
an
agency
for
attainment
of
health
and
disease
physical
and
mental
health
of
the
mother
and
foetus.
Ihs
is
why
the
bio
psychosocial
and
integrated
care
models
identify
family
as
an
important
partner
in
the
assessment
and
the
therapeutic
process.
Social
groups
A
group
is
formed
when
individuals
join
together
for
a
common
pur
pose
that
cannot
be
achieved
atone.
Primary
groups
are
small,
intimate
social
groups.
These
are
commonly
seen
amongst
family,
friends
and/
or
like-minded
people.
An
example
of
a
primary
group
is
the
‘committee
group’
bound
by
financial
interest
(money
pooling)
that
also
ensures
social
interaction
(‘kitty
parties’)
on
a
regular
basis.
Religious
organisations
also
form
primary
groups
to
spread
their
message.
People
who
go
to
the
same
mosque
also
behave
as
a
primary
group.
These
primary
groups
can
play
an
influential
role
in
promotion
of
health
and
disease.
They
do
this
by
serving
as
a
support
system,
influencing
beliefs
about
health,
referral
pathways,
lifestyles
changes
and
even
preventing
or
causing
spread
of
disease.
Secondary
group
is
a
larger
groups
where
face-
to-face
interaction
amongst
members
of
the
group
may
not
be
possible,
yet
the
common
ality
of
interest
or
purpose
joins
the
members.
Secondary
groups
can
be
formed
on
the
basis
of
communities,
religious,
cultural,
politicaL
or
sec
tarian
allegiance.
The
advent
of
social
media
has
made
the
formation
of
secondary
groups
far
more
common
through
social
networks.
Secondary
groups
have
a
great
deal
of
public
heatth
development
potential.
Health
parameters
in
Gitgit
and
Baltistan
have
improved
on
account
of
the
positive
role
by
one
such
secondary
group.
SOCIOECONOMIC
FAMILY
BACKGROUND
COMPOSmON
FAMILY
STRUC1UPE
ROLE
POWER
&
STATUS
I
I
DY
AGEI
STAT
U
S
OF
WOMAN.
CILD

134. Seconday
group
Usually
large
in
size
High
level
of
intimacy
amongst
members
Less
intimacy
amongst
members
Relationships
are
personal
Relationships
usually
formal
frequent
interactions
between
members
Limited
contact
between
members
Members
are
accepted
regardless
Members
are
accepted
on
the
basis
of
of
who
they
are
what
they
can
do
for
the
group
xample
Family,
group
of
friends
Example
Political
party
Social
Class
ALL
societies
have
ways
of
pLacing
people
in
social
strata.
These
can
be
based
on
weaLth,
education,
inheritance
or
other
criteria.
Social
grading
may
often
have
direct
relevance
for
health
care
provision,
interpersonal
communication,
outlook
on
Life
and
knowledge.
Providers
of
health
care
must
be
aware
of
the
prevailing
division
of
the
society
into
social
cLasses.
The
Western
method
of
dividing
a
society
into
six
classes
is
as
fot[ows:
I:
Professionats
II:
Managers
and
Technicians
NI:
Non-manuat-skitted
IV:
Manual
SkitLed
V:
Partly
Skilled
VI:
Unskilled
Due
to
the
remnants
of
the
caste
system
stilt
prevalent
in
the
rural
and
semi
urban
sections
of
the
society,
this
division
may
not
be
retevant
to
us.
In
our
society
individuals
are
classified
on
account
of
their
land
holding
and
professions
into
I.
Feudal,
II.
Businessman,
III.
Technician.
IV
Farmer.
V.
Labourer,
Social
class
in
cities
in
Pakistan
is
often
determined
by
wealth.
power,
area
and
size
of
housing.
social
connections
or
networking,
and
types
ofjobs.
Health
parameters
may
greatly
vary
amongst
social
classes.
Social
class
es
may
differ
in
types
and
patterns
of
diseases,
prevalence
of
infectious
and
lifestyle
diseases,
longevity,
quatity
of
life
and
disabilities.
The
type
of
health
infrastructure
utilised
by
each
class
is
the
single
biggest
health
variable,
Lower
socioeconomic
classes
rely
largely
on
public
sector
health
facilities
or
are
at
the
mercy
of
non-professional
(yet
culturally
endorsed)
health
workers
such
as
quacks.
omits,
and
charlatans.
The
higher
social
classes
largely
rely
on
private
health
care
infrastructure
or
treatment
in
other
countries.
Smaller
in
size

135. From
a
behavioural
sciences
perspective
it
is
useful
to
divide
these
sec
tions
of
the
society
into
the
advantaged’
and
the
disadvantaged’.
This
division
is
based
on
access
to
education,
scientift
and
modern
health
services,
clean
water,
sanitation
and
shelter.
Gender Gender
is
reinforced
at
the
family
Level
through
socialisation
to
determine
•
the
male
and
female
behavior
in
social
life.
Larkoy
rotoy
nohi
hain
(“boys
don’t
cry’),
and
torkiyon
oisoykaproynahipehnti”C’girls
don’t
dress
that
way”)
are
statements
commonly
given
to
children
to
help
them
make
appropriate
gender
associations.
Gender
as
a
determinant
of
health
and
disease
is
debatable
but
clear
differences
exist
in
terms
of
patterns,
and
health
parameters.
On
the
whole,
men
are
at
a
higher
risk
of
dying
earli
er
(shorter
life
expectancy),
and
women
are
at
a
higher
risk
of
ill-health.
Females
report
a
higher
number
of
symptoms
in
a
clinical
consultation
and
are
at
a
2-3
times
higher
risk
of
developing
anxiety
and
depression
related
disorders.
Females
also
seek
medical
and
spiritual
help
far
more
com
monly
than
men.
This
could
be
one
reason
for
their
longevity
as
compared
to
men.
It
is
also
interesting
to
note
that
marriage
is
a
protective
factor
for
health
in
males
and
a
risk
factor
for
female
health.
ChiLd
Rearing
Practices
Parents
and
families
shape
the
behaviour
and
lifestyles
of
their
children
by
a
combination
of
rewards
and
punishment
(operant
conditioning)
and
by
modelling
behaviour
which
the
child
emulates.
The
growing
middle
class
means
that
more
people
are
able
to
afford
domestic
help
to
care
for
their
children.
With
the
advent
of
the
nuclear
family,
children
who
were
previ
ously
cared
for
by
aunts,
uncles
and
grandparents
are
now
being
cared
•
for
by
a
domestic
servant/maid.
The
implications
of
this
family
system
are
many
and
manifest.
The
joint
famity
system
as
a
melting
pot
of
various
in
dividuals
and
their
experience
was
a
place
parents
would
have
a
chance
to
learn
from
the
mistakes
and
advice
of
other
parents
raising
their
children
in
close
proximity.
In
the
absence
of
books
about
raising
children
in
our
part
of
the
world,
training/workshops
on
parenting
or
experienced
individuals,
new
parents
must
learn
the
do’s
and
don’ts
of
the
most
important
and
diffi
cult
job
one
can
do,
from
trial
and
error.
One
recurring
problem
seen
in
this
generation
is
that
of
permissive
(apologetic)
parenting
[see
tablel.
The
last
generation
of
parents
practised
primarily
authoritarian
parenting,
where
the
parents’
word
was
law,
and
children
were
meant
to
be
“seen
and
not
heard.”
Punishments
were
handed
out
to
those
who
disobeyed
and
the
primary
emotion
was
fear.
The
result
was
well-behaved
children,
who
were
afraid
to
voice
their
opinions.
Partly
as
a
reaction
to
this,
when
these
children
grew
up
and
became
parents,
they
decided
to
approach
parenting
in
a
com
pletely
different
way
to
their
own.
Their
children
are
the
Little
rulers
of
the
house:
their
wishes
are
always
catered
to
and
their
word
is
law.
The
result
is
children
who
are
badly
behaved
and
have
a
sense
of
entitlement.
One
advantage
of
nuclear
families
is
consistent
parenting.
This
may
not
be
the
case
with
joint
families,
where
multiple
authority
figures
such
as
the
grandparents
may
contradict
each
other.
A
serious
problem
with
families
in
which
domestic
servants
are
the
primary
care-givers
for
all
or
part
of
the
day,
is
that
these
children
are
at
a
high
risk
for
physical,
emotional
and
sexual
abuse.
There
is
also
little
opportunity

136. 7
Type
of
Parenting
Description
----,,r-
V
i’.4-
Authoritarian
.
Parents
impose
rules
and
expect
complete
obedience.’
Permissive
Parents
submit
to
children’s
demands
V
Autttatiw
Parents
demand
obed’i
also
responsive
totheirchlldren
for
emotional
and
intelLectual
development.
n
the
absence
of
profession
al
child
care
with
both
parents
working,
however,
there
may
be
no
other
choice.
Parents,
especialty
mothers
who
are
doctors
who
may
spend
up
to
36
hours
at
a
stretch
on
call
and
away
from
their
children,
may
become
guilty
for
their
absence
and
try
to
overcompensate
in
the
time
they
do
spend
with
their
children.
They
may
do
this
by
trying
to
stuff
their
children
with
food,
or
even
worse,
spend
all
their
time
with
their
children
“teach
ing”
them
coursework
or
completing
homework.
The
problem
with
this
is
that
time
previously
spent
with
parents
learning
vatues.
and
attitudes
and
having
fun
is
now
entirely
monopolised
by
“studying.”
This
may
lead
to
the
child
resenting
the
learning
process.
Effective
child
rearing
depends
on
tailoring
the
demands
to
the
intettectual
stage
of
development
of
the
child
and
providing
clear
and
consistent
re
assurance
and
rewards.
However
some
children
seem
to
be
“difficult”
from
the
very
start.
Such
a
child
is
characterised
by
a
negative
reaction
to
events
and
objects
(meal,
stranger,
new
toys),
magnified
emotions,
slow
adapt
ability
to
new
situations
and
irregular
biological
functioning
(e.g.
sleeping
and
eating).
Specialised
family
therapy
techniques
and
behaviour
therapy
can
greatly
reduce
the
degree
of
stress
in
a
family
with
such
an
offspring.
RotesRoles
consist
of
a
set
of
expectations
about
how
people
should
behave
in
various
circumstances.
The
doctor’s
role,
for
example,
is
that
of
a
carer
who
is
scientific,
impartiaL
knowledgeable
and
courteous.
The
patient’s
role
(sick
role)
involves
being
excused
from
various
obligations,
a
commitment
to
wanting
to
get
well
and
to
following
medical
advice.
Rote
conflict
refers
to
when
one
individual
has
multiple
roles
which
have
conflicting
demands
on
the
individuaL
An
example
of
this
when
a
doctor
has
to
run
a
busy
clinic
(fulfil
her
rote
as
doctor)
but
also
has
to
manage
her
household
responsi
bilities
(fulfil
her
role
as
homemaker)
and
take
care
of
her
children
(fulfil
her
role
as
a
mother).
SociaL
support
Research
shows
that
having
social
support
ameliorates
the
effects
of
physical
and
psychological
stress
and
hastens
recovery
from
surgery
and
illness.
This
social
support
may
be
in
the
form
of
family
members,
friends,
work
colleagues
or
other
agencies
that
provide
emotional
and/or
practical
support.
Support
may
also
enhance
adherence
to
health
advice
and
reha
bilitation.
it
is,
therefore,
the
duty
of
a
doctor
practicing
holistic
medicine
to
mobilise
social
support
around
a
patient
as
an
essential
therapeutic
strate
gy.
This
can
come
from
amongst
family
members,
friends
or
volunteers

137. Retigion Retigion
may
be
considered
a
collection
of
beliefs
and
practices
that
are
external
expressions
of
spiritual
experience.
Spirituality
may
be
considered
an
orientation
towards
or
experiences
with
the
transcendental
or
sacred
•
dimensions
of
life.
It
is
possible
for
peopte
to
engage
in
religious
activi
ties
independent
of
having
spiritual
experiences.
Similarly
certain
people
consider
themselves
intensely
spiritual
without
being
religious.
Religious
practices
such
as
regular
prayers
and
fasting
are
an
essential
component
of
almost
all
formal
religions,
especially
the
Islamic
faith.
Western
co-re
lational
studies
have
shown
a
positive
association
of
religious/spiritual
involvement
with
improved
health
outcomes
and
longer
life
spans.
Reli
gious/spiritual
minded
individuals
suffer
less
from
cardiovascular
disease
and
hypertension.
They
are
more
likely
to
be
engaged
in
health-promot
ing
behaviours,
They
also
have
a
decreased
risk
of
depression,
anxiety,
substance
abuse
and
suicide.
They
are
better
at
coping
with
illness
and
have
better
health-related
quality
of
life.
Despite
this,
doctors
must
never
make
recommendations
for
patients
to
follow
various
religious
practices
from
their
personal
faith.
This
practice
grossly
undermines
the
respect
that
every
health
professional
must
have
for
the
patients’
religious
beliefs
and
what
they
might
find
comforting.
It
is,
therefore,
enough
to
highlight
the
research
based
positive
inftuence
of
faith,
spirituality
and
religion
in
healthy
life
styles
and
coping
with
stress
and
the
challenges
of
chronic
illness
and
hospitalisation. Stigma Stigma
is
defined
as
a
mark
of
disgrace
or
having
a”
shameful
difference.”
Some
stigmatised
conditions
such
as
infertility,
delay
in
onset
of
menstru
ation,
congenital
malformations
and
physical
deformity
may
be
obvious.
Other
conditions
such
as
epilepsy
or
mental
illness
may
have
a
stigma
that
is
hidden
but
just
as
severe.
People
witb
stigmatised
illnesses
are
socially
rejected,
which
can
compound
their
difficulty.
Often
the
families
of
such
individuals
are
also
rejected
by
society.
Health
professionals,
especially
doctors,
should
be
aware
not
only
of
this
additional
stress
on
patients
and
their
families
but
also
that
they
may
be
one
of
the
few
sources
of
support
and
advice
for
these
people.
A
common
example
of
this
is
the
public’s
stig
ma
against
the
mentatly
ill
due
to
the
association
of
mental
illness
with
vio
lence.
The
belief
that
people
with
mental
illness
are
dangerous
and
unpre
dictable
is
a
popular
misconception
which
arises
from
sensational
media
reporting.
What
the
media
fails
to
report
is
that
only
a
very
small
minority
of
mental
patients
commit
violent
or
serious
crimes,
a
finding
which
has
been
established
by
several
studies.
Also
it
must
be
stated
that
the
vast
majority
of
people
with
mental
illness
are
not
mentally
ill.
or
formally
enrolled
social
workers
from
the
community.
A
social
worker
in
charge
of
mobilising
and
optimising
social
support
for
a
patient
must
be
recognised
as
an
important
member
of
the
health
team.
Stigma
can
delay
the
detection
of
an
illness,
obstruct
provision
of
scien
tific
management
and
undermine
the
social,
occupational
and
economic
standing
of
the
patient.
Some
methods
of
dealing
with
stigma
include
reaching
out
to
stigmatised
groups
(such
as
the
mentalLy
ill)
and
integrat
ing
their
care
in
general
health
care
and
the
use
of
media
to
launch
destig
matising
campaigns.

138. Sick
RoLe
The
sick
rote
invotves
being
excused
from
various
obligations
and
duties,
and
not
being
blamed
for
being
ilL
It
occurs
when
a
patient
continues
to
maintain
the
tote
of
an
unwell
person
long
after
the
initiat
ittness
has
settted.
A
patient
adopting
the
sick
rote,
continues
to
have
symptoms
that
are
not
related
to
his/her
previous
illness
and
cannot
be
attributed
to
any
other
disease
or
disorder.
This
exaggerated
response
is
often
an
indication
of
underlying
anxiety.
rote
contusion,
unresolved
conflicts
and
personality
vulnerabilities.
Social
factors
such
as
positive
or
negative
reinforcement
of
the
sick
rote
can
be
disastrous
and
may
tead
to
the
patient
becoming
an
invalid.The
ideal
intervention
includes
early
detection,
removal
of
reinforcing
factors,
and
withdrawal
of
the
perks
of
the
sick
role.
It
is
important
that
the
patient
is
neither
confronted,
nor
bLamed.
S/he
needs
to
be
reassured
of
the
benign
nature
of
their
symptoms
and
made
to
see
the
benefits
of
health,
The
symptoms
should
be
sensitively
listened
to,
but
not
attended,
explained
or
rationalised.
Uncatted
for
investigations
and
over
enthusiastic
symptomatic
treatment
can
further
reinforce
the
sick
role.
The
use
of
‘gold
en
injections’,
‘spirit
ammonia’
or
multivitamins
(“taaqat
ka
sherbet’3
and
other
dramatic
measures
shoutd
always
be
avoided.
It
may
help
to
invotve
psychiatric
services
in
the
assessment
of
the
patient
and
rule
out
underLy
ing
conflicts,
stress
or
the
possibility
of
a
latent
disease.
It
is
important
to
note
that
both
over
reporting
of
symptoms
(as
in
a
sick
role),
and
under
reporting
are
influenced
by
socioeconomic
factors.
What
these
symptoms
mean
to
the
individual
at
a
psychotogica[
level
is
also
of
significance.Death
and
Dying
Death
of
a
patient,
in
our
cutture
is
seen
as
‘will
of
God’
(Attah
ki
marzy).
This
should
never
stop
a
doctor
from
undertaking
a
scientific
enquiry/audit
into
the
causes
of
death
in
a
patient.
The
attribution
of
death
and
disabitity
to
nature
is
fast
giving
way
to
the
influence
of
the
west,
where
more
and
more
people
may
seek
a
scientific
understanding
of
the
cause
of
death.
Such
a
change
is
tikety
to
lead
to
the
culture
of
suing
health
professionals
in
a
court
of
law
for
what
may
be
perceived
as
negligence.
SociaL
institutions
of
grieving
such
as
‘iddat’
‘sog
and
‘phuree’
provide
psychosocial
relief
to
the
aggrieved
and
hetp
resolve
grief.
There
are
atso
times
when
the
friends
and
family
of
the
deceased
are
unwitting
to
accept
the
outcome
and
resort
to
viotence
against
the
health
care
providers.
This
is
usuatty
the
conse
quence
of
a
breakdown
of
communication
between
the
treating
doctor
and
the
family
of
a
terminatty
itt/a
patient
who
dies
suddenly.
A
constant
update
on
death
being
a
possible
outcome
in
such
patients
should
be
shared
with
the
famity
from
the
very
beginning
and
at
regutar
intervals
of
the
management
process.
Impact
of
sociat
factors
on
Treatment
Adherence
(CompLiance):
Failure
to
foltow
heatth
retated
advice
(sometimes
termed
“non-compli
ance”)
is
widespread.
According
to
the
WHO
up
to
50%
patients
do
not
take
medication
as
advised.
This
includes
taking
medications
incorrectly
or
not
at
all,
forgetting
or
refusing
to
make
essentiat
behavioural
changes
and
persisting
in
behaviours
such
as
smoking
that
may
jeopardise
their
heatth.

139. FaiLure
to
adhere
to
treatment
is
determined
by:
•
patients
age,
•
socioeconomic
status
•
education
status
type
&
chronicity
of
illness,
lack
of
social
support
•
patient-doctor
trust
•
miscommunication
and
ignorance
of
side-effects
of
treatment
•
failure
to
understand
the
doctor’s
advice
depression
•
cost
of
drug
•
dosing
frequency
•
multiple
medication
use
Non-compliance
is
counter-therapeutic
and
an
economic
drain.
It
should
not
be
underestimated.
As
a
result
of
their
failure
to
adhere
to
recommended
treatments,
patients
might
become
more
seriously
ill,
and
treatment-resis
tant
pathogens
may
develop.
Failing
to
recognise
patients’
non-adherence
may
prompt
physicians
to
adjust
medication
dosages,
and
to
be
misled
in
their
diagnoses.
Practitioners
and
patients
tend
to
become
frustrated
by
non-adherence,
and
the
time
and
money
spent
on
medical
visits
is
wasted.
Some
of
the
clues
which
shoutd
alert
a
physician
that
a
patient
might
not
be
adhering
to
the
treatment
plan
are
as
follows:
•
Indifference
and
lack
of
involvement
in
the
treatment/healthcare
pLan
•
Appearance
of
unquestioning
obedience
•
Depressed
patient
•
Lack
of
response
or
inconsistent
response
to
treatment
•
Confusing
clinical
picture
Treatment
adherence,
or
the
lack
of
it,
is
often
on
account
of
social
reasons.
Advice
from
a
neighbour,
a
wise
man
siyana’,
or
another
patient
is
often
the
basis
of
the
path
that
a
patient
or
the
family
will
take.
Essential
elements
required
to
improve
a
patient’s
compliance
are
sum
marised
below:
•
Accurate
communication
of
information
between
patient
and
doctor.
•
Emotional
support
for
the
patient
•
Awareness
of
patient’s
health
belief
models
•
Choosing
an
acceptable
course
of
action
to
which
a
commitment
can
be
made.
•
Focus
on
the
overall
quality
of
life
of
the
patient
•
Development
of
a
specific
plan
to
implement
the
regimen
•
Recognition
of
the
patient’s
depression
or
hopelessness

140. 2.
AnthropoLogy
and
HeaLth
AnthropologyAnthropology
is
the
study
of
evolution
of
civilizations,
their
social
charac
teristics.
languages,
cultures
and
ways
of
life.
A
health
professional
com
mitted
to
the
biopsychosocial
and
integrated
models
of
hea[th
is
a
provider
of
culturally
sensitive
heatthcare.
This
is
why
anthropology
is
relevant
to
behavioural
sciences.
A
health
professional
must
be
aware
of
and
accept
cultural
differences;
collect
data
about
the
patient’s
culture,
and
adapt
the
scientific
care
plan
accordingly.
S/he
must
also
remain
aware
of
and
understands
his/her
own
biases
and
attitudes.
For
example,
some
doctors
may
find
themselves
giving
more
attention
and
care
to
patients
able
to
give
histories
in
English,
rather
than
patients
from
a
rural
background.
A
culturally
sensitive
doctor
is
interested
in
learning
all
the
cultural
variations
in
the
patient
population
and
then
tries
to
merge
his/her
professional
knowledge
with
each
patient’s
health
beliefs.
S/he
needs
to
interact
as
directly
as
possible
with
individu
als
from
diverse
cultural
backgrounds
and
collect
valuable
data
about
their
norms,
values
and
beliefs
regarding
health
and
diseases.
In
a
culturally
sensitive
health
care
approach
social
aspects
are
treated
at
par
with
biological
determinants
of
disease.
The
social
dimension
of
health
is
thus
an
integral
part
of
history
taking,
assessment,
diagnostics
and
ther
apeutics.
The
understanding
of
terms
like
culture,
subculture,
beliefs,
val
ues,
and
norms,
society,
family,
social
class,
social
roles,
and
child
rearing
practices
is
basic
to
this
form
of
health
care.
CultureUntike
att
other
creatures,
human
beings
are
unique
in
that
they
are
abte
to
transmit
ideats,
knowledge,
betiefs,
vatues,
and
patterns
of
behaviour
from
one
generation
to
the
next.
This
sociat
heritage
is
catted
“culture.
It
is
what
makes
our
species
human
and
sets
us
apart
from
other
primates.
As
one
anthropologist
has
put
it:
“Without
the
presence
of
culture,
conserving
past
gains
and
shaping
each
succeeding
generation
to
its
patterns.
homo
sapiens
woutd
be
nothing
more
than
a
terrestrial
anthropoid
ape,
slightly
divergent
in
structure
and
slightty
superior/n
Thteltigenc&
(Linton
in
‘The
Individual
and
Society’
1936).
CuLture
is
the
set
of
values,
mores,
beliefs
and
perceptions
of
the
world
that
are
passed
on
from
one
generation
to
the
next.
It
is
thus
our
social
her
itage.
We
share
it
with
other
members
of
our
society
as
our
common
world
view.
It
is
our
culture
that
makes
us
behave
like
those
around
us
and
thus
makes
our
behavior
acceptable
to
others.
Culture
is
dynamic
and,
therefore,
continues
to
evolve,
although
never
at
the
same
pace
as
scientific,
economic
or
technological
progress.
It
is
revealed
in
people’s
language,
art,
architecture,
religion,
norms,
values
and
health
care
beliefs
and
practices.
ft
is
not
inherited
biologically,
but
is
learnt
from
the
environment.
Culture
provides
one
with
a
sense
of
identity.
encourages
group
survival
and
gives
its
members
a
useful
picture
of
the
universe.
Pakistan
is
a
country
that
brings
together
a
variety
of
cultures
in
its
four
provinces,
Gilgit,
Baltistan
and
Kashmir.
Subcultures
may
develop
within
a
culture.
These
result
in
a
distinctive
set
of
standards
and
behaviour
patterns
in
which
a
small
group
within
a
larger
society
operates.
People
living
in
and
around
shrines,
with
their
distinctive

141. behaviour
patterns
and
routines
are
an
example
of
a
subculture,
The
typ
cal
example
of
subcultures
relevant
to
health
are
the
language,
learned
acceptable
behaviour
patterns
and
a
shared
view
of
the
world
that
prevails
in
hospitals
and
medical
colLeges.
Cultural
influences
are
seen
in
many
beliefs
and
practices
of
doctors
as
well,
in
addition
to
their
patients.
For
example,
the
doctor
knows
best;
patients
must
comply
with
the
doctor’s
orders
if
they
want
to
get
better.
If
they
do
not
listen
to
the
doctor,
they
do
not
want
to
get
better,
and
therefore,
are
not
worthy
of
their
time.”
This
belief
is
part
of
the
doctor/
hospitaL
subculture.
Most
people
believe
that
their
culture
is
superior
to
all
others.
Cultural
and
societal
biases,
prejudices
and
ethno
centrism
must,
therefore,
never
be
confronted
in
a
doctor-patient
relationship.
They
can
best
be
addressed
by
understanding
the
following:
The
easiest
response
to
transcultural
conflict
is
to
behave
as
if
it
does
not
exist,
and
is
not
a
barrier
in
the
doctor
patient
relationship.
Every
individual
is
expected
to
behave
according
to
unwritten
ethnic
customs.
These
traditions
and
the
diversity
of
behaviour
should
be
accepted,
and
catered
for,
in
outpatients.
wards,
waiting
areas
and
therapeutic
interactions.
One
can
make
mistakes
in
transcultural
interactions
but
one
should
readily
accept
and
acknowledge
them
and
learn
never
to
repeat
them.
Understanding
Culture
in
Health
Care
Beliefs,
values,
norms,
mores,
folk
ways
and
laws
form
the
fabric
of
society.
They
are
the
basis
for
social
control
and
the
‘do’s
and
donts’
of
cultures
and
subcultures.
They
tend
to
evolve
and
change
but
hardly
ever
com
pletely
transform
ih
a
single
lifetime
Beliefs
are
tenets
with
a
shared
meaning
in
a
culture
that
are
held
to
be
true
e.g.
in
most
Islamic
cultures,
the
benevolent
role
of
God
in
the
healing
process
is
an
established
belief.
This
is
reflected
in
all
doctor-
patient
inter
actions
which
nearly
always
end
with
a
mutual
prayer
such
as
“Only
Allah
granteth
health”
(Allah
sehat
denay
wala
hai).
Values
are
those
aspects
of
a
culture
that
are
held
in
high
regard,
are
desirable
and,
therefore,
worthy
of
emulation.
A
doctor’s
deatings
with
patients
must
never
be
commercial’,
‘elders
always
know
better’,
‘the
sick
must
always
be
visited
in
the
hospital’
are
commonly
held
Eastern
values.
Culturally
sensitive
doctors
must
keep
beliefs
and
values
in
mind
as
they
may
need
to
cater
for
them
in
the
administrative
running
of
wards.
This
may
save
unnecessary
worry
over
matters
such
as
families
not
adhering
to
‘visiting
hours’,
or
‘far
too
many
visitors’,
and
relatives
asking
details
about
the
health
and
prognosis
of
the
patient.
Norms
refer
to
principles
of
right
and
wrong
that
govern
acceptable
and
unacceptable
behaviour
in
a
society.
Abortions,
euthanasia,
intake
of
alco
hot,
cannabis
and
heroin,
nursing
of
femate
and
mate
patients
in
the
same
wards
(except
in
emergency
or
intensive
care
settings)
for
example,
are
all
against
local
norms.
A
doctor
needs
to
have
a
flexible
approach
regard
ing
a
patient’s
beliefs,
values
and
norms
and
try
not
to
pass
judgments
on
them.
It
is
equally
important,
however,
to
not
break
professional
norms
(such
as
that
of
confidentiality)
and
not
let
the
two
clash.

142. Norms
may
be
divided
into
three
types
on
the
basis
of
the
kind
of
disap
proval
that
resutts
when
they
are
violated:
fotkways,
mores,
and
taws,
Mores
are
considered
vital
for
the
group’s
welfare
and
survival,
thus
mak
ing
them
very
important.
They
define
what
is
morally
right
and
wrong
and
as
a
consequence,
their
violation
results
in
strong
disapproval
and
even
severe
punishment.
Respect
for
sexual
boundaries
by
a
health
profession
al,
for
example,
is
a
more.
Persons
who
violate
mores
may
be
ostracised,
imprisoned,
or
killed.
Conformance
to
mores
is
taken
for
granted
and
most
people
in
a
society
accept
them
without
question.
Unlike
laws,
mores
are
not
formally
written
but
are
respected
with
the
same
fervour
and
commitment.Many
mores
are
incorporated
into
law
and
serve
to
reinforce
it.
In
fact,
laws
are
most
effective
when
they
are
rooted
in
the
mores.
Abortion
is
legally
prohibited
as
well
is
considered
against
the
mores
in
Pakistan.
At
times,
however,
mores
and
folkways
may
conflict
with
the
laws,
The
classic
example
is
that
of
the
jurisdiction
of
Pakistan
Medical
and
Dental
Council.
This
is
a
formal
body
that
enforces
regulations
pertaining
to
health
care
in
the
country.
It
is
empowered
to
take
punitive
action
against
medical
practitioners
when
found
guilty
of
ftouting
a
certain
regulation.
or
in
cases
of
malpractice.
It
does
not,
however,
currently
have
jurisdiction
over
prac
titioners
of
alternative
medicine
or
even
aamils,
charlatans,
and
self-styled
hakims
who
openly
practice
their
own
methods
of
‘health
care’.
This
is
on
account
of
the
permissiveness
to
these
practitioners
by
the
mores
of
our
culture.Inftuence
of
cu[ture
on
heatth
care
Culture
determines
beliefs
about
health
and
disease.
The
way
Pakistanis
view
health,
causes
of
disease,
the
meaning
of
various
symptoms.
ap
proach
therapeutic
interventions
and
determine
their
relationship
with
health
professionals
is
largely
influenced
by
their
culture.
For
the
predominantly
Muslim
population
of
the
country.
health
and
dis
ease,
like
life
and
death
are
predestined
by
the
will
of
Allah.
The
process
of
healing
and
cure
similarly
rest
with
the
Almighty.
Virtually
every
health
outlet,
and
the
prescription
letterheads
of
physicians
have
Arabic
inscrip
tions
from
Holy
Quran
that
endorse
the
same
belief.
This
unfaltering
belief
forms
the
basis
of
trust
in
the
physician
as
a
mere
executioner
on
behatf
of
God.
Practitioners
of
health
care
for
the
same
faith
also
share
this
cultural
and
religious
belief
with
their
patients.
Fotkways
are
customary
patterns
of
everyday
life
that
specify
what
is
socially
correct.
These
are
social
niceties
such
as
referring
to
health
profes
sionals
as
“Doctor
Sahib”,
offering
a
seat
in
the
bus
to
a
lady
or
an
elder,
and
not
calling
parents
or
elders
by
their
names.
Laws
are
formally
compiled
written
rules
and
regulations
coded
after
debate
and
deliberation.
They
are
then
enforced
by
organisations
com
posed
of
persons
authorised
to
use
force
if
necessary.
Laws
are
similar
to
folkways
and
mores
in
many
ways
but
are
far
more
adaptable
to
changing
times.Our
culture
tends
to
classify
diseases
into
those
caused
by
supernatural
forces,
stresses
of
life,
unhealthy
lifestyles
and
habits,
environmental
fac
tors
and
germs
and
chemicals.
Social
and
family
problems
and
feuds
are
often
seen
as
causes
of
the
evil
eye
(“nazar”)
or
a
curse
leading
to
illness.

143. In
our
culture,
most
psychiatric
disorders,
epilepsy,
fits
and
related
chang
es
in
consciousness,
and
headache
are
attributed
to
supernatural
causes
or
‘evil
eye’.
Heart
conditions,
diabetes,
and
hypertension
are
attributed
to
stress,
poor
dietary
habits,
and
unhealthy
lifestyles.
Liver
and
kidney
disease
are
attributed
to
eating
the
‘wrong
food’
(
“garam
taseer”).
Sexual
diseases
are
considered
a
curse
of
nature,
caused
by
moral
depravity.
Cultural
views
on
treatments
and
interventions
are
largely
diverse
and
vary
with
social
class,
educational
background.
urban
and
rural
setting
and
in-
fluence
of
prevailing
subcultures.
Altopathic
medication
are
Largely
viewed
as
‘goram’
and
dangerous.
and
essentially
lesser
of
the
two
evils
when
confronted
with
disease.
Pharmacological
preparations
are
called
‘ongrezi
dawayi’
(a
reference
to
the
days
of
the
British
Pa]).
This
is
to
distinguish
it
from
‘des!
dawa’
(local
or
medicine
of
our
own
heritage).
‘Des!
dawn’
is
considered
‘thand/’
and
thus,
more
appropriate
in
a
predominantly
hot
and
humid
temperate
setting.
Local
translations
of
the
words
‘tablet’,
‘injection’
have
dangerous
connotations
e.g.
‘tablet’
is
translated
as
‘got/which
is
the
same
as
‘bullet’,
injections
are
often
just
referred
to
as
“su/”fneedle).
The
most
preferred
and
the
first
line
of
treatment
in
our
culture
are
house
hold
remedies
and
herbs
based
on
past
experience
and
conventional
wisdom.
These
are
supplemented
by
prayers
to
The
Almighty
by
the
individuaL
his
family,
and
sometimes
the
pit,
the
local
faith
healer,
or
the
prayer
leader
at
the
local
mosque.
Alms,
sadqo,
taweez,
and
holy
water
are
also
used.
It
is
only
after
the
failure
of
these
convenient,
easily
accessible,
inexpensive
and
trustworthy
interventions
that
professional
treatments
and
interventions
are
considered
an
option.
Alternative
medicine,
folk
medicine,
healing
through
spiritualists,
omits,
sorcerers,
shamans,
and
faith
healers
are
often
reserved
for
patients
with
psychiatric
disorders
and
epilepsy.
Often
inhumane
methods
of
‘treatment’
are
used
by
these
agents
in
the
presence
of
and
in
connivance
with
the
referring
members
of
the
family.
Cuftura[ty
Sensitive
Clinical
Assessment
A
culturally
sensitive
assessment
may
not
he
required
in
all
patients
and
not
always
at
the
start
of
a
treatment
plan.
It
would,
however,
be
urgently
required
when
a
patient
is
obviously
from
a
different
ethnic
background
e.g.
a
patient
from
rural
Sindh,
central-Punjab,
Balochistan
or
Northern
Areas
being
nursed
in
Lahore,
Karachi
or
Islamabad.
It
is
also
important
to
consider
the
concept
of
heritage
consistency.
This
refers
to
how
closely
an
individual
is
influenced
by
or
practices
his/her
particular
ethnic
back
ground.
The
lifestyle,
health
belief
model,
or
practices
of
an
individual
may
not
always
be
the
same
as
their
cultural
heritage,
In
case
a
patient
has
a
high
heritage
consistency,
the
next
step
is
to
note
how
much
of
his/her
beliefs
are
influenced
by
the
cultural
background.
The
following
questions
can
be
asked
in
a
clinicat
setting
to
ensure
a
deeper
cultural
understanding
of
the
patient’s
explanatory
model
of
illness
•
What
do
you
call
your
problem?
What
name
does
it
have?
•
What
do
you
think
has
caused
your
problem?
•
How
do
you
think
it
started
and
what
course
do
you
think
it
will
take?
A
recommended
approach
for
culturally
sensitive
health
professional
was
suggested
by
Fowkes
and
Berlin
in
lg8os.
This
approach
can
yield
not
only
invaluable
information
about
the
patient
and
family’s
cultural
understand
ing
of
the
disease
(their
health
belief
model
HBM)
but
also
improves

144. treatment
adherence
and
their
ownership
of
the
health
care
plan.
It
can
be
remembered
with
the
acronym
LEARN:
1.
Listen:
Active
listening
and
understanding
of
the
patient
and
the
family’s
cultural
views
is
central
to
this
approach,
A
conscious
attempt
to
elicit
the
health
belief
model
of
the
patient
and
family
has
to
be
made
by
the
health
professional.2.
Explain:
At
this
stage
the
doctor
explains
the
scientific
basis
of
the
dis
ease
without
chaltenging,
rejecting
or
ridiculing
the
health
belief
model
of
the
patient
and
family.
This
view
is
presented
in
simple
language
using
symbols
from
the
patient’s
cultural
context.
Making
simple
drawings
on
a
piece
of
paper
while
doing
so
(as
illustrated
in
the
section
on
informational
care),
can
be
helpful.
3.
Acknowledge:
The
differences
between
the
two
explanatory
models
are
discussed
to
achieve
consensus
and
common
understanding.
This
witI
ensure
treatment
adherence
and
improve
prognosis
and
follow
up.
4.
Recommend:
A
line
of
action
regarding
further
assessment,
diagnos
tic
tests
and
short
and
long
term
management
plan,
with
options,
is
then
recommended.
A
sensible
physician
will
give
the
patient
the
final
choice
to
proceed
with
the
plan
or
opt
out,
without
feeling
offended
or
hurt.
5.
Negotiate:
Offer
a
jointly
conceived
plan
of
action
in
which
the
doctor,
patient
and
family
are
all
active
partners.
This
adds
to
ownership
of
the
healthcare
plan
and
chances
of
treatment
adherence.
I
Inftuence
of
sociocuLturat
factors
on
therapeutics
Patients
with
different
sociocultural
backgrounds
look
at
treatment
from
different
perspectives.
The
traditional
concept
of
the
“taaseer
of
the
medicine,
whether
it
is
‘hot’
or
‘cold’
is
respected
by
the
culturally
sensitive
doctor.
S/he
must
adapt
scientific
knowledge
to
the
patients’
language
to
explain
the
different
aspects
of
therapeutics.
Many
patients
hold
very
strong
views
about
injections
because
in
their
culture
and
social
setup,
injections
are
correlated
with
‘dramatic
results’.
In
other
cultures,
inject
ables
are
viewed
with
fear
as
they
denote
extreme
illness
or
the
last
stage
of
treatment’.
Interestingly,
many
Asian
races
are
traditionally
known
to
respond
to
low
doses
of
psychotropic
medications
as
compared
to
their
western
coun
terparts,
who
need
higher
doses.
A
practitioner
of
holistic
medicine
must
understand
these
differences
and
belief
models
and
address
them
tact
fully
using
language
and
context
that
the
patient
understands.
The
stigma
attached
to
many
modes
and
methods
of
treatments
needs
to
be
ad
dressed
on
the
same
principles
as
stigma.
Some
patients
need
education
about
their
treatment
options
while
others
requirejust
the
word
of
doctor
to
make
them
adhere
to
treatment.
The
doctor
must
understand
the
strong
influence
these
sociocultural
factors
play
in
the
treatment
of
disorders.
ii.
Cutture
and
PubLic
Health
Clinics
and
hospitals
are
not
the
only
places
where
a
culturally
sensitive
approach
is
beneficial.
It
also
yields
good
results
in
public
health
settings.
Prevention
of
illness
and
promotion
of
health
depends
largely
on
an
indi
vidual’s
attitude
towards
help
seeking
and
the
value
of
health.
The
health
betief
model
has
a
number
of
variables,
all
of
which
contribute
to
some

145. extent
to
health
behaviour,
These
include:
concern
with
health
matters,
be
liefs
about
susceptibility
to
illness,
ideas
about
illness
and
its
severity,
ben
efits
and
costs
of
various
treatment
and
howwe[tthose
measures
will
work.
The
heatth
belief
modet
also
emphasises
the
importance
of
the
opinion
of
respected
people
in
the
individual’s
life
and
the
amount
of
personat
control
that
people
perceive
they
have
over
events.
The
health
betief
model
and
illness
explanatory
models
of
a
community
determine
the
pathway
that
a
patient
will
follow
in
pursuit
of
health.
A
comprehensive
plan
to
promote
health
literacy,
develop
health
infrastructure
and
allocate
resources
must,
therefore,
be
based
on
this
pathway.
Such
a
culture
sensitive
approach
im
proves
community
ownerships
and
participation
in
public
health
initiatives.
It
also
adds
to
acceptability,
utilisation
and
sustainability
of
preventive
and
promotive
public
health
initiatives.

