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Pennebaker also reported that symptom perception is related to an individual’s attentional state and that boredom and the absence of environmental stimuli may result in over-reporting order 500mg amoxil mastercard, whereas distraction and attention diversion may lead to under-reporting (Pennebaker 1983) buy discount amoxil 250mg online. Sixty-one women who had been hospitalized during pre-term labour were randomized to receive either information purchase discount amoxil online, distraction or nothing (van Zuuren 1998). The results showed that distraction had the most beneﬁcial eﬀect on measures of both physical and psychological symptoms suggesting that symptom per- ception is sensitive to attention. Symptom perception can also be inﬂuenced by the ways in which symptoms are elicited. For example, Eiser (2000) carried out an experimental study whereby students were asked to indicate their symptoms, from a list of 30 symp- toms, over the past month and the past year and also to rate their health status. The results showed that those in the ‘exclude’ condition reported 70 per cent more symptoms than those in the ‘endorse’ condition. In addition, those who had endorsed the symptoms rated their health more negatively than those who had excluded symptoms. This suggests that it is not only focus and attention that can inﬂuence symptom perception but also the ways in which this focus is directed. These diﬀerent factors are illustrated by a condition known as ‘medical students’ disease’, which has been described by Mechanic (1962). A large component of the medical curriculum involves learning about the symptoms associated with a multitude of diﬀerent illnesses. More than two-thirds of medical students incorrectly report that at some time they have had the symptoms they are being taught about. Perhaps this phenomena can be understood in terms of: s Mood: medical students become quite anxious due to their workload. This anxiety may heighten their awareness of any physiological changes making them more internally focused. Therefore, symptom perception inﬂuences how an individual interprets the problem of illness. This may come in the form of a formal diagnosis from a health professional or a positive test result from a routine health check. However, screening and health checks may detect illness at an asymptomatic stage of development and therefore attendance for such a test may not have been moti- vated by symptom perception. Information about illness may also come from other lay individuals who are not health professionals. Before (and after) consulting a health professional, people often access their social network, which has been called their ‘lay referral system’ by Freidson (1970). This can take the form of colleagues, friends or family and involves seeking information and advice from multiple sources. For example, coughing in front of one friend may result in the advice to speak to another friend who had a similar cough, or a suggestion to take a favoured home remedy. Alternatively, it may result in a lay diagnosis or a suggestion to seek professional help from the doctor. Such social messages will inﬂuence how the individual interprets the ‘problem’ of illness. This section will examine three approaches to coping with illness: (1) coping with a diagnosis; (2) coping with the crisis of illness; and (3) adjustment to physical illness and the theory of cognitive adaptation. These diﬀerent theoretical approaches have implications for understanding the diﬀerences between adaptive and maladaptive coping, and the role of reality and illusions in the coping process. They therefore have diﬀerent implications for understanding the outcome of the coping process. Coping with a diagnosis Shontz (1975) described the following stages of coping that individuals often go through after a diagnosis of a chronic illness: s Shock: initially, according to Shontz most people go into a state of shock following a diagnosis of a serious illness. Being in shock is characterized by being stunned and bewildered, behaving in an automatic fashion and having feelings of detachment from the situation. This is characterized by disorganized thinking and feelings of loss, grief, helplessness and despair. Shontz argued that this stage is characterized by denial of the problem and its implications and a retreat into the self. According to Shontz, retreat is only a temporary stage and denial of reality cannot last for ever. Therefore, the retreat stage acts as a launch pad for a gradual reorientation towards the reality of the situation and as reality intrudes the individual begins to face up to their illness. Therefore, this model of coping focuses on the immediate changes following a diagnosis, suggesting that the desired outcome of any coping process is to face up to reality and that reality orientation is an adaptive coping mechanism. Coping with the crisis of illness In an alternative approach to coping with illness, Moos and Schaefer (1984) have applied ‘crisis theory’ to the crisis of physical illness. Crisis theory has been generally used to examine how people cope with major life crises and transitions and has traditionally provided a framework for understanding the impact of illness or injury. The theory was developed from work done on grief and mourning and a model of developmental crises at transition points in the life cycle. In general, crisis theory examines the impact of any form of disruption on an indi- vidual’s established personal and social identity. It suggests that psychological systems are driven towards