Jurnal terbitan berkala : Gangguan Personaliti di Kalangan Rakyat Malaysia | Personality Disorders in Malaysia

Gangguan Personaliti di Kalangan Rakyat Malaysia

Penerbit: Afiq Shahiri 7 June 2023 

Gangguan personaliti merupakan satu keadaan mental yang dicirikan oleh corak pemikiran, perasaan, dan tingkah laku yang berbeza daripada norma masyarakat dan kekal dalam jangka masa panjang. Ia boleh menjejaskan fungsi harian dan hubungan interpersonal seseorang individu. Di Malaysia, kesedaran tentang gangguan ini semakin meningkat, namun masih terdapat banyak stigma dan salah faham mengenainya.

Jenis-jenis Gangguan Personaliti

Menurut Manual Diagnostik dan Statistik Gangguan Mental (DSM-5), gangguan personaliti boleh diklasifikasikan kepada beberapa kategori utama:

1. Gangguan Personaliti Klasifikasi A (Eksentrik atau Aneh):

   • Paranoid: Mempunyai kepercayaan bahawa orang lain berniat jahat atau tidak boleh dipercayai.
   • Schizoid: Mengelakkan hubungan sosial dan tidak menunjukkan banyak emosi.
   • Schizotypal: Memiliki pemikiran atau kelakuan aneh dan percaya pada perkara yang luar biasa.

2. Gangguan Personaliti Klasifikasi B (Dramatik, Emosional atau Tidak Stabil):

   • Antisosial: Tidak mengambil kira hak atau perasaan orang lain.
   • Borderline: Emosi yang tidak stabil, imej diri yang kabur, dan hubungan yang tidak tetap.
   • Histrionik: Sentiasa mencari perhatian dan cenderung dramatik.
   • Narsistik: Mempunyai perasaan kepentingan diri yang berlebihan dan memerlukan penghargaan berterusan.

3. Gangguan Personaliti Klasifikasi C (Cemas atau Takut):

   • Avoidant: Mengelak daripada situasi sosial kerana rasa takut terhadap kritikan atau penolakan.
   • Dependent: Bergantung secara berlebihan kepada orang lain untuk membuat keputusan dan memenuhi keperluan diri.
   • Obsessive-Compulsive: Terlalu fokus kepada kesempurnaan, peraturan, dan kawalan.

Faktor Penyumbang di Malaysia

Terdapat pelbagai faktor yang boleh menyumbang kepada perkembangan gangguan personaliti di kalangan rakyat Malaysia:

1. Budaya dan Sosial:

   • Tekanan sosial dan harapan budaya yang tinggi, seperti kepentingan keluarga dan kejayaan akademik, boleh mencetuskan atau memperburuk gangguan personaliti.
   • Stigma sosial terhadap gangguan mental menyebabkan ramai individu tidak mendapatkan bantuan yang diperlukan.

2. Ekonomi:

   • Kesempitan hidup dan tekanan ekonomi boleh mempengaruhi kesejahteraan mental seseorang.
   • Perubahan pantas dalam ekonomi negara turut memberi kesan kepada kestabilan emosi dan psikologi rakyat.

3. Keluarga dan Persekitaran:

   • Pengalaman zaman kanak-kanak yang negatif, seperti penderaan atau pengabaian, boleh menyumbang kepada perkembangan gangguan personaliti.
   • Dinamika keluarga yang disfungsional juga boleh menjadi faktor risiko.

4. Genetik dan Biologi:

   • Faktor genetik mungkin memainkan peranan dalam perkembangan gangguan personaliti, di mana sejarah keluarga dengan gangguan mental boleh meningkatkan risiko.

Prevalensi dan Cabaran dalam Penjagaan

Kajian menunjukkan bahawa gangguan personaliti agak umum di kalangan rakyat Malaysia, namun prevalensinya sering diabaikan atau disalah tafsir sebagai masalah sosial atau moral. National Health and Morbidity Survey (NHMS) pada tahun 2015 mencatatkan bahawa sekitar 29.2% rakyat Malaysia mengalami masalah kesihatan mental, yang termasuk pelbagai jenis gangguan personaliti.

Cabaran utama dalam menangani gangguan personaliti di Malaysia termasuk:

1. Kekurangan Kesedaran dan Pendidikan:

   • Masih terdapat banyak salah faham dan kurang pengetahuan tentang gangguan ini.
   • Usaha pendidikan awam masih kurang, menyebabkan kesedaran masyarakat terhadap isu ini berada pada tahap yang rendah.

2. Akses kepada Rawatan:

   • Kekurangan sumber dan kemudahan perubatan untuk rawatan kesihatan mental di kawasan luar bandar.
   • Kurangnya pakar psikologi dan psikiatri yang terlatih dalam menangani gangguan personaliti.

3. Stigma dan Diskriminasi:

• Individu dengan gangguan personaliti sering berhadapan dengan stigma dan diskriminasi, yang menyukarkan mereka untuk mendapatkan bantuan atau rawatan.
• Tanggapan negatif masyarakat terhadap gangguan mental menghalang mereka daripada mendapatkan sokongan yang diperlukan.

Intervensi dan Sokongan

Untuk mengatasi masalah gangguan personaliti di kalangan rakyat Malaysia, beberapa langkah boleh diambil:

1. Meningkatkan Kesedaran dan Pendidikan:

   • Melalui kempen kesedaran awam dan program pendidikan di sekolah untuk mengurangkan stigma dan meningkatkan pemahaman mengenai gangguan personaliti.
   • Penglibatan media dalam menyebarkan maklumat yang betul dan mengurangkan stereotaip negatif tentang gangguan ini.

2. Memperbaiki Akses kepada Rawatan:

   • Meningkatkan bilangan pakar kesihatan mental dan kemudahan di seluruh negara, terutamanya di kawasan luar bandar.
   • Menyediakan latihan untuk profesional kesihatan agar mereka lebih bersedia untuk menangani kes gangguan personaliti.

3. Menyokong Keluarga dan Komuniti:

   • Menyediakan sokongan dan sumber untuk keluarga dan individu yang terjejas, seperti kumpulan sokongan dan perkhidmatan kaunseling.
   • Menggalakkan persekitaran yang inklusif dan penyayang dalam komuniti untuk membantu individu yang menghadapi gangguan personaliti.