146. SAMPLE
MCQ
FOR
SECTION
D
1.
A
35
yr
old
worker
injured
himself
on
the
construction
site
and
Lost
a
Limb.
The
sociaL
support,
in
our
cuLture,
that
he
can
rely
the
most
on,
will
come
from:
a)
The
owners
of
the
construction
site
b)
Volunteers.
C)
Health
care
system.
d)
NGO’s
e)
Family
members
2.
A
56
year
otd
tabourer
diagnosed
with
hypertension
is
prescribed
an
ACEI.
He
refuses
to
take
it,
insisting
that
“angrezi
dawai
garam
hoti
hai”
and
is
not
appropriate
to
take
in
the
hot
weather.
He
says
he
wittjust
get
his
faith
heater
for
dum
(prayer)
and
this
witl
make
him
better.
How
shouLd
you
respond?
a)
Hand
the
patient
the
prescription
and
tell
him
to
do
as
he
pleases,
you’re
too
busy
to
argue.
b)
Tell
the
patient
that
there
is
no
such
thing
as
“garam
dawai”
and
he
will
suffer
and
become
very
ill
if
he
does
not
take
it
c)
ExpLain
to
the
labourer’s
educated
son
how
important
the
medication
is
for
him
and
ask
him
to
hide
it
in
his
food
d)
Tell
the
patient
you
understand
his
concerns
but
this
drug
has
been
tested
on
people
in
the
region
and
they
got
much
better,
Faith
healers
cannot
cure
hypertension
e)
TelL
the
patient
that
the
medication
is
safe,
and
he
can
take
it
as
well
as
see
the
faith
healer
and
he
wilt
feet
better,
God
witting
3.
Stigma
refers
to:
a)
Having
a
dangerous
illness
b)
Being
shameful.
c)
The
inability
to
interact
with
normat
people.
d)
Suffering
from
mental
illness.
e)
Having
a
difference
that
is
considered
disgraceful
or
shameful
by
society
4.
Doctors
can
help
reduce
the
stigma
regarding
mental
iltness
by:
a)
Ignore
the
stigma
and
providing
the
best
avaiLabLe
treatment
to
the
mentally
ill
b)
Think
of
methods
to
rehabilitate
the
patient
after
s/he
recovers
C)
Start
a
sociaL
media/public
health
campaign
to
change
the
mind
of
the
public
about
the
mentatly
ill
d)
Reach
out
to
the
mentally
ill;
integrate
their
care
in
general
heatth
care
and
use
the
media
to
run
a
destigmatising
campaign.
e)
Inform
the
family
and
everyone
you
know
that
stigma
worsens
the
effects
of
mental
illness

147. .
How
should
doctors
behave
in
the
face
of
cutturat
differences
between
the
patient
and
themselves?
a)
Try
to
read
up
on
the
patients
cutture
and
behave
with
them
accordingly
b)
Agree
with
patient’s
notion
that
the
culture
he
comes
from
is
the
best
one,
in
order
to
get
him
to
do
what
is
required
c)
State
categorically
that
we
are
all
one
human
race
and
cultural
differences
are
meaningless
d)
Behave
as
if
the
conflict
does
not
exist
and
is
not
a
barrier
in
doctor-patient
relationship.
e)
State
the
doctor
do
not
object
to
patient’s
cuLtural
practices.
SampLe
Short
Essay
Question
For
Section
D
01.
Briefly
discuss
the
concept
of
Beliefs,
VaLues
and
Norms
as
it
appLies
to
BPS
ModeL
of
heatth
care.
02.
How
does
culture
affect
treatment
adherence?
Answers i.e 2.
e
3.
e
4.
d
5.
d

148. Chapter
1
Psychosocial
Aspects
of
Health
and
Disease
The
World
Health
Organization
(WHO)
defines
health
as
a
state
of
com
plete
physical,
mental
and
social
well-being
and
not
the
mere
absence
of
disease.
In
order
to
understand
the
factors
contributing
towards
a
state
of
psychological
and
sociaL
well-being
we
must
acknowledge
that
a
human
being
is
a
complex
organism
with
a
multi-dimensional
existence.
HeaLth
and
Normality
The
parameters
that
describe
a
state
of
psychosocial
health
and
normality
include:
•
Dynamism
•
Optimisation
•
Personal
contentment
•
Social
responsibility-
Occupational
efficacy
•
Economic
emancipation
•
Relief
from
pain
Homeostasis
DynamismDynamism
refers
to
the
various
roles
and
functions
a
person
has
in
life,
and
their
changing
and
evolving
nature.
In
one
tifetime
s/he
performs
many
roles
and
contribute
to
their
own
growth,
that
of
the
society
and
the
world
at
large.
One
person
may
simultaneously
be
playing
the
roles
of
family
member,
student,
teacher,
friend
and
breadwinner.
The
more
roles
a
person
performs
the
more
dynamic
s/he
is.
Illness
and
disability
limit
the
dynamism
of
a
human
being.
OUTLINE
PsychosocialAspects
of
Health
and
Disease
Psychosocial
Assessment
Psychosocial
Issues
in
Special
Hospital
Settings
Psychosocial
Peculiarities
of
Dentistry
Psychosocial
Aspects
of
Alternative
Medicine
Common
Psychiatric
Disorders
in
General
Health
Settings
Psychosocial
Aspects
of
Gender
and
Sexuality
PsychosocialAspects
of
Pain
PsychosocialAspects
of
Aging,
Death
and
Dying
PsychotraumaPsychosocial
Aspects
of
Terrorism
Stress
and
its
Management

149. Optimization When
a
person
performs
most
of
his
roles
in
an
optimum
state,
s/he
is
considered
psychosocially
healthy.
While
it
may
not
be
possible
to
stay
at
your
best
alt
the
time,
a
healthy
person
views
themselves
as
being
in
a
state
of
productivity
in
most
roles
a
majority
of
the
time.
Personat
contentment
Personal
contentment
is
when
despite
failures
and
difficulties
and
inability
to
be
the
world’s
best
scientist
or
best
parent,
a
person
accepts
them
selves
as
‘good
enough’.
S/he
is
able
to
focus
on
the
positive
aspects
and
achievements
of
their
Life
to
attain
a
sustained
state
of
satisfaction
and
contentment. Sociatresponsibitity A
healthy
person
takes
responsibility
of
the
roles
and
duties
assigned
by
the
society.
These
begin
from
the
immediate
family
to
the
neighbourhood,
town
and
country,
to
the
world
at
large.
S/he
works
towards
making
this
world
a
better
place
for
their
own
self
and
subsequent
generations.
OccupationaL
efficacy
In
order
for
an
individual
to
be
normal
and
healthy,
they
must
be
well-
versed
in
the
knowledge,
skills
and
attitudes
required
for
their
occupation,
i.e
they
must
perform
effectively.
Such
individuals
are
also
helpful
to
so
ciety
through
their
occupation,
and
attempt
to
pass
their
skill,
knowledge
and
wisdom
to
others.
Economic
stabitity
A
core
component
of
health
and
normality
is
economic
stability.
This
means
that
whatever
a
person’
means
of
earning
may
be,
s/he
is
free
of
the
pressure
to
acquire
the
basic
necessities
of
life.
This
allows
an
individu
al
to
pursue
their
goals
of
self-actualisation.
Retief
from
pain
and
discomfort
In
order
for
an
individual
to
be
healthy,
s/he
must
be
devoid
of
distress,
discomfort
and
pain
at
the
physical
as
well
as
at
a
psychological
level.
S/
he
must
also
be
able
to
form
and
sustain
relationships
that
are
free
of
mis
trust,
deceit,
jealousy,
prejudice,
and
ignorance.
Homeostasis When
a
person
respects
the
rights
of
others
in
their
interactions
with
other
human
beings
and
gives
due
importance
to
the
laws
of
nature
in
his/her
interaction
with
the
environment
they
are
said
to
maintain
homeostasis

150. with
the
world
around
them.
S/he
neither
threatens
the
environment
nor
do
they
feel.
threatened
by
it,
but
instead
make
an
earnest
effort
to
improve
it.
They
are
able
to,
thus,
be
in
harmony
with
their
internal
and
externat
environment.Defence
Mechanisms
In
order
to
acquire
and
maintain
a
state
of
health
and
normality,
a
person
uses
different
psychological
mechanisms
which
help
to
endure
the
chal
lenges
of
le.
These
are
called
defence
mechanisms.
Some
of
these
are
basic
defences
of
all
human
beings
in
a
particular
situation,
whereas
others
are
more
complex
defences
which
come
into
play
under
certain
circum
stances.
Defence
mechanisms
function
to
help
individuals
cope
with
their
internal
and
external
states
of
anxiety
and
distress.
Defence
mechanisms
have
the
following
characteristics:
•
They
emerge
in
a
developmental
sequence
from
less
mature
to
more
mature.
•
They
can
be
brought
under
conscious
controL
to
ward
off
anxiety.
•
They
maintain
a
sense
of
wellbeing
and
safety.
•
They
may
be
episodic
or
become
more
habitual
and
pervasive.
•
They
may
contribute
towards
formation
of
personality
traits.
This
is
a
list
of
many
other
defence
mechanisms
which
people
use
unconsciously.
Some
of
these,
in
addition
to
those
mentioned
in
the
example
above,
are:
repression.
•
denial,
•
displacement,
•
projection,introjection
•
rationalization
•
intellectualization
•
identificationattruism
•
sublimation
RepressionUnconscious
exclusion
of
an
unwanted
or
painful
feeling,
thought
or
mem
ory
from
the
conscious
mind
is
called
repression.
It
is
one
of
the
basic
de
fences
of
the
mind
that
we
almost
regutarly
use
to
push
away
unpleasant
happenings,
thoughts
and
impulses
from
our
active
memory.
One
tends
to
forget
the
painful
details
of
an
exam
faiture,
a
setback,
or
an
insult,
through
the
use
of
repression.
RationaLizationUnconsciouslyjustifying
one’s
feelings.
impu[ses
and
thoughts
that
are
un
reasonable
and
unacceptable
in
reality
in
order
to
seek
retief
from
anxiety
or
guilt
is
called
rationalization.
It
is
usually
seen
in
people
who
have
per
sonality
traits
of
being
obstinate
and
stubborn.
People
in
stress
and
those
with
limited
capabilities,
tend
to
use
this
defence
mechanism
as
a
routine.

151. Displacement
Discharging
pent-up
feelings
on
people
less
dangerous
then
those
who
initially
aroused
the
emotion.
A
student
who
has
just
received
a
low
grade
on
a
ward
test
starts
to
shout
on
the
junior
paramedical
staff
over
a
ttIial
misunderstanding.
Reaction
formation
It
is
the
devetopment
of
a
conscious
attitude,
opposite
to
an
attitude
in
the
unconscious,
to
avoid
awareness
of
unacceptabe
feeling,
fear
or
impuLse
or
a
thought,
It
is
usuaLly
seen
in
peopte
taking
on
sky
diving
to
master
their
fears
of
heights.
Defence
Mechanism
Definition
Example
Symbolic
satisfaction
of
A
student
struggling
through
wishes
through
non-rational
graduate
school
thinks
about
thought
a
prestigious
hIgh
paying
job
sure
wants
Separating
an
emotion
from
an
Idea
or
thought
because
the
emotional
reaction
is
too
painful
to
be
acknowledged.
A
man
learns
from
his
doctor
that
he
has
cancer,
14e
studies
the
physiology
and
treatment
ofcancerwlthout axperiendng
any
emotion
Rationalization
Falsification
of
experience
through
the
construction
of
logical
or
socially
approved
explanations
of
behaviour.
A
patient
misses
out
on
hlslhex
daily
dose
of
medication
and
thInks
that
aJhe
doesn’t
need
it
any
more
Repression
UnconscIously
keepIng
unacceptable
faellngs
out
of
awareness,
Amen
lsjealous
of
a
good
fri.nd’t
success
but
Is
unaware
of
hIs
feelings,

152. Case
Scenario
A
young
doctor
brings
his
52
year
otd
father
who
has
met
a
road-traffic
accident
and
suffered
serious
injuries,
to
the
casuatty
department
of
the
hospitaL
Incidentatty
the
surgeon
arrives
tate
to
examine
the
patient.
By
the
time
she
examines
the
patient,
he
has
already
passed
into
a
state
of
un
consciousness
with
falling
breathing.
Att
resuscitative
measures
fqit
and
the
patient
dies.
The
son
is
shocked
but
insisted
that
his
father
should
be
taken
to
the
intensive
care
and
put
on
a
ventilator,
and
that
he
was,
in
fact
“not
really
dead
(shock
and
disbelief).
He
regained
control
after
a
while
and
with
a
mask
like
face,
started
to
take
responsibitity
for
alt
the
affairs
of
the
family
(denial;
acting
as
if
nothing
has
happened).
He
was
seen
handling
his
moth
er
and
other
siblings
and
relatives,
consoling
them,
arranging
for
the
coffin,
transportation
of
the
dead
body,
informing
other
relatives
about
the
news,
making
arrangements
for
the
funeral,
arranging
for
food
and
lodging
of
the
guests.
Never
during
this
whole
period
did
he
shed
a
tear.
Eventually
after
the
burial
the
doctor
returned
to
go
to
his
job
in
a
week’s
time.
During
this
peri
od,
he
found
that
he
was
unabte
to
steep
property
and
felt
exhausted
every
morning.
He
tried
to
manage
as
best
as
he
coutd,
but
one
day
saw
his
dead
father
in
a
dream
and
woke
up
in
a
state
of
panic
and
felt
a
huge
sense
of
weight
over
his
chest.
Fearing
he
may
be
having
a
heart
attack,
he
went
to
a
cardiologist
When
he
was
found
fit
and
healthy
by
the
physician,
he
suddenly
burst
out
making
accusations
and
blaming
doctors
for
being
inept,
inefficient
and
irresponsible
(anger).
He
blamed
‘all
doctors
and
hospitals’for
killing
his
father
and
claimed
that
they
are
going
to
kill
him
as
well
(projection
and
displacement;
putting
the
blame
and
responsibility
on
somebody
ets&.
His
accompanying
ret
atives
took
him
home,
but
he
continued
with
his
outburst,
eventually
exhausting
himself
and
gave
in
to
dying
and
weeping
loudly
tike
a
child
(regression).
Since
the
death
of
his
father
this
was
the
first
time
he
had
cried
in
20
days.
The
crying
continued
off
and
on
for
the
next
few
days,
until
one
day
he
decided
to
visit
Data
Darbar.
He
prayed
to
Allah
and
promised
to
give
away
food
to
one
hundred
people,
if
given
a
chance
to
see
his
fatherjust
once
(bargaining;
“If
God
gives
him
back
I’ll
sacrifice
so
and
so”).
After
dis
tributing
the
food
to
street
dwellers,
he
waited
for
signs
of
his
father’s
return
but
nothing
changed.
He
started
feeling
responsible
for
his
father’s
death.
He
would
talk
of
the
incidents
when
he
had
disobeyed
his
father;
when
he
had
hurt
peoples’
feetings,
or
had
committed
some
other
sins
(depression).
He
started
to
believe
that
Allah
was
punishing
him
(Introjection;
taking
the
blame
on
his
own
self).
This
tasted
for
few
months
until
finatly
he
accepted
that
nothing
could
bring
his
father
back,
no
matter
how
hard
he
may
try
and
a
big
vacuum
had
been
created
in
his
life
(acceptance;
“There
is
a
problem”).
Grad
ualty
he
started
to
return
to
his
life
and
his
routines
to
resolve
his
bereavement
(resolution;
“Life
moves
on”).
Grief:
An
exampLe
of
use
of
psychological
defence
mechanisms
A
patient’s
death
is
an
unfortunate
yetsometimes
inevitable
event
at
hospitals.
It
bring
into
pLay
a
whoLe
series
of
defence
mechanisms.
The
following
cage
scenario
illustrates
the
sequence
of
defence
mechanisms
that
come
into
play
in
such
a
setting:
I

153. In
order
to
bear
the
toss
of
his
father
the
doctor
in
this
scenario
passed
through
7
different
stages
of
grief,
listed
in
the
brackets
as
denial,
anger,
bargaining,
depression,
acceptance
and
resolution.
These
stages
invotve
use
of
unconscious
defence
mechanisms
which
hetp
him
resolve
his
toss.
These
stages
of
grief
are
universal
and
present
in
all
cultures.
In
fact
different
cultures
have
varied
rituals
tohelp
people
move
through
the
grief
e.g.
the
rituals
of
bain,
Qul,
Daswan
and
Chaleeswan’
or
Chehtum’
all
are
events
that
facilitate
the
resolution
of
the
bereavement
process.
As
health
care
providers
we
need
to
be
sensitive
towards
these
stages
of
grief
and
wherever
possible
must
proactively
work
through
with
the
griev
ing
people
to
ensure
a
smooth
and
early
return
to
routines
of
life.
PsychosociaL
Assessment
in
HeaLth
Care
Practitioners
of
a
biopsychosocial
model
of
health
care
are
expected
to
make
psychosocial
assessments
of
their
patients
as
well
as
the
biological
assessment.
Psychosocial
assessment
is
a
study
of
the
mental,
familial
and
cultural
aspects
that
can
inftuence
health.
These
factors
affect
the
etiolo
gy,
presentation,
diagnosis,
interventions
and
management
of
illness
and
prognosis
in
an
individual.
Certain
questions
asked
by
a
health
professional
may
hetp
develop
a
comprehensive
understanding
of
the
patient.
The
goal
of
this
is
not
only
to
determine
treatment
goals
but
also
include
social
and
psychological
treatments
that
the
patient
may
need.
Such
an
assessment
ensures
the
comprehensiveness
of
a
treatment
plan.
While
the
psychoso
cial
assessment
is
routinely
undertaken
for
psychiatric
patients,
it
is
often
ignored
in
pediatric,
medical,
surgical
and
reproductivehealth
settings.
CLinicaL
Situations
Demanding
a
Comprehensive
PsychosociaL
Assessment
While
psychosocial
assessment
should
be
routinely
undertaken
for
all
patients,
it
becomes
crucial
in
the
following
settings:
1.
Patients
affected
by
natural
and
human-made
disasters
and
catastrophes
(wars,
violent
crimes,
floods,
earthquakes,
tsunamis
etc).
2.
History
of
psychological
trauma
3.
Cancer
patients
4.
Psychiatric
patients
5.
Sexually
transmitted
diseases
like
AIDS,
and
infectious
diseases
6.
Lifestyle
disorders
such
as
diabetes
mellitus,
hypertension,
coronary
artery
disease,
cancer,
cerebro-vascular
accident
fCVA),
depression
7.
Dementias
•
8.
Intractable
diseases
such
as
spinal
injuries,
paraplegias.
How
to
undertake
a
psychosocial
assessment?
A
comprehensive
psychosocial
assessment
must
include
the
following
1.
Identification
of
stresses
in
a
patient’s
life,
2.
Emotional
and
psychological
reactions
to
these
stresses,
3.
Symptoms,
4.
Challenges
to
health,
5.
MentaL
state
examination,
6.
Assessment
for
risk
of
deliberate
self-harm
or
suicide
7.
Risk
of
violence
or
harm
to
others
F
-—--
—

154. It
must
result
in
a
List
of
expectations
or
needs
of
the
patient
that
are
to
be
fulfilled,
particularly
at
the
psychological
and
social
levels
and
his
personal
goals
of
treatment.
-
L
Psychological
reactions
to
ILlness
and
Hospitatization
As
all
of
us
who
have
ever
fallen
ill
may
realise,
disease
and
hospitalization
are
a
source
of
major
stress
to
a
patient,
The
severity
of
stress
and
individual’s
response
to
it
plays
a
major
role
in
the
suffering
the
patient
experiences
and
prognosis
of
the
illness,
Major
concerns
about
the
illness
include
its
infectious
nature,
the
possibil
ity
of
passing
it
to
the
next
generation
through
inheritance,
how
long
the
treatment
will
last
and
whether
there
are
any
consequent/residual
disabil
ities.
While
these
questions
lurk
in
the
patient’s
mind,
s/he
often
expects
the
health
professional
to
read
their
mind
and
many
a
time
may
never
ask
them.
In
case
the
health
professional
is
not
sensitive
to
this
need
of
the
patient,
these
questions
can
serve
as
a
source
of
fear
and
anguish
for
the
patient.
(How
to
address
these
questions
and
answer
them
appropriately
is
discussed
in
Chapter
3)
The
result
is
of
this
is
stress
that
combines
with
a
variety
of
other
situations
to
become
an
important
perpetuating
factor
for
the
disease.
1.
Stress
due
to
ilLness
In
addition
to
the
effects
of
the
illness
the
patient
also
experiences
the
stress
of
the
illness
in
the
following
ways:
Change
of
rote:
The
patient
is
usually
relieved
of
alt
his
obligations
and
consequently
is
assigned
a
passive
role.
S/he
is
not
considered
well
enough
to
manage
anything
or
even
think
for
their
own
self.
Financiat
toss:
The
disease
and
the
consequent
disability
may
result
in
a
temporary
or
permanent
loss
of
job.
In
the
absence
of
insurance
or
free
health
care
the
consultation
with
the
health
professional,
inves
tigations.
treatment
and
hospitalization
result
in
a
significant
financial
burden
on
the
patient
and
family.
Stigmatization:
Cardiovascular
diseases
and
iiabetes
are
considered
‘acceptable’
diseases.
Psychiatric
illnesses,
tuberculosis,
venereal
disease,
sex-linked
disorders,
AIDS,
epilepsy
and
skin
diseases,
on
the
other
hand,
carry
myths
and
stigma.
This
leads
to
concealment,
secre
cy,
delay
in
seeking
help,
somatization
and
‘cover-up’
presentations.
Loss
of
seLf-esteem:
The
passive
role,
stigma.
feeling
of
being
a
source
of
financial
stress
and
distress
caused
by
the
disease
lead
to
the
patient
feeling
like
a
burden
and
having
a
poorer
view
of
them
selves.Fear
of
becoming
handicapped:
Failure
of
treatment,
fitness
resulting
in
a
disability,
handicap
or
a
cosmetic
or
functional
loss
all
generate
a
fear
that
haunts
the
patient
all
through
the
illness.
Uncertain
prognosis:
The
short
and
long
term
prognosis
as
well
as
the
possibility
of
a
relapse
are
a
major
source
of
stress
for
the
patient
and
his
family.
.
.
.
.
..,
—.
—
0<
isL
Lora
Zombie

155. Intervention: Most
of
the
factors
Listed
above
require
a
mere
explanation
and
reassur
ance
based
on
facts
and
scientific
data.
The
information
sought
needs
to
be
furnished
in
the
Language
best
understood
by
the
subject
with
minimal
technicaljargon.
The
stress
can
therefore
be
significantly
relieved
and
the
resutt
is
a
positive
impact
on
the
prognosis
of
the
disease
and
a
greater
patient
satisfaction.
2.
Stress
of
Hospitalization:
Hospital
is
a
place
associated
with
disease,
disability
and
death
that
we
learn
to
fear
from
our
childhood.
The
word
hospital
is
synonymous
with
bad
news’
and
thus
a
source
of
major
stress.
The
prospect
of
being
admit
ted
in
it
heralds
a
variety
of
losses
and
[imitations
on
our
being.
Anatomy
and
physiology
of
hospitals:
The
layout.
arcnitecture
and
design
of
hospitals,
particularly
in
the
public
sector
settings
is,
unfortunately.
far
from
pleasant.
The
most
traumatic
parts
such
as
the
trauma
centre,
the
emergency,
and
the
intensive
care
units
are
set
at
the
front
of
the
hospitaL
A
person
accompanying
the
sick,
visiting
a
patient
or
someone
who
merely
is
there
to
get
their
blood
pressure
checked
may
be
traumatised
and
fear
ful
for
the
rest
of
their
life
at
the
prospects
of
going
to
a
hospital.
The
functioning
of
public
sector
hospitals
is
mostly
bureaucratic,
with
a
series
of
long
cues
for
a
chaotic
rush)
at
registration
points,
outpatients,
and
pharmacies.
Offices
of
consultants,
as
well
are
manned
by
often
rude,
overworked
assistants
with
little
understanding
of
the
stressful
mind
set
of
a
patient
or
an
anxious
family
member
accompanying
them.
Private
hospitals
and
clinics
are
often
aesthetically
pleasing
and
run
by
staff
that
is
not
as
stressed
due
to
fewer
number
of
patients
but
their
func
tioning
is
driven
by
financial
considerations,
resulting
in
gross
inequity.
Stresses
relating
to
the
hospitalization
are
thus
over
and
above
those
of
illness.
The
common
stressors
include:
Loss
of
privacy:
Once
admitted
in
a
hospitaL
the
individual
finds
him
self
surrounded
by
patients
and
hospital
staff.
S/he
is
expected
to
eat,
steep
and
perform
all
routine
tasks
without
any
privacy,
in
the
midst
of
virtual
strangers.
This
is
usually
not
the
case
when
one
is
well
and
the
patient
may
be
helpless
in
changing
this
which
may
cause
a
great
deal
of
stress,.
Loss
of
autonomy:
Once
an
individual
is
assigned
the
role
of
patient”,
his
diet,
dress,
bedding,
lodging,
sleep
and
pattern
of
all
routine
tasks
will
now
be
decided
either
by
their
care-givers
or
health
personnel.
While
some
patients
might
enjoy
this
departure
from
decision
mak
ing
and
feeling
of
control,
others
may
find
it
disturbing.
The
patient
may
find
it
impossible
to
adjust
to
this
change
and
is,
therefore,
seen
seeking
an
early
discharge
from
the
hospitaL
At
times,
the
patient
may
take
a
‘ftight
to
health’
i.e.
a
sudden
disappearance
of
all
symptoms,
appearing
to
be
‘fit
for
discharge’.
Separation:
Most
patients
are
admitted
without
attendants
and
are
ex
pected
to
meet
no
visitors
or
a
minimal
number,
during
visiting
hours.
A
sense
of
loneliness
ensues
and
the
day
is
spent
in
awaiting
the
dear
ones.
The
parents,
children,
spouse.
friends,
relatives
and
neigh
bours
are
all
expected
to
visit
and
share
the
sorrow
of
the
patient.
Any
absentees
are
noted
with
concern,
resulting
in
strained
ties
of
friend
ship
or
family.
Often
these
absentees
may
be
cast
out
from
the
social
group,
deemed
callous
and
uncaring.

156. Handing
over
health
matters:
While
the
doctor
is
a
fairly
familiar
figure
for
the
patient,
the
rest
of
the
hospital
staff
are
all
new
to
the
patient.
This
may
serve
as
a
source
of
great
stress
when
they
take
for
granted
that
the
patient
will
hand
over
all
matters
relating
to
his
physical
and
mental
health
to
them
with
little
or
no
inhibition.
Threat
to
social
or
financial
circumstances:
A
hospital
admission
can
mean
loss
of
much-needed
income,
which
may
cause
financial
dis
tress
to
the
entire
family.
Other
causes
of
stress
are
the
care
of
young
er
children
and
etderly
retatives.
Unsatisfactory
information:
Under
most
circumstances
in
the
acute
situation
leading
to
the
patient’s
admission
the
doctor
is
more
focused
on
management.
Thegueries
of
the
patient
and
the
family
are
mostly
ignored
or
postponed.
This
adds
to
the
patient’s
and
family’s
anxiety
and
causes
stress.
3.
Reaction
of
the
Patient
to
Ittness
and
Hospitatisation
In
the
circumstances
surrounding
the
illness
and
subsequent
hospitalisa
tion
the
patient
has
a
myriad
of
different
reactions
to
what
is
going
on
in
and
around
him/her.
These
include:
•
DenialAnger
•
Depression
•
Dependance
Patients
who
are
at
a
higher
risk
of
reacting
to
the
stress
of
illness
and
hospitalisation
include
those
suffering
from
psychiatric
illness,
those
with
a
past
history
of
psychiatric
illness,
elderly
patients,
children
and
those
with
poor
pre-morbid
psychosocial
and
psychosexual
adjustment.
DeniaL:
Hospitalisation
may
be
an
overwhelming
challenge
to
some
individuals.
Their
response
may
initally
be
a
state
of
disbelief
and
de
niaL
The
patient
may
refuse
to
believe
that
the
admission
is
required.
or
in
some
cases
deny
they
are
ill
at
alL
Such
a
state
may
be
shared
by
the
family
and
may
last
for
few
hours
to
a
day.
Need
for
doctor’s
approval:
Health
professionals
enjoy
unparalleled
prestige
and
status.
Their
word
is
given
a
special
consideration
and
often
considered
irrefutable.
The
vulnerability
of
the
patient
further
enhances
the
aura
of
the
doctor.
S/he,
therefore,
tries
to
get
the
ap
proval
of
the
‘saviour’
by
being
the
model
patient
who
follows
advice,
never
argues
or
asks
questions,
and
always
nods
‘yes’
when
asked
“Are
you
feeling
better”?
This
model
is
gradually
being
replaced
by
that
of
a
more
critical,
argumentative
patient
who
is
informed
of
his/
her
rights.
S/he
speaks
as
a
client
who
is
trading
health
services
for
the
large
sum
of
money
paid
in
cash,
insurance
or
in
taxes.
Anger:
The
state
of
denial
may
give
way
to
anger.
The
degree
of
anger
is
influenced
by
the
personality
and
emotional
stability
of
the
patient.
This
anger
generated
may
be
directed
towards
self
or
the
hospital
staff,
When
directed
to
the
patient’s
own
self
it
may
be
in
the
form
of
refusat
to
take
medication
or
meals,
disturbed
sleep,
and
frequent
losses
of
temper
with
or
without
provocation.
A
team
of
health
professionals
sensitive
to
this
displacement
of
anger
gives
the
patient

157. It
is
evident
from
the
above
description
that
the
stresses
of
illness
and
hos
pitalization
are
responsible
for
‘secondary
suffering
over
and
above
those
directty
caused
by
the
illness.
A
vast
majority
of
these
can
be
prevented
by
prediction,
identification
sensitivity
and
understanding
at
the
appropri
ate
hour.
Nearly
alt
these
states
respond
welt
to
the
empathic
attitude
of
a
considerate
health
professionaL
(who
may
be
joined
by
the
family
/
attendants)
the
chance
to
venti
late.
It
is
important
to
avoid
both
an
apologetic
and
a
confrontationat
attitude. Depression:
A
state
of
resignation,
apathy
and
depression
may
ensue
by
about
the
third
day.
The
state
is
often
transient
as
benefits
of
the
treatment
start
to
become
visible.
A
delay
in
recovery,
worsening
or
persistence
of
symptoms
may
however
aggravate
this
stage.
It
may
lead
to
a
depressive
reaction
or
syndrome
with
adverse
effects
on
biological
functions
such
as
appetite
and
sleep.
Dependence:
The
combined
effect
of
the
disease,
the
stress
of
hospi
talization
and
the
consequent
stresses
often
result
in
a
strong
de
pendence-hunger’.
The
patient
has
a
constant
need
on
the
part
to
be
pampered,
sympathised
and
helped
white
eating,
drinking
or
perform
ing
routine
tasks.
The
extent
of
this
dependence
varies
with
the
kind
of
experience
the
patient
had
when
previously
ilt,
and
the
sociocuttural
context.

158. Chapter
2
Psychosocial
Assessment
Modet
Psychosocial
Assessment
And
Management
Protocol
You
have
been
asked
to
undertake
the
psychosocial
assessment
of
a
26
year
old,
single,
male:
MrX.
Presenting
Probtem
Mr
X
is
admitted
in
a
medical
ward
with
the
diagnosis
of
Hepatitis
B.
He
is
also
being
investigated
for
spikes
of
high
grade
fever,
unexplained
by
the
diagnosis
of
hepatitis.
In
spite
of
the
ward
staff’s
repeated
requests,
He
leaves
the
ward
every
now
and
then
and
returns
after
two
hours
or
so.
He
sometimes
fights
with
fellow
patients
and
ignores
rules
and
regulations
of
the
ward.
He
occasionatly
refuses
treatment
and
states
that
he
does
not
want
to
live
anymore.
Personal
Status
Mr
X
is
the
youngest
of
six
sibs.
He
has
two
sisters
and
three
brothers.
He
was
born
in
Sheikhupura.
and
his
father,
a
cobbler,
shifted
to
Lahore
when
X
was
a
six
year
old,
to
put
up
a
roadside
stall.
None
of
X’s
sibs
went
to
schooL
S/he
collects
waste
from
the
waste
disposal
dumps
on
the
banks
of
River
Ravi.
S/he
started
to
smoke
cigarettes
at
the
age
often.
He
now
smokes
chars
(marijuana)
and
is
addicted
to
heroin.
S/he
inhates
the
heroin
on
a
silver
foil.
X
is
HIV
positive.
He
gives
a
history
suggestive
of
repeated
urinary
tract
infections
and
gonorrhea.
Famity
History
and
Current
Relationships
X
has
been
in
an
extended
family
system
for
the
first
ten
years
of
his
life.
He
lived
in
Sheikhupura
in
a
three
room
pukka
house
with
his
paternal
cousins
and
uncles.
The
family
practiced
some
basic
Islamic
rituals
but
was
not
very
religious.
He
was
physically
abused
by
his
father
and
a
paternal
uncle.
S/he
was
bullied
and
sexually
abused
by
a
cousin
regularly
till
his
family
moved
to
Lahore.
S/he
never
attended
a
regular
school,
but
went
to
a
Local
madressa
to
study
religious
text.
S/he
would
get
physical
beatings
at
the
madressa
as
he
was
poor
in
studies.
His
father
earned
about
five
hundred
rupees
on
the
days
he
worked.
His
mother
worked
as
a
household
servant
to
earn
five
thousand
rupees
a
month.
He
often
fought
with
his
siblings
and
had
no
confiding
relationship
except
with
his
mother.
Positive
Support
Systems
Mr
X
feels
comfortable
in
the
company
of
his
mother,
and
a
friend
from
whom
he
usually
buys
chars
and
heroin.
He
hates
his
father
as
he
is
ag
gressive
and
has
beaten
him
repeatedly
on
account
of
his
smoking
and
drug
use.
Lately
Mr
X
has
started
to
attend
the
local
mosque.
The
prayer
leader
there
gives
him
sermons
about
leading
a
pious
life
and
assures
him
that
he
will
be
granted
Allah’s
mercy
if
he
gives
up
his
bad
habits.
He
feels
some
com
fort
in
the
company
of
the
prayer
leader.
It
is
he
who
brought
him
to
the
hospital
for
treatment.