maintaining homeostasis and equilibrium in the same way as physical systems. Within this framework any crisis is self-limiting as the individual will ﬁnd a way of returning to a stable state; individuals are therefore regarded as self-regulators. Physical illness as a crisis Moos and Schaefer (1984) argued that physical illness can be considered a crisis as it represents a turning point in an individual’s life. They suggest that physical illness causes the following changes, which can be conceptualized as a crisis: s Changes in identity: illness can create a shift in identity, such as from carer to patient, or from breadwinner to person with an illness. In addition, the crisis nature of illness may be exacerbated by factors that are often speciﬁc to illness such as: s Illness is often unpredicted: if an illness is not expected then the individual will not have had the opportunity to consider possible coping strategies. Therefore, illness is infrequent and may occur to individuals with limited prior experience. This lack of experience has implications for the development of coping strategies and eﬃcacy based on other similar situations (e. Many other crises may be easier to predict, have clearer meanings and occur to indi- viduals with a greater degree of relevant previous experience. Within this framework, Moos and Schaefer considered illness a particular kind of crisis, and applied crisis theory to illness in an attempt to examine how individuals cope with this crisis. The coping process Once confronted with the crisis of physical illness, Moos and Schaefer (1984) described three processes that constitute the coping process: (1) cognitive appraisal; (2) adaptive tasks; and (3) coping skills. Process 1: Cognitive appraisal At the stage of disequilibrium triggered by the illness, an individual initially appraises the seriousness and signiﬁcance of the illness (e. Factors such as knowledge, previous experience and social support may inﬂuence this appraisal process.
Third parties may be employed to act as mules discount 250 mg amoxil with visa, and a case of body packing using children amoxil 500 mg fast delivery, two boys aged 6 and 12 years order amoxil from india, Care of Detainees 215 who had concealed heroin has been reported (31). A person who is about to be arrested by the police may swallow drugs (“body swallower” or “stuffer”). Doctors may then be called by the police to conduct intimate searches of those arrested (see Chapter 2) (32). Any health care professional who agrees to perform an intimate search should have the required skills and a comprehensive under- standing of the risks involved and their management. The doctor should discuss the possible implications of the ingestion of certain drugs and obtain fully informed consent from the detainee before conducting any search that may involve examination of the mouth, nostrils, ears, umbilicus, foreskin, rectum, or vagina. Variable quantities of drugs, such as heroin, cocaine, cannabis, and am- phetamine, may be packaged in layers of cellophane or in condoms. All searches for such drugs should be carried out in premises where there are full facilities for resuscitation (32a) in case significant quantities of the drugs leak into the bloodstream, resulting in acute intoxication and death from overdose (33). The aim of medical management is to prevent these complications, but for ethical reasons, the retrieval of packages for legal purposes alone is no indi- cation for intervention without the patient’s permission. Therefore, without such permission, the doctor can do nothing except advise the police authorities that the detainee should be observed. In most patients who are asymptomatic, a trial of conservative treatment, provided bowel obstruction or package perforation is not suspected, will result in the uncomplicated elimination of all ingested packages (34,35). In a genuine emergency when there is no possibility of obtaining consent, the doctor has a duty to perform treatment to safeguard the life and health of a patient in accordance with what would be accepted as appropriate treatment in the patient’s best interests (36). These samples should only be taken by a doctor or nurse for evidential purposes with the detainee’s fully informed consent and should be packaged in accordance with local procedures to ensure the chain of evidence. Introduction The custodial interrogation of suspects is an essential component of all criminal investigation systems. The confessions and other incriminating state- 216 Norfolk and Stark ments that are obtained during these interrogations have always played an important role in prosecutions and continue to be relied on as evidence of guilt in a substantial number of trials. For example, in England and Wales, confes- sions provide the single most important piece of evidence against defendants in the Crown Court, being crucial in approx 30% of cases (37). Similarly, an influential American observational study found that interrogation was neces- sary for solving the crime in approx 17% of cases (38). The quest to obtain confessions from suspects’ mouths has seen a slow and uneven move away from the inquisitions aided by torture and oppression of the Middle Ages toward the doctrine that: A free and voluntary confession is deserving of the highest credit, because it is presumed to flow from the strongest sense of guilt and therefore it is admitted as proof of the crime to which it refers; but a confession forced from the mind by the flattery of hope or by the torture of fear comes in so questionable a shape when it is to be considered as the evidence