4. Mengembangkan Polisi dan Sokongan Kerajaan:

   • Kerajaan perlu menggubal dasar yang menyokong penjagaan kesihatan mental yang komprehensif dan mudah diakses.
   • Meningkatkan pembiayaan dan sumber untuk program kesihatan mental di seluruh negara.

Gangguan personaliti adalah isu yang signifikan dan memerlukan perhatian serius di Malaysia. Dengan meningkatkan kesedaran, memperbaiki akses kepada rawatan, mengurangkan stigma, dan menyediakan sokongan yang berkesan, kita boleh membantu mereka yang terjejas oleh gangguan ini untuk menjalani kehidupan yang lebih baik dan lebih bermakna. 

Rujukan 

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association.
2. Institute for Public Health. (2015). National Health and Morbidity Survey (NHMS) 2015. Ministry of Health Malaysia.
3. Teoh, H. J., & Rose, P. (2001). Child mental health: An integrated approach to the planning and delivery of services with respect to culturally diverse communities. Asia Pacific Journal of Social Work and Development, 11(2), 80-91.

Mood Disorder !!!!!! 🙇 Jom Baca - Kalau nak selamat 😭

Mood disorders introduction

▪ DSM-IV-TR recognizes two broad types of mood disorders: those that involve only depressive symptoms (depressive disorders) and those involve manic symptoms (bipolar disorders).

Depressive disorders 🙇

▪ The symptoms of depression include profound sadness and/or an inability to experience pleasure. 

▪ When people develop a depressive disorder, their heads may reverberate with self-recriminations. They may become focused on their flaws and deficits. 

▪ Paying attention can be so exhausting that they have difficulty absorbing what they read and hear. They often view things in a very negative light, and they tend to lose hope. 

▪ Physical symptoms of depression are also common, including fatigue and low energy as well as physical aches and pains. Depressive disorders 

▪ Although people with depression typically feel exhausted – they may find it hard to fall asleep and may wake up frequently. Other people sleep throughout the day. 

▪ They may find that food tastes bland or that their appetite is gone, or they may experience an increase in appetite. 

▪ Sexual interest disappears. 

▪ Thought and movement may slow for some (psychomotor retardation), but others can’t sit still – they pace, fidget, and wring their hands (psychomotor agitation). 

▪ When people become utterly dejected and hopeless, thoughts about suicide are common. Depressive disorders 

▪ Under depressive disorders, there are another two types of disorders as mentioned in DSM-IV-TR. They are: 

1. Major depressive disorder (MDD)

2. Dysthymic disorder (also called dysthymia). 

Major depressive disorder

▪ The DSM-IV-TR diagnosis of major depressive disorder (MDD) requires depressive symptoms to be present for at least 2 weeks. 

▪ As shown in the DSM-IV-TR criteria, at least 4 additional symptoms must be present. They are: 

i. Changes in sleep

ii. Changes in appetite; 

iii. Changes in concentration and decision-making

iv. Feeling of worthlessness; v. Suicidal

vi. Psychomotor agitation or retardation.

▪ MDD is called an episodic disorder – because symptoms tend to be present for period of time and then clear. Even though episodes tend to dissipate over time, an untreated episode may stretch on for 5 months or even longer. 

▪ Major depressive episodes tend to recur – once given episode clear, a person is likely to experience another episode.     

Dysthymic disorder

▪ Dysthymic disorder shares many of the symptoms of major depressive disorder but differ in its course. The symptoms are somewhat milder but remain relatively unchanged over long period of time, sometimes 20 or 30 years or more. 

▪ Dysthymic disorder is defined as a persistently depressed mood that continues at least 2 years, during the patient cannot be symptom free for more than 2 months at a time. 

▪ Dysthymic disorder differs from a major depressive episode only in the severity, chronicity, and number of its symptoms, which are milder and fewer but last longer. 

▪ Typically, dysthymic disorder develops first, perhaps at an early age, and then one or more major depressive episodes occur later. 

Bipolar disorders

▪ DSM-IV-TR recognizes 3 forms of bipolar disorders: 

1. Bipolar I disorder

2. Bipolar II disorder

3. Cyclothymic disorder. 

▪ Manic symptoms are the defining feature of each of these disorders. 

▪ These disorders are labelled “bipolar” because most people who experience mania will also experience depression during their lifetime 

▪ What is mania? 

▪ People may experience with abnormally exaggerated elation, joy, or euphoria. 

▪ In mania, individuals find extremely pleasure in every activity: they become extraordinary active (hyperactive), require little sleep, and may develop grandiose plan, believing they can accomplish anything they desire. 

▪ Speech is typically rapid and may become incoherent (attempting to express so many exciting ideas at once: flight of ideas) 

▪ Hospitalization may require – if individual was engaging self-destructive activities. 

Bipolar I disorder

▪ In DSM-IV-TR, the criteria for diagnosis of bipolar I disorder (formerly known as manic-depressive disorder) include a single episode of mania or a single mixed episode during the course of a person’s life.

Bipolar II disorder

▪ DSM-IV-TR also includes a milder form of bipolar disorder, called bipolar II disorder.  

Cyclothymic disorder

▪ A milder but chronic version of bipolar disorder called cyclothymic disorder is similar in many ways to dysthymic disorder. 

▪ Cyclothymic disorder is a chronic alternation of mood elevation and major depression that does not reach the severity of manic or major depressive episodes. 

▪ Individual who have this tend to be in one mood state or the other years with relatively few periods of neutral mood. 

Causes of mood disorders 

▪ Neurotransmitters: 

▪ 3 neurotransmitters have been studied the most in terms of their possible roles in mood disorders: 

▪ Norepinephrine; 

▪ Dopamine; 

▪ Serotonin. 

 

▪ Original models suggested that depression would be tied to low levels of norepinephrine and dopamine. 

▪ Mania would be tied to high levels of norepinephrine and dopamine

▪ Mania and depression were also both posited to be tied to low levels of serotonin. 

▪ Researchers initially believed that mood disorders would be explained by absolute levels of neurotransmitters in the synaptic cleft that were either too high or too low. 