159. Crime
and
Delinquency
Mr
X
has
had
repeated
run-ins
with
the
police
on
account
of
possessing
charas
and
heroin.
He
has
also
been
arrested
and
sentenced
for
selling
drugs.
He
once
beat
up
a
fellow
drug
addict.
He
has
been
to
prison
twice.
Education X
has
never
attended
a
format
schoot
and
was
taught
onLy
to
read
Quran
at
the
madressa.
He
can
do
simple
counting
and
count
currency.
He
cannot
Write. Emptoyment X
has
been
making
three
to
four
hundred
rupees
a
day
by
selling
used
syringes
and
ptastic
bottles
picked
from
the
dumping
grounds
on
Ravi.
He
once
worked
for
six
months
at
a
tea
bar
near
Daata
Darbar,
Lately
he
has
been
emptoyed
by
a
syringe
packing
factory
as
a
daily
wager
for
two
months. Readiness
for
treatment
X
has
opted
for
treatment
of
hepatitis
but
is
still
unsure
about
giving
up
charas
and
heroin.
Available
social,
economic,
occupationaL
resources
X
is
admitted
in
a
public
sector
hospital
receiving
free
treatment,
but
has
to
pay
for
interferon
therapy.
He
has
no
job
to
return
to
and
is
a
poorly
skilled
labourer,
working
on
waste
disposal
area
which
is
a
high
risk
setting.
His
bond
with
brothers
and
sisters,
and
father
is
weak.
Personal
Values
and
Attitudes
Mr
X
often
prays
at
the
mosque
for
the
last
six
months
but
was
raised
in
a
house
with
little
or
no
religious
values.
He
cheats
and
tells
lies.
He
is
bisexual,
and
has
had
several
sexual
liaisons
with
mates
and
females
since
the
age
of
twelve.
He
has
been
involved
in
petty
thefts
from
his
home
and
various
shops.
Mental
Status
Exam
Appearance
and
generat
behavior
Mr
X
is
a
young
mate
with
a
medium
build.
He
appears
older
than
his
age,
is
shabbily
dressed,
and
poorly
groomed.
He
is
cooperative
and
forms
a
fair
emotional
rapport
but
is
restless
and
fidgety.
Speech: He
speaks
in
a
low
tone
and
volume,
giving
brief
and
relevant
replies,
but
starts
to
speak
with
pressure,
and
rapidly
while
discussing
religious
beliefs.
Mood
and
affect:
His
mood
is
anxious
and
defensive.
His
affect
is
appropriate
to
his
speech
and
mood
state.

160. Thoughts.’His
thinking
processes
are
normat.
logical,
and
he
has
no
delusions.
He
does
have
some
overvalued
ideas
about
the
relationship
of
his
medical
and
drug
issues
with
his
fate:
he
considers
them
Gods
curse
on
him
because
of
his
inability
to
serve
his
mother,
Perceptions.’Mr
X
denies
any
visual
or
auditory
illusions
or
hallucinations
at
presenc
He
states
that
he
does
have
hallucinations
of
police
sirens
getting
closer
while
under
the
effect
of
drugs.
This
state
has
never
occurred
white
he
is
sober
and
drug
free.
He
has
not
noticed
any
change
in
his
perception
of
taste,
olfaction
or
bodily
sensations.
There
are
no
obsessive-compulsive
phenomenon.
He
does
not
experience
any
phobias,
dereaUsation
or
depersonalisation.
Cognitive
Functions.’
He
is
fully
conscious,
attentive
and
is
able
to
concentrate.
He
is
oriented
in
time,
placeand
person.
and
has
normal
short,
intermediate,
and
long
term
memory.
His
abstract
thinking
is
intact,
and
his
arithmetical
skills
and
general
knowtedge
are
appropriate
with
his
educational
and
cultural
setting.
His
judgment
is
not
impaired.
Insight:He
is
aware
of
the
physical
and
drug
abuse
issues
he
is
facing
and
wants
to
seek
appropriate
treatment
from
the
hospitaL
Suicide
and
homicide
risk:
He
has
thought
of
killing
himself
by
taking
an
overdose
of
heroin,
but
has
not
attempted
it
so
far,
and
has
a
moderate
risk
of
self-harm.
He
has
no
plans
to
harm
anybody.
DiagnosisAXIS
I:
(Psychiatric
Diagnosis)
Heroin
and
Cannabis
dependence
AXIS
II:
(Personality):
Sociopathy
/
Antisocial
Personality
Disorder
AXIS
III:
(Medical
Condition):
Hepatitis
B,
HIV
positive,
gonorrhea
AXIS
IV:
Problems
related
to
family,
police,
and
hospital
administration
AXIS
V:
(Social
and
occupational
functioning):
Global
Assessment
of
Functioning
(GAF)
score:
71
PsychosociaL
Management:
Major
Issues:
Medical
and
Psychiatric
illness
Antisocial
personality
Poor
socioeconomic
status
Inadequate
family
support
Unemployment,
and
intermittent
exposure
to
hazardous
waste
and
infected
syringes
due
to
occupation

161. No
housing
Legal
problems
Easy
access
to
drugs
of
abuse
Strengths
And
Weaknesses:
Strengths:
Cooperative,
has
insight,
and
adequate
cognitive
functions,
link
with
the
local
mosque
and
religious
inclinations,
strong
bonding
with
mother.
Weaknesses:
Multiple
psychosocial
issues
listed
above,
poor
motivation
to
give
up
drugs,
antisocial
personality
traits
and
delinquency
history,
mild
to
moderate
suicide
risk.
Management
Goals:
1.
Improvement
of
motivation
to
overcome
drug
dependence
2.
Adherence
to
hospital
norms
and
rules,
as
well
as
social
values
3.
Meaningful
occupational
skills
and
employment
and
giving
up
current
exposure
to
syringes
and
infected
material
4.
Mobilisation
of
family
support
particularly
improved
relationship
with
father
and
brothers
5.
Estrangement
from
drug
dealers,
and
drug
abusers
6.
Risk
reduction
regarding
sharing
of
needles,
dissemination
of
hepatitis
B,
suicidal
ideation,
and
safe
sexual
practices
7.
Informational
care
on
medical
and
psychiatric
diseases,
drugs,
follow
up,
prognosis,
cross
infection,
treatment
adherence
8.
Relapse
prevention
through
active
engagement
with
medical,
and
psychiatric
services
--
9.
Availability
of
medication
.-
-
Strategies
and
Interventions:
1.
Motivational
interview
to
deal
with
drug
abuse
issues
2.
Informational
Care
session
3.
Counseling
and
support
to
refuse
peer
pressure
in
drug
abuse,
avoid
risk
taking,
and
high
risk
situations,
mobilization
and
re-establishing
family
bonds.
4.
Occupational
therapy
5.
Improved
treatment
adherence
and
follow
up
6.
Conflict
resolution
at
home
and
hospital
settings
7.
Medicolegal
/
forensic
support
8.
Mobilisation
of
economic
support
for
treatment
of
medical
and
psychiatric
disorders
g.
Cognitive
behavior
therapy
to
deal
with
issues
related
to
suicidal
ideation,
social
bonds,
drug
abuse.
10.
Anger
management
and
impulse
control
methods
11.
Group
counseling
/
group
therapy
for
drug
abuse

162. a.
Coronary
Care
Unit
Coronary
Artery
Disease
(CAD)
is
commonly
seen
in
people
who
have
a
characteristic
combination
ambition,
time
urgency,
anxiety,
competitive
ness
and
hostility
(Type
A
personalities).
It
is
more
likely
to
occur
in
persons
with
high
environmental
stress,
life
dissatisfaction,
less
social
mobility,
sta
tus
incongruity
and
those
with
personal
loss.
These
patients
when
hospi
talised
to
CCU
nd
themselves
faced
with
a
situation
when
their
health
and
environment
is
not
in
their
control.
The
surroundings
of
CCU
depict
a
very
grim
picture.
Patients
are
attached
to
different
kinds
of
tubes,
wires
and
gadgets
and
neighbouring
patients
are
being
resuscitated
or
dying.
For
a
patient,
therefore,
the
CCU
may
appear
to
be
a
‘chamber
of
horrors’
and
further
complicate
his
state.
Certain
patients,
however,
may
feel
calm
and
“protected”
in
the
same
setting.
The
common
psychological
reaction
in
patients
in
CCU
settings
is
a
state
of
anxiety,
fear,
distress
and/or
a
sense
of
loss
following
the
cardiac
event.
This
is
known
to
lead
into
clinical
depression
in
up
to
one-third
of
the
pa
tients,
who
may
present
with
weeping
spells,
low
mood,
disturbed
sleep.
loss
of
appetite
and
even
non-
cardiac
chest
pain.
Some
of
these
patients
may
use
the
defence
mechanism
of
‘denial’.
In
this
state
they
may
appear
joviaL
talkative
and
found
cracking
jokes.
The
co-morbid
depression
and
anxiety
ma,
delay
recovery
and
adversely
affect
the
short
and
long
term
morbidity
and
mortality.
To
manage
this
certain
physicians
may
prescribe
benzodiazepines
in
cardi
ac
patients
as
a
routine.
Benzodiazepines
are
not
currently
recommended
in
clinical
guidelines
for
long
term
use
due
to
their
addictive
potentiaL
This
practice
may
result
in
benzodiazepine
misuse,
abuse
and
dependence.
Family
members
visiting
the
patient
or
those
asked
to
wait
outside
the
CCU
may
be
equally
distressed
and
anxious.
Their
anxiety
is
often
on
account
of
a
lack
of
information
and
awareness
about
the
events
taking
place
inside
the
CCU,
hidden
from
their
eyes,
They
are
often
found
waiting
on
the
edge
of
their
seats,
walking
anxiously
in
the
corridors
or
feeling
exhausted
after
waiting
for
long
hours
in
the
open
or
the
poorly
furnished
waiting
rooms.
Interventions:A
medical
student
or
a
doctor
on
duty
in
CCU
must
actively
look
for
the
above
mentioned
psychological
reactions,
make
clinical
notes
and
promptly
start
treatment
or
make
a
referral
for
a
psychiatric
opinion.
The
effectiveness
of
biological
treatment
and
clinical
outcome
in
CCU
settings
can
be
greatly
enhanced
using
nonpharmacological
interventions
(NPIs).
Use
of
informational
care,
counselling
and
ventilation
sessions,
progres
sive
muscular
relaxation,
visual
imagery,
relaxation
techniques,
hypnosis,
meditation
and
biofeedback
can
help.
Opportunities
for
stable
patients
in
CCU
to
interact
in
groups
with
each
other
and
share
their
experiences
have
tremendous
therapeutic
value.
Group
sessions
conducted
by
doctors
and
cardiologists
to
educate
patients
on
behaviour
modifying
strategies
regarding
smoking,
anger,
time
and
stress
management
can
also
enhance
the
therapeutic
outcome
and
prevention
of
future
cardiac
events.
Chapter
3
Psychosocial
Issues
in
Special
Hospital
Settings

163. Alt
CCUs
should
ideaLLy
ensure
comfortable,
dedicated
waiting
rooms
and
rest
rooms
for
famiLy
members
and
attendants.
A
regular
flow
of
informa
tion
about
the
patients
state
progress
based
on
scientific
data
should
be
ensured
through
a
medical
officer
or
a
senior
nurse,
trained
in
principles
of
effective
communication
(Section
A).
This
is
preferable
to
the
usual
“tassalti”
with
statements
such
as
“atl
is
well
‘mareez
theek
hai
or
5mareez
ki
halat
theek
nahin.”
b.
intensive
Care
Unit
Long
periods
of
sensory
deprivation
and
sensory
overtoad
will
often
give
rise
to
a
state
called
CU-
Psychosis
or
Intensive
Care
Syndrome.
This
syndrome
is
characterised
by
increased
wakefulness,
disorientation
and
visuat
hallucinations,
depression,
social
withdrawal,
anxiety,
delusions
and
delirium.
There
is
a
combination
of
sensory
overload
and
sensory
depri
vation
in
ITC
syndrome.
Sensory
overload
occurs
in
the
form
of
noise
of
monitors,
activity
of
the
staff,
constantly
lit
setting,
and
high
level
of
activity.
The
sensory
deprivation
as
a
result
of
immobility,
restraints
and
bandages,
contribute
towards
the
ICU
syndrome.
The
lack
of
familiar
orienting
objects
such
as
clocks,
calendars,
windows,
meals,
and
close
proximity
to
other
patients
further
worsen
this
condition.
An
already
distressed
patient
is
ex
•
posed
to
constant
attendance
by
physicians,
nurses
and
technicians.
S/he
also
suffers
sleep
deprivation,
physical
and
emotional
pain
of
disease,
fear
of
mutilation
or
death,
unfamiliar
medical
procedures,
(often
conducted
without
consent
and
information)
and
minimal
control
on
one’s
draping
and
dress.
All
this
leads
to
extreme
stress
and
a
feeling
of
powerlessness.
The
•
typical
psychological
reaction
of
hyperactivity,
anger
and
anxiety
in
ICU
•
patients
should
not,
therefore,
come
as
a
surprise.
Interventions A
redesigning
of
CU’s
architectural
and
administrative
layout
with
the
is
sues
identified
above
in
mind
can
greatly
reduce
the
risk
and
frequency
of
ICU
syndrome.
The
steps
that
can
be
undertaken
to
improve
psycho
care
of
patients
in
ICU
can
be
divided
into
those
focused
on
the
inside
of
the
CU
and
those
aimed
at
their
family
waiting
outside.
Inside
the
ICU:
•
Educate
and
prepare
the
patient.
Use
orientation
devices
e.g.
clocks
and
calendars.
•
Minimise
pain
through
pharmacological
as
well
as
non-
pharmacological
interventions.
•
Be
careful
while
discussing
the
patient’s
plight
assuming
the
patient
to
be
unconscious,
comatose
or
sedated.
Many
patients
in
these
states
report
having
heard
and
painfully
remember
the
negative
and
sometimes
insensitive
remarks
of
the
health
care
staff.
•
Reduce
environmentaL
stressors.
Outside
the
ICU:
•
Designate
a
space
for
the
family
and
visitors.
•
Provide
support
and
educate
the
family
using
Informational.
Care
principles.
•
Set
up
a
counselling
or
a
‘solace
room’
where
those
in
distress
can
be

164. attended
to.
The
same
space
can
be
used
to
breakbad
news.
Hospital
staff
shoutd
be
trained
in
counselling
and
non-
pharmacological
interventions
in
ICU
and
CCU
settings
c.
The
Emergency
Department
The
emergency
department
is
the
face
of
a
hospital
and
often
the
most
frequently
visited
part.
It
is,
therefore,
crucial
to
incorporate
psychosocial
care
in
deaLing
with
patients
brought
to
this
part
of
hospitaL
With
emotions
running
high
in
a
crisis
situation,
Emergency
health
professionals
often
are
forced
to
handle
anger,
frustration,
guilt,
depression,
dependency
and
infantilisation
in
patients
and
families.
Patients
who
have
gone
through
a
health
issue
requiring
emergency
care
become
reluctant
to
resume
routine
tasks
and
adoption
of
sick
role”
is
a
common
associated
finding.
The
pa
tient’s
family
fears
the
unpredictability
and
outcome
of
the
illness,
change
of
rotes
and
economic
burden
of
treatment
of
the
patient.
Interventions
•
Educate
the
patient
and
the
family.
•
Keep
the
patient
informed
about
the
progress
of
his
illness,
•
Give
the
patient
a
chance
to
express
him/herself
and
work
through
the
problem
with
them
•
Manage
‘sick
role’.
Aim
for
early
rehabilitation
and
return
to
previous
level
of
functioning.
A
comprehensive
psychosocial
assessment
and
intervention
in
emergency
department
can
prevent
uncalled
for
admissions
and
save
the
family,
the
patients
and
the
doctors
a
great
degree
of
distress
and
resources.
d.
PsychosociaL
Aspects
of
Organ
Transplantation
While
the
future
holds
promise
for
transplants
of
possibly
all
or
many
organs,
the
most
common
are
the
kidney.
bone
marrow,
liver
and
heart
transplants.
Other
than
the
ethical
issues
and
the
legal
bindings
now
in
position
in
Pakistan,
the
psychosocial
aspects
of
this
intervention
are
often
ignored.
While
the
recipient
is
of
primary
significance
on
account
of
his
or
her
severe
illness,
the
donor
must
never
be
forgotten.
Before,
during
and
well
after
donating
the
organ
the
donor
has
to
be
cared
for
with
sensitivity
and
concern.
Other
than
the
surgical
and
medical
risks
that
s/he
may
carry,
S/he
is
looking
for
approval,
and
support
from
the
medical
staff.
A
profuse
and
oft
repeated
thankful
stance,
and
eulogising
of
his
altruistic
behaviour
is
the
least
that
we
can
do.
This
aspect
is
often
left
to
the
family
of
the
recipient
or
the
recipient
himself;
which
many
a
times
is
not
enough.
As
a
medical
student
it
is
important
that
you
ask
for
the
donor,
visit
him,
and
use
principles
of
effective
communication
such
as
understanding
for
emotions,
active
listening
and
above
all,
empathy,
in
interacting
with
him.
A
single
in
teraction
of
this
kind
can
lift
his
psychological
state
and
may
be
enough
to
comfort
him.
It
is
also
important
to
give
him
or
her
a
detailed
informational
care
session
to
remove
his
myths
and
misconceptions,
respond
to
his
con
cerns
and
reassure
him
that
s/he
is
not
a
disabled
individual
after
donating
an
organ
and
can
still
lead
a
full
and
productive
life.
Particular
emphasis
needs
to
be
given
to
the
impact
on
his
diet,
sleep,
sexual
life,
return
to
work,
and
address
his
concerns
about
Perhez.

165. e.
The
DiaLysis
Unit
Memoirs
of
a
young
doctor;
The
turning
point
in
my
medicat
career
came
in
final
year
MBBS
when
I
was
on
rotation
in
the
medical
ward
of
the
hospital
attached
with
our
medical
cottege.
I
was
to
take
histories
of
some
patients
and
carry
out
physical
ex
aminations.
I
was
surprisingty
drawn
towards
one
65
year
oLd
fern
ate
patient
who
was
admitted
in
the
ward
with
chronic
renal
failure.
She
needed
a
kidney
transplant
but
the
family
could
not
afford
to
have
the
surgery.
She
was
under
going
haernodialysis
at
regutar
intervals
in
an
effort
to
somehow
maintain
her
failing
health.
The
frequency
of
dialysis
required
gradually
kept
increasing
as
her
kidney
function
deteriorated.
As
the
family
and
the
patient
herself
slowly
seemed
to
be
preparing
for
the
inevitable
outcome,
I
fett
I
was
witnessing
the
realistic
limits
of
our
health
care
system.
As
a
medical
student,
I
could
not
offer
her
much
technical
assistance,
but
I
would
always
take
some
time
in
the
evenings
to
come
and
listen
to
her
I
saw
her
progress
from
frustration
and
anger
to
gradual
acceptance.
I
was
able
to
see
how
the
whole
family
pulled
together
in
an
effort
to
make
her
journey
easier,
and
how
they
found
peace
and
comfort
in
their
cutturat
and
spirituat
beliefs.
She
said,
and
I
believed,
that
the
opportunity
to
talk
to
a
caring
and
non-judgmental
individual
helped
her
I
realised
that
one
of
the
gaps
in
medical
care
in
Pakistan
is
that
our
doctors
and
nurses
are
not
trained
in
practical
counselling
skills
that
they
can
use
in
their
daily
interaction
with
patients.
That
was
when
I
decided
to
take
up
mental
health
as
my
future
specialization,
becoming
a
psychiatrist
and
finally
a
stress
counsellor.
The
training
also
helped
me
answer
another
unresolved
question,
‘why
was
I
drawn
towards
this
particular
patient?’!
realised
that
this
patient
unconsciously
reminded
me
of
someone
very
important
to
me:
my
mother Psychosociat
concerns
and
interventions
in
a
diaLysis
unit
Acute
uremic
encephalopathy,
intra-cerebral
thrombotic
stroke
or
hemato
ma,
dialysis
dementia
(characterised
by
dyspraxia.
facial
grimaces,
myoc
Ionic
seizures,
schizophrenia
like
state,
mania
and
depressive
symptoms),
maladaptive
coping
behaviour,
loss
of
independence,
difficulty
in
perform
ing
routine
tasks,
fulfilling
family
and
financial
obligations
are
a
cause
of
many
psychosocial
concerns
in
a
patient
admitted
to
a
Dialysis
Unit
and
her/his
family.
These
include:
1.
The
burden
of
treatment
costs,
2.
medication,
3.
special
diet
4.
transportation,
5.
loss
and
change
in
function,
6.
roLe
reversals,
marital
difficutties
7.
Depression,
with
or
without
suicidal
thoughts
8.
Emotional
reactions
are
seen
with
such
patients
such
as
guitt,
hostility
and
ambivalence.
Interventions:
•
Emotional
support
•
Education
and
preparation
of
the
patient,
and
the
family
through
regular
Informational
care
and
emotional
support
through

166. counsetting
sessions
can
greatly
reduce
the
distress
of
patients
and
families
in
a
Dialysis
Unit
setting.
•
It
is
also
important
to
detect
the
co-morbid
psychiatric
conditions
and
treat
them
early.
f.
Reproductive
HeaLth
The
WHO
defines
reproductive
health,
within
the
framework
of
the
defini
tion
of
health,
as
a
state
of
complete
physical,
mental
and
social
well-being
and
not
merely
the
absence
of
disease
of
the
reproductive
system.
Reproductive
health
is
central
to
general
health.
It
a
reflection
of
health
in
childhood
and
adolescence
and
sets
the
stage
for
health
beyond
the
re
productive
years
for
both
women
and
children.
It
includes
women’s
health
in
general
as
well
as
safe
motherhood,
fertility
regulation,
prevention
of
infertility,
prevention
and
management
of
cancer,
prevention
and
manage
ment
of
reproductive
tract
infections
and
sexually
transmitted
diseases.
Only
the
key
times
in
the
reproductive
life
are
however
addressed
here.
PubertyA
fairly
regular
sequence
of
events
happen
between
the
ages
of
9
and
r6
years.
Vaginal
secretions
are
generated
for
the
first
time
and
may
lead
to
misconceptions
e.g.
‘the
body
is
dirty
or
diseased’.
Increased
body
fat
is
perceived
as
ugly”
before
final
feminine
features
mature.
There
are
concerns
about
breast
size.
Many
negative
reactions
occur
in
response
to
menstruation,
particutarly
if
it
is
precocious.
All
these
factors
generate
anxiety.
mood
changes,
anger
and
a
desire
for
tonetiness
and
confiding
relationships.
Changing
moods
can
cause
family
conflicts
and
frictions
and
[ow
self-
esteem
in
them
within
the
peer
group.
InterventionsClose
and
healthy
bond
based
on
free
communication
within
the
family
(mother,
elder
sister)
to
share
anxieties
and
worries
usually
improves
the
situation.
Professional
advice
should
be
sought
also
for
delayed
/
preco
cious
puberty,
and
a
sensitive
physician
is
expected
to
address
the
con
cerns
of
the
adolescent
and
the
family
members
with
reassurance.
Myths
such
as
perceiving
normal
vaginal
secretion
(“leukorrhea”)
to
be
unclean
are
often
brought
to
reproductive
health
professionals
for
treatment.
It
is
up
to
the
health
professional
to
debunk
this
and
other
myths,
instead
of
“throwing
drugs
at
the
problem”
as
overuse
of
drugs.
especiaLly
antibiotics,
is
already
showing
dangerous
consequences
worldwide.
Pregnancy
&
childbirth
During
pregnancy
both
parent
have
concerns
about
genetic
endowment,
intelligence,
temperament.
physical
health
and
stature
of
the
child.
Cultural
practices
and
myths
of
the
society
greatly
influence
on
parental
expec
tations.
A
prevalent
example
of
this
is
the
diet
that
a
pregnant
woman
is
asked
to
consume.
Various
cultures,
deem
different
food
groups
out
of
bounds
for
the
pregnant
female,
with
next
to
no
evidence
or
research
base.
The
parents’
own
childhood
experiences
and
how
prepared
they
feel
to
become
parents
also
greatly
influences
the
parental
expectations.
Con
genital
anomalies
due
to
non-inherent
factors
such
as
nutrition,
medica
tions,
alcohol,
caffeine,
cigarette,
toxin,
infection
are
some
of
the
other
con
cerns
of
parents
at
childbirth.
All
these
factors
contribute
towards
quality
of

167. bonding
of
each
parent
with
infant,
The
child
bears
high
risk
in
this
regard
if
the
mother
develops
puerperal
psychosis
or
depression.
Pregnancies
at
risk
for
Devetoping
Psychosocial
Complications
•
Primigravida,
precious
pregnancy,
unwanted
pregnancy
•
Past
history
of
psychiatric
illness
or
family
history
of
psychiatric
illness
•
Strained
maritaL
relationship,
•
Poor
social
support
•
Children
under
the
age
of
14
years
•
History
of
drug
abuse
Minor
problems
in
pregnancy,
like
heartburn,
nausea,
cough,
generalised
itching,
varicose
veins
etc.
may
generate
undue
anxiety,
particuLarly
if
organic
cause
has
not
been
effectively
ruled
out.
Unlike
the
west,
in
our
culture
adequate
training
for
labour
and
psychological
support
during
labour
is
preferred
from
mother
or
elder
sister
rather
than
from
husbands.
However
with
changing
times
more
and
more
husbands
are
playing
a
more
supportive
role
during
the
pregnancy,
labour
and
even
in
the
care
of
the
offsprings.
Majority
of
deliveries
in
Pakistan
are
still
done
by
Traditional
Birth
Atten
dants
(TBAs)
and
Dais.
This
increases
the
risk
of
birth
complications.
On
the
other
hand
a
number
of
Caesarean
sections
are
also
done
without
giving
an
adequate
trial
of
labour.
World
literature
provides
evidence
for
better
results
from
natural
childbirth.
Problems
with
breast
feeding
may
occur,
amongst
mothers
on
account
of
the
misconception
about
disfigurement
if
they
feed
their
children.
While
mothers
milk
is
considered
to
be,
by
tar
the
best
feed
for
the
baby.
Psychosocial
issues
during
Puerperium
The
risk
of
developing
morbid
psychological
reactions
during
the
puerpe
rium
is
higher
amongst
the
primigravida,
those
with
past
history
of
psychi
atric
illness,
family
history
of
psychiatric
illness,
past
history
of
puerperal
illness,
previous
childbirth
with
congenital
abnormality,
poor
social
support
or
poor
marital
relationship.
The
common
psychiatric
conditions
that
can
develop
during
puerperium
include:
•
Postpartum
btues:
a
self-limiting
state
of
low
mood,
weeping
spells
and
disturbed
sleep
that
lasts
for
10-14
days.
•
Puerperat
depression:
If
the
sad
mood
and
disturbed
biological
functions
lasts
for
more
than
2
weeks,
puerperal
depression
should
be
considered.
•
Puerperat
psychosis:
A
relatively
rare
state,
characterised
by
delusions
and
hallucinations
and
gross
abnormalities
of
behaviour.
Both
Puerperat
depression
and
psychosis
should
be
treated
by
a
psychi
atrist.
An
early
referrat
of
such
patients
to
a
mental
health
professional
is
therefore
mandatory.

168. psychiatrist
is
the
best
option.
g.
Paediatrics
Ward
A
poem
Alt
the
way
to
the
hospital
The
tights
were
green
as
peppermints
Trees
of
black
iron
broke
into
teaf
ahead
of
me,
as
if
I
were
the
lucky
prince
in
an
enchanted
wood
Summoning
summer
with
my
whistle,
Banishing
winter
with
a
nod.
Swung
by
the
road
from
bend
to
bend,
I
was
aware
that
btood
was
running
Down
through
the
delta
of
my
wrist
And
under
arches
of
bright
bone
Centuries,
continents
it
had
crossed;
from
an
undisclosed
beginning
spiralling
to
an
unmapped
end.
Crossing
tat
sixty)
Magdaten
Bridge
Let
it
be
a
son,
a
son,
said
the
man
in
the
driving
mirror,
Let
it
be
a
son.
The
tower
held
up
its
hand:
the
college
bells
shook
their
blessings
on
his
head.
I
parked
in
an
atmond’s
shadow
blossom,
for
the
tree
was
waving,
waving
at
me
upstairs
with
a
child’s
hands
At
seven-thirty
the
visitors’
bell
scissored
the
calm
of
the
corridors.
The
doctor
walked
with
to
the
sticing
doors.
His
hand
is
upon
my
arm,
his
voice
-
I
have
to
tell
you
-
set
another
bell
beat
ing
in
my
head:
Your
son
is
a
Mongol
the
doctor
said.
How
easily
the
word
went
in
-clean
as
a
bullet
leaving
no
mark
on
the
skin,
stopping
the
heart
within
it
This
was
my
first
death
Wrenched
from
the
caul
of
my
thirty
years’
gro
wing,
fathered
by
my
son,
unkindly
in
a
kind
season
by
love
shattered
and
set
free.
You
turn
to
the
window
for
the
first
time.
I
am
catted
to
the
cot
to
see
your
focus
shift,
take
tendril-hold
on
a
shaft
of
sun,
explore
its
dusty
surface,
climb
to
an
eye
you
cannot
meet
You
have
a
sickness
they
cannot
heal
the
doctors
say’
locked
in
your
body
you
wilt
remain.
Welt,
I
have
been
locked
in
mine.
We
will
tunnel
each
other
out
You
seal
the
covenant
with
a
grin.
In
the
days
we
have
known
one
another
my
little
Mangol
love,
I
have
learnt
more
from
your
tips
than
you
will
from
mine
perhaps:
I
have
learnt
that
to
live
is
to
suffer,
To
suffer
is
to
live.
Ctinicat
situations
with
a
high
risk
of
psychosociaL
morbidity
in
Reproduc
tive
Health
Settings
Couples
with
infertility,
females
with
vaginismus
and
those
who
have
tong-standing
premenstrual
syndrome,
dysmenorrhoea.
chronic
petvic
pain
or
those
who
undergo
hysterectomy
form
a
high
risk
group
for
devel
oping
psychiatric
morbidity.
An
early
detection
of
psychosociat
correlates
in
these
patients
should
be
followed
with
informational
care
sessions
and
the
use
of
N
P15.
Long-term
use
of
benzodiazepines,
analgesics,
placebos
and
megavitamin
therapies
are
often
unproductive
measures,
and
should
be
avoided.
In
case
the
symptoms
do
not
improve,
a
prompt
referral
to
a
-
Jon
Stall
worthy

169. PsychosociaL
aspects
of
parenting
a
child
with
disabiLity
Having
a
child
with
a
physical
or
mental
disability
is
an
emotionatty,
phys
ically
and
often
financially
challenging
experience.
Many
parents
experi
ence
periods
of
extreme
stress
as
they
adjust
to
the
demands
of
parenting
a
disabled
child.
These
feelings
are
often
similar
to
those
commonly
expe
rienced
after
a
significant
loss
such
as
a
divorce
or
death
of
a
loved
one.
1.
Denial
of
the
Childs
Disability.
One
or
both
the
parents
may
deny
their
childs
disabitity,
especially
if
it
is
not
an
obvious
one.
A
patent
in
denial
will
avoid
talking
about
the
disability
and
will
make
up
excuses
and
alternate
exptanations
of
the
problem.
They
may
behave
as
if
everything
is
fine,
completely
ignoring
the
child’s
problems.
A
child
whose
parents
are
in
denial
is
at
risk
for
being
punished
for
his
poor
performance.
This
is
inappropriate
and
may
cause
psychological
damage
to
the
child.
This
stage
is
especially
difficult
when
the
parents
disagree
about
the
degree
of
the
child’s
disability
and
how
the
problems
should
be
handled.
2.
Anger
and
guilt
about
the
child’s
disorder.
Anger
is
a
common
reaction
in
parents
of
children
with
disabilities.
Parents
struggling
with
anger
may
become
argumentative,
demanding,
and
verbally
aggressive
when
dealing
with
a
child’s
problem.
They
may
project
their
anger
toward
a
teacher,
their
spouse,
and
worst
of
atl,
their
child.
Some
may
also
be
angry
with
themselves
over
the
child’s
disability
and
their
inability
to
‘fix”
the
problem.
3.
Blaming
others
for
the
Disabitity.
Some
parents
of
children
with
disabilities
attempt
to
cope
by
blaming
others
for
the
disorder.
The
parent
in
the
blaming
stage
may
believe
or
say
that
the
other
spouse.
doctors,
school
staff,
or
even
the
chitd
themselves
is
at
fault
or
making
excuses.
Again,
this
stage
is
especially
difficult
and
stressful
when
both
spouses
disagree
about
who
is
responsible.
Furthermore,
the
blamer
may
become
unable
to
get
past
blaming
someone
to
focus
on
coping
with
the
child’s
problems.
4.
Grief:
Parents
of
disabled
children
may
go
through
a
grieving
process
that
begins
when
they
learn
about
the
disability.
Parents
who
grieve
over
their
children’s
disabilities
are
usually
concerned
that
their
children
may
struggle
for
the
rest
of
their
lives.
They
may
worry
that
the
child
will
not
be
successful
in
life
because
of
the
disability.
Parents
may
feel
new
grief
over
the
years
if
their
child
has
difficulties
achieving
various
milestones
when
other
children
succeed.
Passing
a
driver’s
test,
college
entrance
exams,
and
similar
events
may
trigger
this
grief.
5.
Worry:
Worry
and
grief
often
go
hand-in-hand
in
parents
of
disabled
children.
Patents
may
worry
about
their
child’s
self-esteem,
achievement
and
ability
to
make
it
through
school.
They
worry
whether
the
child
will
learn
to
read,
write,
or
perform
other
important
life
skills,
whether
the
child
will
be
able
to
attend
college
or
a
vocational
program,
have
a
successful
career;
have
a
family
and/or
lead
a
normal
adult
life.