of guilt, that no credit ought to be given to it; and therefore it is rejected (39). In the years since this judgment, considerable effort has been expended attempting to regulate the custodial interview to minimize the risk of false confessions while preserving the value of interrogation as a means of solving crime. In this section, the important psychological aspects of interrogation and confession are considered and the role the forensic physician can play in ensuring that suspects are fit to be interviewed is discussed. Police Interview Techniques Numerous American manuals detail the way in which coercive and manip- ulative interrogation techniques can be employed by police officers to obtain a confession (40,41), with similar techniques being advocated by Walkley (42) in the first such manual written for British officers. The authors of these manuals propound various highly effective methods for breaking down a suspect’s resis- tance while justifying a certain amount of pressure, deception, persuasion, and manipulation as necessary for the “truth” to be revealed. Walkley acknowledges that “if an interviewer wrongly assesses the truth-teller as a lie-teller he may subject that suspect to questioning of a type which induces a false confession. Although studies in the United Kingdom have suggested that coercive interview techniques are employed less frequently than in the past, manipulative and persuasive tactics continue to be used, particularly in relation to more serious crimes (43,44). Care of Detainees 217 Interrogators are encouraged to look for nonverbal signs of anxiety, which are often assumed to indicate deception. Innocent suspects may be anxious because they are erroneously being accused of being guilty, because of wor- ries about what is going to happen to them while in custody, and possibly because of concerns that the police may discover some previous transgres- sion. Furthermore, there are three aspects of a police interview that are likely to be as stressful to the innocent as to the guilty: the stress caused by the physical environment in the police station, the stress of being isolated from family and friends, and the stress caused by the suspect’s submission to authority. All these factors can markedly impair the performance of a suspect during an interview. Indeed, American research has suggested that for most suspects, interrogations are likely to be so stressful that they may impair their judgment on such crucial matters as the exercise of legal rights (45). Given the interview techniques employed by the police and the stresses interrogation places on the accused, there is little wonder that false confes- sions are occasionally made to the police. False Confessions During the last two decades, the United Kingdom has witnessed several well-publicized miscarriages of justice in which the convictions depended heavily on admissions and confessions made to the police that were subse- quently shown to be untrue (46–48). In reviewing 70 wrongful imprisonments that occurred between 1950 and 1970, Brandon and Davies (49) found that false confessions were second only to incorrect identification evidence as the most common cause of wrongful conviction. More recently, in 1994, Justice (50) identified 89 cases in which an alleged miscarriage of justice rested on a disputed confession. Thus, it is clear that people can and do make false and misleading admissions against their own interest. There is no single reason why people falsely confess to crimes they have not committed. Indeed, such confessions usually result from a combination of factors unique to the individual case. These categories are voluntary, accommodating-compliant, coerced-com- pliant, and coerced-internalized. Voluntary False Confessions Voluntary false confessions are offered by individuals without any exter- nal pressure from the police. Commonly, the individuals go voluntarily to the police to confess to a crime they may have read about in the press or seen reported on television. Often, they do so out of a morbid desire for notoriety because the individual seemingly has a pathological desire to become infa- mous, even at the risk of facing possible imprisonment. Alternatively, a voluntary false confession may result from the individual’s unconscious need to expiate guilty feelings through receiving pun- ishment. The guilt may concern real or imagined past transgressions or, occa- sionally, may be part of the constant feeling of guilt felt by some individuals with a poor self-image and high levels of trait anxiety. By contrast, some people making this type of confession do so because they are unable to distinguish between fact and fantasy. Such individuals are unable to differentiate between real events and events that originate in their thinking, imagination, or planning. Such a breakdown in reality monitoring is normally associated with major psychiatric illness, such as schizophrenia. Occasionally, people may volunteer a false confession to assist or protect the real culprit. Gudjonsson (52) highlights some evidence that confessing to crimes to protect others may be particularly common in juvenile delinquents. Finally, Shepherd (53) identifies a subset of individuals who falsely con- fess to crimes to preempt further investigation of a more serious crime. Accommodating-Compliant False Confessions Expanding on the original three distinct categories of false confession, Shepherd recognizes a group of people for whom acquiescing with the police is more important than contradicting police assertions about what happened. In such circumstances, a false confession arises from a strong need for approval and to be liked. Police conduct is noncoercive, although it does involve the use of leading questions sufficiently obvious to suggest to the suspect what answers the police want to hear.