▪ Brain imaging studies: 

▪ Brain imaging studies suggest that episodes of MDD are associated with changes in many of the brain systems that are activated when a person without symptoms of depression experiences strong emotions. 

▪ As one might expect, many different brain structures become involved when a person experiences emotion: the person needs to attend to and interpret the stimuli that are causing the emotion and then must make plans to deal with those stimuli. 

 ▪ Psychological: 

▪ Various aspects of personality and its development appear to be integral to the occurrence and persistence of depression. 

▪ Although depressive episodes are strongly correlated with adverse events, a person's characteristic style of coping may be correlated with his or her resilience. 

▪ In addition, low self-esteem and self-defeating or distorted thinking are related to depression.

▪ Social: 

▪ Poverty and social isolation are associated with increased risk of mental health problems in general. 

▪ Child abuse (physical, emotional, sexual, or neglect) is also associated with increased risk of developing depressive disorders later in life. 

▪ Abuse of the child by the caregiver is bound to distort the developing personality and create a much greater risk for depression and many other debilitating mental and emotional states. 

▪ Disturbances in family functioning, such as parental (particularly maternal) depression, severe marital conflict or divorce, death of a parent, or other disturbances in parenting are additional risk factors.  

▪ Medications: 

▪ The effectiveness of antidepressants is none to minimal in those with mild or moderate depression but significant in those with very severe disease. 

▪ The effects of antidepressants are somewhat superior to those of psychotherapy, especially in cases of chronic major depression. 

▪ Antidepressant medication treatment is usually continued for 16 to 20 weeks after remission, to minimize the chance of recurrence, and even up to one year of continuation is recommended 

 

Treatment of Mood Disorders 

▪ Electroconvulsive Therapy and Transcranial Magnetic Stimulation (ECT): 

1. Electroconvulsive therapy (ECT) is a procedure whereby pulses of electricity are sent through the brain via two electrodes, hospital psychiatrists may recommend ECT for cases of severe major depression that have not responded to antidepressant medication or, less often, psychotherapy or supportive interventions.  
2. ECT can have a quicker effect than antidepressant therapy and thus may be the treatment of choice in emergencies such as catatonic depression where the person has stopped eating and drinking, or where a person is severely suicidal. 

▪ Psychological treatments for depression: 

▪ Cognitive-Behavioral Therapy: 

1. ▪ Clients are taught to examine carefully their thought processes while they are depressed and to recognize “depressive” errors in thinking. ▪ Clients are thought that errors in thinking can directly cause depression. 
2. ▪ Treatment involves correcting cognitive errors and substituting less depressing and more realistic thoughts and appraisals.

▪ Interpersonal Psychotherapy: 

▪ After identifying life stressors that seem to precipitate the depression, the therapist and patient work collaboratively on the patient’s current interpersonal problems’: 

1. Dealing with interpersonal role disputes – marital conflicts; 
2. Adjusting to the loss of a relationship; 
3. Acquiring new relationships; 
4. Identifying and correcting deficits in social skills. 

▪ After helping identifying the dispute… the next steps? 

1. ✓Negotiation stage – both partners are aware it is a dispute, and they are trying to renegotiate it. ✓Impasse stage – the dispute smolders beneath the surface and results in lowlevel resentment, but no attempts are made to resolve it. 
2. ✓Resolution stage – the partners are taking some action, such as divorce, separation or recommitting to the marriage. 

Pengurusan Stress (Management Stress ilness) !!

 What is stress 

  Stress is your body's way of responding to any kind of demand. 

 It can be caused by both good and bad experiences. 

 When people feel stressed by something going on around them, their bodies react by releasing chemicals into the blood. 

 These chemicals give people more energy and strength, which can be a good thing if their stress is caused by physical danger. 

 But this can also be a bad thing, if their stress is in response to something emotional and there is no outlet for this extra energy and strength

What cause of stress

  Many different things can cause stress. 

 From physical (such as fear of something dangerous) to emotional (such as worry over your family or job) – these often referred as “stressors.” 

 Some of the most common sources of stress are: 

 Survival Stress - You may have heard the phrase "fight or flight" before. This is a common response to danger in all people and animals. When you are afraid that someone or something may physically hurt you, your body naturally responds with a burst of energy so that you will be better able to survive the dangerous situation (fight) or escape it all together (flight). This is survival stress. 

 Internal Stress - Have you ever caught yourself worrying about things you can do nothing about or worrying for no reason at all? This is internal stress and it is one of the most important kinds of stress to understand and manage. Internal stress is when people make themselves stressed. This often happens when we worry about things we can't control or put ourselves in situations we know will cause us stress. Some people become addicted to the kind of hurried, tense, lifestyle that results from being under stress. They even look for stressful situations and feel stress about things that aren't stressful. 

 Environmental Stress - This is a response to things around you that cause stress, such as noise, crowding, and pressure from work or family. Identifying these environmental stresses and learning to avoid them or deal with them will help lower your stress level. 

 Fatigue and Overwork - This kind of stress builds up over a long time and can take a hard toll on your body. It can be caused by working too much or too hard at your job(s), school, or home. It can also be caused by not knowing how to manage your time well or how to take time out for rest and relaxation. 

Good stress vs Bad stress

 So if stress can be so bad for you, how can there be "good" or "positive" stress? 

 If you are suffering from extreme stress or long-term stress, your body will eventually wear itself down. But sometimes, small amounts of stress can actually be good. 

 Understanding your stress level is important. If nothing in your life causes you any stress or excitement, you may become bored or may not be living up to your potential. If everything in your life, or large portions of your life, cause you stress, you may experience health or mental problems that will make your behavior worse.

Understanding the illness link about the stress:

 Neurobiological perspectives: 

 The body pays a price if must constantly adapt to stress. 

 This ‘price’ can be expressed in terms of what is referred to as allostatic load - (allostatic (or allotasis) - is the process of achieving stability, or homeostasis, through physiological or behavioral change). 

 If the body is exposed to high levels of stress hormones such as cortisol and becomes susceptible to disease because of altered immune system functioning – a high allostatic load.

  Psychodynamic perspectives: 

 Franz Alexander (1950) – repressed emotional impulses created a chronic negative emotional state that impacted health, thus setting the stage for problems like ulcers, asthma, or essential hypertension.