170. Psychosociat
issues
faced
by
a
child
with
disability
Various
disorders
can
render
a
child
partiatty
or
ftilty
handicapped
leading
to
restrictions
on
movement,
ptay
and/or
diet.
These
timitations
over
an
extended
period
of
time
can
result
in
psychosocial
problems
both
at
home
and
at
school.
Frequent
absences
from
school,
low
expectations
of
teach
ers
and
parents
and
poor
grades
lead
to
[ow
self-esteem.
Such
children
have
few
or
no
friends
at
alt.
The
result
is
inadequate
or
stow
verbal
and
language
proficiency,
which
may
make
matters
worse.
In
the
event
of
un
controlled
seizures,
memory
and
thinking
may
be
affected
and
scars
and
disfigurement
may
occur.
These
issues
lead
to
further
decline
in
the
poor
self-concept
and
a
state
of
chronic
dysphoria
and
gloom.
Delayed
sexual
maturation
may
further
complicate
the
situation
by
causing
poor
peer
inte
gration
and
a
state
of
alienation.
On
the
other
hand,
if
a
child
with
disabitity
receives
the
proper
guidance,
psychosociat
and
practical
support,
s/he
can
overcome
these
disabilities.
to
become
a
highly
successful
professional
and
a
highly
motivated
human
being.
The
basic
principle
is
the
same
as
with
alt
so
called
normal”
chil
dren:
to
provide
a
safe,
non-threatening
environment
in
which
they
can
learn
to
manage
their
apparent
disabilities
and
explore
and
develop
their
strengths.Psychosocial
interventions
As
mentioned
earlier,
timely
psychosocial
intervention
with
the
family
and
individual
in
such
a
situation
is
imperative
to
their
prognosis
and
integration
into
society.
The
following
guidelines
may
provide
structure
to
such
an
intervention:
•
Informational
care
by
the
senior
member
of
the
health
team,
in
a
frank
and
honest
fashion
to
the
patient
and/
or
parents
in
simple
language,
as
early
as
possible,
is
recommended.
Both
parents
must
be
seen
together
and
involved
in
the
care
simultaneously.
•
Adequate
time
for
this
interviewshoutd
be
spared
so
that
issues
can
be
discussed
in
detail
and
alt
the
queries
of
the
parents,
patient
and
the
siblings
dealt
with,
without
any
rush.
A
home
visit
by
the
health
professional
or
the
mental
health
social
worker
is
regular
practice
in
the
West.
This
may
not
be
possible
locaLLy
but
a
formal
setting
of
the
hospital
cad
be
used
effectively.
Privacy
must
be
ensured
for
an
open
expression
of
emotions,
when
such
an
issue
is
being
discussed.
•
A
multidisciptinary
approach
involving
a
psychologist
or
a
social
worker,
nurse
and
doctor
is
ideal.
Elective
surgery,
if
indicated,
should
not
be
scheduled
during
the
sensitive
period
of
psychosexual
development
between
4-7
years
in
order
to
avoid
heightened
anxiety
and
possible
psychological
trauma.
Ideally,
the
patient
should
not
be
segregated
from
the
general
population.
S/he
may
be
taught
to
be
appropriatety
dressed,
and
taken
along
to
the
various
festivals
and
social
gatherings.
In
the
long
run
this
approach
helps
to
reduce
the
stigma
and
enhances
the
self-esteem
of
the
patient
and
the
family.
A
fair
amount
of
peer
contact
in
games,
play,
television
watching,
telephone
conversations
and
reading
stories
can
work
wonders
after
the
peer
group
has
been
adequately
guided.
Communication
skills
and
training
at
the
verbal
and
non-verbal
level
should
be
taken
up
as
early
as
possible.
Verbal
communication
to

171. convey
warmth,
acceptance,
empathy,
care,
while
nonverbal
communication
(tone
of
voice,
facial
expression)
to
convey
humanistic
concern
should
be
encouraged.
Evaluation
of
the
psychosocial
environment
that
influences
the
child
has
to
be
done
on
a
regular
basis.
it
is
important
to
ensure
emotional
support
for
the
family
of
a
child
with
a
disability,
as
a
whole.
Recognition
of
the
roles
of
all
the
members
indi
vidually
and
due
appreciation
and
valuation
should
never
be
forgotten,
Encouragement
and
facilitation
of
needs
through
parent-to-parent
support
amongst
the
affected
families
is
most
helpful.
it
is
also
useful
to
teach
and
train
the
family
in
the
techniques
of
coping
with
stress
(discussed
later
in
this
section).
Dear
Professionals:
What
Parents
Want
to
Tett
You
(Adapted
from
a
piece
by
Muriel
Hykes)
;.
Please
don’t
predict
the
outcome
for
a
specific
case.
You
can
give
general
advice,
but
caution
that
nobody
can
predict
how
this
child
wilt
turn
out
2.
Do
not
write
off
a
complaint
as
“Goes
with
the
syndrome.”
Just
because
a
child
has
one
diagnosis,
does
not
mean
that
all
his
other
problems
are
due
to
that
3.
Ptease
don’t
get
angry
with
our
questions.
We
are
worried
and
trying
to
do
our
best
for
our
child.
4.
Be
open.
Realise
that
the
parents
are
going
to
be
looking
for
a
cure
and
will
pursue
alt
avenues.
Please
respect
that
5.
When
the
parents
are
depressed
and
in
shock,
be
avaiabte
for
them.
Find
something
good
to
say
about
the
patient’s
development
Appreciate
their
efforts
6.
Promote
a
team
approach
to
the
child’s
rehabilitation:
practice
“family-centred”
care.
Do
not
be
surprised
if
other
doctors
have
told
the
parents
conflicting
in
formation
or
failed
to
tetl
them
something.
Coordinate
care
with
alt
other
team
members.
z
Understand
that
most
parents
are
new
to
this...atl
the
medical
terms,
conditions
and
stuff
So
please
go
slow
and
be
patient
with
us.
On
the
other
hand,
recognise
that
some
of
us
are
very
wett
versed
on
our
kids
situation,
and
you
need
to
address
us
as
your
peer
in
the
treatment
of
our
child.
8.
Remember
that
your
patients
are
little
human
beings
who
feel
and
hear,
and
do
things
just
like
other
people.
It
just
takes
them
a
bit
tonger
to
achieve
those
goats.
Be
careful
how
you
talk
about
them
in
front
of
them.
Set
f-esteem,
confidence,
and
acceptance
are
major
needs
for
everyone.
g.
Please
be
careful
when
using
words
like
“handicap”
and
“disabled”
because
they
hurt
us
like
knives.
These
are
just
children
with
special
needs,
and
nobody
knows
what
our
chitdren
can
achieve.

172. Psychosocial
issues
in
chronic
illnesses
and
disabilities
The
reactions
of
a
person
who
has
been
diagnosed
with
a
chronic
illness
or
devetoped
a
disability,
are
similar
to
reactions
after
other
major
life
loss
es.
The
individual
experiences
deniaL,
anger.
depression,
and
attempts
to
figure
out
how
this
change
will
affect
them.
f
these
feelings
are
resolved
one
can
accept
the
new
set
of
circumstances
and
[imitations.
Long-term
painful
thoughts
and
emotions
can
lead
to
alienation,
Loss
of
friends,
more
symptoms,
feeling
alone,
and
so
on.
The
onset
of
a
disability
Lat
er
in
life
creates
dramatic
changes
in
how
to
live
and
feet.
Studies
show
that
people
who
are
born
with
disabilities
tend
to
be
better
adjusted
than
people
whose
disabilities
came
later
in
life.
A
person
who
goes
blind
at
20
years
old
deals
with
issues
around
the
loss
of
never
seeing
what’s
around
them
again,
and
the
fear
of,
‘Will
I
be
okay?
Can
I
still
live
without
seeing?”
Someone
who
has
done
physical
work
his
whole
life
may
experience
a
tremendous
struggle.
Finding
out
that
s/he
can
no
longer
work
or
be
inde
pendent
can
be
especially
debilitating.
Effects
on
care-givers
Many
people
who
suddenly
become
disabled,
or
develop
an
illness
which
creates
a
disability,
suddenly
have
a
greater
need
for
support,
both
physicalty
and
emotionally.
At
times,
just
when
a
family
member
thinks
everything
is
‘under
control”,
more
needs
or
emotions
may
arise.
As
many
disabilities
and
iltnesses
take
place
later
in
life,
many
times
these
people
are
in
committed
relationships.
This
creates
a
special
set
of
conditions
affecting
the
spouse.
It
is
a
problem
they
have
little
control
over.
Many
new
issues
surface,
not
just
in
coping
with
the
issues
of
the
person
who’s
ill,
but
also
coping
with
what
one’s
commitment
is,
finances,
change
of
lifestyle,
increased
responsibility.
It
becomes
an
ongoing.
lifetime
struggle.
Some
one
diagnosed
with
multiple
sclerosis,
for
example.
sees
their
abilities
disappear.
and
can
see
their
family
trying
to
accommodate.
They
see
their
state
deteriorating
and
their
need
for
assistance
increasing
and
therefore,
feel
Like
more
of
a
burden.
It
may
become
imperative
to
an
individual’s
mental
and
physical
health
to
get
support
from
friends,
family.
or
a
coun
sellor/mental
health
professional.
h.
OncoLogy
Patients
admitted
to
Oncology
Wards
face
a
high
morbidity
and
mottality
risk.
They
have
grave
concerns
about
the
unpredictability
of
their
illness
and
about
their
loved
ones.
They
are
faced
with
the
painful
side-effects
of
chemo
and
radiotherapy
and
have
fears
of
disfigurement
and
disability.
This
fear,
and
that
of
impending
death
and
associated
pain
and
distress
be
come
the
major
preoccupation
for
these
patients.
Some
of
these
patients
would
not
even
understand
the
meaning
of
their
illness.
Others
may
have
strange
unexpected
reactions
upon
hearing
the
news
for
the
first
time.
This
may
include
manic
reactions,
dissociative
reactions,
denial,
panic
reactions
and
depression.
Some
individuals
may
even
begin
to
think
about
suicide.
The
patient’s
relatives
may
also
have
similar
reactions
to
the
news.
Most
of
them
expect
a
miracle
from
the
doctors
and
staff
and
it
may
take
time
for
the
realities
of
the
illness
to
set
in.
In
addition
to
the
patients
and
relatives,
the
staff
and
doctors
working
with
patients
of
terminal
illnesses
also
undergo
slow
and
gradual
changes
in
their
attitudes.
Exhaustion
and
emotional
burnouts
are
common
amongst

173. oncologists.
Working
as
a
team,
taking
time
out
for
catharsis,
ventilation
and
for
relaxation
and
changing
the
monotony
of
this
very
demanding
job
are
some
of
the
methods
to
prevent
against
such
conditions.
Interventions Studying
and
seeing
the
reactions
that
people
have
to
hearing
bad
news
may
give
the
naïve
health
professional
the
idea
that
it
should
be
avoid
ed,
As
discussed
in
Section
A.
to
decide
what
information
is
to
be
given
to
the
patient
is
not
the
prerogative
or
choice
of
the
doctor.
The
patient
must
be
specificatly
asked
what
information
they
would
like
to
receive
regarding
their
illness.
Breaking
bad
news
to
the
patient
and
the
relatives
is
a
common
scenario
in
oncology
wards.
It
requires
some
skitls
in
coun
selling
techniques
(See
Section
A,
Non-Pharmacological
Interventions).
Each
patient
and
family
is
different
and
requires
a
unique
and
personatised
approach
towards
breaking
the
news.
It
is
advisabte
that
the
senior
doc
tor
or
consultant
should
take
the
responsibility
of
delivering
the
news
and
handling
of
the
reactions,
afterwards.
With
most
patients
this
may
be
all
that
is
required.
In
some,
however,
the
help
of
a
mental
health
professional
may
be
needed
to
help
the
patient
work
through
their
sense
of
loss.
The
patient’s
role
in
the
house
may
determine
what
the
loss
would
mean
to
the
family
when
the
patient
is
gone.
Ifs/he
is
head
of
the
family,
they
may
need
time
to
delegate
responsibiLities
before
starting
the
treatment.
The
treating
doctor
should
give
due
consideration
to
the
patient’s
needs.
If
the
patient
goes
into
a
state
of
dependency
and
loses
all
witl
to
fight
his/
her
illness
or
becomes
depressed
s/he
may
require
treatment
with
anti-
depressants
and
professional
handling.
All
available
social
and
emotional
support
must
be
mobilised
for
the
patient.
The
queries
of
the
relatives
and
the
patient
about
the
illness
and
its
treatment,
likely
outcome,
side
effects
of
the
drugs,
prognosis
and
duration
of
the
treatment
and
any
alternatives
should
be
discussed.
The
doctor
must
arrange
a
separate
session
for
providing
this
informational
care.
i.
Operating
Theatre
Operating
theatres
(01)
are
viewed
as
sinister
places
by
the
patients.
They
feel
that
“nobody
knows
what
goes
on
behind
those
closed
doors,
till
they
themselves
enter
the
room.
Most
of
them
are
scared
of
what
is
going
to
happen
to
them.
The
fears
are
of
being
vulnerable,
being
undressed
and
exposed
to
the
eyes
of
complete
strangers,
of
going
through
pain,
of
being
under
the
knife
and
of
dying
on
the
table.
When
in
fear
people
may
react
with
anxiety,
restlessness,
irritability,
anger
and
frank
outbursts
of
aggression
and
panic.
These
reactions
of
the
patient
should
be
viewed
as
natural
response
to
a
fearful
situation.
The
existing
envi
ronments
in
the
theatres
are
such
that
they
depict
a
coLd
and
indifferent
atmosphere
to
the
patients
that
further
increases
their
anxieties
and
fears.
Machines,
surgical
instruments,
bLood
spills
here
and
there,
shouts
of
panic
and
heLp
from
staff
members
to
each
other
adds
to
the
patients’
anxieties
and
Leave
him/her
aLone
to
handle
them.
The
casual
communication
of
the
doctors
and
nurses
may
further
enhance
the
scary
image
of
the
OT.
The
patient’s
reLatives,
waiting
outside,
are
in
a
state
of
extreme
distress,
fear
and
apprehension
about
the
outcome
of
the
surgery.
The
fears
are
not
only
about
the
success
or
otherwise
of
the
surgery
and
the
Life
of
the
patient.

174. interventionsMost
of
the
fears
and
anxieties
of
the
patients
are
alleviated
by
reassur
ance
and
providing
informational
care.
The
surgical
procedure
and
its
likely
results,
how
long
the
surgery
will
last,
what
kind
of
pain
is
expected
all
need
to
be
discussed
with
the
patient
prior
to
surgery.
An
introduction
of
the
surgeons
help
in
removing
apprehensions
of
patients.
Receiving
the
patients
in
the
theatre
by
the
operating
surgeon
or
assistants
in
an
empathic
and
professional
manner
helps
removing
many
uncertain
ties
of
the
patients.
An
informational
care
session
about
the
procedure,
anaesthesia
and
tike[y
results
to
the
relatives
helps
in
mobilizing
necessary
social
and
emotional
support
to
the
patient.
The
patient
has
a
right
to
be
informed
of
any
complications
in
the
surgery.
This
is
less
stressful
for
alt
parties
involved
if
the
surgeon
discusses
prob
lems
that
are
tikely
to
occur
with
the
patient
before
the
surgery.
I

175. Chapter
4
Psychosocial
Peculiarities
of
Dentistry
,The
oral
cavity
is
one
of
the
most
tender
and
most
vulnerable
parts
of
our
body.
We
teed
ourselves
through
it
and
kiss
our
loved
ones
with
it
The
mouth
is
literali.y
a
path
to
our
innermost
setf.
The
tongue
is
the
only
organ
in
our
body
which
is
fully
developed
at
birth
and
functions
during
the
first
2
months
of
life.
Infants
are
de
pendent
upon
it
for
nourishment,
to
communicate
and
express
their
feelings,
and
to’explore
the
world
(we
all
know
how
infants
put
everything
they
touch
into
their
mouthsD.
During
this
early
part
of
our
lives,
we
are
helpless.
dependent
vulnera
ble
and
unable
to
express
oursetves
fully.
A
visit
to
the
dentist
is
unlike
any
other
medical
experience.
During
dental
interven
tions,
we
place
our
mouths
in
a
vulnerable
position.
The
feeling
of
hetptessness
that
ilievitably
arises
from
these
infant
experiences
of
dependency
and
vulnera
bility
come
from
our
unconscious
minds.
The
resutt
is
anxiety.
We
place
ourselves
in
a
physically
vulnerable
position
and
suspend
our
usual
physical
boundaries.
We
render
ourselves
unable
to
communicate
in
the
usual
way
(since
our
mouths
are
what
is
being
tended
to)
and
anticipate
pain,
while
remaining
conscious
and
fully
alert.
The
close
physical
proximity
of
the
dentist
may
also
be
perceived
as
threat-
ening.
If
we
add
to
the
mix
the
negative
associations
many
of
us
have
with
doctors
•
or
other
authority
figures.
it
is
easy
to
see
how
feelings
otanxiety
might
arise
in
typica
dental
settings.
DentaL
anxiety
and
phobias
Dental
anxiety
or
fear
of
the
dentist
is
a
major
stumbling
block
for
many
people.
It
usually
prevents
otherwise
intelligent,
rational
peopLe
from
optimizing
and
main
taining
their
oral
health.
Dental
phobia
is
a
fear
and
avoidance
of
going
to
the
dentist
or
fear
of
any
dental
treatment
or
care.
It
is
believed
that
more
than
half
the
population
fears
dental
•
treatment
and
because
of
this
avoid
seeking
dental
treatment
It
is
a
serious
con
dition
that
leaves
people
panic-stricken
and
terrified.
People
with
dental
phobia
have
an
awareness
that
the
fear
is
totally
irrational
but
are
unable
to
change
t
They
exhibit
classic
avoidance
behaviour
that
is,
they
will
do
everything
possible
to
avoid
going
to
the
dentist
People
with
dental
phobia
usually
go
to
the
dentist
only
when
forced
to
do
so
by
extreme
pain.
Other
signs
of
dental
phobia
include:
•
Trouble
sleeping
the
night
before
the
dental
exam.
•
Feelings
of
nervousness
that
escalates
white
in
the
dental
office
wailing
room.
•
Crying
or
feeling
physically
ill
at
the
very
thought
of
visiting
the
dentist
•
Intense
uneasiness
at
the
thought
of,
or
when
actually
objects
are
placed
in
the
mouth
during
the
dental
appointment
or
suddenly
feeling
like
it
is
difficult
to
breathe.
Causes
of
Dentat
Phobi,and
Anxiety
There
are
maiy
reasons
why
some
people
have
dental
phobia
and
anxiety.
Some
of
the
common
reasons
include:
•
Fear
of
pain
is
a
common
reason
for
avoiding
the
dentist,
This
fear
usually
sterns
from
an
early
dental
experience
that
was
unpleasant
or
painful
or
from
dental
‘pain
and
horror”
stories
told
by
others.
___
170

176. Thanks
to
the
many
advances
in
dentistry
made
over
the
years,
most
of
today’s
dentaL
procedures
are
considerably
less
painfuL
or
even
pain
free.
•
Fear
of
injections
or
fear
that
the
injection
won’t
work.
Many
peopte
are
terrified
of
needles,
especially
when
they
are
inserted
into
their
mouth.
•
Fear
of
anaesthesia
and
its
side
effects
Peopte
may
fear
that
the
anaesthesia
has
not
yet
taken
effect
or
was
not
a
large
enough
dose
to
knock
out
any
pain
before
the
dental
procedure
begins.
Some
people
fear
the
potential
side
effects
of
anaesthesia
such
as
nausea,
dizziness
or
feeling
faint.
Others
do
not
like
the
numbness
or
“fat
lip”
associated
with
local
anaesthetics.
•
Feetings
of
hetplessness
and
toss
of
controt.
It
is
common
for
people
to
feel
these
emotions
considering
the
situation
—
sitting
in
a
dental
chair
with
your
mouth
wide
open,
unable
to
see
what
is
going
on.
•
Embarrassment
and
toss
of
personat
space.
Many
peopte
feel
uncomfortable
about
the
physical
closeness
of
the
dentist
or
hygienist
to
their
face.
Others
may
feel
self-conscious
about
the
appearance
of
their
teeth
or
possible
mouth
odours.
Most
individuats
with
dental
phobias
have
had
very
negative
experiences
with
either
unskilled
or
incompetent
dentists.
The
most
important
step
for
many
patients
to
overcome
dental
anxiety
is
to
find
an
expert
dentist.
An
expert
dentist
is
one
who:
•
communicates
effectively.
•
is
highty
competent.
•
endeavours
to
make
each
meeting
pain
free.
•
genuinely
cares
about
the
patient.
•
has
the
ability
to
nurture
a
patient
through
past
traumas.
The
most
significant
factor
in
reducing
dental
anxiety
is
the
ability
of
the
dentist
and
staff
to
quickly
develop
rapport
with
each
patient.
With
ade
quate
rapport.
the
patient
feels
understood,
safe
and
protected.
Knowing
how
to
ask
the
patient
what
they
are
thinking
and
feeling
is
crucial
to
de
veloping
a
connection.
By
eliciting
this
information,
the
dentist
can
respond
to
each
patient
appropriately
and
meaningfully.
Additionally,
a
connection
with
each
patient
is
fostered
when
the
dental
office
environment
is
relaxed,
welt
organised,
and
the
staff
is
friendly,
warm
and
caring.
Psychological
techniques
to
reduce
anxiety
There
are
a
number
of
psychological
techniques
that
can
be
used
to
re
duce
levels
of
anxiety.
i.
Psychological
support
and
counsetting
Counselling
can
help
with
a
whole
range
of
phobias.
There
are
several
different
approaches,
but
generally
the
aim
is
to
discuss
your
anxieties
in
a
way
that
can
hetp
to
overcome
them.
This
may
involve:
•
exptoring
the
origins
of
a
feat
in
chitdhood.
•
looking
at
the
thinking
patterns
that
arouse
a
fear.

177. •
facing
fear
gradually
so
that
one
may
learn
to
cope
with
it.
•
teaming
ways
to
cope,
such
as
relaxation
techniques,
breathing
exercises
or
meditation.
ii.
Distraction
techniques
It
is
sometimes
heLpful
to
draw
attention
away
from
the
treatment.
This
can
be
done
in
a
number
of
ways:
•
Listening
to
music.
For
children
cartoons
may
be
played
on
a
tv
that
has
a
view
from
the
chair
•
Concentrating
on
relaxing
each
part
of
the
body
in
turn.
•
Thinking
about
something
one
is
looking
forward
to.
iii.
Hypnotherapy Hypnotherapy
creates
an
attered
state
of
mind
that
feels
[ike
being
very
relaxed.
In
this
state,
suggestions
made
by
a
therapist
(or
a
dentist
trained
in
hypnotherapy)
can
help
people
to
receive
dentat
treatment.
People
can
also
be
taught
how
to
do
this
for
themselves.
Hypnotherapy
may
not
work
for
everybody,
however,
while
some
people
may
be
more
susceptible
than
others.
Dental
appearance
and
psychosociaL
welt
being
Aesthetic
dentistry
has
become
a
prominent
force
in
today’s
popular
culture,
with
treatments
ranging
from
bleaching
to
“invisible”
braces
being
commonplace.
A
healthy
and
attractive
smile
is
undoubtedly
valuabte,
given
the
current
focus
on
aesthetics.
It
is
understandable
that
any
devia
tions
from
an
“ideal”
dental
appearance
could
be
detrimental
to
a
person’s
•
psychosocial
well-being.
A
number
of
investigations
of
craniofaciaL
malformations
(such
as
cleft
lip
with
or
without
cleft
palate)
have
sought
to
eLucidate
the
psychosocial
im
pact
these
conditions
have
on
affected
people.
These
people
are
generally
welt-adjusted
psychosocially:
however,
they
reportedly
have
decreased
social
interactions,
fewer
close
relationships
and
feelings
of
self-con
sciousness
regarding
their
facial
features.
For
these
reasons,
patients
with
clefts
should
be
treated
early
to
prevent
or
interrupt
negative
psychosocial
outcomes. Research
has
documented
the
effects
of
malocclusion
and
motivations
for
orthodontic
treatment.
Malocclusion
has
been
identified
as
a
potential
threat
to
one’s
body
image
and
seLf-concept
in
both
adolescence
and
adulthood.
Many
of
these
patients
have
a
negative
self-image
as
motivation
for
treatment.
These
individuals
frequently
report
experiencing
a
level
of
psychological
distress
concerning
their
appearance
that
warrants
intervention.
It
is
essential
that
all
health
care
providers
understand
how
dental
health
and
appearance
fits
into
the
larger
picture
of
overall
health
and
well-being.
Teeth
are
important
to
an
individual’s
self-
perception
during
adolescence,
but
by
aduLthood
other
factors
have
greater
significance.
The
importance
of
having
the
perfect
smile
changes
as
people
age.
This
is
why
although
it
may
make
a
minor
contribution
to
an
individual’s
perception
of
self-worth,
orthodontics
cannot
be
justified
on
psychological
grounds
alone.
I
I

178. Stress
Reductive
Objective
To
condition
muscle
relaxation
response
Symptoms
primarily
related
to
anxiety
Symptonis
secondarily
aggravated
by
anxiety
Bwxism
or
clenching
activity
Muscle
pain
Techniques
Relaxation
techniques
Biofeedback
training
Anxiety
Disorders
and
Oral
Health
•
Patients
with
anxiety
disorders
may
disregard
their
oral
health
altogether
and
are
at
an
increased
risk
for
dental
caries,
periodontal
disease,
and
bruxism
(grinding).
•
Oral
health
problems
associated
with
anxiety
disorders
can
manifest
in
tle
form
of
canker
sores,
dry
mouth,
Lichen
Planus,
mouth
ulcers.
burning
mouth
syndrome,
and
ternporomandibutarjoint
dordes.
•
Anxiety
disorders,
which
include
phobias.
panic
attacks.
generalised
anxiety
and
post-
traumatic
stress
disorders
(PTSD).
are
serious
conditions
with
oral
health
implications
that
can
be
treated
with
a
variety
of
methods.
Medications
such
as
anti-depressants
and
some
anti-psychotics
decrease
the
mouth’s
ability
to
produce
saliva,
which
can
increase
the
risk
of
developing
tooth
decay
and
periodontal
disease.
A
liaison
of
the
mental
health
professionals
with
dentists
can
benefit
such
patients.
Temporomandibutar
and
Facial
pain
It
is
an
established
fact
that
temporomandibular
and
facial
pain
have
mul
tiple
causes
with
the
role
of
stress
being
significant
in
aggravating
them.
Condition
such
as
Burning
Mouth
syndrome’
usually
seen
in
elderly
women
may
sometimes
have
a
psychogenic
origin.
Conversely,
in
cases
where
an
organic
pathology
exists,
a
chronic
history
of
pain
and
dysfunction
can
pro
duce
psychologicat
changes.
These
patients
may
frequently
display
charac
teristics
of
‘chronic
pain
syndrome’.
This
is
characterised
by
increased
anxiety,
depression
and
reinforcement
of
illness
behaviour.
These
features
lead
to
an
increase
in
the
patient’s
pain
behaviour
and
an
increase
in
pain
perception.
When
taking
the
history
of
such
a
patient,
it
is
prudent
to
ask
questions
such
as
“What
does
this
pain
or
dysfunction
keep
you
from
doing?”
If
the
patient
complains
of
significant
alteration
in
occupational
or
social
activities
as
a
result
of
the
pain,
a
careful
evaluation
needs
to
be
done.
This
process
though
time
consuming
may
be
therapeutically
reward
ing
in
the
long
run.
Stress
Reduction
Techniques
Stress
produces
physiological
responses
in
the
body
such
as
release
of
adrenaline,
contraction
of
sketetat
muscle,
restriction
of
blood
flow
to
the
digestive
system,
increased
blood
flow
to
the
brain,
increased
heart
rate
and
increased
blood
pressure.
Pain
in
the
TM
joint
movement
that
results
from
stress
induced
muscle
contraction
can
benefit
from
a
variety
of
stress
reduction
techniques.
Most
famous
of
these
is
the
Jacobson’s
technique
which
teaches
the
patient
to
become
aware
of
a
particular
muscle,
usually
by
contracting
it.
The
goal
of
the
relaxation
training
is
to
condition
the
mus
cle
to
achieve
a
relaxed
state
quickly
and
for
a
prolonged
period
of
time.
This
process
is
also
facititated
by
relaxation
audio
tapes
designed
for
the
patient.Biofeedback
is
another
technique
that
has
been
shown
to
be
helpful
in
reducing
stress-induced
muscle
activity.
Biofeedback
teaches
the
patient
voLuntary
control
over
automatically
regulated
functions
of
the
body.
It
provides
the
patieht
with
instant
monitoring
of
the
physioLogical
parameters
of
stress.
For
example
Electromyographic
(EMG)
biofeedback
monitors
the
level
of
muscle
activity
and
the
patient
can
monitor
this
through
visual
and
auditory
displays
indicating
the
degree
of
contraction
of
selected
muscles.
With
good
training
the
patient
learns
to
adequately
relax
these
muscles
-—--
-j

179. Chapter
5
Psychosocial
Aspects
of
Alternative
Medicine
The
term
alternative
medicine
refers
to
atl
medicine
that
has
not
been
tested
using
the
scientific
method,
and
has
no
evidence
to
prove
its
efficacy.
This
includes
homeopathy,
acupuncture.
hikmat
and
other
forms
of
herb
al
medicine.
In
our
culture,
alternative
medicine
is
usually
the
first
line
of
treatment
that
a
patient
adopts
when
s/he
first
becomes
ilL
It
is
practiced
by
anyone
and
everyone
who
has
ever
experienced
illness,
and
alternative
medical
advice
can
be
sought
from
anyone,
whether
it
is
a
fruit
vendor,
a
neighbour
or
your
grandmother.
The
reasons
for
this
are
that
traditionalLy
a[Lopathic
medicine
was
considered
a
western
invention,
harsh’
on
the
body
and
unsuitable
for
the
subcontinentat
climate.
It
was
only
to
be
turned
to
if
and
when
all
else
had
failed,
and
the
healing
properUes
of
household
remedies
had
failed.
A
return
to
the
use
of
alternative
medicine
is
seen
in
patients
in
situations
where
allopathic
medicine
suggests
a
painful
cure,
or
does
not
have
one.
White
anecdotal
evidence
states
that
these
alternative
methods
are
ef
fective
there
is
no
scientific
evidence
to
back
this
claim.
Homeopathy,
in
particutar,
according
to
the
NHS
UK
has
been
cited
as
‘performing
no
better
than
placebos.”
The
National
Institute
of
Health
and
Care
Excellence
(NICE)
guidelines
do
not
recommend
the
use
of
homeopathy
for
the
treatment
of
any
ailment.
In
a
2013
large
scale
study
conducted
by
the
Nationat
Health
and
Medical
Research
Council
of
Australia,
57
systematic
reviews
containing
176
individual
studies,
published
between
1997
and
2013
were
evaluated
by
an
independent
contractor
overseen
by
a
body
of
homeopaths.
The
study
found
that
there
is
no
evidence
that
homeopathy
caused
greater
health
im
provements
than
placebo.
or
caused
health
improvements
equal
to
those
of
another
treatment.
This
finding
has
been
repeatedly
confirmed
by
find
ings
in
various
peer
reviewed
journals.
tl][21[3][41
As
health
professionals
it
is
therefore,
unethical
to
recommend
homeo
pathic
treatment
to
any
of
our
patients,
even
if
we
have
personally
feel
that
they
are
effective.
Any
patients
who
report
that
they
are
using
homeopathic
medication
must
be
informed
that
there
is
no
evidence
to
support
their
effi
cacy.
They
must
also
be
instructed
to
continue
the
use
of
altopathic
medi
cine
if
they
insist
on
using
homeopathic
or
other
remedies.
References 1.
Fisher,
P.,
&
Ernst,
E.
(2015).
Should
doctors
recommend
homeopathy?.
www.bmj.com 2.
Australian
National
Health
and
Medicat
Research
CounciL
Statement
on
homeopathy.
2015.
www.nhmrc.gov.au/_ffles_nhmrc/pubtications/attachments/camo2_nhm- rc_statement_homeopathy.pdf. 3.
Ernst
E.
A
systematic
review
of
systematic
reviews
of
homeopathy.
British
journal
of
clinical
pharmacology.
2002
Dec
1;54(6):577-82.
4.
Campbell
A.
Homeopathy
in
perspective.
Lulu,
2008.
5.
Cucherat
M,
Haugh
MC,
Gooch
M,
BoisselJP.
Evidence
of
clinical
effica
cy
of
homeopathy.
European
Journal
of
Clinical
Pharmacology.
2000
Apr
1:56t1):27-33. 6.
Smith
K.
Against
homeopathy—a
utilitarian
perspective.
Bioethics.
2012
Oct
1;26(8):398-409.

180. Chapter
6
Common
Psychiatric
Disorders
in
General
Health
Settings
The
workings
of
the
human
mind
have
remained
mysterious
since
the
beginning
of
time.
Psychiatry.
the
medical
specialty
devoted
to
the
study.
diagnosis,
treatment,
and
prevention
of
mental
illness,
is
just
as
Little
understood,
despite
being
the
oldest
profession
known
to
man.
In
prehis
toric
times,
people
haunted
by
‘evil
spirits”
were
taken
to
medicine
men
to
have
holes
drilled
into
their
skutts
to
let
the
spirits
escape.
The
need
to
understand
the
way
our
minds
work
coupled
with
lack
of
scientific
prowess
to
investigate
the
mechanics
of
the
brain
led
to
the
perpetuation
of
these
myths.
The
first
psychiatric
facilities
were
set
up
in
the
8th
century
in
the
Islamic
world
but
methods
more
humane
than
exorcisms
did
not
come
into
use
until
the
seventeenth
and
eighteenth
centuries.
Psychiatry
has
come
a
long
way
since
then
but
sadly
the
perceptions
surrounding
it
are
very
much
prehistoric,
especially
in
our
part
of
the
world.
The
myths
and
misconceptions
surrounding
mental
illness,
treatments
and
mental
health
professionals
themselves
are
many
and
manifest.
The
war
against
the
stigma
of
mental
illness
is
one
that
we
alt
fight.
whether
we
are
protesting
against
being
called
“crazy”
or
fighting
for
a
loved
one
to
get
help.
According
to
the
WHO
Mental
Health
Action
Plan
2013-2020
Re
port,
“mental,
neurological
and
substance
use
disorders
exact
a
high
toll,
accounting
for
13%
of
the
total
global
burden
of
disease
in
the
year
2004,
Depression
atone
accounts
for
4.3%
of
the
global
burden
of
disease
and
is
among
the
largest
single
causes
of
disability
worldwide
Eli
%
of
all
years
lived
with
disabitity
globally],
particularty
for
women.
The
economic
conse
quences
of
these
health
losses
are
equally
large:
a
recent
study
estimated
that
the
cumutative
global
impact
of
mental
disorders
in
terms
of
lost
eco
nomic
output
will
amount
to
US$
16.3
million
between
2011
and
2030.”
Some
of
the
most
common
myths
and
misconceptions
surrounding
mentaL
health
issues,
their
treatments
and
mentat
health
professionals
are
being
dealt
with
here
hi:
Myth:
Psychiatric
Illnesses
do
not
exist
or
are
caused
by
magic
and
evit
spiritsReatity:
Psychiatric
illnesses
are
caused
by
structural
and
chemical
chang
es
in
various
structures
of
the
body,
especially
the
brain,
and
are
just
as
much
a
“curse”
as
any
other
illness
or
adverse
life
event.
The
reasons
for
this
are
genetic,
biochemical,
behavioural
and
environmentaL
According
to
a
WHO
Report,
one
in
every
four
people
in
the
world
wilt
be
affected
by
mental
or
neurological
disorders
at
some
point
in
their
lives.
Psychiatric
Illnesses
constitute
15%
of
all
diseases
incurred
in
people
throughout
the
world.
33%
of
all
hospital
attendances
are
for
psychiatric
diseases.
Myth:
Psychological
factors
do
not
cause
any
other
diseases
Reality:
Psychological
factors
are
acause
of
the
disease
for
at
least
60%
of
alt
patients
with
any
disease.
In
fact,
mental
illnesses
such
as
depression
may
predispose
one
to
developing
infections,
heart
disease,
diabetes
and
even
cancer.
•xed!nistHyaKhan

181. Myth:
Psychiatric
patients
are
dangerous:
theycan
harm
tife
and
property:
Reality:
gg%
of
aU.violence,
crimes
and
homicides
are
committed
by
the
so-called
“normaL”
The
large
spectrum
of
patients
with
mental
illnesses
is
non-viotent
and
not
dangerous
to
other
people.
In
fact,
according
to
a
study
published
in
The
Lancet,
“people
with
psychiatric
disabilities
are
far
more
tikely
to
be
victims
than
perpetrators
of
violent
crime
(Appteby,
et
al.,
2001).
“People
with
severe
mental
illnesses,
schizophrenia,
bipolar
disorder
or
psychosis,
are
2
Y2
times
more
likely
to
be
attacked,
raped
or
robbed
than
the
general
population
(Hiday.
et
aL,;ggg).
Myth:
Psychiatric
Patients
Are
‘“Fraudulent,
Matingerers,
Hysterical”,
Be
having
Abnormalty
To
Fulfil
Ulterior
Motives
Reality:
Extensive
research
has
shown
that
those
who
were
labetled
“fraud”
‘fake”
“attention
seekers”
were
in
fact
misdiagnosed
and
misun
derstood.
Follow
up
studies
conducted
ten
and
fifteen
years
after
people
were
Labelled
matingerers
and
frauds,
revealed
very
high
rates
of
death
and
disease
amongst
the
“frauds.”
The
nature
of
psychiatric
disorders
is
such
that
people
are
unable
to
cope
with
their
daily
routines,
experience
a
lack
of
motivation,
and
start
to
behave
differently.
They,
therefore,
seem
to
be
malingering
or
“seeking
attention.”
The
real
reason
for
this
is
the
brain
experiencing
neurobiologicaL
chemical
or
structural
changes.
As
all
bodily
functions
are
controlled
by
the
brain,
patients
with
psychiatric
illnesses
also
experience
changes
in
their
appetite,
sleep
and
sex
lives
for
extended
periods
of
time.
Myth:
Psychiatric
treatments
are
lifelong,
addictive,
put
you
to
sleep
and
render
you
incapable
of
living
your
tife
Reality:
Psychiatric
treatment
includes
a
myriad
of
different
kinds
of
treatments
including
medication
and
therapy.
Medication
is
not
addic
tive
if
used
according
to
prescription,
white
therapy
is
conducted
for
a
set
number
of
sessions.
Only
a
certain
class
of
prescribed
medication
induces
sleep.
The
main
aim
of
treatment
in
psychiatry
is,
in
fact,
to
ensure
patients
are
abLe
to
return
to
their
daiLy
routine
and
living
their
lives
as
fully
as
possible. Myth:
Spiritual
Interventions,
homeopathy
and
“ghareLu
totkas”
can
be
used
in
place
of
medication
prescribed
by
the
psychiatrist.
Reality:
Medications
and
psychotherapy
should
be
used
in
conjunction
with
spiritual
interventions
and
neither
should
replace
the
other.
Both
med
ication
and
psychotherapy
use
in
the
treatment
of
psychiatric
issues
have
been
researched
extensively
and
found
to
be
effective.
According
to
The
National
Health
Service
of
the
UK
“There
is
no
good-quality
evidence
that
homeopathy
is
effective
as
a
treatment
for
any
health
condition.”
The
larg
est
to-date
analysis
of
all
data
on
homeopathic
treatments,
conducted
by
the
National
Health
and
Research
Council
of
Australia
has
concluded
that
they
are
ineffective
in
the
treatment
of
any
clinical
conditions
in
humans.
Myth:
Psychiatrists
give
“electric
treatment”
to
alt
patients
ReaLity:
Electroconvulsive
therapy
or
electroptexy
is
a
welt
researched,
safe,
painless
and
effective
treatment
used
for
serious
issues
in
very
specif
ic
disorders.