  Cognitive and personality perspectives: 

 Physical threats obviously create stress – so do negative emotions such as resentment, regret, and worry. 

 Negative emotions stimulate sympathetic nervous system activity and may keep the body’s stress systems aroused and the body in a continual state of emergency, sometimes for far longer than it can bear, as suggested by the notion of allostatic load. 

 Personality traits have been linked to immune system functioning – e.g. negative emotions linked to slow antibody production. 

Physical and mental signs of short-term stress

 Often occurring in quick 'bursts' in reaction to something in your environment, short-term stress can affect your body in many ways. Some examples: 

• •Making your heartbeat and breath faster
• •Making you sweat more
• •Leaving you with cold hands, feet, or skin
• •Making you feel sick to your stomach
• •Tightening your muscles or making you feel tense
• •Leaving your mouth dry
• •Making you have to go to the bathroom frequently
• •Increasing muscle spasms, headaches, fatigue, and shortness of breath. 

 While this burst of energy may help you in physical situations where your body needs to react quickly, it can have bad effects on your mind and performance if there is no outlet or reason for your stress. These effects may include: 

• •Interfering with your judgment and causing you to make bad decisions
• •Making you see difficult situations as threatening
• •Reducing your enjoyment and making you feel bad
• •Making it difficult for you to concentrate or to deal with distraction
• •Leaving you anxious, frustrated or mad
• •Making you feel rejected, unable to laugh, afraid of free time, unable to work, and not willing to discuss your problems with others. 

Physical and mental signs of short-term stress

 Long-term stress or stress that is occurring over long periods of time can have an even greater effect on your body and mind. Long-term stress can affect your body by: 

• Changing your appetite (making you eat either less or more)
• Changing your sleep habits (either causing you to sleep too much or not letting you sleep enough)
•  Encouraging 'nervous' behavior such as twitching, fiddling, talking too much, nail biting, teeth grinding, pacing, and other repetitive habits
• Causing you to catch colds or the flu more often and causing other illnesses such as asthma, headaches, stomach problems, skin problems, and other aches and pains
• Affecting your sex life and performance
• Making you feel constantly tired and worn out. 

 Long-term stress can also have serious effects on your mental health and behavior: 

• Worrying and feeling anxious (which can sometimes lead to anxiety disorder and panic attacks) 
• Feeling out of control, overwhelmed, confused, and/or unable to make decisions
• Experiencing mood changes such as depression, frustration, anger, helplessness, irritability, defensiveness, irrationality, overreaction, or impatience and restlessness
• Increasing dependence on food, cigarettes, alcohol, or drugs
• Neglecting important things in life such as work, school, and even personal appearance
• Developing irrational fears of things such as physical illnesses, natural disasters like thunderstorms and earthquakes, and even being terrified of ordinary situations like heights or small spaces.  

Stress Management

 Relaxation training – the most common form of relaxation training is progressive muscle relaxation, which involves systematically tensing and then relaxing each major muscle group in the body. 

 Cognitive restructuring – includes approaches to alter people’s belief systems and reduce the negativity of their interpretations of experience. 

 Behavioral skills training – practice in skills such as time management and effective prioritizing. 

Abnormal Breathing Technique

Breathing exercises such as this one should be done twice a day or whenever you find your mind dwelling on upsetting thoughts or when you are experiencing pain: 

• Place one hand on your chest and the other on your abdomen. When you take a deep breath in, the hand on the abdomen should rise higher than the one on the chest. This insures that the diaphragm is pulling air into the bases of the lungs. 
• After exhaling through the mouth, take a slow deep breath in through your nose imagining that you are sucking in all the air in the room and hold it for a count of 7 (or as long as you are able, not exceeding 7). 
• Slowly exhale through your mouth for a count of 8. As all the air is released with relaxation, gently contract your abdominal muscles to completely evacuate the remaining air from the lungs. It is important to remember that we deepen respiration not by inhaling more air but through completely exhaling it. 
• Repeat the cycle four more times for a total of 5 deep breaths and try to breathe at a rate of one breath every 10 seconds (or 6 breaths per minute). At this rate our heart rate variability increases which has a positive effect on cardiac health. 

Case Study : End of life Decisions : What is the story and what is dilemma !!!! Read Read Read Now 😟😞

End of life Decisions: Case Study

By: Afiq Shahiri 12 January 2022 2(4)

Ethical quandaries develop when individuals or communities are forced to make difficult judgements involving moral principles or values that are in contradiction with one another. These quandaries frequently give rise to challenges and disputes. Because they require individuals to make decisions between opposing interests, ethical dilemmas can offer substantial problems. However, there is not always a straightforward answer to these conundrums. Its include decision-making conflicts, stakeholder conflicts, legal and regulatory conflicts, public perception and reputation and emotional distress.

It is essential to confront ethical conundrums in a methodical and reflective manner, taking into account a variety of viewpoints, ethical frameworks, and the potential outcomes of one's actions. Participating in open discourse, looking for ethical counsel, and fostering a culture of ethical awareness are all things that may help reduce the likelihood of disputes and make it easier to deal with these issues. The decision to put an end to one's life presents complicated obstacles and tensions since it requires one to make challenging choices regarding medical treatment, care, and the preservation of human life in the face of severe circumstances or terminal sickness. This moral conundrum emerges when individuals, families, and healthcare professionals are put in a position where they must make decisions that will have an effect on the persons' quality of life, autonomy, and dignity as they draw closer to the end of their lives.

Communication that is both open and empathic is necessary to address the problems and tensions that are inherent in end-of-life choice dilemmas. This communication must involve patients, their families, healthcare providers, and other stakeholders. Access to palliative care, advance care planning, and ethical frameworks, such as shared decision making models can all be helpful in navigating these issues and promoting compassionate decision-making in end of life circumstances.

1.     Case Study 1 

Adam was a 2-year-old child with congenital acute myeloid leukemia. He was admitted to the pediatric intensive care unit (PICU) after receiving an allogeneic bone marrow transplant. One week after the transplant, a severe pulmonary infection developed, resulting in irreversible lung injury; he was ventilator dependent. Adam was a patient in the PICU for 2 months and he had good and bad days. On his bad days, the PICU staff struggled to manage his hypoxemia, hypercapnia, and hemodynamic instability. He had several close calls to death, including being resuscitated twice after having cardiac arrests. Neurologically at times, he opened his eyes; he had limited motor ability. When he became restless, he was given sedative drugs.

Several family meetings occurred over his 2-month PICU stay. The palliative care team was consulted 5 weeks into his stay. At the most recent meeting, the palliative care APRN reviewed Adam’s illness trajectory, discussed his current condition and told Adam’s parents that the team would like to consider a change in the focus of Adam’s care.

The pediatric intensivist discussed Adam’s poor prognosis and his parents were given time to ask questions. The palliative care APRN discussed the possibility of focusing Adam’s care on comfort and suggested that it was time to consider decisions such as withholding cardiopulmonary resuscitation (CPR) if Adam’s heart were to stop again. She asked Adam’s parents whether they would support this decision. Adam’s mother said that she agreed that CPR should not be started if her son’s heart stopped. Adam’s father became angry and stated that the staff was giving up on his son. He absolutely wanted all treatment continued, including CPR. He got up and stormed out of the conference room.

Adam’s PICU nurse was not sure whether to stay in the meeting or leave. She decided to leave and look for Adam’s father. She found him sitting at his son’s bedside crying. He told her that he needed a little time alone, so the nurse left and gave him time with his son. When she returned, she acknowledged how difficult it must be to participate in these types of decisions. Adam’s father told her that he did not want to give up on his son. The nurse reinforced what good parents both he and his wife were. Adam’s father said that he needed time to think about everything. He had hoped that his son would recover and he was just starting to realize that he might not. The PICU nurse emphasized that Adam would continue to receive the best care possible, regardless of what decision was made, and that the team was there to help not only Adam but also his family. (Wiegand, 2015, pg. 145)

This case study presents a conflicting decision between both parents of a terminally ill 2-year-old boy with acute myeloid leukemia. Despite a poor prognosis as well as multiple resuscitations from cardiac arrests, the father refused to discontinue resuscitation attempts with the perception that the medical team is giving up on his son. The mother, however, was accepting of the decision due to the condition of her son. The medical team, however, was adhering to the ethical principle of autonomy, by allowing both of the parents, the autonomous legal guardian of their son, to give their final decision on this end-of-life matter. Despite wanting to provide the best treatment that may benefit the patient (beneficence), the medical team also would like to reduce and minimize any harm that may be inflicted on the 2-year-old boy (non-maleficence).

One of the dilemmas that may be seen here is the contradiction between the father’s decision from the medical team’s advice. Other than the literal physical definition of ‘alive’ towards the patient, the decision-maker, in this case, the parents, must also consider the weight of their son’s quality of life should the treatment and resuscitation be continued, apart from the consideration of their cultural and religious norm. The process of end-of-life decision-making should consider the well-being of the patient from all aspects; physical, emotional, religious, and even personal beliefs (Puteri, 2015). Though admittedly, a 2-year-old may have less consideration for religion and personal beliefs, the consideration of end-of-life decisions should also include the immediate family and guardian.

The counsel team did a praiseworthy job in assuring the parents that they will strive in providing the best care possible for whichever path the parents choose to decide. Should the parents choose the continue treatment, the medical team will work hard in providing the best treatment that benefits the patient, and if the parents choose to discontinue treatment and resuscitation, the medicals team will also give as much effort in maximizing comfort and care if the provision of the best palliative care for their son, Adam.

Ethically, this end-of-life decision may only be made by the parents and should not be interfered with by any other party. However, the medical team and the psychological support team, if any, should be ready to be transparent and honest (veracity) in providing a full, detailed explanation of Adam’s condition to both parents. The parents should be able to make a fully informed decision and psychological and emotional support services should be made available to the parents should they need them. End-of-life care is an all-hands-on-deck situation where every party serves a huge role in ensuring the best outcome for the patient, the parents as well as the medical team. Despite everyone’s involvement, both decisions of continuing or discontinuing treatment are not ethical violations as long as all information is given and received by all parties involved

     2.     Case Study 2

The case of Ms. Rahimah is a hypothetical case study of a 65-year-old woman with end-stage chronic obstructive pulmonary disease (COPD), a condition characterized by the progressive deterioration of the airways in the lungs. Despite undergoing various treatments for her condition over the years, her COPD has continued to worsen, and she has now reached a point where her doctors have determined that there are no more viable treatment options available. They have explained that her condition will ultimately lead to her death, and they have suggested that she and her family begin to think about her end-of-life care.

Rahimah has expressed to her doctors and family that she does not want to prolong her suffering any further, and she has decided to elect hospice care. Hospice care is a form of palliative care that provides comfort and pain relief to patients who are dying, and it often involves the withdrawal of life-preservation interventions such as intubation or resuscitation. Ms. Rahimah's decision to elect hospice care reflects her desire to prioritize comfort and quality of life overextending her life at all costs.

While Ms. Rahimah's decision may be a difficult one for some family members to understand, it is ultimately her right to self-determination, as she is entitled to make decisions about her healthcare based on her values and preferences. Her decision is an example of the importance of open and honest discussions about end-of-life care and the role that patients, families, and healthcare professionals play in these discussions. By taking an approach to end-of-life care, we can help patients and families make informed decisions that prioritize comfort, dignity, and quality of life.

End-of-life decisions are complex and require careful consideration of the patient's preferences and values. The case of Ms. Rahimah illustrates the importance of respecting a patient's autonomy in making these decisions, and providing care that prioritizes comfort, relief from suffering, and an increase in quality of life.

Autonomy is a fundamental principle in ethics and is especially important in end-of-life care. It involves allowing a patient to make their own healthcare decisions, including decisions about their end-of-life care. By treating a patient as autonomous person, we respect their dignity and agency, and we help to ensure that their values and preferences are considered in care planning.

In the case of Ms. Rahimah, it was important to respect her autonomy in making her decision to elect hospice care. She had the right to make this decision, and it was not appropriate for others to impose their own beliefs or values on her. Healthcare professionals should provide information, support, and guidance to help patients make informed decisions, but they should not pressure patients to choose a particular course of care.

Aside from respecting autonomy, it is also important to provide care that is non-maleficent or that does not cause harm. Hospice care is designed to provide comfort and relief from suffering, rather than to prolong life at all costs. Healthcare professionals should ensure that they are not providing treatments or interventions that could cause harm or prolong suffering and should instead focus on providing palliative care that addresses the patient's needs and aims to improve their quality of life.