182. Myth:
“Once
a
psychiatric
patient...Atways
a
psychiatric
patient’
Reatity:
Psychiatric
itlnesses
are
not
Like
heart
disease,
diabetes
or
hyper
tension
(all
of
which
require
lifelong
treatment).
Mote
than
sixty
percent
of
psychiatric
illnesses
are
curable
and
adherence
to
medication
as
pre
scribed
can
lead
to
cure
within
6
months
to
a
year.
Following
is
a
brief
account
of
some
of
the
most
commonty
encountered
Priority
Psychiatric
Disorders
as
far
as
the
general
heatth
settings
are
concerned.
All
health
professionals
must
have
an
understanding
of
the
presentation
and
management
of
these
disorders.
a.
Mixed
Anxiety
and
Depression
Mixed
Anxiety
and
Depression
may
present
initiatly
with
a
history
of
two
or
more
weeks
of
physical
symptoms
such
as
fatigue
and
pain.
Further
inquiry
will
reveal
depressed
mood
and
feeling
of
fear,
apprehension,
or
a
state
of
gloom.
When
symptoms
are
not
severe
enough
for
the
individual
to
be
diagnosed
with
either
an
anxiety
disorder
or
a
depressive
disorder,
a
diag
nosis
of
mixed
anxiety
and
depression
can
be
made.
Diagnostic
Features:
•
Low
or
sad
mood,
•
Loss
of
interest
in
activities
•
Loss
of
pleasure
in
things
previously
found
enjoyable.
•
Inability
to
cope
with
routines/duties,
at
work
and/or
at
home
•
Prominent
anxiety
or
worry.
Disturbed
sleep,
•
Poor
concentration
expressed
as
forgetfulness,
•
Change
in
appetite,
•
Dry
mouth,
•
Tremors,
•
Palpitations,
•
Dizziness,
•
Suicidal
thoughts
or
acts.
Differential
Diagnosis
•
If
either
depression
or
anxiety
is
severe,
consider
depressive
disorder,
or
anxiety
disorder
as
independent
conditions.
•
If
hallucinations
(hearing
voices,
seeing
visions)
or
delusions
(strange
or
unusual
beliefs)
are
present
consider
Acute
Psychotic
Disorder.
If
excitement,
elevated
mood,
rapid
speech
is
present,
consider
Bipolar
Affective
Disorder
Management
Guidelines
If
the
diagnosis
of
anxiety
and
depression
is
made
follow
the
steps
as
listed
below:
Provide
Informational
Care
The
patient
and
family
members
must
be
provided
informational
care
regarding
the
aetiotogy,
management
and
prognosis.
The
following

183. must
also
be
mentioned,
in
tight
of
the
stigmaandmythssurrounding
mental
illness:
•
Stress
or
anxiety
has
many
physical
and
mental
effects.
The
symptoms
are
reat
and
understandable.
They
can
be
managed
and
relief
is
possibte.
•
These
problems
are
not
due
to
weakness
or
laziness;
patients
are
trying
their
hardest.
Do
not
blame
the
patient
for
not
trying
hard
enough
or
consider
him
weak
and
timid.
Do
not
repeatedly
tell
him!
her
to
use
wilLpower,
go
on
a
holiday,
change
jobs,
etc.
to
get
better
Counsetting
•
Teach
the
patient
to
practice
relaxation
methods
such
as
progressive
muscular
relaxation,
deep
breathing
exercises
or
visuaL
imagery
to
reduce
physical
symptoms.
Ask
the
family
to
remind
and
encourage
the
patient
to
undertake
the
exercises.
•
Ask
about
risk
of
suicide
in
explicit
terms
—
can
patient
be
sure
of
not
acting
on
suicidal
ideas?
(See
box)
•
Help
the
patient
to
plan
short-term
activities
which
are
relaxing,
distracting
or
are
known
to
build
confidence
in
the
patient.
Resume
activities
which
have
been
helpful
in
the
past.
•
Identify
exaggerated
worries
or
pessimistic
thoughts.
Discuss
ways
to
chaltenge
these
negative
thoughts.
•
If
physical
symptoms
are
present,
discuss
the
link
between
physical
symptoms
and
mental
distress
(Reattribution).
•
If
tension-related
symptoms
are
prominent,
advise
relaxation
methods
to
relieve
physical
symptoms.
Medication Consider
antidepressant
drugs
if
depressed
mood
is
prominent.
In
mixed
anxiety
&
depression
tower
doses
may
be
effectiv,
e.g.
imipramine
starting
at
25
mg
each
night
increasing
to
150
mg
by
the
15th
day,
or
fluoxetine
20
mg/
after
breakfast.
Explain
to
the
patient
that:
•
Medication
must
be
taken
every
day
•
Improvement
wilt
build
over
2-3
weeks.
•
Mild
side
effects
may
occur
that
usuatty
fade
in
7-10
days,
or
become
less
disturbing.
These
may
inctude
dryness
of
mouth,
constipatior’i.
excessive
sweating.
•
Check
with
the
doctor
before
stopping
medication
as
abruptly
stopping
it
may
result
in
discomfort.
•
Continue
antidepressant
for
6-8
months
after
the
symptoms
improve.
Specialist
ConsuLtation/Referral
If
suicide
risk
is
severe,
consider
urgent
referral
tothe
nearest
psychiatric
facility
after
admission.
Refer
the
patient
to
nearest
psychiatric
OPD
if
the
patient
does
not
respond
to
the
management
plan
even
after
06
weeks
of
treatment.

184. b.
Panic
Disorder
Presenting
Complaints
These
patients
usually
present
to
the
Emergency
Room
with
one
or
more
physical
symptoms
such
as
chest
pain,
dizziness,
shortness
of
breath,
feeL
ing
of
suffocation
and
fear
of
having
a
‘heart
attack.”
Further
inquiry
shows
the
full
pattern
described
below.
Diagnostic
Features
3-4
attacks
of
sudden
onset
of
anxiety
or
fear
in
which
there
is
a
feeling
of
dread,
impending
disaster,
accident
and
the
patient
feels
as
ifs/he
is
about
to
die.
It
often
occurs
with
physical
symptoms
such
as
palpitations.
chest
pain,
a
choking
feeling,
churning
stomach,
dizziness,
feelings
of
unreality,
or
fear
of
some
disaster
(losing
control
or
going
mad,
heart
attack
and
sudden
death).
A
typical
panic
attack
begins
suddenly.
builds
rapidly.
and
may
last
only
a
few
minutes.
Symptoms
start
white
the
patient
is
at
rest.
It
often
leads
to
fear
of
another
attack
and
avoidance
of
places
where
attacks
have
oc
curred.
Patients
may
start
to
avoid
exercise
or
other
activities
which
pro
duce
physical
sensations
like
panic.
Differentiat
Diagnosis
Many
medical
conditions
may
cause
symptoms
similar
to
panic
attacks,
such
as
coronary
artery
disease
(CAD)
and
asthma.
These
can
be
ruled
out
with
appropriate
history
such
as
onset
of
pain
or
breathlessness
on
effort.
changes
in
rhythm,
rhonchi
or
crepitations
on
examination
of
the
chest
and
typical
changes
in
ECG.
This
exercise
should
not
be
repeated
with
each
subsequent
attack
once
the
diagnosis
of
panic
attack
is
established.
•
If
attacks
occur
only
in
specific
feared
situations,
consider
Phobic
Disorders.
•
flow
or
sad
mood
is
also
present,
consider
Depression.
Management
Guidelines
Provide
InformationaL
Care
Essential
Information
for
Patient
and
Family
•
Panic
Disorder
is
common
condition
and
effective
treatments
are
available.
•
Anxiety
often
produces
frightening
physical
symptoms.
Chest
pain.
dizziness,
or
shortness
of
breath
are
not
necessarily
signs
of
heart
disease,
asthma
or
similar
disorders.
None
of
the
symptoms
being
experienced
are
dangerous
or
fatal.
They
are
like
a
storm.
that
comes
and
then
passes.
Alt
you
have
to
do
is
tie
low.
do
not
start
to
rush
to
the
hospital,
or
GP,
and
practice
deep
breathing
and
progressive
muscle
relaxation.
Keep
repeating
in
the
mind
that
the
symptoms
of
a
panic
attack
are
transient
and
always
pass.
They
cannot
cause
any
harm
to
heart,
brain
or
any
of
the
vitaL
organs.
To
develop
a
belief
that
a
panic
attack
is
not
a
threat
to
life
is
an
important
step
in
effective
management
of
a
panic
attack.
-.....
,,
,,
..
.
..
L.

185. •
Mental
and
physical
anxiety
reinforce
each
other.
Concentrating
on
physica’.
symptoms
will
increase
fear.
•
Do
not
withdraw
from
or
avoid
situations
whereattacks
have
occurred;
this
will
strengthen
anxiety.
CounseLling Counsel
the
patient
and
family
to:
•
Concentrate
on
controtting
anxiety.
not
on
medical
worries.
•
Practice
slow,
relaxed
breathing.
Controlled
breathing
will
reduce
physical
symptoms.
•
Identify
exaggerated
fears
which
occur
during
panic
(e.g.
patient
fears,
he
is
having
a
heart
attack).
Discuss
ways
to
challenge
these
fears
which
occur
during
panic
e.g.
the
patient
could
tet[
himself
am
not
having
a
heart
attack.
This
is
a
panic
attack
and
it
will
pass
in
a
few
minutes.
•
While
the
symptoms
may
appear
scary,
the
patient
must
be
left
alone
when
they
are
having
a
panic
attack
to
practice
their
relaxation
exercise,
and
learn
how
to
calm
their
ownsetves.
The
panic
generated
by
family
members
on
seeing
their
condition
will
only
worsen
matters.
Medication
•
Many
patients
with
panic
disorder
will
not
need
medication.
The
use
of
relaxation
exercises
and
reassurance
is
sufficient.
•
If
attacks
are
frequent
and
severe
or
if
significant
depression
is
present,
antidepressants
may
be
helpful
e.g.
imipramine
25
mg
at
night
increasing
upto
75—
100
mg
at
night
after
2
weeks.
•
For
patients
with
infrequent
and
limited
attacks,
occasional
use
of
anti-anxiety
medication
may
be
helpful:
torazepam
one
mg
up
to
three
times
a
day
for
two
to
three
weeks
but
never
more
than
five
weeks.
•
Always
taper
the
dose
in
allowances
of
1/4th
of
the
dose
every
fifth
day.
Regular
use
of
benzodiazepines
may
lead
to
dependence
and
is
likely
to
result
in
the
return
of
the
symptoms
when
discontinued.
Avoid
unnecessary
medical
tests
or
therapies.
Speciatist
Consuttation/Referrat
•
Consider
a
referral
for
consultation
with
psychiatrist,
if
severe
attacks
continue
after
the
above
treatment,
for
4
weeks.
•
Avoid
referral
for
medical
consultation
for
exaggerated
worrying
regarding
medical
symptoms.
_.1

186. c.
UnexpLained
Somatic
Complaints:
Persistent
Comptainers
Presenting
Comptaints
Any
physical
symptom
may
be
present,
but
the
symptoms
may
vary
ac
cording
to
the
geographical
and
cultural
settings
of
patients.
Complaints
may
be
singLe
or
multiple.
but
tend
to
be
atypical
or
unusuaL
Some
of
the
common
complaints
incLude
a
feeling
of
gas’
or
‘gota’,
aches
and
pains
from
head
to
toe,
headache,
stomachache,
backache,
shoulder
or
neck
ache
in
a
peculiar
and
circumscribed
site
that
cannot
be
explained
on
medical
or
anatomical
basis.
These
are
accompanied
by
an
extraordinary
concern
of
harbouring
a
dangerous
or
dreadful
disorder.
Diagnostic
Features
•
Physical
symptoms
without
medical
explanation
(proper
history
and
physical
examination
are
necessary
to
determine
this).
•
Frequent
medical
visits
and
laboratory
investigations
that
yield
no
unusual
findings.
•
Patient
may
be
overty
concerned
about
medical
illness.
•
Symptoms
of
depression
and
anxiety
are
common,
but
are
not
forth
coming.
Differential
Diagnosis
•
If
anxiety
symptoms
are
prominent,
consider
Panic
Disorder,
and
manage
as
mentioned
above
•
If
low
or
sad
mood
is
prominent,
consider
Depression.
If
it
is
severe
or
associated
with
suicidal
ideas
or
psychiatric
features
such
as
delusions
and
hallucinations,
admit
the
patient,
and
seek
psychiatric
consultation.
•
If
strange
beliefs
about
symptoms
are
present
(e.g.
belief
that
organs
are
decaying)
consider
Acute
Psychotic
Disorder.
Refer
to
the
nearest
psychiatric
facility.
•
If
the
diagnosis
of
unexplained
somatic
complaints/somatization
is
confirmed:
move
to
implement
following
steps.
Management
Guidelines
Provide
Informationat
Care
Essentiat
Information
for
patient
and
famity:
•
Stress
often
produces
physical
symptoms.
•
Focus
on
managing
the
symptoms.
not
on
discovering
their
cause.
•
Cure
may
not
be
possible:
the
goal
is
to
live
the
best
life
possible
even
if
symptoms
continue.
Counselling
•
Acknowtedge
that
physical
symptoms
are
real.
They
are
not
lies
or
inventions
or
“veham.”
The
patient
is
not
imagining
these
symptoms.
•
Ask
about
what
the
patient
thinks
is
causing
the
symptoms,
offer
appropriate
reassurance
(e.g.
abdominal
pain
does
not
indicate
cancer).
Advise
patients
not
to
focus
on
medical
worries.

187. •
Discuss
emotional
stresses
that
were
present
when
symptoms
arose.
•
Reattribution:
link
physical
compLaints
ith
emotional
distress.
Discuss
emotional
stresses
that
were
present
when
symptoms
arose
such
as
feeling
of
anger.
envy,
jealousy,
grief,
loss,
disgust.
fear,
sadness
or
threat.
•
Relaxation
methods
may
help
relieve
symptoms
related
to
tension
(headache,
neck
or
back
pain).
•
Encourage
exercise
and
enjoyable
activities.
Do
not
wait
until
all
symptoms
are
gone
to
return
to
normal
routines.
Medication
•
Avoid
unnecessary
diagnostic
testing
or
prescription
of
new
medication
for
each
new
symptom.
Offer
reassurance,
reattribution,
relaxation
exercises,
massages,
and
physical
exercises
in
place
of
symptomatic
drugs.
•
Antidepressant
medication
(e.g.
fluoxetine
20
mg
per
day)
may
be
helpful
in
some
cases
e.g.
those
with
headache,
bowel
symptoms,
atypical
chest
pain.
•
Do
not
use
benzodiazepines,
antacids,
analgesics.
multivitamins
or
placebos
as
symptomatic
treatment
in
these
patients.
Specialist
ConsuLtation
Avoid
referrals
to
medical
specialists;
these
patients
are
best
managed
in
primary
care.
Keep
in
mind
that
patients
may
be
offended
by
a
psychiatric
referrat
and
seek
additional
medical
consultation
elsewhere.
d.
Dissociative
and
Possession
States
These
occur
when
a
patient
is
brought
by
family
or
friends
on
account
of
violent
or
unmanageable
behavior
due
to
being
possessed
by
ajinn
or
evil
spirit.
These
states
are
often
an
involuntary
attempt
by
the
individual
to
escape
from
a
stressful
or
demanding
situation.
Presenting
CompLaints
•
Reduced
awareness
of
self
and
surroundings
(I
can
hear
sounds
but
cannot
respond
to
them)
or
a
constricted
level
of
consciousness.
•
Disturbed
memory.
where
simple
information
is
forgotten
for
short
periods
(patient
is
unable
to
answer
queries
Like
what
is
your
name,
who
are
you,
where
are
you,
how
many
Legs
does
a
cow
have?).
•
Attention
and
concentration
lapses.
•
Wandering
away
from
home,
to
be
found
at
a
place
where
others
can
recognise
him
or
her
and
return
home,
or
sleep-walking.
•
Change
or
loss
of
motor
and
sensory
function
of
a
part
or
whole
body
or
inability
to
talk,
swallow,
see,
or
hear
without
any
neurological
signs
to
support
the
change
in
function.

188. •
Statements
of
being
possessed
by
a
jinn’
or
‘bhoot’,
or
a
supernatural
force
or
deity.
causing
a
change
in
language.
voice
tone,
and
assuming
of
another
identity.
Diagnostic
Features:
As
mentioned
earlier
these
symptoms
occur
due
to
the
individual’s
inability
to
cope
with
reatity.
They
are
a
form
of
escape
from
reality
into
a
situation
where
the
individual
is
more
able
to
deat
with
their
issues.
Females
are
more
likely
to
suffer
from
these
symptoms.
This
is
a
result
of
their
voices
often
being
suppressed
and
their
opinions
not
considered.
It
may
be
an
expression
of
a
social,
relationship-related
stress,
or
physical
or
psycholog
ical
stress.
It
may
also
be
seen
in
soldiers,
people
affected
by
disasters,
and
survivors
of
psychotrauma.
Extensive
and
uncalled
for
investigations
and
tests
with
a
view
to
rule-out’
all
posible
physical
causes
should
be
avoid
ed.
The
diagnosis
of
dissociative
and
possession
disorders
is
a
positive
di
agnosis
based
on
a
deeper
understanding
of
the
patient
and
their
psycho
social
world
using
good
clinical
sense
and
effective
communication
skills.
Questions
about
disturbed
mood,
biological
functions,
any
suicidal
wishes,
and
psychosocial
stress
must
always
be
asked,
Patient
often
re
ports
having
a
family
member
with
similar
presentation
or
has
lived
with
or
seen
another
patient
with
possession
state.
A
belief
about
supernatural
forces,
‘evil-eye’
and
a
cuttura[
endorsement
of
possession
states
often
prevails
in
patient’s
own
and
family’s
belief
system.
DifferentiaL
Diagnosis
Dissociative
and
possession
symptoms
can
many
a
times
be
an
earty
symptom
of
an
underlying
serious
physicat.
social
or
a
psychiatric
patholo
gy.
The
symptoms
should
be
therefore
be
approached
like
PUO
(pyrexia
of
unknown
origin).
Underlying
or
co-morbid
severe
depression,
anxiety,
psy
chosis,
psychomotor
epilepsy,
should
be
considered
while
managing
and
investigating
the
patient.
Serious
disorders
[ike
cancers,
multiple
sclerosis
and
degenerative
disorders
may
rarely
present
initially
with
dissociative
symptoms.Management
Guidetines
No
punitive
measures
should
be
adopted.
Patient
must
never
be
ridiculed,
challenged,
or
confronted.
Statements
like
“you
are
malingering”,
you
are
making
it
up”,
“you
have
no
disease”
‘makar
naa
karo”
‘dramay
karna
band
karo”,
should
never
be
given.
An
informational
care
session
conducted
in
simple
easy
to
understand
terms
is
imperative
to
the
management
of
this
state.
It
is
most
important
to
highlight
the
involuntary
nature
of
symptoms
white
reassuring
the
patient
and
family
that
they
are
not
life-threatening
or
dangerous.
It
must
be
con
veyed
to
the
patient
and
the
family
that
the
symptoms
are
an
expression
of
an
underlying
conflict,
nervous
exhaustion,
fatigue
and
inability
to
cope
with
a
situation.
Answers
to
queries
like
“Kya
mareez
per
jin
ya
bhoot
ka
saya
hai?”
should
be
responded
with
statements
tike
“These
phenomena
are
not
my
area
of
expertise,
I
can
however,
try
to
find
and
treat
the
sci
entific
basis
of
the
problem
and
help
you
and
the
patient
understand
the
condition
better
from
a
sLientific
point
of
view.
“Mujhe
iss
baray
mel
toh
itm
nahi
hal
mdgar
sciencey
tahqeeq
ye
kehti
hal
k
ye
musta
zehn
ka
hal
our
mel
iss
ko
science
h
nuqt-e-nazar
se
hut
harne
hi
hoshish
harun
ga/gifl

189. Reassure
that
the
symptoms
may
be
toud
and
dramatic
to
look
at
but
are
not
dangerous
and
often
result
in
recovery
with
specialised
psychosociaL
care
and
medication
if
needed.
The
family
must
be
couneled
against
the
use
of
force,
undue
attention
and
gathering
around
the
patient
or
trying
to
hold
or
physically
handle
the
patient
during
the
attack.
The
family
must
leave
the
patient
alone
and
only
approach
the
patient
to
prevent
any
serious
bodiLy
harm.
The
patient
must
be
encouraged
to
try
and
predict
when
an
attack
is
about
to
occur
and
use
relaxation
techniques
to
overcome
the
state
preferably
by
staying
in
a
calm
setting
away
from
crowded
places.
A
supportive,
kind
and
re
[axed
approach
with
the
patient
with
repeated
empathic
reassurances
can
help
relieve
the
symptoms.
Rest,
adequate
ftuids
and
food,
adequate
sleep
and
tranquil
settings
help
in
early
recovery.
Medication:
There
is
no
specific
medication
to
relieve
the
symptoms
of
dissociation.
The
use
of
antidepressants
or
small
doses
of
tranquillisers
may
help
if
they
are
associated
with
an
underlying
symptom
of
depression
and
anxiety.
Specialist
Consultation
Such
patients
should
be
referred
for
speciatised
psychiatric
help
as
soon
as
possible,
especially
if
they
have
associated
depression
or
psychosis.
Earlyinvolvementofa
mental
health
facility
may
help
in
making
a
quicker
diagnosis
and
they
may
be
better
equipped
to
manage
such
a
patient.
e.
Drug
Abuse,
ALcohoL
&
Tobacco
Use
Smoking
and
drug
abuse
is
common
amongst
adolescents,
young
adults
and
sometimes
even
medical
students
and
health
persQnnel.
Alcohol
abuse
is
also
becoming
common
in
the
same
sections
of
the
society.
Depending
on
their
specific
personalities
and
various
other
environmental
factors,
these
people
resort
to
drug
abuse
mainly
for
the
following
reasons:
•
An
escape
from
painful
reality
and
responsibility
of
adulthood
•
Peer
pressures
for
identifying
with
their
specific
peer
group
•
To
avoid
physically
painful
conditions,
e.g.
narcotic
injections
for
relieving
pain
cause
by
a
fracture.
•
To
seek
novelty
and
thrill.
•
Misconceptions
about
drugs
such
as
‘doing
it
once
in
a
while
does
not
make
you
an
addict’.
•
To
use
drugs
to
copy
or
imitate
an
ideal
or
famous
figure.
Management The
management
of
tobacco
dependence
and
drug
abuse
is
assessed
on
the
following
parameters:
•
Cutturat
and
social
pressures
that
led
to
the
start
and
are
now
leading
to
the
abuse
of
tobacco
or
a
drug
•
Patient’s
motivation

190. Create
an
individuaUsed
pLan
for
the
patient
that
includes:
•
Detailed
smoking
history,
•
Assessment
of
degree
of
addiction
to
nicotine
or
the
drug
of
abuse
•
A
bio-psycho-sociaL
perspective
of
the
patients
smoking
or
abuse
patterns,Realistic
expectations
•
A
specific
date
to
quit.
The
physical
symptoms
of
nicotine
withdrawal
syndrome
subside
within
1
-3
weeks
but
the
psychotogical
addiction
lasts
much
Longer.
Nicotine
chewing
gum
and
tow
tar
cigarettes
can
be
used
as
alternatives
during
the
initial
phase.
The
withdrawal
state
with
stimulants,
solvents
and
opiates
may
last
for
one
to
two
weeks.
It
is
important
to
view
the
use
of
tobacco,
alcohol
and
drug
abuse
in
the
same
bracket.
All
three
can
cause
the
following
states:
i.
Addiction
ii.
Physical
and
Psychological
Harm
iii
Ever-increasing
Demand
iv,
Withdrawal
leading
to:
-
Tremors,
chills
-
Cramps
-
Emotional
problems
—
Cognitive
and
attention
deficits
—
Hallucinations
—
Convulsions
and
even
death.
The
tobacco,
alcohol,
and
drug
abuse
need
to
be
seen
as
disease
states
for
which
the
sufferer
requires
help
and
support.
A
medical
or
a
dental
stu
dent
who
is
challenged
by
these
disorders
may
initially
seek
counselling
and
support
from
the
behavioural
sciences
teacher
and
for
severer
forms
with
psychiatric
services.
Patients
should
be
encouraged
to
learn
and
practice
healthy
coping
skills
for
high
risk
situations
such
as
negative
mood
states,
sudden
boredom,
and
social
situations
that
cause
anxiety.
Many
medical
students
start
the
use
of
tobacco,
alcohoL
and
drugs
of
abuse
to
“learn
quickly”,
“stay
awake
for
longer
hours”,
improve
memory”,
and
sometimes
to
enhance
“sexual
pleasure.”
All
of
these
states
can
be
effec
tively
managed
through
physiological
and
healthy
means.
Drugs
of
abuse.
alcohol
and
cigarette
smoking
may
work
in
the
short
run
but
may
cause
serious
long
term
damage.
•
Simple
techniques
that
can
be
used
to
avoid
cigarette
smoking,
alcohol,
and
drug
abuse
include:
•
distraction,
•
detay,
•
not
giving
in
to
the
urge,
•
deep
breathing.

191. •
physical
exercise
•
escape.
•
positive
statements,
•
cognitive
restructuring
and
recommitting
to
the
benefits
of
quitting.
Physicat
exercise,
sports,
and
relaxation
techniques
have
been
found
to
be
particularly
effective
in
dealing
with
nicotine
withdrawaL
It
is
important
not
to
abandon
patients
of
tobacco,
drug
and
alcohol
abuse,
to
deal
with
their
challenges
all.by
themselves.
They
require
support.
guidance.
and
constant
patronage.
They
can
be
rescued
far
more
effectively
and
quickly
through
peer
and
social
support
accompanied
with
professional
help.
Con
stant
bickering,
criticism,
long
lectures
on
morality
and
hazards
of
smok
ing
and
drinking,
and
threats
for
dire
consequences
by
parents.
teachers,
elders,
and
friends
may
cause
more
damage
than
good.
The
Healing
Time
Line
A
realistic
look
at
how
long
takes
for
your
body
to
recover
after
your
last
puff
S
Tenyasro:
Yotntiskotat smoking- related
cancers
wxhaskerg, mouth,
and
moat
decreases
by
up
to
50
percent.
E
.Twenly minutes
alter
quitblng,
year
blood
pe0550re
decreases.
Eight
hours:
The
amount
of
carbon
non
snide
hr
yow
bleed
drops
bockto
normal
oxygen
increases
to
normal,
•
Fortysight
hours:
Your
nerve
endings
03rtlnregnO mate,
and
you
can
noelt
and
tunIC
things
bettor.
0we
year.
The
added
risk
of
heart
disease
decleses
to
half
of
that
of
a
smoker.
One
10
nine
months: Coughing. dew
csngen
bow,
larigue,
arid
diiorttmess
at
breath
decrease.
O
the
years:
Your
steths
risk
nsaybe
reduced
to
that
of
someone
Mrs
sever
nnohe4
)
Fifteen
years:
Yaw
rink
at
heart
disease
and
orioking’
retalod
death
is
nowskreiarto that
of
seone
one
who
never
nnoke
anawncavtnessocoooe

192. CNS
Depressants
CNS
Stimulants
Opiates
Cannabinols
c—a
•
mncNtJs
-
Umg
fectio
•
Lung
cancer
•
LOSS
Of
ihofttwn
m.mcry
concentration
and
abitract
tNnldng
•AnxI.ty.
Personality
disturbances
Daçx.sslrs
•
Aniotivadon
Syn
dmmW
set
of
parsonall
tychangeslh
which
users
less
active
and
ambitious
Unconcerned
about
th.
future
and
unwilling
or
unable
to
ma
long-tacos
plans.
•
Amotjvadoni
vyrrdrotr
•
Totersnc..
tolansory
end
other
peychologica
affects
occtan
es
icon
a
theseosrdorthkdd,of
auccaisjve
LSDw.
-Olthcets.dbyplbnlcal
hlurywhan
ISO
use
Impalrsjudgnsantegabout
trflcoraper
wn’sebllltytofly
nood
Barbiturates
Axnphetarninas
Morphine
HaShish
Nicotine
Long-term
•
Alcoholic
hepati
Effects
tis,
•
Peptic
ulcer
dis
ease
•cNs
damage
•
Pana.atith
•incraased
bid
denc.
otcaicer
of
head
nedcoe
sophagus,
stom
ad-i.
hepatic,co
ionk.
end
tI.aIg
cancer
•
Mak-,utrWon
•Fatigu.•Insomnla•
Sevrn
anxiety
•
immunosuppr.sslon
•
BizarneMoientbehatilour
•
Amphetaminepsychosis
•
chronic
contdpa
tion
•
Impairad
vision
-Mood
swings
Instability
•
As
tolerance
develops,
the
user
can
no
longerget
the
pleesurabie
effects,
but
must
continue
taking
the
drug
to
pie
vent
withdrawaL
•Wthrae:ç•1Nmo
4.upIa.H.adacb.

193. f
Suicide
and
Detiberate
Self
harm
(DSH)
All
patients
of
depression
must
be
screened
for
suicide
risk
as
go%
of
those
committing
suicide
or
deliberate
self
harm
are
suffering
from
a
psychiatric
illness.
It
is
one
of
the
top
10
causes
of
death
in
all
age
groups
and
one
of
the
top
3
causes
in
young
adults
and
teenagers.
Certain
risk
factors
are
particutarty
associated
with
completed
suicide
including:
•
Gender
(elderly
white
males
being
at
highest
risk),
•
Psychosis,
•
Alcoholism,
•
Chronic
physical
illness,
lack
of
social
support
and
use
of
generally
lethal
methods
in
the
past
(e.g.
Gun
rather
than
overdose
of
medication).
(For
more,
see
box)
Medical
students
and
young
doctors
may
be
reluctant
to
explore
suicid
al
ideation
in
the
mistaken
belief
that
asking
about
suicide
may
actually
increase
a
patient’s
risk
or
give
them
ideas
of
suicide.”
In
fact,
the
opposite
may
be
true.
Assessment
of
suicidal
tendencies
usually
reassures
patients,
reduces
anxiety
for
both
patient
and
doctor
and
facilitates
partnership
in
suicide
prevention.
The
assessment
should
begin
gradually
by
asking
questions
such
as
Sometimes
when
people
who
are
going
through
the
circumstances
that
you
are,
they
may
start
to
feel
like
life
is
not
worth
tiv
ingr
and
then
asking
more
specifically
about
a
history
of
suicidal
attempts.
any
specific
current
plans,
hopelessness
and
any
specific
current
inten
tions. Deliberate
self-harm
is
a
term
used
to
describe
an
act
in
which
an
individ
ual
deliberately
causes
injury
or
harm
to
themselves,
without
the
intent
to
commit
suicide.
This
may
be
in
the
form
of
cutting,
or
ingesting
substances
in
non-lethal
doses.
Where
doctors
globally
have
a
lower
mortality
rate
from
cancer
and
heart
disease
relative
to
the
general
population,
they
sadly
have
a
significantly
higher
risk
of
dying
from
suicide
[3].
In
fact,
according
to
a
survey
in
2015,
doctors
are
the
most
professionals
to
commit
suicide,
followed
closely
by
dentists.
The
leading
cause
of
this
is
the
prevalence
of
depression
in
med
ical
students
and
postgraduate
trainees.
Completed
suicide
is
also
more
prevalent
amongst
medical
professionals
partialLy
because
of
availability
and
access
to
lethal
means.
Medical
students
and
trainees
are
at
particular
risk
because
they
are
unlikely
to
report
a
history
of
depression.
Sadly.
even
when
it
is
reported,
it
may
be
neglected.
This
is
due
to
myth
that
people
who
ctaim
to
be
having
suicidal
ideas
are
not
likely
to
commit
suicide.
The
truth
is
67%
of
individuals
who
committed
suicide
had
confessed
to
some
one
that
they
wanted
to
kill
themselves.
The
famous
Urdu
saying
o
garajte
ham
wo
baraste
nahi’
is
untrue
when
it
comes
to
a
risk
assessment
of
sui
cide.
Any
suicidal
ideation
being
reported
should,
therefore,
immediately
be
considered
as
serious
and
requiring
intervention.
A
detailed
suicide
risk
assessment
must
be
carried
out
in
all
such
cases.
‘The
biggest
risk
of
sui
cide
is
a
direct
statement
of
intent”
[41
.
These
statements
should
never
be
ignored,
or
responded
to
with
statements
of
how
the
person
is
just
looking
for
attention”
or
‘doesn’t
reatly
mean
it.”

194. Protective
factors
of
suicide
Sane.
of
connectadneas
Having
Chfl*.n
Good
health
flestrictad
Access
to
means
•
U&.
gender
•
Early
adufrage
•
Psychological/emotionalproblems
•
P,dcal
health
problems
•Stranful
I
wants
•
Major
Depression
•4polerAfbctlveDbuitler•
Subetanc.abus.
plenrd.r
•
Antioclal
Personality
Dlsord.r
•
HLstoryofpsychlattlccare
•
Previous
5ulcldai
b.hauiow
•Slngh•
Separated
•
Family
conflicts
•
History
oFchUdhood
abuse
•Family
history
of
suicide
.
r
g.
DeLirium
Delirium,
also
referred
to
as
acute
confusional
state,
refers
to
an
acute
de
dine
in
consciousness,
cognition
and
attention.
There
is
an
incidence
of
up
to
55%
in
medicat
and
surgical
inpatients
12].
Presenting
Complaints
Families
rather
than
the
patient
may
request
help
because
the
patient
is
often
in
a
state
of
confusion
or
agitation.
Delirium
may
commonly
occur
in
patients
who
are
hospitalised
for
medical
conditions,
particularly
in
inten
sive
care
units
and
acute
surgical
units.
Diagnostic
Features
Delirium
is
characterised
by
its
sudden
onset
of
hours
or
days.
Confusion
is
often
present
and
patient
struggles
to
understand
surroundings.
The
following
neuropsychiatric
symptoms
are
common:
Individualised
Family
Related
Social
Environmental
Risk
Factors
Risk
Factors
Risk
Factors
Risk
Factors
•
Socioeconomic
..
Easy
access
to
methods
disadvantage
•
cuturaisuppcttersuicisie
•
Migrant
population
M.dio
UflernpbYrneflt
Suicide
among
peers
•Soc
•
Clouding
of
consciousness
•
Poor
memory,
•
Agitation,
•
Changi
ng/ftuctuating
emotions,
•
Loss
of
orientation,

195. •
Tremors
•
Nystagmus Asterixis
•
Urinary
incontinence
•
Wandering
attention,
•
Auditory
hallucinations
(hearing
voices
without
anyone
speaking),
•
Withdrawal
from
others,
•
Visions
or
illusions,
•
Suspiciousness
•
Disturbed
steep/reversal
of
steep
pattern.
Symptoms
often
develop
rapidly
and
may
change
from
minute
to
minute
and
hour
to
hour,
but
are
worse
at
night.
There
may
be
periods
of
clear
consciousness
or
lucid
intervals.
DeLirium
may
occur
in
patients
with
previ
ously
normal
mental
function
or
in
those
with
dementia.
Mild
stresses
such
as
medications
or
mild
infections
may
cause
delirium
in
the
elderly.
Dilferentiat
Diagnosis
Attempt
to
identify
and
correct
any
physical
causes
of
confusion.
Common
causes
include;
•
Alcohol
intoxication
or
withdrawal
•
Drug
intoxication
or
withdrawal
Cncluding
prescribed
drugs)
Severe
infections
•
Metabolic
changes
(e.g.
liver
disease,
uremia,
dehydration
electrolyte
imbalance,
alkalosis/
acidosis)
If
symptoms
are
persistent
and
delusions
and
disordered
thinking
predom
inates,
consider
Acute
Psychotic
Disorder.
Management
Guidelines
Informational
Care
Essential
information
for
patient
and
famity:
Strange
behaviour
or
speech
is
a
symptom
of
a
medical
ilLness;
as
primary
cause
is
treated,
patient
will
return
to
complete
normality.
Counsetting •
Take
measures
to
prevent
the
patient
from
harming
himself
or
others
(e.g.,
remove
unsafe
objects,
restrain
the
patient
if
needed).
Supportive
contact
with
familiar
people
can
reduce
confusion.
Visits
by
unfamiliar
individuals
should
be
stopped.
Provide
frequent
reminders
of
time
and
place
with
clocks
and
calenders
in
full
view
of
the
patient
to
reduce
confusion.
Place
the
patient’s
bed
facing
a
window,
trying
to
keep
tights
as
dim
as
possible
at
night.
Introduce
yourself
to
the
patient
even
if
you
are
a
close
friend
or
a
relative
of
the
patient.