In addition to non-maleficence, it is also important to provide care that is beneficial or that brings about good. End-of-life care should not only be about avoiding harm but should also be about providing benefits to the patient, such as relief from pain and distress, and an increase in their quality of life. Palliative care is designed to do just that, and healthcare professionals should take a holistic approach to care that addresses the patient's physical, emotional, and spiritual needs.

Finally, justice is a principle that requires individuals to be treated fairly and equitably and not be subjected to discrimination or bias. In the case of Ms. Jones, it is important that healthcare professionals do not discriminate against her based on her age, or gender.

3.     Case Study 3

John Anderson, a 68-year-old man, has been living with end-stage heart failure for the past two years. Current Condition severe shortness of breath, fluid retention, declining organ function. Despite various medical interventions, his condition has progressively worsened. John's heart function has significantly declined, leading to severe shortness of breath and fluid retention. He is frequently hospitalized for complications related to his heart failure. The medical team believes that John is approaching the end stages of his illness.

 Ethical Dilemma:

John's family and healthcare providers are facing an ethical dilemma regarding end-of-life decisions. John's condition is unlikely to improve, and his quality of life is greatly compromised. The medical team and family members have different opinions on the best course of action. Some family members advocate for continuing

aggressive interventions, while others believe that focusing on comfort care and ensuring a peaceful end is more appropriate.

Options Considered:

Continuation of Aggressive Interventions:

Continue with advanced medical treatments, such as cardiac interventions, mechanical circulatory support, or transplantation, with the goal of extending John's life. Engage in ongoing discussions with the medical team to assess the potential benefits, risks, and burdens of these interventions. Understanding these factors will help John and his loved ones make informed decisions regarding the continuation of aggressive treatments. Ensure that John's goals and preferences are considered in the decision-making process.

 Transition to Palliative Care and Symptom Management:

Transitioning to palliative care signifies a shift in the treatment approach, placing emphasis on improving John's quality of life. Instead of pursuing aggressive interventions, the focus now shifts to providing holistic care that addresses his physical, emotional, and spiritual well-being. Palliative care aims to alleviate symptoms, manage pain, and enhance overall comfort, allowing John to make the most of his remaining time. Symptom management is a vital aspect of palliative care. Medications are commonly used to alleviate symptoms such as pain, nausea, anxiety, and shortness of breath. The palliative care team, in collaboration with John, will develop an individualized plan tailored to his specific needs. This approach ensures that medication regimens are optimized, providing effective relief while minimizing potential side effects. Shortness of breath is a distressing symptom often experienced by individuals with advanced medical conditions. In palliative care, oxygen therapy and non-invasive ventilation can significantly improve John's breathing and enhance his comfort. These interventions aim to alleviate breathlessness, allowing him to engage in activities that bring joy and maintain a sense of independence.

 Shared Decision-Making and Advance Care Planning:

Shared decision-making is crucial in the continuation of aggressive interventions. It involves collaboration between John, his family, and the medical team. By providing comprehensive information about the available treatment options, their potential outcomes, and associated risks, the medical team can empower John and his family to actively participate in the decision-making process. This collaborative approach ensures that the final decision aligns with John's values, preferences, and long-term goals.

4.     Conclusion 

From the case study presented, there are 3 prong conflicts that can be observed regarding decision-making for end-of-life care; the patient’s advocate vs healthcare worker, the patient vs her family member, and the patient’s family member vs the healthcare worker.

In this dire situation, everyone involved does have their best intention at heart, aiming for the best outcome for the patient, but when it concerning the end of life care, the willingness to participate in the conversation is varied, both for the patient’s themself and their relatives as it is emotionally challenging (Gjerberg, E. et al, 2015) and it poses communication challenge even with the healthcare provider (Naomi, R. et al. 2016). Adding the weight of the situation is when the patient can’t exercise their autonomy, the responsibility to make the decision will fall onto their legal next-of-kin, as this has always been part of hospital policies.

However, many of the patient’s relatives did not really know what the patient’s needs were, despite the patient’s belief in them (Georg Bollig et al. 2016).

Since all the case studies happen in hospital settings and involve palliative care, referring to Palliative Care Services Operational Policy 2010 by the Ministry of Health (MOH) is essential as it provides ethical guidelines for handling the situation. As palliative care is generally a new medical specialty recognized by MOH in 2005, another guideline that can be helpful to assist in the decision-making for the professional parties is Handbook in Palliative Medicine in Malaysia, developed in 2015. The reasons this was emphasized was that this policy and handbook can assist in making better solutions for the case studies, as it is coherence with Principal A: Beneficence and Non-Maleficence, of APA General Principle (2010) when the psychologists' scientific and professional judgments and actions may affect the lives of others, they need to be alert and guarded against personal, financial, social, organizational, or political factors that might lead to misuse of their influence.

According to the policy, effective communication skills are essential tools in palliative care and healthcare providers must develop these skills, including effective listening, providing information, facilitating decision making and coordinating care among the patient, family, and other healthcare providers, as this has proven to better prepare the patient for their final outcome and reduce moral distress for their relatives (Georg Bollig et al. 2016). This provision is aligned with Principle E: Respect for People's Rights and Dignity, of APA General Principle (2010), where individual differences are respected and taking these differences into consideration when working with others.

Managing end-of-life care decision’s making can also be guided by the Resolution on Palliative Care and End-of-life Issues, adopted by the APA Council of Representatives, which “endorses the principles that care for individuals with advanced serious illness should be comprehensive, high quality, integrated, interdisciplinary, patient-centered and family oriented, coordinated across all providers and settings; accessible, and available through governmental and private health insurers and care delivery programs. Individuals should have the opportunity to engage in conversations about their health care, the results of which should be incorporated into ongoing care plans.” (2017, para 74).

5.     Reference

• American Psychological Association (2017) Ethical Principles of Psychologists and Code of Conduct from https://www.apa.org/ethics/code?item=7#405
• American Psychological Association (2017) Resolution on Palliative Care and End-of-life Issues from https://www.apa.org/about/policy/palliative-care-eol
• eorg Bollig, Eva Gjengedal and Jan Henrik Rosland (2016) They know! —Do they? A qualitative study of residents and relatives’ views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliative Medicine Vol. 30(5) 456–470 DOI: 10.1177/0269216315605753 
• Gjerberg, E., Lillemoen, L., Førde, R. et al. (2015) End-of-life care communications and shared decision-making in Norwegian nursing homes - experiences and perspectives of patients and relatives. BMC Geriatric 15  https://doi.org/10.1186/s12877-015-0096-y
• Naomi R. George, Jennifer Kryworuchko, Katherine M. et al. (2016) Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda. Academic Emergency Medicine https://doi.org/10.1111/acem.13083
• Jahn Kassim, P. N., & Alias, F. (2015). End-of-life decisions in Malaysia: Adequacies of Ethical Codes and Developing Legal Standards. Journal of Law and Medicine.
• Wiegand, D. L., MacMillan, J., dos Santos, M. R., & Bousso, R. S. (2015). Palliative and end-of-life ethical dilemmas in the Intensive Care Unit. AACN Advanced Critical Care, 26(2), 145–146. https://doi.org/10.4037/nci.0000000000000085
•  American Heart Association. (2017). Shared Decision-Making in Advanced Heart Failure: A Scientific Statement from the American Heart Association. Circulation: Heart Failure, 10(9), e000025.
• National Hospice and Palliative Care Organization. (2021). What is Palliative Care? Retrieved from https://www.nhpco.org/patients-and-caregivers/palliative-care/.
• National Consensus Project for Quality Palliative Care. (2021). Clinical Practice Guidelines for Quality Palliative Care, 4th edition. Retrieved from https://www.nationalcoalitionhpc.org/ncp/.
• Meier, D. E. (2011). Increased access to palliative care and hospice services: Opportunities to improve value in health care. The Milbank Quarterly, 89(3), 343-380.
• World Health Organization. (2018). WHO Definition of Palliative Care. Retrieved from https://www.who.int/cancer/palliative/definition/en/.
• Upadhyay, A., & Mello, M. M. (2014). The ethics of chronic pain management. In J. C. Ballantyne & D. J. Sullivan (Eds.), The Oxford Textbook of Palliative Medicine (5th ed., pp. 126-134). Oxford University Press.
• Akdeniz, M., Yardımcı, B., & Kavukcu, E. (2021). Ethical considerations in end-of-life care. SAGE Open Medicine, 9, 20503121211000918.
• Cavallaro, V. (2014). Advance Directive Accessibility: Unlocking the toolbox containing our end-of-life decisions. Touro L. Rev., 31, 555.
• Parks, S. M., Winter, L., Santana, A. J., Parker, B., Diamond, J. J., Rose, M., & Myers, R. E. (2011). Family factors in end-of-life decision-making: Family conflict and proxy relationship. Journal of palliative medicine, 14(2), 179-184.

Article Shared : Explain the conditions that are essential for operand and classical conditioning to occur and provide an example in the classroom context.

 

Explain the conditions that are essential for operand and classical conditioning to occur and provide an example in the classroom context.

Afiq Shahiri : 15/12/2021

 

Classical conditioning it is how one learns to associate stimuli or connect with the thinking brain. According to Ivan Pavlov (1927) gave a theory to two types of stimuli and two types of responses namely unconditioned stimulus (UCS), unconditioned response (UCR), conditioned stimulus (CS), and conditioned response (CR). And furthermore, when a neutral stimulus gets linked with a significant stimulus, it gains the ability to trigger a comparable reaction. This is an example of associative learning.

Pavlov gave the example of a dog as a response for example unconditional stimulus (UCS) which shows the dog only listens to the door without responding while conditioned response (CR) is a learned response to a conditioned stimulus that occurs after the UCS-CS pair example gives sound as well as followed by feeding. According to him again, Involved in both good and bad experiences of youngsters in the school. Like favorite songs and the perception that the classroom is a secure and enjoyable environment are two examples of items in children's learning that have become classics and so provide hours of entertainment. To be clear in classical conditioning is included:

UCS is anything that elicits an instant or somewhat instinctive reaction might be defined as automatic reaction.

UCR is a response which is elicited by an unconditioned stimulus.

CS is when a conditioned stimulus is offered repeatedly for a period of time prior to an unconditioned stimulus, it is said to have been conditionally presented. At the conclusion of the experiment, it will produce the same reaction as the conditioned stimulus.

CR is described as a reaction that occurs as a consequence of exposure to a conditioned stimulus

So operant conditioning is a learning process in which purposeful activities are rewarded by the consequences of those behaviours. If the dog then improves his or her ability to sit and remain in order to earn the reward, this is an example of operant conditioning. Other than that, positive reinforcement, such as giving a dog a treat or providing food to a rat, may be used in operant conditioning experiments. Furthermore, negative reinforcement is used to reward a dog for staying close to its human by relieving the uncomfortable strain on the leash. Opportunistic training might include punishment in certain cases. Each and every example of operant conditioning shows how a desired behaviour is reinforced via the use of consequences.

In operant conditioning, the concepts of reinforcement and punishment are used to achieve the desired results. You are enhancing a behaviour when you reinforce it. A consequence or result that raises the probability of a certain behavioural response is defined as reinforcement. The behavior-strengthening impact may present itself in a variety of ways, including increased frequency, longer duration, larger amplitude, and shorter latency in response. It is any consequence or event that reduces the chance of a behavioural reaction that is defined as a kind of punitive action.

Furthermore, both reinforcement and punishment might be positive and negative and have the potential to be effective. Positive and negative may not always imply good or bad behaviour in operant conditioning. Instead, positive implies that you are adding something, while negative implies that you are subtracting something. All of these techniques may be used to affect the behaviour of a subject, but each one operates in a different way.

For example, when in class, students like to run around in class. This thing cannot be saved because it is the nature of boys to do such a thing. But when they hear the rattan they will automatically stop. This is an example where the UCS response occurs. However, if this matter continues to be practiced then indirectly the students will recognize the sound and continue to respond then this matter is CR. At the same time, it can happen if the teacher makes an angry face at the students then automatically UCR happens. It is customary if done then they will understand if the teacher looks with a sharp gaze it signals to reprimand and the students will be silent. If this happens repeatedly then it has been embedded in the brains of the pupils. For example, the conditional stimulus arises when it is presented repeatedly for some time before the unconditional stimulus. Eventually, it will give the same response as the conditioned stimulus. So, the students have become accustomed to the conditions and react naturally when it happens. So, this is included in CS conditional stimuli.