196. Medication•
Avoid
use
of
sedative
hypnotic
medications
such
as
benzodiazepines
(except
for
the
treatment
of
alcohot
or
sedative
withdrawat).
•
To
controt
agitation,
prescribe
antipsychotic
medication
e.g.
hatoperidol
1-2
mg
by
mouth
or
by
injection
up
to
three
times
per
day.
SpeciaList
consuLtation
•
Patients
in
delirium
should
always
be
admitted,
preferably
in
intensive
care
settings.
Necessary
investigations
should
be
conducted
promptly
and
assistance
and
advice
from
consultant
physicians
should
be
urgently
sought,
for
diagnosis
and
management
of
underlying
cause.
•
Referral
to
psychiatrist
is
only
needed
if
residual
psychiatric
symptoms
are
seen
even
at
the
end
of
the
treatment
of
the
primary
cause
of
delirium.
References1
http://depts.washington.edu/mhreport/facts_violence.php
2.
Kaplan
&
Saddock’s,
Synopsis
of
Psychiatry
3.
Schernhammer
ES,
Co[ditz
GA.
Suicide
rates
among
physicians:
a
quanti
tative
and
gender
assessment
(meta-analysis).
American
Journal
of
Psychi
atry.
2004
Dec
;;;61(;2):22g5-3o2.
4.
Cowen
Philip,
Harrison
Paul,
Burns
Tom.
Chapter
16.
Suicide
and
Deliber
ate
self
harm.
fl:
The
Shorter
Oxford
Textbook
of
Psychiatry
6th
edn.

197. Chapter
7
Psychosocial
Aspects
of
Gender
and
Sexuality
The
World
Health
Organisation
defined
sexuality
as
a
central
aspect
of
being
human
that
encompasses
sex,
gender
identities
and
roles,
sexual
orientation,
eroticism,
pteasure,
intimacy
and
reproduction.
Sexuality
is
ex
perienced
and
expressed
in
thoughts,
fantasies,
desires,
betiefs,
attitudes,
vaLues,
behaviours,
practices,
roles
and
relationships.
While
sexuality
can
include
all
of
these
dimensions,
not
all
of
them
are
always
experienced
or
expressed.
Sexuality
is
influenced
by
the
interaction
of
biological,
psycho
logical,
sociaL
economic,
political,
cultural,
legal,
historicaL
religious
and
spiritual
factors.”
(WHO,
2006a).
In
society
at
large
and
since
the
beginning
of
time,
sexuality
and
the
fac
tors
associated
with
it
have
remained
a
source
of
taboo,
and
thus,
curiosity.
This
is
not
the
case
in
clinical
settings
where
health
professiOnals
are
often
faced
with
issues
related
to
gender,
psychosexual
issues,
sexual
dysfunc
tion
and
sexually
transmitted
disease.
While
the
medical
aspects
of
these
can
be
found
in
physiology
and
pathology
textbooks,
there
is
a
need
to
clarify
terms
in
use
and
the
provide
insight
into
how
to
manage
issues
of
such
a
delicate
nature.
As
health
professionals
we
may
feel
not
only
ill-equipped
to
handle
these
issues,
but
even
uncomfortable
in
speaking
of
them
without
educating
ourselves
on
the
matter.
This
chapter
aims
to
relieve
some
of
that
discomfort
by
educating
health
professionals
in
the
basic
factors
pertaining
to
human
sexuality.
Human
sexuality
depends
on
the
following
factors:
Sexual
identity
•
Gender
identity
•
Sexual
behaviour
Sexual
orientation
These
factors
are
also
known
as
psychosexual
factors
as
they
determine
the
interaction
between
personality
and
sexuality
in
a
human
being.
Sexuat
Identity
This
refers
to
the
biological
sex
of
the
individuaL
This
is
determined
by
chromosomes,
internal
and
external
genitalia
and
hormones.
Embryology
studies
show
that
alt
genitalia
in
both
XX
and
XY
embryos
is
initially
female.
The
presence
of
genes
such
as
SRY
and
SOXg
leads
to
the
production
of
androgens
which
then
cause
the
genitalia
to
differentiate
into
male
in
the
6th
week
of
life.
In
the
absence
of
these
genes
the
genitalia
devetops
and
differentiates
as
female.
In
normat
individuals
all
these
factors
may
fall
into
one
or
the
other
classi
fication
of
either
male
or
female.
In
individuals
with
ambiguous
genitalia,
or
chromosomal
abnormalities
such
as
Klinefelter’s
(XXY)
and
Turner’s
syn
drome
(XO)
this
may
not
be
the
case.
In
hermaphroditism
both
ovaries
and
testes
may
coexist
in
the
same
individual
white
having
a
genotype
of
46XX
or
46XY,
Virilising
adrenal
hyperplasia,
the
most
common
female
intersex
disorder
can
be
caused
by
an
XX
foetus
becoming
exposed
to
excessive
androgens.

198. “Z_z.
Gender
Identity
This
refers
to
how
individuals
identify
themselves
as
belonging
to
a
certain
gender.
This
is
most
often
retated
to
the
sexual
identity
of
the
individuaL
but
may
not
always
be
the
case.
The
gender
identity
that
an
individual
takes
on
is
determined
by
two
factors:
the
temperament
of
the
child,
and
his/hei
interaction
with
the
parents
and
their
attitude
towards
the
child.
The
gender
identity
of
a
child
is
often
solidified
by
the
time
they
are
three
years
of
age.
Children
are
now
placed
in
a
certain
category
of
boy
or
girl
and
treated
as
such.
This
is
often
seen
as
when
children
start
to
refer
to
themselves
with
gender
specific
pronouns.
They
give
statements
such
as
“Mai
nahi
khetta”
or
“Mai
nahijaoon
gi.
It
is
important
to
notice
here
that
these
statements
in
the
English
language
are
gender
neutrat,
which
helps
to
illustrate
the
influence
the
effects
culture,
language
and
sociat
factors
ptay
in
determining
gender.
Gender
identity
is
determined
largely
by
parental
inftuence
and
that
of
other
adutts
surrounding
the
child.
In
cultures
such
as
ours,
it
is
considered
extremely
important
that
the
child
be
placed
in
one
of
two
gender
categories
as
early
as
possible.
This
is
be
cause
this
may
be
in
many
cases
the
only
determinant
of
what
behaviour
is
expected
and
acceptable
in
a
child.
A
boy
child
may
cause
a
great
deal
of
concern
if
seen
playing
with
dolls,
while
it
may
be
laughed
off
when
a
girt
chitd
prefers
to
ride
her
bike
rather
than
play
‘ghar
ghar.
This
is
reversed
when
the
individual
reaches
puberty
as
this
is
considered
a
time
in
which
the
gender
of
the
individual
will
determine
what
is
appropriate.
Girls,
in
particular,
are
expected
to
dress
differently,
sit,
walk
and
eat
in
an
appro
priate
manner
and
become
more
aware
of
their
bodies
physically.
Boys
of
that
age
may
be
allowed
more
freedom
to
leave
the
house
while
girls
may
have
a
lesser
degree
of
it.
While
this
is
certainly
a
measure
adopted
for
the
security
of
the
child,
certain
measures
may
undermine
or
cause
dissatisfaction
with
the
gender
of
the
individual.
One
such
example
is
that
of
teenage
girls
being
allowed
to
leave
the
house
only
in
the
company
of
a
mate
relative,
even
if
the
male
is
younger
than
her.
In
the
same
way.
while
girls
may
often
be
allowed
to
express
all
their
emotions,
boys
are
expect
ed
to
remain
more
indifferent,
(“Larkay
rotay
nahi
ham”)
and
often
the
only
emotion
that
may
be
considered
acceptabte
is
aggression.
Research
reveals
that
children,
whether
boys
or
girls.
are
largely
similar
in
their
behaviour.
Some
notable
differences
are
that
boys
are
more
likely
to
exhibit
aggression
(both
physical
and
verbal)
than
girls.
Girls
are
also
less
likely
than
boys
to
throw
tantrums
after
a8
months
of
age.
Parents
often
bring
their
sons
to
health
professionats
due
to
concern
that
the
boy
“does
not
behave
like
a
boy.”
They
may
be
worried
that
the
boy
spends
mote
time
in
the
kitchen,
or
prefers
to
play
with
dolls
rather
than
cars.
In
situations
where
there
is
one
male
amongst
many
female
sibtings
this
becomes
more
common,
especially
in
the
absence
of
a
strong
father
figure.
The
male
child
has
only
female
modets
to
emulate
and
at
times
this
confusion
is
worsened
by
the
sisters
dressing
him
as
a
girl
and
a
lack
of
activities
considered
“boyish.”
These
children
may
be
ridicuted
for
being
effeminate
by
other
children
with
mote
definite
gender
identities.
Often
this
may
be
a
phase
in
a
child’s
tife
and
with
age
and
more
male
exposure
to
emulate
may
disappear.
Parents
should
be
discouraged
from
forcing
the
child
into
only
doing
what
they
consider
“gender
appropriate”
as
this
may
cause
significant
distress
and
according
to
research
yields
no
benefits
(Zucker
2006).

199. Sexuat
Behaviour
Certain
areas
of
the
brain
have
been
identified
as
ptaying
pivotal
totes
in
human
sexuality.
The
limbic
system,
as
previousty
mentioned,
is
involved
in
generating
emotion
and
sexual
desire.
This
has
been
determined
in
studies
in
which
electrical
or
chemical
stimulation
of
hippocampus,
the
preoptic
area,
anterior
thalamic
nuclei
resulted
in
penile
erections.
During
orgasm,
female
brain
areas
involved
in
anxiety
and
feat
showed
significantly
[ow
activity. The
regulation
and
processing
of
sexual
desire
and
stimuli
is
conducted
by
the
cerebral
cortex.
The
prefrontal
cortex
is
involved
in
the
inhibition
of
sexual
impulses.
white
the
orbitoftontat
cortex
processes
emotional
input
from
the
amygdala.
Right
caudate
nucleus
activity
factors
into
the
determination
of
whether
arousal
will
lead
to
sexual
activity.
The
left
anterior
cingutate
cortex
ptays
a
role
in
the
sexual
arousaL
as
well
as
hormonal
controt.
Afferent
input
from
the
pelvic,
pudendal
and
hypogastric
nerves
conveys
sensory
stimuli
to
the
spinal
cord,
where
arousal
and
orgasm
are.
Sexual
reftexes
are
mediated
in
the
lumbosacral
segments.
Neurotransmitters
that
play
a
role
in
sexual
function
include
serotonin,
dopamine,
oxytocin,
norepinephrine
and
epinephrine.
Oxytocin
is
released
following
sexual
activity
and
leads
to
bonding
between
sexual
partners,
as
wetl
as
feelings
of
contentment,
calmness
and
security.
Stimuli
that
increase
dopamine
increase
sexual
desire.
Inhibition
of
sexual
function
is
mediated
by
serotonin
released
by
the
pons
and
the
midbrain.
Certain
hormones
have
long
since
been
known
to
mediate
sexual
be
haviour.
Chief
amongst
these
are
testosterone
and
oestrogen.
In
both
mates
and
females,
testosterone
is
known
to
increase
sexual
desire.
Oestrogen,
in
females
teads
to
increased
sensitivity
to
sexual
stimulation
and
teads
to
lubrication
caused
by
arousaL
Progesterone.
cortisol
and
excessive
prolactin
lead
to
decreased
sexual
desire.
Gender
differences
in
SexuaL
Behaviour
Contrary
to
myths
regarding
the
matter,
men
and
women
both
experience
sexual
desire
(Hyde
2005).
Men,
however,
tend
to
experience
a
greater
frequency
of
sexual
thoughts,
and
readiness
to
engage
in
sexual
activity.
It
must
be
stated
here
thatdue
to
human
socialisation,
sexual
desire
may
not
be
the
only
reason
to
engage
in
sexual
activity.
This
is
especially
true
for
women.
Women
are
more
tikely
to
engage
in
sexual
contact
(even
in
the
absence
of
desire
to
do
so)
for
reasons
such
as
pleasing
and
maintaining
the
interest
of
their
partner,
as
welt
as
establishing
a
closer
relationship.
It
is
also
important
to
note
that
in
women
physiological
arousal
may
not
always
coincide
with
a
subjective
sense
of
arousal
or
a
desire
to
indulge
in
sexual
activity,
That
is
to
say,
physiological
sexuat
arousal
in
women
cn
occur
independently
of
psychological
arousal.
Men
and
women
differ
in
the
determination
of
their
sex
drive
(Baumeis
ter,
2000).
In
men
sex
drive
appears
to
be
biologically
determined,
white
in
women,
factors
such
as
cultural
background,
education,
religion
and
parenting
all
may
play
a
part.
Furthermore
in
culfures
such
as
ours,
wom
en
may
indulge
to
hold
on
to”
their
male
counterparts,
as
they
have
their
sense
of
security
(financial
and
otherwise)
invested
in
the
mate
partner.

200. MasturbationNo
other
form
of
sexual
activity
has
been
more
frequently
discussed,
more
roundly
condemned,
and
more
universally
practiced
than
masturbation.
-
Kaplan
and
Saddock,
Synopsis
of
Psychiatry
Masturbation
refers
to
the
physical
stimulation
of
genitalia
by
oneself
for
sexuat
pteasure.
This
is
a
normal
part
of
psychosexual
devetopment.
It
is
an
activity
shrouded
in
shame
and
mystery
despite
the
fact
that
nearly
all
post-pubescent
males
and
up
to
three
fourths
of
females
indutge
in
it
(Kinsey).Children
become
aware
of
their
genitalia
just
as
they
become
aware
of
their
other
body
parts.
Upon
reaching
puberty.
however,
due
to
the
in
crease
in
sex
hormones
and
development
of
secondary
sexual
characteris
tics,
masturbation
may
become
a
regular
activity.
Myths
and
misconceptions
such
as
“masturbation
may
result
in
loss
of
sexual
prowess
and
potency”
and
“masturbation
can
cause
mental
illness”
or
“masturbation
may
result
in
a
loss
of
manhood
and
mate
virility”
abound,
especially
in
our
culture.
There
is
no
scientific
evidence
to
support
these
claims.
Masturbation
is
a
symptom
of
an
emotional
disturbance
(not
a
sexual
one)
only
if
it
results
in
the
individual
losing
control
and
compulsively
indulging
in
it
ho].
SexuaL
orientation
According
to
the
American
Psychological
Association,
sexual
orientation
refers
to
the
sex
of
those
to
whom
one
is
sexuatly
and
romanticatl.y
attract-
ed.
For
the
majority
of
the
population
(according
to
census
data
worldwide)
sexuat
orientation
is
heterosexual
i.e.
individuals
are
attracted
to
the
oppo
site
sex.
Statistics
suggest
that
about
1-5%
of
the
population
of
the
world
has
different
sexual
orientations.
This
number
may
be
understated,
how
ever,
given
government
and
religious
taws
banning
homosexuality
in
most
parts
of
the
world.
This
may
be
homosexual,
i.e
attraction
to
the
same
sex,
bisexual,
i.e
attraction
to
both
genders
and
asexual,
i.e
no
sexual
attrac
tion.
Another
subset
of
individuals
exists,
who
feel
that
sexuality
cannot
be
labelled.
These
individuals
refer
to
themselves
as
“queer”
or
pansexual
or
polysexual.
Some
research
indicates
that
for
some
individuals,
sexual
orientation
may
be
fluid.
This
may
be
especiatly
true
for
women
(e.g..
Dia
mond,
2007;
Golden,
1987;
Peptau
&
Garnets,
2000),
As
of
July
2015,
72
countries
and
five
sub-nationaljurisdictions
have
laws
criminaUzing
homosexuality.
A
majority
of
these
countries,
inctuding
Paki
stan
are
in
Asia
and
Africa.
According
to
Darwin,
natural
selection
dictates
that
any
variations
that
occur
have
to
be
‘useful
to
man’
i.e.
they
must
aid
in
an
organism’s
struggle
for
survival
and
procreation.
Homosexuality
defies
laws
of
natural
selection
by
preventing
procreation
due
to
same-sex
sexual
behaviour.
Despite
this,
it
remains
a
stable
population
level
trait
in
humans
and
animals,
resulting
in
a
so-catted
Darwinian
“paradox.”
Evolutionary
models
propose
that
genes
influencing
homosexuality
have
a
reproductive
benefit
on
heterosexual
carriers
of
the
gene
121.
This
may
be
the
reason
that
homosexuality
continues
to
persist.

201. In
2006,
a
study
found
that
human
sexual
preference
has
a
significant
ge
netic
component.
[41.
It
was
also
seen
that
biological
and
congenital
factors
regulate
human
sexuatity
13].
These
findings
were
corroborated
in
a
study
2015,
in
which
a
Large
scate
genome-wide
scan
resulted
in
findings
that
support
the
existence
of
genes
on
chromosome
8
and
Xq28
influencing
the
development
of
mate
sexual
orientation.
ti]
.
Another
study
found
linkage
between
male
sexual
orientation
and
markers
on
the
X
chromosome
of
the
mother
in
some
famities.
The
study
found
that
the
X
chromosome
played
a
role
in
regutating
sexuat
orientation
in
a
subgroup
of
homosexual
males
[41.
Some
studies
indicate
females
with
hyperadrenocorticalism
are
more
likely
to
be
homosexual
as
welt
as
bisexual
than
the
general
population.
Research
in
this
field
has
been,
for
the
most
part,
inconclusive.
This
may
he
due
to
the
tack
of
definitive
samples,
the
abstract
concept
of
attraction
or
the
taboo
associated
with
nonheterosexuality.
Continued
research
efforts
are
required
to
enhance
understanding
of
the
genetics
factors
affecting
human
sexuality.
Psychiatric
morbidity
Research
shows
that
non-heterosexual
individuals
are
more
likely
to
suffer
from
poor
general
health
[71.
They
are
also
twice
as
Likely
to
suffer
from
depression,
panic
disorder,
generatised
anxiety
disorder
and
have
a
higher
risk
of
suicide
[51181.
This
is
especially
true
for
younger
adults
[6].
They
also
have
significantly
higher
rates
of
alcohol
dependency
and
drug
abuse
Ig].
One
factor
in
this
is
of
course,
the
societal
pressures
and
religious
taboo
associated
with
non-heterosexuality.
Due
to
this
taboo,
such
individuals
may
often
present
to
a
health
professional
with
medically
unexplained
symptoms,
and/or
severe
depression
and
anxiety.
Sexuat
Disorders
According
to
the
International
Classification
of
Disease,
Tenth
Edition,
sex
ual
disorders
encompass
three
categories:
sexual
dysfunction
(not
caused
by
organic
disorders),
disorders
of
sexual
preference
(paraphilias)
and
gender
identity
disorders
(gender
dysphoria).
These
are
of
importance
due
to
the
higher
number
of
psychiatric
morbid
ities
associated
with
them.
These
individuals
are
more
likely
to
suffer
from
anxiety,
depression
and
somatoform
disorders.
They
also
have
higher
risks
of
suicide
and
deliberate
self-harm.
Often
the
clinical
presentation
may
he
that
of
persistent
headache,
backache,
abdominal
discomfort.
and
gener
alised
aches
and
pains.
Low
mood
and
other
depressive
features,
especially
guilt
and
severe
anxiety
may
he
present.
SexuaL
Dysfunction
Sexual
dysfunction
occurs
when
there
is
inability,
difficulty
or
pain
involving
sexual
intercourse.
This
includes
disorders
such
as
those
described
in
the
table
above,
The
presence
of
any
sexual
dysfunction
is
a
difficult
situation
for
not
just
the
individual
but
also
the
sexual
partner.
In
cases
where
the
dys
function
is
severe
enough
to
not
allow
for
consummation
of
the
marriage
or
lead
to
reproductive
problems.
the
entire
family
may
become
involved.
This
can
be
a
source
for
great
discomfort
for
the
individual.
This
is
especially
true
for
males
as
they
are
expected
to
be
‘more
informed’
in
the
sexual
act
and
all
its
nuances),
even
if
they
have
no
prior
experience.
Also
in
males,
sexual
prowess
or
lack
thereof,
is
closely
connected
to
their
self-esteem.

202. This
makes
it
much
harder
to
confront
a
problem
and
seek
help
for
it..
n
females,
this
is
tess
often
the
case.
Due
to
the
taboo
and
emphasis
attached
to
virginity,
however,
they
may
be
poorLy
acquainted
with
their
own
anatomy.
as
well
as
poorly
educated
about
the
sexual
act
and
its
stages.
variations,
and
nuances.
Most
health
professionals
may
feel
embarrassed,
uncomfort
able
or
nervous,
while
talking
to
and
managing
such
patients.
especially
f
they
are
the
opposite
gender.
It
is
important
here
to
remind
oneself
of
the
neutrality
of
one’s
gender
in
a
clinical
situation.
One
is
neither
a
ternate
nor
a
mate
in
the
white
coat,
simply
a
heater.
This
situaton
is,
thus,
best
approached
as
one
would
approach
an
invasive
physical
examination:
begin
by
informing
the
patient
that
you
would
like
to
discuss
their
sexual
problem
in
further
detail.
Acknowtedge
that
they
might
feel
uncomfortable
but
that
as
a
doctor
you
are
only
asking
to
understand
the
problem
better
and
provide
evidence
based
solutions.
Encourage
the
individual
to
be
as
frank
as
possible.
Provide
frequent
reassurances,
Remember
to
reiterate
that
laws
of
confidentiality
apply
and,
therefore,
you
cannot
share
any
of
the
information
they
give
you
with
anyone
thout
their
consent.
Often
mild
to
moderate
problems
of
sexual
dysfunction
may
be
solved
with
an
open,
frank
and
honest
informational
care
session
in
which
expec
tations
are
managed
and
fears
and
anxieties
acknowtedged
and
discussed.
In
the
absence
of
organic
causes,
severe
cases
of
sexual
dysfunctions
are
best
managed
by
a
psychiatrist,
and
a
referral
must
be
made
Disorders
of
SexuaL
Preference/
Paraphitias
As
previously
discussed,
a
major
determinant
of
sexuality
and
what
is
ac
ceptable
is
society
and
culture.
Paraphitias
refers
to
sexual
acts
or
interests
that
are
considered
abnormal
by
society,
According
to
Diagnostic
and
Sta
tistical
Manual
of
Mental
Disorders.
5th
ed.2o;5,
these
disorders
collectively
involve
“any
intense
and
persistent
sexual
interest
other
than
sexual
interest
in
phenotypicatly
normal,
physically
mature,
consenting
human
partners.”
Individuals
suffering
from
these
disorders
are
onty
able
to
achieve
Sexual
Dncti
Sexual
desire
disorders
Sexual
arousal
dIsorders
Or5asm
disorders
Premature
Ejaculation
Sexual
pain
disorders
Sahibrdonism
Fetishism
Paedophilia
Sadomasochism
FetishiStic
transvestitIsm
L
L

203. sexual
pleasure
from
performing
abnormal
sexual
acts.
This
does
not
inctude
people
who
may
hve
abnormal
sexual
thoughts;
only
those
that
behave
and
iridulge
in
abnormal
sexuat
acts.
Some
of
these
disorders
are
considered
punishable
by
law,
according
to
the
Pakistan
Penal
Code.
As
such,
if
a
health
professional
is
confronted
with
a
situation
in
which
the
patient
is
a
perpetrator
of
such
an
act,
confidentiality
must
be
breached
and
the
individual
reported,
especially
if
a
human
victim
is
invoLved.
There
are
two
main
types
of
disorders
of
sexual
preference:
i)
Disorders
reLating
to
the
object
of
sexuat
interest.
2)
Disorders
relating
topreferences
in
the
sexual
act.
Disorders
relating
to
the
objectbf
sexual
interest
include
paedophilia,
objectophilia
and
fetishism.
These
involve
sexual
interest
being
directed
towards
children,
inanimate
objects,
animals
or
non-consenting
humans.
Disorders
relating
to
the
abnorml
preferences
in
the
sexual
act
include
sadomasochism,
exhibitionism
and
voyeurism.
Such
individuals
are
able
to
achieve
sexual
pleasure
only
from
either
causing
or
receiving
painful
stim
uli,
exposing
themselves
inappropriately
or
observing
the
sexual
activities
of
others.
I.
These
disorders
are
best
managed
by
a
mental
hea[th
professional,
and
an
urgent
referral
must
be
made.
4
I
Gender
Dysphoria
(DSM
V)
or
Gender
Identity
Disorder
(lCD
io)
According
to
Robert
Stotter
gender
is
socia[
and
sex
biologicaL:
“Most
often
the
two
are
relatively
congruent,
that
is,
males
tend
to
be
manly
and
females
womanly.”
In
some
individuals,
however,
this
may
not
be
the
case.
An
individual
who
is
biologically
male,
may
feel
like
“a
woman
trapped
in
a
man’s
body
and
vice
versa.
Transgender
individuals
experience
what
is
referred
to
as
“gender
dysphoria”
in
the
Diagnostic
and
Statistics
Manual,
Fifth
Edition.
Individuals
who
are
transgender
may
biotogically
be
one
sex
but
identify
as
the
other,
i.e
there
is
a
discord
between
the
gender
they
have
been
assigned
and
the
gender
they
experience
or
feel
themselves
to
be.
The
International
Classification
of
Disease,
ioth
revision
refers
to
this
as
Gender
Identity
Disorder.
The
term
transgender
encompasses
those
who
-
are:
a)
Transsexual:
individual
who
prefer
to
have
the
body
of
the
sex
opposite
to
their
own.
b)
Gender-queer:
Individuals
who
prefer
to
belong
to
neither
gender
c)
Cross-dressers
(Dual
Transvestitism):
Individuals
who
identify
with
their
biotogicat
sex,
yet
prefer
to
dress
in
clothes
of
the
other
gender.
They
do
not
wish
to
change
genders.

204. Management
of
Gender
and
Sexuatity
Issues
Some
say
that
sexuot
orientation
and
gender
identity
are
sensitive
issues.
I
understand.
Like
many
of
my
generation,
I
did
not
grow
up
totking
about
these
issues.
But!
teamed
to
speat’
out
because
tives
are
at
sta1’e,
and
be
cause
it
is
our
duty
under
the
United
Nations
Charter
and
the
Universat
Declaration
of
Human
Rights
to
protect
the
rights
of
everyone,
everywhere.’—
UN
Secretary-Generat
Ban
Ki-moon
to
the
Human
Rights
Council,
7
March
2012
In
the
management
of
atl
clinical
problems,
a
health
professional
is
ex
pected
to
react
with
empathy.
Often
in
issues
related
to
gender,
however,
socialisation,
religious
beliefs
and
stigma
may
make
t
extremely
difficult
to
do
so.
The
doctor
may
find
themselves
at
a
loss
as
to
how
to
put
them
selves
in
the
shoes
of
an
individualwho
is
dealing
with
gender
dysphoria
or
issues
with
their
sexuality.
In
such
a
situation,
the
most
important
emotion
that
a
health
professional
can
express
is
compassion.
A
health
profession
al’s
presence
may
be
the
only
place
where
an
individual
with
these
issues
can
expect
to
not
to
be
judged.
In
most
clinical
situations
related
to
gender
and
sexuality
issues,
non-judgemental
compassion
and
giving
the
patient
room
to
express
their
fears
and
problems
may
be
the
only
intervention
re
quired.
It
is
also
important
at
this
juncture
to
remind
oneself
of
the
role
as
a
health
professional,
rather
than
a
member
of
a
particular
society
or
culture.
The
individual
who
has
presented
to
a
health
professional
is
not
looking
for
a
personal
opinion,
a
religious
judgement
or
an
argument.
The
health
professional
is
equipped
only
to
treat
any
health
related
issues
and
should
limit
their
interaction
to
this
alone.
It
must
be
added
here
that
according
to
the
ioth
revision
of
the
International
Statistical
Ctassification
of
Diseases
and
Related
Health
Problems
((CD-b):
“Sexual
orientation
alone
is
not
to
be
regarded
as
a
disorder.
Individuals
who
are
nonheterosexuat
(homosex
uals
and
bisexuals)
are,
however,
as
mentioned
earlier,
at
a
higher
risk
for
developing
psychiatric
morbidities.
If
signs
of
a
major
depressive
or
anxiety
disorder,
or
risk
of
suicide
are
present,
the
individual
must
be
referred
to
a
psychiatrist
urgently.
In
all
patients
with
such
issue,
on
account
of
the
high
risk
of
suicide,
it
must
be
directly
enquired
if
the
individual
is
having
suicid
al
thoughts
or
has
made
any
attempts
in
the
past
(See
Section
D).
Again,
this
merits
an
urgent
referral
to
a
psychiatrist.
I.
I

205. References 1.
Sanders
AR,
Martin
ER,
Beecham
GW,
Guo
5,
Dawood
K,
Rieger
G,
Bad
nerJA,
Gershon
ES,
Krishnappa
RS,
Kolundza
AS,
Duan].
Genome-wide
scan
demonstrates
significant
linkage
for
male
sexual
orientation.
Psychotogicat
medicine.
2015
May
1:45(07):1379-88.
2.
Burn
A,
SpectorT,
Rahman
Q.
Common
genetic
factors
among
sexual
orientation,
gender
nonconformity,
and
number
of
sex
partners
in
female
twins:
ImpLications
for
the
evolution
of
homosexuality.
The
journal
of
sexual
medicine.
2015
Apr
1;12(4):1004-11.
3.
Jannini
EA,
Burn
A,
Jern
P.
and
Nove[ti
G.
Genetics
of
human
sexual
be
havior:
Where
we
are,
where
we
are
going.
Sex
Med
Rev
2015;3:65-77.
4,
Bocktandt
S,
Horvath
5,
Vilain
E,
Hamer
DH.
Extreme
skewing
of
X
chro
mosome
inactivation
in
mothers
of
homosexual
men.
Human
Genetics.
2006
Feb
1:118(6):691-4.
5.
Prajapati
AC,
Parikh
S,
Bala
DV.
A
study
of
mental
heatth
status
of
men
who
have
sex
with
men
in
Ahmedabad
city.
Indian
journal
of
psychiatry.
2014
Apr:56(2161.
6.
Bränström
R,
Pachankis
JE.
Hatzenbuehler
ML.
Sexual
orientation
differ-
ences
in
mentaL
health
morbidity:
A
population-based
longitudinal
study.
The
European
Journal
of
Public
Health.
2015
Oct
1:25(suppl
3):ckVl74-062,
7.
Fredriksen-Gotdsen
KI,
Emlet
CA,
Kim
HJ,
Muraco
A,
Erosheva
EA,
Gold-
sen
J,
Hoy-Ellis
CP.
The
physical
and
mental
health
of
lesbian,
gay
male,
and
bisexuat
(LGB)
o[der
adults:
The
rote
of
key
health
indicators
and
risk
and
protective
factors.
The
Gerontologist.
2013
Aug
1:53(4):664-75.
8.
Cochran
SD,
Sullivan
JG,
Mays
VM.
Prevalence
of
mental
disorders,
psychological
distress,
and
mental
health
services
use
among
lesbian,
gay,
and
bisexual
adults
in
the
United
States.
Journal
of
consulting
and
clinical
psychology.
2003
Feb;71t1):53.
9.
Cochran
SD,
Mays
VM.
Relation
between
psychiatric
syndromes
and
behavioraLly
defined
sexual
orientation
in
a
sample
of
the
US,
population.
American
Journat
of
Epidemiology.
2000b;151:516-523.
[PMC
tree
artictel
tPubMedl io.
Kaplan
and
Saddock
Synopsis
of
Psychiatry,
Eleventh
Edition,
page
570.
V

206. Chapter
8
Psychosocial
Aspects
of
Pain
Was
it
onLy
a
tooth
ache?
Mrs
H
was
a
Pathan
tady
married
into
a
Punjabi
family.
In
the
third
year
other
marrJagMrsJ±devetaped
pain
in
her
upper
jaw
She
initially
used
house
hotd
remedies
for
a
few
days
without
any
retief
She
then
saw
a
dentist
who
advised
a
tooth
extraction
of
the
third
tett
upper
molar
which
was
decaying.
She
experienced
temporary
relief
but
the
pain
persisted
and
started
to
radiate
towards
the
teft
ear
and
eye.
The
dentist
gave
her
short
courses
of
parac
etamot,
aspirin,
and
mefenamic
acid,
but
nothing
worked.
She
then
referred
her
to
the
eye
and
ENTspeciatists.
No
abnormalities
were
tound
and
she
came
home
with
escriptiOtis
of
more
pain
killers.
Many
months
passed.
yet
Mrs
H
was
not
relieved
of
her
pain.
She
then
saw
a
physician
who
discussed
her
pain
in
greater
detaiL
Mrs
H
described
her
pain
as
“dull,
and
disgusting.”
The
physician
then
asked
about
the
symptoms
that
were
associated
with
her
chronic
pain
in
the
jaw.
Mrs
H
readily
expressed
that
she
has
had
disturbed
steep,
a
change
in
appetite,
and
has
become
irritabte
and
angry
The
sensi
tive
physician
asked
her
about
her
domestic
circumstances
and
personal
life.
He
found
out
that
Mrs
H
had
a
difficult
mother-in-tow
and
a
husband
who
did
not
find
Mrs
H
attractive
anymore.
Mrs
H
broke
into
tears
during
the
interview
and
totd
the
doctor
that
she
was
Ted
up”
with
life
and
often
wished
for
death.
A
detailed
assessment
revealed
a
diagnosis
of
depressive
disorder
Mrs
H
was
counselled
and
placed
on
Amitnptytine,
a
type
of
antidepressant,
for
six
months.
The
doctQr
involved
Mr
H
and
the
family
in
the
care
plan
to
mobilise
emotional
and
sociat
support
for
Mrs
H.
Within
six
weeks,
Mrs
H’s
pain
was
gone
and
she
was
symptom
free
at
the
end
of
the
six
month
period.
She
then
managed
to
form
a
fairly
loving
relationship
with
hr
husband
and
a
ret
ation
ship
based
on
mutual
respect
and
healthy
communication
with
her
mother
in-law.It
is
fairly
well
established
now
that
pain
is
not
a
straight
forward
specific
sensation
that
is
transmitted
from
the
periphery
to
the
brain
by
a
simple
transmission
system.
Instead
it
is
a
‘complex
perceptual
and
affective
(emotional)
experience
determined
by
the
unique
past
history
of
the
individuaL
by
the
meaning
of
the
injurious
agent
or
situation
that
s/he
ascribes,
by
the
state
of
mind
at
the
moment,
and
the
sensory
nerve
pat
terns
that
evoked
physical
stimulation”
(Gregory.
1987).
Such
an
approach
wouLd
suggest
that
‘pain’
has
two
aspects,
a
sensory
and
an
affective
(emotional)
one.
It
is
primarily
the
affective
aspect
which
imparts
the
un
pleasant
quality
to
pain
and
is,
therefore,
of
greater
ctinicat
significance.
In
the
case
of
Mrs
H,
mentioned
above,
for
example,
the
pain
did
not
respond
to
analgesics
alone
and
a
combination
of
antidepressant
medication
and
psychosocial
support
relieved
the
chronic
jaw
pain.
The
cognitive
dimen
sion
greatly
influences
the
patient’s
reaction
to
pain
as
welt
as
attempts
at
analgesia,
both
in
the
short
and
in
the
long
term.
The
psychology
of
pain.
therefore.
revolves
around
its
affective,
motivational
and
cognitive
aspects.

207. Factors
that
influence
the
content,
and
the
quality
of
psychological
correLates
of
pain
are:
•
intensity
of
pain,
•
meaning
of
the
pain
to
the
individuat,
(which
in
itself
is
influenced
by
the
location
and
quality
of
pain),
•
personality
traits
of
the
individual,
•
psychosocial
factors
at
home
and
at
work,
•
past
psychiatric
morbidity
•
cultural
settings
of
the
patient.
Psychosocial
aspects
of
pain
are
different
in
different
kinds
and
types
of
pain: i.
Acute
pain
The
subjective
experience
of
acute
pain
is
distinctly
unpleasant.
The
emo
tional
content
of
such
pain
can
be
judged
by
the
descriptions
used
by
the
sufferer.
“Wretched”,
“excruciating’.
“boring”,
‘sickening”
(‘dull
and
disgust
ing”
in
the
case
of
Mrs
H)
are
few
of
the
words
used
in
the
expression
of
pain.
White
the
sensory
words
communicate
a
somatic
sensation
that
can
be
at
least
vaguely
tocalised
to
part
of
the
body,
the
emotional
words
(e.g.,
pounding,
throbbing,
terrifying,
killing)
do
not
point
to
a
specific
region.
These
describe
an
emotion
instead.
Anxiety
is
another
correlate
of
this
kind
of
pain,
characterised
by
a
feeling
of
impending
disaster
and
dread.
•
Patients
with
repeated
episodes
of
acute
pain
often
have
traits
of
anxiety
in
their
premorbid
personatity.
They
may
require
more
analgesic
medication
after
surgery
than
other
patients.
Relief
of
anxiety
by
employing
reassur
ance,
instilling
a
sense
of
control
and
the
use
of
anxiotytics
contribute
to
analgesia
in
an
acute
episode
of
pain.
ii.
Chronic
pain
Various
psychoLogical
abnormalities
have
been
described
in
patients
with
chronic
pain.
The
exact
‘cause
and
effect’
relationship
between
chronic
pain
and
associated
psychological
morbidity
remains
to
be
established.
Studies
have
shown
presence
of
clinical
depression
in
over
75%
of
patients
with
chronic
lower
backache.
A
change
in
the
form
of
constant
preoccu
pation
with
the
pain,
seeking
repeated
medical
check-ups
and
radiolog
ical
and
laboratory
.investigations,
often
just
for
reassurance
is
commonly
seen
amongst
such
patients.
The
chronic
pain
attains
a
central
position
in
the
sufferer’s
life.
S/he
loses
interest
in
extracurricular,
social,
intellectual
and
spiritual
pursuits.
Patients
of
chronic
pain
often
seem
to
lose
interest
in
family
and
friends,
while
their
dependence
on
them
for
physicat
and
emotional
support
increases.
Loss
ofjob,
financial
worries
and
substantial
hospital
bills
worsen
the
already
grim
picture.
Poor
self-esteem,
a
state
of
boredom
and
unhappiness,
follow
as
a
prelude
to
severe
depression
which
can
at
times
result
in
deliberate
self-harm
or
even
suicide,
Disturbances
of
sleep,
changes
in
appetite
and
undue
irritability
are
often
seen
in
patients
of
chronic
pain
(as
in
Mrs
H).

208. •
Insomnia
•
Anorexia
•
Constipation
•
A
feeling
of
indigestion
-
Gases
•
Lethargy
•
Exhaustion
•
Fatigue
Presence
ot
such
a
symptort
complex
is
associated
with
poor
pain
toler
ance
drid
these
patierts
run
a
higher
risk
of
developing
chronic
pain.
The
commonest
sites
for
chronic
pain
are
the
precordium.
genitals,
face
and
the
cranium,
Females
are
twice
as
more
prone.
Pain
is
virtualLy
contin
uous
white
the
patient
is
awake,
yet
never
wakes
him/her
from
steep.
The
site
of
pain
cisualty
has
a
symbolic
significance
for
the
patient.
It
responds
k
to
analgesics
Backache,
a
common
site
for
chronic
pain.
may
be
aggia’ated
by
underlying
negative
emotions
such
as
unexpressed
anger.
h
ust
ation.
jealousy
or
chronic
psychiatric
disorders
such
as
depression
.nd
anxiety.
The
characteristic
of
such
pain
is
that
it
is
usually
manifested
in
the
extensor
groups
of
muscles.
Fibromyalgia
is
another
common
entity
which
reveals
itself
in
the
form
of
chronic
widespread
pain,
fatigue
and
?‘(
essive
pain
in
response
to
tactile
pessure
and
is
precipitated
by
stress
md
other
psychotogicat
factors.
iv.
Psychogenic
pain
disorder
ihere
is
a
proportion
of
patienls
whose
pain
and
associated
symptoms
do
not
fit
any
of
the
known
psychiatric
morbidities.
The
term
used
for
such
patiei
its
is
‘Psychogenic
Pain
Disorder’
and
it
has
its
own
diagnostic
criteria.
The
pain
in
these
cases
does
not
originate
in
response
to
a
noxious
stim
ulus
or
a
pain
transmission
anomaly.
nor
is
it
secondary
to
a
demonstrable
underl.,’ing
psychiatric
/
structLiral
illness.
It
has
a
mechanism
similar
to
hallucnation,
dreams
or
has
ioots
in
the
psychotogicat
development
of
the
individual.
Psychodynamic
mudets
in
the
Freudian
tradition
and
learn
iiig
theories
have
been
proposed
to
explain
this
disorder
but
both
remain
speculative.
It
is
also
suggested
that
psychogenic
pain
could
be
mereLy
a
hieiqhtuned
response
to
somatin
pain
seen
in
certain
predisposed
individ
cials
and.
therefore.
may
not
need
to
he
considered
a
separate
entity.
It
is
rolunqecl
and
severe
and
inconsistent
with
anatomical
distribution
PsychotogicaL
symptoms
in
chronic
pain
Chronic
pain
is
often
associated
with
psychiatric
morbidity.
Chronic
pain
has
been
proposed
as
a
symptom
of
various
psychiatric
conditions,
es
pecially
in
cultures
with
a
poor
recognition
and
awareness
of
psychotog
ica[
symptoms.
People
without
a
known
cause
of
chronic
pain
have
been
shown
to
have
a
higher
prevalence
rate
of
depression,
as
compared
to
those
with
painful
disorders
such
as
rheumatoid
arthritis.
Dyssomnias
tabnorrnatities
of
pattern
of
sleep).
loss
of
libido
and
sociaLwithdrawalwere
more
common
and
more
se\Jere
in
this
group.
These
patients
also
have
a
higher
percentage
of
positive
family
history
for
mental
illness
and
often
have
a
physically
abusive
spouse.
Emotional
conflicts
are
also
common
features.
The
foLlowing
somatic
expressions
of
depressive
features
are
often
seen
in
patients
with
chronic
pain.

209. of
the
nervous
system.
The
onset
of
psychogenic
pain
disorder
is
related
to
environmentaL
stress.
v.
Pain
behaviour
(sick
rote)
If
the
patient
has
adopted
the
sick
rote
and
pain
has
become
a
behaviour
rather
than
a
symptom.
the
following
features
start
to
determine
the
inten
sity.
type
and
location
of
pain:
•
Functional
disabilities,
•
Overuse
of
medications.
•
Sleep
disturbances
•
Decreased
social
activities
The
typical
behaviour
pattern
in
such
cases
is
a
new
unhealthy
lifestyle
characterised
by
avoidance
based
on
the
feat
of
pain
and
reinforcement
of
passive
learning.
This
involves
the
individual
being
in
too
much
pain
to
work/study/indulge
in
physical
activity
but
fine
while
watching
TV,
reading
or
indulging
in
other
passive
pastimes.
Psychological
management
of
pain
The
aim
of
psychological
management
of
pain
is
to
make
a
thorough
and
methodical
evaluation
based
on
the
approaches
discussed
above.
A
treatment
strategy
tailored
towards
the
specific
needs
of
the
patient
can
be
developed
by:
•
Allowing
the
patient
to
express
feelings
of
distress.
•
Providing
an
opportunity
to
describe
the
experience
and
•
Taking
the
patients
views
about
the
cause
•
Discussing
the
perpetuating
and
the
precipitating
factors
All
this
has
long
term
positive
effects
on
the
treatment
of
pain
and
its
outcome. Steps
of
Management
These
inctude:
•
Psychological
assessment
•
Psychotropic
drug
treatment
•
Psychological
Interventions
Psychological
Assessment
•
Establish
the
primary
cause
of
the
pain
i.e.
is
the
pain
organic.
a
symptom
of
a
psychiatric
morbidity
or
primarily
psychogenic
in
origin.
•
Define
the
exact
role
of
psychological
factors
(psychodynamic
or
cognitive)
in
the
clinical
scenario:
are
they
etiologicaL
precipitating
or
perpetuating
in
their
influence?
•
Make
an
assessment
of
the
various
environmental
factors
i.e.
interpersonal,
social,
occupationat.
economic
and
cutturat
as
determinants
of
pain
somatization.

210. Psychotropic
Drug
Treatment
Other
than
the
long
Ust
of
narcotic
/
non
-
narcotic
and
non-steroidal
anti-inflammatory
(NSAID)
analgesics,
certain
psychotropic
drugs
have
also
been
found
useful
in
the
treatment
of
pain.
This
includes
some
antidepressants,
e.g
tricyclic
antidepressants
(Imipramine)
relieve
pain
by
blocking
biogenic
amine
uptake,
thus
enhancing
the
inhibitory
action
of
serotonin
and
nor-adienatine
on
the
spinal
pair
transmission
pathways.
Phenothiazines
and
drugs
[ike
Carbamezapine.
Valproic
acid
and
Gabapentin
are
aLso
hetpfuL.
Benzodiazepines
are
primarity
used
for
relief
of
associated
anxiety.
The
following
psychologicat
interventions
can
be
empLoyed
to
deaL
with
chronic
pain:
•
Relaxation
methods
•
Operant
Techniques
•
Cognitive
Strategies.
•
Social
skills
training
•
Assertiveness
training
•
Coping
Strategies
Approach
Relaxation
Methods
Using
muscular
biofeedback
(EMG
Biofeedback),
progressive
relaxation,
cognitive
relaxation
and
cue
controlled
relaxation
the
muscular
tension
is
brought
under
control
thereby
breaking
the
pain
cycle.Operant
Techniques
These
are
based
on
learning
theory
and
aim
to
identify
the
problems
and
modify
an
individual’s
responses
to
the
problem.
Techniques
include
activities
training,
medication
reduction
and
activities
focused
on
functional
disability.
The
techniques
resuLt
in
decreased
disability
levels
and
fear,
and
improved
physical
fitness
and
body
image.
The
steps
include:
•
Measuring
the
baseline
level.
•
Selecting
target
activities,
•
Starting
with
simple
activities
and
moving
on
to
complex
ones
•
Gradually
increasing
the
activity
level,
•
Reinforcing
the
activities
by
providing
feedback
and
verbal
praise.
•
Checking
progress
and
modifying
the
target
as
necessary.
•
Selecting
a
new
activity
once
the
first
activity
has
been
accomplished.
Operant
techniques
are
also
used
in
medication-
reduction
training
in
chronic
opioid
use.
The
drugs
are
dispensed
using
a
“time
contingent’
rather
than
a
“pain
contingert’
treatment
technique.
This
improves
pain
retief,
decreases
pain
behaviour
and
has
a
decreased
addictive
potentiat.
In
this
technique
the
medication
is
provided
at
regular
time
intervals
rather
than
pain
intensity.
The
dose
is
then
systematically
reduced.
*

211. *Von
KorffM,
MerrittJO,
RutterCM,
Sullivan
M,
Campbell
CI,
Weisner
C.
Time-scheduled
vs.
pain-contingent
opioid
dosing
in
chronic
opioid
therapy.
Pain.
2011
Jun
30;152f6):1256-62.
Cognitive
Strategies
Cognitive
strategies
aimed
at
pain
management
focus
on
Dealing
with
stress
•
Modifying
pain
related
cognitions
This
involves
the
stress
oriented
techniques
like
relaxation
therapies
and
cognitive
techniques
such
as
a)
Imaginative
Inattention:
thinking
about
something
incompatible
with
the
pain
experience
e.g.
relaxing
in
a
beautiful
quiet
place
alongside
transformations
of
context,
that
is,
imagining
that
pain
is
actually
occurring
but
under
more
appropriate
circumstance
b)
Attention
diversion
methods:
attention
is
diverted
toward
another
engaging
task
e.g.
counting
or
reading.
iv.
Sociat
Skilts
and
Assertiveness
Training
Social
skills
training
focuses
on
increasing
social
activities
at
work
and
at
home.
Assertiveness
training
is
similar
but
focuses
more
on
communica
tion
skills.
It
enhances
quality
of
life
and
reduces
pain-related
stress.
v.
Coping
Strategies
Approach
This
focuses
on
the
patients’
interpretation
of
the
pain
problem
and
various
coping
methods.
Patients
with
chronic
pain
syndromes
usually
use
passive
methods
of
deating
with
pain
such
as
hoping
pain
will
go
away).
Coping
skills
training
identifies
methods
of
dealing
with
pain,
belief
about
pain
and
resulting
disability.
Relaxation
and
activity
programmes
can
later
be
added
to
the
plan.
Active
coping:
•
Engaging
in
physical
exercise
or
physical
therapy
•
Clearing
your
mind
of
bothersome
thoughts
or
worries
Passive
coping:
•
Restricting
or
cancelling
your
social
activities
Taking
medication
for
the
purposes
of
immediate
pain
relief

212. Chapter
9
Psychosocial
Aspects
of
Aging
Every
man
desires
to
tive
tong,
but
no
man
wants
to
be
old.
Jonathan
Swift
Medical
advancements,
improvements
in
heaLthcare
and
Living
conditions
mean
people
can
now
expect
to
live
Longer
lives
than
ever
before.
Today,
the
proportion
of
elderLy
people
in
the
world
population
is
on
the
increase
mainly
because
people
are
living
longer
today
than
in
the
past.
The
rise
in
the
proportion
of
older
people
has
been
accompanied
by
an
increase
in
research
on
the
intelligence
and
personality
of
the
elderly
and
the
psycho
social
aspects
of
old
age.
Gerontology
(the
study
of
aging)
and
geriatrics.
(the
care
of
aging
people).
have
emerged
as
important
new
medicaL
fields
Late
adulthood
or
old
age
usually
refers
to
the
portion
of
human
life
cycle
that
begins
at
age
65.
Wherever
the
elderly
may
live,
they
are
recognised
by
characteristic
physical
changes.
Aging
is
generally
characterised
by
the
declining
ability
to
respond
to
stress,
increasing
imbalance
and
increased
risk
of
morbidity
and
mortality,
Aging
refers
to
aging
of
cells
The
aging
process
or
senes
cence
is
characterised
by
a
gradual
decline
in
the
functioning
of
all
the
body
systems.
The
biological
changes
of
aging
occur
at
a
cellular
level
and
effects
the
immune,
musculoskeletal,
reproductive,
cardiovascular,
gastrointestinal,
respiratory.
endocrine
and
the
central
nervous
systems.
A
popular
theory
holds
that
each
cell
has
a
genetically
determined
life
span
during
which
it
can
replicate
a
limited
number
of
times
before
it
dies
Structural
changes
in
cells
occur
with
age
In
the
centraL
nervous
system
for
instance,
neurons
show
signs
of
degeneration
ri
certain
age
related
disorders
such
as
dementia
of
Alzheimer’s
type,
signs
of
degeneration
are
much
more
severe
and
characterised
by
severe
memory
toss
and
toss
of
intellectual
functioning.
Neurobiotogicat
changes
of
aging
•
The
weight
and
volume
of
the
brain
decreases
by
5%
between
ages
of
30
and
70,
by
10%
by
the
age
of
So,
and
by
20%
by
the
age
of
go
The
ventricles
and
the
sub-arachnoid
spaces
also
increase
in
size
proportionately.
•
Cerebral
blood
flow
in
frontal
and
temporal
lobes
decreases
with
age.Nerve
cell
loss
occurs
in
the
cortex,
hippocampus,
substantia
nigra
and
cerebellum.
The
links
between
neurofilaments
and
microtubutes
called
Tau
proteins
can
accumulate
to
form
neurofibriltary
tangles
in
some
nerve
cells.
•
Senile
plaques
are
found
in
the
normal
aging
brain
in
the
neocortex.
amygdala
and
hippocampus.

213. Psychologicat
changes
of
aging
IQ
peaks
at
25
years
of
age,
plateaus
until
60-70,
and
then
declines.
Performance
10
drops
faster
then
verbal
10.
This
may
be
due
to
reduced
processing
speed
or
to
the
fact
that
verbal
10
depends
largely
on
familiar
information
while
performance
IQ
involves
novel
information.
•
Problem
solving
deteriorates
due
to
declining
abstract
thinking
abiLity
and
increasing
difficulty
in
applying
information
from
one
situation
to
another.
•
Short
term
memory
fSTM)
does
not
alter
with
age.
Working
memory,
however,
shows
a
gradual
decrease
in
capacity
and
this
is
worse
with
increasing
complexity
of
task
and
increased
memory
load.
•
Long
term
memory
tLTM)
declines,
except
for
remote
events
of
personal
and
emotional
significance
which
may
be
recalled
with
great
clarity.
•
There
is
a
typical
pattern
of
psychomotor
slowing
and
impairment
in
the
manipulation
of
new
information.
•
Well-rehearsed
skills
such
as
verbal
comprehension
show
little
or
no
decline.
•
Given
the
physical
and
cognitive
declines
seen
in
aging,
a
surprising
finding
is
that
emotional
experience
improves
with
age.
Older
aduLts
are
better
at
regulating
their
emotions
and
experience
negative
emotions
less
frequently
than
younger
adults.
To
keep
cognitive
functions
and
attitudes
flexible,
the
brain
must
be
exer
cised.
The
elderly
brain
is
as
capable
as
the
young
brain
of
growing
new
connections
between
cells
with
use.
Researchers
have
reported
evidence
of
increased
dendritic
branching
in
healthy,
aged
human
brains,
which
suggests
the
brain
remains
plastic
even
in
old
age.
Many
scientists
have
discovered
that
cognitive
functions
of
the
brain
in
the
elderly
can
be
main
tained
and
even
improved
with
training
and
environmental
enrichment.
Social
problems
of
old
age
With
the
breakdown
of
traditions
and
family
bonds
in
many
modern
soci
eties;
increasing
numbers
of
the
elderly
population.
especially
in
the
West,
live
alone
or
in
homes
for
the
aged.
Social
problems
include
loss
of
their
social
status,
independence,
and/or
the
toss
of
a
spouse/partner.
Most
of
the
elderly
popuLation.
especially
in
our
society.
have
limited
incomes,
and
are
unemployed
as
well
as
dependent.
Medical
problems
compound
deficiency
and
care
needs.
Unlike
the
West
where
the
eLderly
face
variable
degrees
of
isoLation,
marginaLisation
and
stigmatisation,
most
elderly
indi
viduals
in
Pakistan
are
well
taken
care
of
by
their
off-springs.
This
is
primar
ily
due
to
traditional
values
and
the
joint
family
system
that
exists
in
many
parts
of
the
country.
The
future
may
see
the
culture
of
‘old
people
homes’
in
our
part
of
the
world
as
well.
The
belief
that
old
age
is
associated
with
mental
and
physicaL
illness
is
a
myth.
This
stereotype
image
is
a
source
of
stigmatisation
and
discrimina
tion.
Most
elderly
individuals
enjoy
gooqi
health
through
most
part
of
their
twilight
years.

214. There
are
several
psychologicaL
and
socia[
factors
that
have
been
linked
to
increased
individual
Lite
expectancy
and
quality
of
tife
in
older
adults.
The
majority
of
attention
in
the
life
extension
and
successful
aging
fieLd
has
fo
cused
on
physical.
factors
such
as
exercise,
diet,
sleep
and
genetics.
There
is
a
growing
body
of
evidence
that
suggests
that
psychological
and
socio
logical
factors
also
have
a
significant
influence
on
how
well
individuals
age.
Jt
is
believed
that
adjusting
to
changes
that
accompany
late
adulthood
and
old
age
require
an
individual
to
be
flexible
and
develop
new
coping
skills.
Aging
research
has
demonstrated
a
positive
correlation
between
religious
beliefs,
social
relationships,
perceived
health,
socioeconomic
status,
cop
ing
skills
and
their
ability
to
age
more
successfully.
The
term
successful
aging
has
been
defined
by
three
main
components:
low
probability
of
dis
ease
and
disease
related
disability,
high
cognitive
and
physical
functional
capacity,
and
active
engagement
with
life.
Development
during
old
age
According
to
Erikson,
old
age
brings
with
it
a
core
developmental
conflict:
integrity
versus
despair
(see
Section
C).
Integrity
can
be
achieved
by
inte
grating
attitudes,
betiefs
and
experiences
so
that
they
fit
together
comfort
ably
and
form
a
coherent
whole.
This
results
in
a
feeling
of
satisfaction
with
a
life
well-lived.
Such
integrity
is
most
likely
to
occur
among
those
who
have
cared
for
people
and
have
adapted
themsetves
to
different
triumphs
and
disappointments.
Without
this
integrity
the
elderly
individual
is
filled
with
a
growing
sense
of
despair
and
a
fear
that
time
is
running
out
on
life.
This
despair
manifests
in
the
form
of
persistent
irritability,
disgust
or
a
nag
ging
fear
of
death.
Those
who
do
achieve
a
sense
of
integrity
and
whole
ness
may
develop
one
of
the
hallmarks
of
successful
aging:
wisdom.
This
wisdom
forms
the
basis
of
seeking
advice
about
complex
life
problems
from
the
elderly
in
cultures
such
as
ours.

215. Chapter
10
Psychosocial
Aspects
of
Death
and
Dying
Death
is,
perhaps,
the
ultimate
test
with
that
we,
as
patients,
relatives
and
members
of
the
caring
professions
must
face,
No
matter
how
experienced
we
become,
coping
with
death
is
seldom
easy.
Death
is
a
loss
but
it
can
aLso
be
a
time
of
peacefut
transition.
t
may
represent
failure
or
success,
ending
or
beginning,
disaster
or
triumph.
When
patients
are
dose
to
death,
heatth
professionals
may
have
little
or
no
control
over
what
is
happening.
Medication
can
help
us
to
mitigate
some
of
the
pains
of
dying
but,
with
alt
our
knowledge.
all
of
our
patients
will
still
die
at
some
point.
Despite
this,
patients
and
their
families
continue
to
turn
to
us
for
hetp.
Death
is
a
social
event,
it
affects
the
lives
of
many
people.
n
this
circle
of
people.
the
patient
is
the
centre
of
care
as
ton9
as
they
are
alive:
but
white
his/her
troubles
will
soon
be
over,
thqse
of
the
famity
may
just
be
beginning.
The
traditional
training
of
doctors
and
nurses
does
little
to
prepare
us
for
the
challenges
of
terminal
and
bereavement
care.
We
are
so
preoccupied
with
saving
life
that
we
are
at
a
loss
to
know
what
to
do
when
life
cannot
be
saved.
Some
of
us
deal
with
the
problem
by
denying
its
existence;
we
insist
on
fighting
for
a
cure
until
the
bitter
end.
Sadly.
the
weapons
that
we
em
ploy
too
often
impair
the
quality
of
the
life
that
is
left
such
that
the
end,
when
it
comes,
is
truly
bitter.
Others
acknowledge
to
themselves
that
the
patient
is
dying
but
attempt
to
conceal
it
from
the
patient.
If
they
succeed,
the
patient
may
die
in
blissful’
ignorance.
but
they
often
fail.
As
the
disease
progresses.
the
patient
looks
in
the
mirror
and
realises
that
somebody
is
lying.
At
a
time
when
they
most
need
to
trust
their
medical
attendants,
they
realise
that
they
have
been
deceived.
In
either
case,
the
family
who
survive
are
denied
the
opportunity
to
say
‘goodbye’.
and
to
conclude
any
unfinished
psychological
business
with
the
patient.
Of
course,
it
is
not
only
the
professional
staff
who
find
it
hard
to
cope
with
people
who
are
dying;
friends.
workmates
and
family
members
are
equally
at
a
loss.
They
may
deal
with
their
own
feelings
of
inadequacy
by
putting
pressure
on
us
to
continue
treatment
long
after
it
can
do
good
or
to
collude
with
them
in
concealing
the
true
situation
from
the
patient.
‘You
won’t
tell
him/her
that
they’re
dying.
will
you
doctor?
It
would
kilt
him/her
if
they
found
out’.
While
such
remarks
on
the
part
of
the
family
are
said
in
the
spirirt
of
caring
for
the
patient.
they
more
likely
reflect
the
informant’s
own
inability
to
cope
with
the
truth
rather
than
that
of
the
patient.
Psychological
reactions
in
a
dying
patient
Corn
Zombi
4—
Despite
the
fact
that
one
hundred
percent
of
people
die,
being
given
a
terminal
prognosis
is
intensety
fear-provoking.
Consequently
talking
about
death
is
a
taboo
in
many
cultures.
Reactions
to
the
news
can
be
seen
as
an
extreme
form
of
psychological
stress,
which
results
in
common
coping
defence
mechanisms.
These
include
“denial”
in
which
the
fact
is
deliber
ately
blocked
from
conscious
awareness.
“Depression
and
anger”
towards
family,
friends
and
health
care
workers
are
also
common
reactions
and
demand
patience,
tolerance
and
understanding
from
care
givers.
Many
people
eventually
reach
a
stage
of
acceptance
in
which
th.e
wishes
of
the
dying
person,and
plans
for
those
who
will
continue
afterwards
can
be
dis
cussed.
All
efforts
should
be
made
to
make
such
people
free
of
pain
and
be
given
the
liberty
to
make
their
choices
and
exercise
their
will.

216. Chapter
11
Psychotrauma
Psychotogical
trauma
or
psychotrauma
is
the
result
of
extraordinarily
stressful
events
that
shatter
a
person’s
sense
of
security,
making
him/her
feel
helpless
and
vulnerable
in
a
dangerous
world.
Psychological
trauma
is
a
wound
to
the
psyche
due
to
an
experience
which
has
endangered
one’s
life
and
threatened
one’s
identity,
integrity,
honour
and
property.
The
experience
is
understood
as
a
threat
to
one’s
physical
and
psychological
well-being
and
is
a
sharp
confrontation
with
death
or
a
challenge
to
life.
A
traumatic
experience
can
leave
scars
on
the
mind
and
body.
Traumatic
experiences
often
invotve
a
threat
to
life
or
safety,
but
any
situ
ation
that
leaves
a
person
feeling
frightened
and
alone
can
be
traumatic,
even
if
it
does
not
involve
physical
harm.
Experiences
such
as
verbal
abuse.
betrayal
or
any
major
loss
can
be
just
as
traumatizing
as
a
life-threatening
event
especially
when
they
happen
during
childhood.
Trauma
can
result
when
an
experience
is
so
overwhelming
that
a
person
goes
numb
or
disconnects
from
what’s
happening,
whether
the
threat
is
psychologicat
or
physical,
While
this
automatic
response
may
be
protective
for
a
short
while.
it
also
prevents
a
person
from
moving
on.
Not
all
potentially
traumatic
events
lead
to
Lasting
psychotrauma.
Some
people
rebound
quickly
from
even
the
most
tragic
and
shocking
experi
ences.
Others
are
devastated
by
experiences
that
on
the
surface
appear
to
be
less
upsetting.
ft
is
not
the
magnitude
of
the
catastrophe
that
deter
mines
whether
an
event
is
traumatic.
but
a
person’s
subjective
emotional
experience
of
the
event.
The
more
endangered,
helpless
and
unprepared
a
person
is,
the
more
likely
that
they
will
be
traumatised.
Causes
of
psychotrauma
Emotional
trauma
can
be
caused
by
one-time
occurrences
such
as
a
house
fire,
a
plane
crash,
a
violent
crime
or
an
earthquake.
Psychological
and
emotional
trauma
can
also
be
caused
by
experiences
of
ongoing
and
relenttess
stress,
such
as
fighting
in
a
war,
living
in
a
dangerous
neighbour
hood,
enduring
chronic
abuse
or
struggling
with
a
life-threatening
disease.
Although
people
respond
differently
to
stressful
experiences,
a
traumatic
event
is
most
likely
to
result
in
negative
effects
if
it
is:
•
Inflicted
by
humans
•
Repeated
and
ongoing
•
Unexpected
or
unpredictable
•
Intentionally
cruel
•
Experienced
in
childhood.
People
are
also
more
likely
to
be
traumatised
as
adults
if
they
have
a
histo
ry
of
childhood
trauma
or
if
they
ate
already
experiencing
a
lot
of
stress.
Devetopmentat
trauma
Stressful
experiences
in
childhood
can
be
traumatizing
whether
it
is
a
one
time
event
such
as
a
car
accident
or
an
ongoing
situation
caused
by
a
neg
ligent
or
abusive
parent
or
family
member.
Developmentat
or
attachment

217. trauma
“esults
from
anything
that
disrupts
a
chitds
sense
of
safety
and
security.
This
can
include
an
unsafe
environment,
separation
from
a
parent
or
a
sei
Quo
iLlness.
Developmental
trauma
is
most
severe
when
it
involves
betraya
or
harm
at
the
hands
of
a
cai’egiver.
This
trauma
has
a
negative
impact
on
a
childs
physical,
emotional
and
social
development.
Children
who
have
been
traumatised
see
the
world
as
a
dangerous
and
frightening
place.
When
childhood
trauma
is
iot
resolved,
this
sense
of
fear
and
help
tessness
can
carry
over
into
adulthood,
setting
the
stage
for
further
trauma.
Normal
responses
to
traumatic
events
It
is
important
to
distinguish
between
normal
reactions
to
traumatic
events
and
symptoms
of
a
more
serious
and
persistent
problem
Following
a
traumatic
event,
most
people
experience
a
variety
of
emotions,
including
shock,
fear,
anger
and
reLief
to
be
alive.
Often
they
think
or
talk
of
nothing
else
except
what
they
went
through.
Many
others
feei]umpy,
detached
or
depressed.
Such
reactions
are
neither
a
sign
of
weakness
nor
a
positive
indicator
of
lasting
trouble.
They
represent
a
normal
response
to
an
abnormal
event.
These
feelings
and
symptoms
typically
last
from
a
few
days
to
a
few
months
gradually
fading
as
one
processes
the
trauma.
Recovering
from
trauma
takes
time
and
everyone
heats
at
his
or
her
own
pace.
However
if
despite
passage
of
months,
the
symptoms
show
no
sign
of
letting
up,
a
person
may
be
experiencing
emotional
or
psychological
trauma.
Professionat
help
is
required
if
a
person
has:
Problems
at
home
or
work
•
Living
with
persistent
fear
and
anxiety
•
Haunted
by
overwhelming
memories
or
emotions
•
Avoiding
more
and
more
things
that
reminds
one
of
trauma
Posttraumatic
Stress
Disorder
Posttraumatic
Stress
Disorder
tPTSD)
is
a
condition
that
results
from
the
most
severe
kind
of
trauma.
It
is
characterised
by
intrusive
memories.
flashbacks
or
nightmares,
avoiding
things
that
remind
one
of
the
traumatic
event
and
living
in
a
constant
state
of
red
alert,
also
known
as
hyperarousal.
Common
reactions
to
trauma
Guilt
and
wff-blarne
Mood
swings
nd
lrtftablIftr
Dlstr.sslng
memories
Social
withdrawal
Feeling
sad

218. The
process
of
heating
emotional
trauma
is
stow
and
complex.
It
involves
facing
and
resolving
unbearable
feetings
and
memories
which
a
person
has
tong
avoided.
The
heating
journey
involves
processing
the
memory
of
the
trauma
through
various
techniques
(see
box)
Posttraumatic
Growth
Although
trauma
is
most
frequently
thought
of
in
negative
terms,
it
is
also
often
seen
to
have
some
positive
aspects.
The
term
posttraumatic
growth
was
coined
in
1996
by
psychologists
Richard
Iedeschi
and
Lawrence
Calhoun.
Posttraumatic
growth
describes
a
posttraumatic
change
in
how
people
think
of
themselves,
their
relationships
with
others
as
well
as
soci
ety,
and
profound
philosophical,
spiritual,
or
religious
changes
According
to
the
proponents
of
this
concept.
trauma
can
lead
to
growth.
though
this
is
not
always
the
case.
They
have
found
that
reports
of
growth
experiences
in
the
aftermath
of
traumatic
events
far
outnumber
reports
of
psychiatric
disorders.
Posttraumatic
growth
can
manifest
in
the
form
of
improved
rela
tionships
and
new
possibilities
for
ones
future.
It
can
also
lead
to
a
deeper
appreciation
for
life,
a
greater
sense
of
personal
strength
and
spiritual
de
velopment.
Some
tosses
can
produce
valuable
gains
and
individuals
may
find
themselves
becoming
more
comfbrtable
with
intimacy
and
having
a
greater
sense
of
compassion
for
others
who
experience
life
difficulties
Techniques
to
manage
trauma
Managing
Psychotrauma
Educate
yourself
about
anxlaty&
PSD
Reintegrate
yourself
Into
your
life:
do
not
Isolate
or
avoid
family
friends
or
actMtlesyou
previously
enjoyed
Know
when
to
seek
professional
help
Visit
a
mental
health
professional
If
your
traumatic
experience
Is
Interfering
with
your
work
and
family
life
I

219. Psychosocial
Aspects
of
Terrorism
Psychosocial
Impact:
Terrorism
hasa
negative
heafth
impact
on
the
individual
and
on
society.as
a
whole.
It
isolates
individuats,
families,
communities,
cultures,
and
even
countries
from
others,
It
generates
strong
feelings
of
mistrust,
paranoia,
depression,
anxiety,
and
can
even
have
clinicaL
consequences
in
form
of
conditions
like
posttraumatic
stress
disorder
(PTSD).
At
an
individual
leveL
the
survivors’
reactions
(see
table)
include
changes
j’
that
may
persist
for
several
weeks.
months
and
even
years.
These
include
a
preference
for
isotation,
intolerance
for
noise,
marked
irritability
and
hyper
vigilance.
Hypervigilance
is
a
state
of
increased
sensory
sensitivity
and
an
increase
in
the
intensity
of
behaviours
that
defuse
threats.
This
is
the
state
when
after
hearing
a
gunshot,
one
starts
to
become
acutely
aware
of
every
little
noise,
and
may
hide
for
cover
even
when
hearing
a
door
banging
loudly.
Survivors
also
experience
periods
of
increased
religiosity,
followed
by
alienation
from
reLigion,
intermittently.
Survivors
are
at
an
increased
risk
for
excessive
smoking
and
misuse
of
tranquiltisers,
cannabis,
opiates
and
atcohot.
They
may
also
devetop
a
tendency
to
undertake
reck[ess
actions,
particularly
while
driving.
They
also
start
believing
in
hearsay,
false
attributions
and
negative
propaganda.
A
higher
degree
of
greed,
mistrust,
jealousy,
prejudice,
need
for
revenge,
paranoia
and
intolerance
towards
minorities
and
certain
cultures
tends
to
prevail
amongst
survivors
of
terror
ist
attacks.
These
individuals
are
more
prone
to
develop
psychiatric
disorders
like
PTSD,
Dissociative
States,
Depression,
and
MedicalLy
UnexpLained
Symp
toms,
and
the
lowered
immunity
leaves
them
vulnerable
to
autoimmune
disorders
in
the
years
to
follow.
Many
survivors
may
undergo
an
enhanced
resilience
and
even
Posttraumatic
Growth
(PTG)
after
recovering
from
their
physical
and
psychological
injuries.
Chapter
12
It’s
hard
to
fight
an
enemy
who
has
outposts
in
your
head.
—Satty
Kempton
Terrorism
has
chattenged
the
physical,
psychosocial,
occupational.
eco
nomic,
and
spiritual
health
of
Pakistan
for
more
than
a
decade
now.
It
has
affected
all
geographic
settings
and
sociocultural
sections
of
the
nation.
What
is
terrorism?
Terrorism
is
a
violent
and
coercive
intimidation
strategy.
It
aims
to
generate
fear,
panic,
insecurity,
hopelessness
and
helptessness
as
wetl
as
mistrust
in
societal
institutions.
It
is
employed
as
a
toot
to
challenge,
destabilise,
and
destroy
a
country,
or
a
society
in
the
same
way
as
war.
Often,
the
country’s
reaction
to
terrorism
in
the
form
of
excessive
use
of
force,
disruptive
leg
islation
and
extensive
security
measures
may
add
to
the
fear
and
distress
of
its
people.
Exhaustive
coverage
of
terrorists
and
acts
of
terrorism
by
the
media
can
also
add
to
feelings
of
insecurity
and
mistrust
in
the
public.
4
h
I-

220. Reactions
commonly
seen
In
Survivors
of
a
Terrorist
Attack
Why
me.
Why
not
him”
-
:
I
want
to
bomb
them
‘Nothing
can
be
done’
‘teave
us
alone’
They
are
partners
with
agencies
and
the
West
I
do
not
want
to
offer
prayers
anymore”
I
w*ft
Am
ProfiLe
of
Suicide
Bombers
Suicide
bombers
are
known
to
share
the
following
sociodemographic
parameters:Suicide
bombers
are
oorne
out
of
social
settings
challenged
by
poverty,
ittiteracy.
ignorance.
intolers:
.e.
disease.
insecurity
and
injustice
They
come
from
large
families
with
many
children
cramped
in
small
houses
with
minimal
civic
amenities
in
slums
andkatchi
abaadis.
The
absence
of
an
effective
authority
figure
in
the
house,
leaves
the
younger
members
of
the
family
more
vulnerable
to
exploitative
forces.
The
tack
of
adequate
moni
toring
and
falling
out
of
regular
schooling
adds
to
the
risks
of
fatling
prey.
High
risk
factors
that
add
to
this
risk
include:
•
homes
with
a
culture
of
domestic
violence
•
physical,
emotional
and
sexual
abuse,
•
history
of
delinquency.
•
conduct
disorder,
•
timited
availability
of
emohonal
outlets
like
music,
sports,
gender
interaction.
A
traumatic
childhood
filled
with
humiliation,
feelings
of
powerlessness
and
lack
of
affection
is
exploited
by
charismatic
trainers
who
provide
group
identity,
strong
affinity
and
‘brotherhood’
to
overcome
isolation
from
family
and
community.
Young
people
in
their
formative
years
can,
thus,
be
easily
indoctrinated.
These
individuals
are
plied
with
high
doses
of
psychotropic
and
street
drugs
to
tower
their
defenses.
The
agents
of
these
forces
often
use
the
name
of
retigion.
sectarianism,
tribal
and
political
divides
to
moti
vate
individuals.
Sometimes
even
families
and
communities
are
manipulat
ed
in
order
to
recruit
individuals
for
ulterior
motives.
Some
techniques
used
by
trainers
to
‘create’
terrorists
are:
•
ritual
communion,
•
bonding,

221. Visible
change
in
their
earlier
approach
towards
religion,
cultural
norms,
values,
and
the
world
in
general.
Sodal
lsolatlqfl
and
avoidance
of
routine
faml!y
and
societal
events,
to
become
a
recluse
Reduced
interest
in
loved
ones,
family,
friends
and
work.
b.pearrIong
pedodswWH
ihoäbo
.öften
cultural
lyäIb
___
asiaflgoracadef?çEveát’ñ
it
—
tógttfrdtabbwhen
asked
to
explain
their
abseace,
____
Giving
away
personal
valuables,
money,
belongings.
..
ylolent
video
games.
.v ‘-
psychological
investment,
•
commitments
of
reaching
heaven,
•
stories
of
futfilment
of
explicit
psychosexual
fantasies
of
adolescent
years
•
promises
of
houses
and
palaces
in
heaven,
for
them
and
their
loved
ones
These
are
achieved
through
lectures,
sermons,
videos,
and
dramatic
reen
actments. Males
between
the
ages
of
10
to
24
are
the
most
common
‘recruits’
of
this
indoctrination.
Recently,
however,
females
have
also
begun
to
be
recruited.
A
‘suicide’
bomber
is
driven
mainly
by
strong
feelings
of
anger,
revenge,
and
hatred.
These
feelings
are
accentuated
and
exploited
by
terrorist
out
fits
through
generating
apathy,
extensive
training
and
use
of
hallucinogens,
stimulants,
and
other
drugs
of
abuse.
With
this
extensive
work
and
organ
ised
exploitation,
it
may
not
be
difficult
to
transform
an
adolescent
into
a
suicide
bomber.
Characteristic
behavior
patterns
seen
amongst
terrorists
planning
to
go
on
a
mission/killing
spree
include
the
following:
S
I
Obsession
with,
and
interest
in
weapons,
knives,
chemicals
and
other
potentially
dangerous
objects
etc.