 Other than that, it can also have a positive impact on behavior when operant conditioning applied. For example,

Positive reinforcers add desired or pleasant stimuli to increase or maintain the frequency of a behavior. For example, students not running around in class will get candy.

Negative reinforcers emit unpleasant or unpleasant stimuli to increase or maintain the frequency of the behavior. For example, a student if he does not run in class, can return early.

Positive punishment adds an unpleasant stimulus to reduce a behavior or reaction. For example, a student running around in class will be fined for having to memorize the numbers 1 through 12 in front of an assembly for four consecutive days.

Negative punishment eliminates pleasant stimuli to reduce behavior or reactions. For example, a student running in class will get a fine of all not being able to go home early at the end of the school day.

 These two things are very related to connect a situation. Stimuli that are used to promote a certain behaviour may be classified as either primary or secondary. The main reinforcer, also known as an unconditional reinforcer, is a stimulus that has a naturally reinforcing effect on the subject's behaviour. There has been no research on such reinforcers. At the sometime, it may include with generalization which is can generalize similar things and respond the same. For all students know, a bell rings to signal a break time. And finally is discrimination is an opportunistic conditioning occurs when an organism reacts differentially to two comparable but not identical stimuli in the context of different way. Like at an assembly when the teacher has finished speech,  half the students some applaud and some are silent. This shows different ways of responding from the same context.

Cara - Cara untuk Mengurus Pesakit yang menghadapi Gangguan Mental | Ways to Manage Mental Disorder Patient !!!

 

Pengurusan Pesakit Gangguan Mental

Disunting oleh: Muhammad Afiq Shahiri Bin Sapie   4 September 2020 1 (2)

    Ramai orang yang telah didiagnosis dengan penyakit mental mendapat kekuatan dan penyembuhan melalui penyertaan dalam terapi individu atau kumpulan yang diprogramkan. Pilihan terapi adalah banyak dan berbeza dari seorang ke seorang. Walaupun tiada satu terapi berkesan untuk semua orang, orang ramai boleh memilih rawatan, atau gabungan terapi, yang mereka percaya paling berkesan untuk mereka.

     Apabila kita pergi ke gangguan kecemasan. Terdapat beberapa cara yang boleh dilakukan untuk menguruskan psikoterapi gangguan kecemasan ini. Psikoterapi sering dikenali sebagai terapi bercakap atau kaunseling psikologi, adalah usaha kolaboratif antara anda dan ahli terapi untuk mengurangkan gejala kebimbangan anda. Ia berpotensi untuk menjadi terapi kebimbangan yang berkesan.

     Pakar psikologi telah memberikan petua dan peranan untuk mencegah atau mengawal jika seseorang itu mengalami kebimbangan seperti mengekalkan tahap aktiviti fizikal yang sihat setiap hari. Elakkan mengambil minuman beralkohol dan menggunakan dadah rekreasi untuk memastikan badan anda kekal sihat dan juga merokok harus dielakkan, dan minuman berkafein harus dikurangkan atau dielakkan sama sekali. Selain itu, pengurusan tekanan dan strategi relaksasi harus digunakan untuk melaksanakan setiap hari.

Bandung 2020

Diagnosis Awal dan Tepat:

• Lakukan penilaian klinikal yang menyeluruh.
• Menggunakan alat penilaian dan diagnostik standard.
• Mengambil kira sejarah perubatan dan psikososial pesakit.

Rawatan perubatan:

• Penggunaan ubat psikotropik seperti antidepresan, antipsikotik, dan penstabil mood.
• Pemantauan kesan sampingan dan pelarasan dos ubat jika perlu.
• Rundingan tetap dengan pakar psikiatri.

Terapi Psikologi:

• Terapi kognitif-tingkah laku (CBT).
• Terapi keluarga atau kumpulan sokongan.
• Terapi berasaskan kesedaran seperti meditasi dan yoga.

Pendidikan dan Sokongan Pesakit:

• Memberi pendidikan tentang gangguan mental yang dialami.
• Membantu pesakit memahami dan menguruskan simptom.
• Membangunkan kemahiran mengatasi dan teknik relaksasi.

Sokongan Sosial:

• Galakkan hubungan sosial yang positif dan sokongan daripada keluarga dan rakan-rakan.
• Menyediakan akses kepada kumpulan sokongan komuniti.
• Mengurangkan stigma terhadap gangguan mental dalam masyarakat.

Pelarasan Gaya Hidup:

• Menggalakkan amalan gaya hidup sihat seperti diet seimbang dan senaman yang kerap.
• Kurangkan atau elakkan penggunaan bahan seperti alkohol dan dadah.
• Uruskan tekanan melalui aktiviti relaksasi dan tidur yang cukup.

Pemantauan dan Penilaian Berkala:

• Penilaian berterusan keberkesanan rawatan.
• Menyesuaikan pelan rawatan berdasarkan kemajuan atau perubahan dalam keadaan pesakit.
• Dapatkan maklum balas daripada pesakit dan keluarga berkenaan rawatan.

Campur Tangan Krisis:

• Penyediaan pelan tindakan untuk situasi kecemasan atau krisis.
• Hubungi perkhidmatan kecemasan atau hospital jika perlu.
• Berikan intervensi segera untuk mengurangkan risiko kepada diri sendiri atau orang lain.

     Akhir sekali, terdapat begitu banyak yang disyorkan oleh ahli psikologi untuk menguruskan gangguan mental. Apa yang dikongsikan di sini adalah sebahagian daripada perkara penting untuk anda tahu bagaimana untuk menguruskan sekiranya berlaku gangguan mental yang akan berlaku. Antara yang penting lain ialah psikoterapi sokongan ialah sejenis psikoterapi yang membantu orang berasa lebih baik tentang diri mereka sendiri. Jenis yang paling kerap digunakan, adalah berdasarkan perkembangan hubungan simpatik dan sokongan antara pesakit dan ahli terapi.