222. Is
a
terrorist
suffering
from
mentaL
ilLness?
Terrorists
are
known
to
experience
paranoid
anxiety,
envy,
magical
think
ing,
omnipotent
denial,
grandiosity
and
massive
depression.
At
the
same
time
they
are
often
highly
intelligent,
sane,
very
focused,
and
have
no
identifiable
psychopathology.
It
is,
therefore,
inappropriate
to
consider
them
sufferers
of
a
clinicat
disorder.
The
traits
and
behavior
patterns
of
terriorists
are
cLoser
to
those
of
hardened
criminals
than
patients.
To
label
them
‘psychotic’
stigmatises
patients
of
psychiatric
disorders.
Psychosocial
Management
of
Consequences
of
Terrorist
Acts
Psychotrauma
consequent
to
a
terrorist
act
is
often
ignored
while
physi
cal
trauma
and
disabilities
draw
most
attention.
Extensive
research
on
the
subject
shows
that
one
third
of
uninjured
survivors
and
two
thirds
of
those
injured
in
a
terrorist
attack
are
likely
to
develop
long-term
disabling
psy
chosocial
consequences.
Some
key
areas
to
be
addressed
include:
i.
Mobilisation
of
Psychotrauma
Teams:
In
the
same
way
as
health
professionals
are
trained
to
respond
to
injuries,
trained
teams
of
health
professionals
need
to
be
formed
to
address
psychotrauma.
These
teams
need
to
operate
as
first
responders.
They
can
be
formed
by
training
volunteers,
rescue
workers,
ambulance
staff,
including
ambulance
drivers,
disaster
relief
workers,
emergency
health
personnel
social
workers,
and
hospital
staff.
2.
Integration
of
Psychosocial
Care
with
Surgical
Care.
Itis
important
to
sensitise
and
train
the
surgical
team
members
in
psychotrauma
and
its
management.
Training
in
the
use
of
effective
communication
skills,
empathy.
and
awareness
that
fear
and
numbness
can
act
as
aggravating
factors
in
the
perception
of
pain
and
reactions
to
injuries
can
help
in
management.
3.
Linking
up
Survivors
and
the
Dead
with
Famities
and
Units/Centres.
The
biggest
psychosocial
support
in
response
following
a
terrorist
activity
comes
through
help
in
establishing
contact
between
the
survivors
of
the
act
and
their
families
and
loved
ones.
In
the
chaos
that
sets
in
as
the
aftermath
of
such
an
act,
the
anguish
of
not
knowing
whether
your
loved
ones
are
safe
leaves
a
lasting
impact.
The
longer
it
takes
to
reestablish
contact.
the
more
traumatizing
it
is
for
the
family
and
friends
as
well
as
the
survivor.
Exact,
reliable
and
valid
information
on
the
injured
and
dead
is
recommended
from
a
behavioural
sciences
perspective.
The
strategy
to
gradually
break
bad
news
by
initially
announcing
that
no
details
are
available,
followed
by
statements
like
‘has
serious
injuries,
but
will
be
alright’,
‘we
are
trying
to
save
them’,
for
those
who
have
been
martyred
in
the
terrorist
attack
is
counterproductive.
Breaking
bad
news
sensitively
and
clearly
about
those
injured
or
martyred
is
a
far
more
appropriate
approach.
The
news
should,
however,
always
be
broken
by
somebody
responsible
and
senior
in
the
hierarchy.
This
helps
the
family
and
the
loved
ones
overcome
their
initial
shock,
numbness
and
denial
reactions.
4.
Updating:
In
case
exact
information
about
the
Lost,
injured
or
dead
is
not
available,
it
is
important
to
not
leave
the
affected
families
unattended
with
crowds,
media,
and
irresponsible
people
often
lurking
outside
such
settings.
Intermittent,
updates
at
regular,
clearly
identified
intervals
and
fixed
timings
by
a
nominated

223. representative
of
the
disaster
management
authority
or
the
concerned
agency
can
help
the
confusion
that
prevails.
All
information
on
the
subject
should
flow
out
of
this
single
source.
Others
involved
in
the
rescue
operation
and
initial
response
must
be
under
clear
instructions
not
to
give
interviews
to
the
media.
They
must
also
refrain
from
making
predictions
about
the
affected
personnel
or
the
identity
of
the
terrorists
and
the
operation.
5.
Reconstruction
of
Dead
Bodies:
The
bodies
of
the
martyrs
in
terrorist
incidents
may
sometimes
be
found
in
a
mutilated
and
deformed
state.
Seeing
such
bodies
can
a
have
a
traumatizing
imt5act.
Attempts
at
reconstruction
of
these
bodies
by
professionals
and
presentation
of
the
dead
bodies
in
customised
coffin
boxes
may
be
considered.
This
should
be
done
with
utmost
sensitivity
to
the
religious,
cultural,
and
ethnic
values
and
norms
of
the
aggrieved
family.
7.
Religious
and
Cultural
Rituals:
Sensitivity
must
be
shown
to
the
burial
customs,
and
funeral
rituals
that
a
family
or
a
community
prefers.
A
genetic
approach
in
this
regard
that
does
not
cater
for
indiyidual
needs
may
cause
lasting
distress
in
the
members
of
the
affeited
family
and
community.
8.
Ongoing
Psychosocial
Support
for
Survivors
and
Families:
The
exhaustive
rescue
operation
following
a
terrorist
attack
is
often
followed
by
a
period
where
everything
goes
quiet.
The
initial
enthusiastic
response
and
commitment
shown
must
be
followed
up
by
a
sustained
effort
to
maintain
medical,
psychological
surgical
follow
up
after
discharge
from
the
hospital.
A
clearly
defined
and
well-communicated
plan
must
be
formed
for
this.
This
must
include
plans
for
physical
rehabilitation
measures,
including
physiotherapy.
prostheses,
and
reconstructive
and
plastic
surgery
needs.
This
is
just
as
important
as
the
acute
response.
The
social,
economic,
occupational,
legal,
and
emotional
needs
of
the
injured
survivors
as
well
as
of
the
families
of
the
martyrs
also
need
to
be
addressed
in
both
the
intermediate
and
tong
term.
This
continuity
of
care
and
follow-up
saves
the
affected
and
the
responders
a
great
deal
of
suffering
and
improves
their
resitience.
This
ensures
an
early
return
to
normality
of
the
survivors
as
well
as
the
affected
families
and
communities,
It
also
helps
build
the
morale
of
the
community
and
the
nation
in
their
resolve
to
fight
terrorism.
9.
Return
to
Normal
Activity:
An
early
restoration
of
life
in
all
its
vigour
and
normality
is
the
key
to
building
resilience
and
health.
Affected
chiLdren
who
do
not
have
disabling
injuries
and
are
not
suffering
from
any
acute
medical
conditions
should
be
encouraged
to
return
to
the
pre-trauma
routines
of
life
as
early
as
possible.
•
sports.
•
drawings,
•
supported
discussion
groups
•
mutual
support
and
organised
activities
cooking
and
eating
together

224. Some
survvors
and
membe
5F
ffectcd
famity
deal
better
with
their
loss
by
sorkinci
towards
5:e
:vrhnl
iltation
and
long
term
support
measures
of
other
chest
cc
They
may
also
join
disaster
rnasacement
and
reter
cIes:F
is
All
these
activities
help
in
restoring
the
esem\’
and
aei
le
mnnqst
the
aggrieved
and
help
the
retu:c.
to
normality
ic
Care
of
Ca
s.
The
fir
:spc.
-
s
terrorist
act
arc
often
traned
rescue,
potrce.
oaramrt:r”
ad
:a{orv
personnel
ft
is
wrong
to
presume
that
n:embsrc
nf
such
:.uidi
a
immune
to
the
psychotraures
cossecisent
to
ties
h.
.l.rci
if
iniired,
and
the
dead.
fact,
alt
first
resoomfe
ncisiu
i’b
‘lance
personnel
drivers
health
persnase1.
it
the
hesntsl
nd
th
support
staff
are
affected.
Ti-.,
coo,
the’ef’.ro
2t
hira
‘ci’
rn
develop
psy’:hotr
ama
in
the
chart
ter:
:fl0
av
show
cigns
of
PTSD
se’.’eral’a’eeks
and
months
itc’.
its
‘
p’wiait
tc’
educate
all
of
them
about
the
effects
5d
Otl\’
:s
:f
a
ws’estrarim_i
The
members
of
such
teams
r,:ev
net
flfic
c.,.
.Cflt
d’anqes
in
their
beha’.
or
the-nestess
ts.
heceE.:
-s
:‘
.;
they
‘catch
for
these
sionc
in
each
other
and
offm
cob
:.
:‘nn
°nme
of
the-
earliest
sicin
inctudo
casio
ftiqaK,litn,
aT
sc’’
acnhnn
-nncentrstion,
and
short
tess:
mneoiort-.
rmi-
am
es
r
nntH,
H
hi
qc
in
5c.boacai.foactonr
-
:i’ce
co’o..e
c.
.:n’’o
escac,t,cs
may
br-
nn
before
the
mme.
cnsons
V
evcrtabitty.
ftashoac.kn
or
h”er..
L.
cL-co
u.
Lecial
5ecurt.
and
Dperatrcca.
esses
V-c
sVci
I;cifies
and
ndi:duets
as
vcell
es
the
commcntc--.
.rCH
Vs
nctn
ei
3r
more
secure,
comforted,
ansi
assured
,ttl
cc
.ro,’mm
snt
tc’
w
enforcrng
agencres
respc.nrl
to
ito
:c
-
scia
ffest”ely
and
in
an
orciacosed
fashron.
Leeatsupocrt.
cc
a
.oocsotcns
ni
effer.tr,e
rehabilitation
measures
when
crnn
V
‘ffti’’e
and
rm
relentless
pursuts
to
apprehoec
a
50
ict
nci
erect
them
adds
to
the
resolve
and
resr’rerce
as
Vs
n.:i
a:
volt
as
at
the
community
level
Any
Vt-um
Owl’
cr
V.iiy
Ly
tho
.o’esrned
quarters
on
the
other
hen1
iss,ctr
so
‘ci:
secirscJ
of
nes
des
morbidities
and
rea:[cns.
ThiS
coca
roasi
to
lsr,qmcLc
‘cons
such
as
feeLings
of
onqe’n:e
a,
o
rvct
pc
tt.at
cm’
sVrt
to
surface
amongst
ndrvrduaV
and
the
iod
aces
:“
mat”
.
ar’
ties
niured.
12.
Miscellaneous
measures
need
to
qo
lflLD
effect
an
the
has’s
of
available
resources,
expertise.
and
tran;ng
These
;ncbuci
esues
related
to
foltowng
human
rights
charters.
ntemat.onai
Ii’s’s,
and
legislation.
ihlS
s
particuLarly
important
n
the
•
handling
ot
suspects
•
treatment
given
to
FamiLies
of
suspects
•
buriaLs
of
the
terrorists
killed
in
the
operation
handling
of
media,
•
traininq
of
hum-an
resource
in
resisonce
and
rescue
operations
•
research
and
audits
evabuatrag
th.
ecienr.y
and
effectiveness
of
the
process.

225. Chapter]3 Stress
and
its
Management
Definition Hans
Setye
introduced
the
concept
of
stress
into
physiology
from
phys
ics,
where
it
generally
refers
to
a
force
acting
against
some
resistance.
He
defined
stress
as
“the
rate
of
wear
and
tear
in
the
body”
and
“the
state
manifested
by
a
specific
syndrome
which
consists
of
all
the
non-specifical
ly
induced
changes
within
a
biological
system.”
In
this
General
adaptation
syndrome
(GAS),
glucocotticoids
are
secreted
by
the
adrenal
cortex
in
re
sponse
to
adaptation
demands
placed
on
the
organism
by
such
disparate
stressors
as
heat,
cold,
starvation,
and
other
environmental
insult.
Any
such
stimulus
to
the
body
results
in
certain
physiological
changes
in
the
body
which
are
cumulatively
termed
as
stress
(Lazarus;
1984).
Stressors
are
the
environmental
sources
of
threat
to
an
organism,
while
stress
is
what
occurs
as
a
result
of
this.
Richard
Lazarus
emphasised
the
potential
threat
of
life
events
in
causing
stress.
Individuals
have
a
personal
view
of
their
stress,
based
on
their
perception
of
the
event,
past
experiences,
strengths.
biographical
assets
and
social
support.
Other
factors
which
influence
the
outcome
of
stress
upon
an
individual
include
race,
gender.
age,
marital
status,
socioeconomic
sta
tus
and
early
developmental
experiences.
For
example,
black
people
are
more
prone
to
develop
hypertension
than
Caucasians.
Females
tend
to
live
tonger
and
recover
quicker
from
illness
than
males.
They
also
show
less
physiological
reactivity
to
stress
as
compared
to
males.
The
elderly
are
more
vulnerable
to
all
kinds
of
stressors.
The
general
observation
that
work
capacity
decreases
by
1%
every
year
after
21
years
of
age,
provides
evidence
that
people.who
continue
to
work
with
same
routines
beyond
50
years
tend
to
have
higher
incidence
of
coronary
heart
disease.
Marriage
is
considered
a
protective
factor
against
stress
and
most
illnesses
in
both
genders.
Educational
and
economic
attainments
provide
more
resilience
against
stress.
Early
parental
loss,
quality
of
love
and
care
received
in
early
life
years
and
children’s
early
exposure
to
socializations
shape
the
re
sponse
of
people
to
different
types
of
stress.
Stress
is
conventionally
divided
into
two
types
based
on
the
causative
factors: Physiological
stress
caused
by
temperature.
noise,
hunger,
disease,
smok
ing,
drinking
and
similar
habits
are
considered
generalised
life
stressors
affecting
most
people.
Psychosocial
stress
caused
by
psychological
factors
such
as
low
self-es
teem,
social
factors
such
as
life
events
(see
table),
job
stability,
career
satis
faction,
economic
viability.
marriage,
children,
relationships
etc.
Stressors
bring
about
a
physiological
change
in
the
body
of
a
person.
Some
stressors
produce
impacts
in
a
short
span
of
time;
such
as
loss
of
parents
or
job.
Others,
such
as
distressed
relationships
or
care
of
a
disabled
person
in
the
house,
inftuence
the
person
gradually
over
a
period
of
time.
Individual
and
situational
variables
mediate
the
relationship
between
life
change
and
illness.

226. Interpretation:
An
individuat
is
prone
to
devetop
a
stress
related
disorder
e.g.
depression
if
his
score
in
a
given
year
rises
above
300.
LCU
Value:
life
change
unit.
is
the
impact
each
event
carries
for
the
person
as
as
sessed
in
the
1994
survey
Adapted
from
Holmes
and
Rahe
scale,
1994
Among
the
psychotogicat
variables
that
seem
to
mediate
the
stress
response
are:
locus
of
conttoL
the
extent
to
which
individuats
prefer
control
of
their
lives
and
how
much
control
they
perceive
they
have
over
specific
Ufe
events,
•
need
for
stimulation,
•
openness
to
change.
stimulus
screening.
self-actualization,use
of
deniaL
•
social
support.
People
who
are
able
to
etfechvety
combat
high
tevets
of
stress
and
stay
healthy
differ
in
hardiness”
from
those
with
high
tevets
of
stress
who
devel
op
illness.
Hardiness
is
a
personal
characteristic
comprising
the
“3
C’s”,
in
which
an
individual
has
a
sense
of:
•
Commitment
to
self,
work,
family,
and
other
important
values;
•
Control
over
one’s
life;
•
Change
as
a
challenge
rather
than
a
threat.
Recently
researchers
have
suggested
a
fourth
C”:
coherence.
Coherence
is
the
belief
that
one’s
internat
and
external
environments
are
predictable
and
that
things
wilt
work
out
as
well
as
can
be
expected.
100
3
65
life
vent
Ranking
of
the
event
LCU
Value
Death
of
spouse
DivorceMarital
separation
all
term
Death
of
close
family
member
Serious
personal
injury
_____________
MarriageDismissal
from
work
Marital
reconciliation
RetirementChange
In
health
and
behaviour
o
a
family
member
I
5
63
7
59
9
45
U
44
p.
V

227. Job-reLated
Stress
&
Burnout
Work-retated
stress
can
be
a
source
of
persistent
and
intense
stress
and
strain.
Job
strain
is
defined
as
a
combination
of
high
job
demands
and
low
perceived
control.
Studies
have
established
that
job
strain
is
associated
with
increased
carotid
atherosclerosis
among
men.
Burnout
is
a
syndrome
associated
with
untetenting
stress.
It
includes
symptoms
of
emotional
ex
haustion
and
a
decreased
sense
of
personal
accomplishment.
Response
to
stress
The
body
responds
to
stress
througft.physical,
emotional
and
behavioural
means. Physical
manifestations
of
stress:
Both
sympathetic
and
parasympathetic
nervous
systems
may
go
into
overdrive
when
faced
with
stress.
The
sympathetic
system
comes
into
play
when
stress
is
acute
and
manifests
in
the
form
of
increased
heart
rate,
dilatation
of
pupils,
dry
mouth,
pitoerection,
increased
muscle
tone,
rapid
breathing
and
increased
blood
pressure.
When
this
state
is
sustained
for
a
prolonged
period
of
time,
three
target
organs
-
stomach,
heart
and
blood
vessels
-
are
affected,
but
none
are
spared.
There
is
increased
acid
secre
tion
in
the
stomach,
increased
gastric
emptying,
nausea,
heartburn,
upset
stomach,
chest
pain,
hypertension
and
muscle
aches
and
pains.
Parasympathetic
system
is
stimulated
when
stress
becomes
chronic.
Some
people
are
more
vulnerable
to
respond
to
stress
through
parasympathetic
system.
This
causes
increased
hunger,
delayed
gut
motility,
constipation,
increased
sweating
and
disturbed
sleep.
Both
systems
operate
through
the
hypothalamic-
pituitary-adrenal
axis,
which
is
a
physiological
tract
invoLved
in
stress
response.
Recent
evidence
indicates
that
chronic
psychological
stress
can
lead
to
increased
production
of
proinflammatory
cytokines,
particularly
interleukin
fIL)-6,
which
is
also
triggered
by
infection
and
trauma.
Proinflammatory
cy
tokines
have
been
implicated
in
a
range
of
diseases
in
oLder
adults
that
can
be
traced
to
inflammation,
including
cardiovascular
disease,
osteoporosis,
arthritis,
type
2
diabetes,
certain
cancers
(including
multiple
myeloma,
non-Hodgkin’s
lymphoma,
and
chronic
lymphocytic
leukemia),
Alzheimer’s
disease,
and
dental
disease.
IL-6
promotes
the
production
of
C-reactive
protein,
which
is
an
important
risk
factor
for
MI.
The
outcomes
of
stress
on
the
physical
health
of
a
person
can
be
summarised
according
to
its
effects
on
each
organ
system:
Cardiovascular
System
Stress
aggravates
all
types
of
heart
disease
including
coronary
artery
disease,
congestive
heart
failure
and
sudden
cardiac
death.
There
is
a
connection
between
hostility
(common
in
people
with
type-A
personality)
and
cardiac
disease.
It
has
been
shown
that
hostility
contributes,
independently
of
other
risk
factors,
to
the
pathogenesis
of
heart
disease
through
lipid
accumulation,
increased
blood
pressure,
and
heart
rate
and
platelet
pathophysiology

228. Centrat
Nervous
System
Dizziness,
vertigo,
and
other
balance
disorders
often
have
stress
as
a
causative
or
contributing
factor.
One
of
the
most
common
neuro[ogic
expressions
of
stress
in
clinical
practice
is
headache.
Tension
headaches
and
migraine
headache
are
two
common
types
of
headaches
which
are
substantially
influenced
by
patient
stressors.
Gastrointestinal.
System
Peptic
ulcer
disease
may
have
an
association
with
stress,
Hyperacidity
and
excess
enzyme
production
are
hallmarks
of
the
sympathetic
arousal
that
occurs
during
stress.
Irritable
Bowet
Syndrome
(IBS),
which
is
characterised
by
abdominal
pain
with
altered
bowel
habits
(constipation
or
diarrhoea)
in
the
absence
of
a
definable
lesion
or
structural
abnormality,
frequently
correlates
with
periods
of
emotional
stress.Muscutosketetat
System
Some
forms
of
arthritis
show
stress-related
exacerbations.
Complex
syndromes
such
as
fibromyalgia
seem
to
have
a
psychosocial
trigger.
Temporo-mandihular
joint
(TMJ)
dysfunction
and
its
related
pain
syndrome
are
frequently
associated
with
mental
stress.
Chronic
pain
tends
to
correlate
with
stress
in
a
person’s
life.
Respiratory
System
Asthma
and
chronic
obstructive
pulmonary
disease
appear
to
be
worsened
by
stress
Conversely,
one
of
the
more
powerful
self-
regulatory
stress-control
techniques
is
relaxed
abdominal
breathing.
Asthmatics
who
participate
in
stress
reduction
programs
have
shown
improved
physical
activity
and
decreased
medical
visits.
Reproductive
System
Amenorrhea
frequently
occurs
during
stressful
times
in
the
lives
of
women
Fertility
also
can
be
affected
by
stress.
Dysmenorrhea.
dyspareunia
and
impotence
all
have
substantial
stress
and
strain
connections.lntegumentary
System
A
variety
of
skin
tosians
and
rashes
have
been
associated
with
the
stress
response.
Stress
can
tower
the
itch
threshold
by
vasodilation
and
may
account
for
the
pruritus
seen
with
many
dermatotogic
syndromes
Emotional
stress,
fear,
and
pain
are
all
accompanied
by
substantial
drops
in
skin
temperature
of
the
fingers.
Immune
System
Stress
can
manifest
in
the
form
of
immune
deficiencies
ranging
from
the
common
cold
to
some
forms
of
cancer.
Although
research
on
P
the
relationship
between
stress
and
cancer
is
still
inconclusive,
there
is
some
evidence
that
stress
and
surgical
excision
of
the
primary
tumour
can
promote
tumour
metastasis
by
suppression
of
cell
mediated
immunity.
In
HIV
positive
patients.
rapid
disease
progression
has
been
associated
with
greater
concealment
of
one’s
sexual
preferences,
more
cumulative
stressful
life
events,
and
less
cumulative
social
support
over
a
5-year
period.

229. Behavioural
Manifestations
of
Stress
SociatwithdrawaL
poor
sleeping
and
eating
habits,
poor
exercise,
ex
cessive
drinking
and
smoking,
drug
abuse,
carelessness.
problems
with
authority
and
rules
and
regulations,
insubordination,
impaired
social
rela
tions,
break
up
of
old
relationships
and
reckless
behaviou
are
att
types
of
behaviours
that
indicate
a
person
is
undergoing
stress
ir
Eneir
life
and
is
unable
to
manage
it,
,,Physical
conditions
with
psychological
components
Essential
hypertension.
angina
pectorls,
tachycardia,
arrhythmia,
cardlospasm,
Cardiovascular
coronary
artery
disease,
mitral
valve
prolapse,
myocardial
infarction,
migraine.
headache.
____
Ji
Irritable
boI
syndrome,
gastric
ulcer,
G4rolnt.stlnal
Uuod.nal
u1ce!
Cmbn’s
disease,
-
____
.
A
-
ulcratjye
colitis.
k
..
Hypoglycemia,
diabetes
mellitus,
Hormonal
hyperthyroidism,
hypothyroidism,
hyperparathyroidism,
hypoparathyroidasm,
premenstrual
syndrome,
obesity
[‘W?”.
‘
‘
‘‘‘
‘‘.
‘
-
-..,
•
.
Neurodermatitis,
pruritis.
psoriasis,
Integumentary
hyperhidrosis,
urticaria,
alopecia,
acne,
•
herpes,
genital
warts
-
ChmnkpaIn,tiaadach.sacrofllacpain.
I.
Neuromuscular!
.
temporomandibular
joint
pln,
Skeletal
I
rheumatoid
arthrftli,
Peynaud’s
diseesa
.‘
Emotional
Manifestations
of
Stress:
People
who
respond
with
sympathetic
reactions
tend
to
show
anxiety,
fear,
anger
and
irritability.
They
try
to
avoid
the
stressor
by
showing
the
fright
and
flight
response.
Hypervigilance,
hyperarousat
and
increased
startle
response
are
seen.
Parasympathetic
system
responders
tend
to
show
guilt.
grief,
sadness,
depression,
feelings
of
being
abandoned
and
isolated
and
tend
to
avoid
seeking
support
from
others.
4
Respiratory
Asthma,
hyperventilation
syndrome,
tuberculosis

230. Managing
behaviour
It
is
important
to
not
get
fixated
on
past
failures,
the
past
cannot
be
changed.
Focusing
on
what
can
be
done
now
and
in
future
is
a
more
productive
approach.
Adopting
the
can
do
attitude,
practicing
anger
management
and
remembering
that
you
are
the
person
in
charge
of
your
behaviour
hetps.
Unless
you
allow
yourself
to
fall
down,
nothing
can
make
4
you
surrender
are
important
mind
sets
to
get
one
through
a
tough
situation.
Time
management
Making
a
list
of
things
to
do
each
morning
and
prioritise
the
work
that
needs
to
be
done
goes
a
tong
way
towards
managing
time
effectively.
Rather
than
working
tong
hours
with
low
productivity,
it
is
far
more
produc
tive
to
work
for
45
minute
stretches
with
short
breaks
in
between.
It
is
also
important
to
take
time
out
to
evatuate
and
reflect
upon
the
work
done
and
efforts
made.
Learning
to
say
‘no’
to
unreasonable
demands
on
your
time
is
an
important
skill.
This
is
especially
true
of
our
culture
where
it
is
consid
ered
rude
to
say
no,
so
instead
we
say
yes,
and
avoid
being
truthiut
about
what
we
can
accomplish.
It
is
also
important
to
give
ones
own
self
“guilt
fre&
time
off
to
enjoy.
Learning
to
delegate
responsibility
also
greatly
improves
one’s
own
productivity.
Managing
stress
Accepting
the
things
that
ate
beyond
one’s
controt
can
sometimes
be
the
first
step
towards
relieving
stress.
It
is
also
important
to
learn
to
deal
with
your
stress
response
and
adopt
effective
coping
methods.
Stress
Management
Managing
stress
is
vital
for
the
health
and
survival
of
a
person.
Poorly
managed
stress
can
result
in
disease
and
seriously
impairs
quality
of
life,
in
addition
to
undermining
the
achievements
and
objectives
of
a
person.
The
goal
of
managing
stress
is
to
achieve
a
state
of
eustress,
a
state
where
a
person
is
managing
stress
effectively,
has
good
health,
is
relaxed
and
is
improving
his
capacity
and
capabilities.
Self-blame,
wishful
thinking,
avoidance
and
taking
things
personally
are
recognised
as
negative
coping
methods
and
result
in
poor
stress
manage
ment
and
disturbance
to
health.
In
contrast,
problem
sotving.
seeking
help
and
utilizing
social
support
and
remaining
optimistic
are
positive
coping
styles
for
handling
stress.
Managing
the
stressor
Managing
the
environment
is
the
first
step
towards
stress
handling.
There
is
always
some
aspect
of
the
stressor
that
can
be
controlled.
That
as
pect
must
be
controlled
and
one
thing
to
be
taken
at
a
time.
Minimising
the
stressors
may
require
imaginative
problem
solving
and
help
from
the
individual’s
support
group.
but
it
helps
to
create
a
sense
of
control
over
the
environment
Exercise
and
nutrition
Exercising
3-5
times
a
week
conditions
the
body
to
deal
with
stress
by
us
ing
the
physical
stress
response.
Keeping
caffeine
intake
to
minimum,
stop
ping
smoking
and
eating
less
fatty
and
sugary
food
and
more
fibre,
vitamin
B
complex
and
Vitamin
C
helps
to
prime
your
body
to
deal
with
stress
as
and
when
it
occurs.

231. Progressive
Muscle
Relaxation
in
progressive
reIaxatlon
each
muscle
or
group
of
muscles
Is
contracted
for
5
to?
seconds
and
then
relaxed
for
20
to
30
seconds.
The
cycle
is
then
repeated.
Mcw.óthethIrdm*rmuIdemup-ch.st,
abdaeean
and
lowr
back.
End
with
the
fourth
major
muscle
group
-
thIghs,
buttocks,
calves
and
feet
areupsthatam
*outd.perr&axatlon
-
Practice
progressive
relaxation
while
lying
down
or
seated
in
chair
with
feet
firmly
on
the
floor.
$gl*f
I
Do
the
same
with
the
left
fist-
tensing
relaxing,
and
noticing
the
difference.
Progress
through
the
next
major
muscle
group
-
head,
face,
throat
and
shoulders
H
I
Relaxation Practicing
progressive
muscle
relaxation
(see
box),
meditation,
deep
breathing
exercises
and
engaging
in
hobbies
provides
energyand
fuel
for
the
body
to
combat
stresses
of
all
kinds.
Social
support
Developing
a
circle
of
friends
and
family
where
one
can
talk
openly
and
honestly
can
help
one
better
understand
stress
and
learn
to
manage
it
more
effectively.
It
is
also
important
to
utilise
resources
that
can
help
such
as
doctors
or
senior
colleagues.
p 4
Communicating
With
Patients
about
Stress
A
primary
component
of
stress
prevention
and
treatment
involves
the
way
stress
is
discussed
with
patients.
A
doctor
must
avoid
phrases
such
as
“it’s
all
in
your
head.
Equally
important
is
avoiding
the
message
that
‘you
are
responsible
for
your
illness’
This
induces
guilt
in
patients
who
become
ill
and
makes
them
feet
that
they
have
failed
at
being
a
“better
person
Avoid
ing
negative
emphasis,
for
example,
‘Your
hectic
pace
is
going
to
kitl
you,
in
favour
of
a
positive
framing
of
the
health
benefits
of
stress
management
is
more
likely
to
have
a
positive
influence.
For
example,
the
clinician
can
express
optimism
about
the
patient’s
ability
to
influence
health
as
follows:
“Fortunately,
there
are
many
avenues
available
for
evaluating
and
changing
your
way
of
responding
to
life
challenges.
I’d
like
to
give
you
an
overview
of
some
strategies
that
we
can
discuss
now
and
in
future
appointments.”

232. Non-pharmacologic
Interventions
for
reducing
Stress
Improve
time
management
Have
a
sense
of
humoAr
Pursue
personal
and
vocational
activities
I
Engage
in
spiritual
activities
such
as
praying
Clarify
valugs
Cultivate
social
support
network
.
ro*a
assertiveness•
Reduce
exposure
to
unnecessary
stressors
.
Haip
othati
In
anyway
you
cm
.
I

233. SAMPLE
MCQ
FOR
SECTION
E
1.
A
35
year
old
gentleman
has
been
admitted
to
the
hospitat
for
the
Last
10
days.
His
investigations
reveal
that
his
condition
is
improving,
yet
he
appears
stressed.
What
could
the
most
important
reason
for
this
be?
a)
The
bad
attitude
of
the
nursing
staff
b)
The
cost
of
the
investigations
C)
Loss
of
autonomy
and
privacy
d)
Feeling
betrayed
at
not
being
visited
in
the
hospitat
by
the
extended
family
e)
Being
dependent
on
other
people
2.
A
23
year
oLd
man
is
diagnosed
with
metastatic
pancreatic
carcinoma.
The
prognosis
is
poor
and
the
treating
doctor
gives
him
the
bad
news
that
he
onLy
has
a
few
weeks
to
Live.
The
first
psychoLogicaL
reaction
in
such
a
patient
wiLt
be:
a)
Anger.
b)
Bargaining
C)
Depression.
d)
Acceptance.
e)
Denial.
4
3.
A
75
year
otd
gentLeman
with
chronic
renaL
faiture,
suddenty
starts
to
t
-
become
irritabLe,
refuses
to
recognise
his
famiLy
members,
and
appears
to
be
seeing
things
that
aren’t
there.
His
daughter
reports
that
he
does
not
steep
at
night
and
steeps
throughout
the
day
instead.
The
most
Likety
diagnosis
is:
a)
Dementia
b)
Delirium
c)
Schizophrenia
d)
Depression
with
psychotic
features
e)
Old
age
4.
In
the
case
of
the
75
yr
oLd
gentLeman
mentioned
above,
after
he
is
admitted
to
the
hospitat,
which
of
the
fottowing
are
tikely
to
make
his
condition
worse?
a)
Unfamiliar
medicaL
procedures
conducted
without
provision
of
informational
care.
b)
Psychological
stress
of
disease
and
hospitalization.
c)
Lack
of
loving
family
members
around
the
patient.
d)
Long
periods
of
sensory
deprivation
as
well
as
sensory
overload.
e)
Antidepressants

234. .
Defense
mechanisms
have
all
of
the
following
characteristics
except
a)
They
emerge
in
a
deve[opmentat
sequence
from
Less
mature
to
more
mature.
b)
They
generally
can
be
brought
under
conscious
control
to
ward
off
anxiety.
c)
They
operate
to
maintain
a
sense
of
welt
being
and
safety.
d)
They
may
be
episodic
or
become
more
habitual
and
pervasive.
e)
They
may
contribute
towards
formation
of
personality
traits
Sampte
Short
Essay
Question
For
Section
E
01.
Briefty
describe
the
psychotogicat
stages
of
Grief
Reaction
hightighting
various
defence
mechanisms.
Q2.
How
does
one
differentiate
between
post-partum
bLues
and
post-partum
depression?
Answersi.b2.
e
3.
b
4.
d
5b

235. Patient
________________________
Examiner
_________________________
Date
/
/
Orientation
Score
Maximum
What
is
the
(year)
(season)
(date)
(day)
(month)?
(
)
5
Where
are
we
(state)
(country)
(hospital)
(floor)?
(
)
5
II
APPENDIX
U
-
-
-
-
The
Mini-Mntãj
_i1MSE)
-
-
L:
-
t 6
Registration Name
3
objects:
I
second
to
say
each.
Then
ask
the
patient
all
3
after
you
have
said
them.
Give
one
point
for
each
correct
answer.
Then
repeat
them
until
he/she
learns
all
3.
Count
trials
and
record.
Trials__________________ Attention
and
Calculation
Serial
7’s
1
point
for
each
correct
answer.
Stop
after
5
answer.
Althernatively
spell
world”
backward.
Recall Ask
for
the
3
objects
repeatd
above.
Give
I
point
for
each
correct
answer.
Language Name
a
pencil
and
watch.
Repeate
the
following
“No
ifs,
ands:
or
buts”
Follow
a
3-stage
command:
“Take
a
paper
in
your
hand,
fold
it
in
half,
and
put
it
on
the
floor.”
Read
and
obey
the
following:
CLOSE
YOUR
EYES
Write
a
sentence.
Copy
the
design
shown.
(
)
(I t
I
3 5 3 2 3
Total
Score
ASSESS
level
of
consciousness
along
a
continum
Alert
Drowsy
Stupor
Coma
24-30:
within
normal
limits:
23:
cognitive
impairment
(further
formal
testing
recommended)

236. \
\
:;j1:
__________________________-
__________________________
7
(çii)
(-.:‘)
(-;))
(-3L-)
L
.(/3)/)
(3)
(fl/)
(Aa)
(re)
(;)a2
3
(,-L-’i,3
L
World
“J,L
5
-4
3
;-
5
-JiL5’
2
.
rVLI—iLL-i
(‘1?L5LI)
3
LI(
.
J
4i
1
(j,y)
c÷_
(
f),3
j
‘1