Conse- quently generic amoxil 500mg otc, in practice it is not economic to obtain solutions for structures consist- ing of more than about 50 atoms order cheapest amoxil and amoxil. It is not possible to obtain a direct solution of a Schrodinger equation for a structure containing more than two particles purchase genuine amoxil online. Solutions are normally obtained by simplifying H by using the Hartree–Fock approximation. This approxima- tion uses the concept of an effective field V to represent the interactions of an electron with all the other electrons in the structure. For example, the Hartree– Fock approximation converts the Hamiltonian operator (5. The use of the Hartree–Fock approxima- tion reduces computer time and reduces the cost without losing too much in the way of accuracy. These methods use experimentally determined data to sim- plify many of the atomic orbitals, which in turn simplifies the Schrodinger equation for the structure. Solving the Schrodinger equation uses a mathemat- ical method, which is initially based on guessing a solution for each electrons molecular orbital. The computer tests the accuracy of this trial solution and based on its findings modifies the trial solution to produce a new solution. The accuracy of this new solution is tested and a further solution is proposed by the computer. This process is repeated until the testing the solution gives answers within acceptable limits. In molecular modelling the solutions obtained by the use of these methods describe the molecular orbitals of each electron in the molecule. The solutions are normally in the form of sets of equations, which may be interpretated in terms of the probability of finding an electron at specific points in the structure. Graphics programs may be used to convert these prob- abilities into either presentations like those shown in Figures 5. However, because of the computer time involved, it is not feasible to deal with structures with more than several hundred atoms, which makes the quantum mechanical approach less suitable for large molecules such as the proteins that are of interest to medicinal chemists. It can also be used to calculate the relative probabilities of finding electrons (the electron density) in a structure (Figure 5. A knowledge of the shape and electron density of a molecule may also be used to assess the nature of the binding of a possible drug to a target site (see section 5. With more complex molecular mechanics programs it is possible to superimpose one structure on top of another. In other words, it is possible to superimpose the three dimensional structure of a potential drug on its possible target site. It enables the medicinal chemist to evaluate the fit of potential drugs (ligands) to their target site. If the structure of a ligand is complementary to that of its target site the ligand is more likely to be biologically active. Furthermore, the use of a colour code to indicate the nature of the atoms and functional groups present in the three dimensional structures also enables the medicinal chemist to investi- gate the binding of the ligand to the target site. However, it should be remembered that in many cases the binding of a drug to its target should be weak, because in most cases it has to be able to leave the target after it has activated that site. A major problem with docking procedures is that the conformation adopted by a ligand when it binds to its target site will depend on the energy of the molecular environment at that site. This means that, although a ligand may have the right pharmacophore, its global minimum energy conformer is not necessar- ily the conformation that binds to the target site, that is: global minimum energy conformer Ð bioactive conformer However, it is normally assumed that the conformers that bind to target sites will be those with a minimum potential energy. The techniques used by these systems are collectively known as high throughput screening. High throughput screening methods give accurate results even when extremely small amounts of the test substance are available. However, if it is to be used in an economic fashion as well as efficiently this technology requires the rapid production of a large number of substances for testing, which cannot be met by the stepwise approach of traditional organic synthesis methods (Figure 6. It allows the simultaneous synthesis of a large number of the possible compounds that could be formed from a number of building blocks. Screening the components of a library for activity using high throughput screening techniques enables the development team to select suitable compounds for a more detailed investigation by either combina- torial chemistry or other methods. Consider, the reaction of a set of three compounds (A1–3) with a set of three building blocks (B1–3). If this process is repeated by reacting these nine products with three new building blocks (C1–3) a combinatorial library of 27 new products would be obtained. The reactions used at each stage in such a synthesis normally involve the same functional groups, that is, the same type of reaction occurs in each case. Very few libraries have been constructed where different types of reaction are involved in the same stage. In theory this approach results in the formation of all the possible products that could be formed. In the first case the building blocks are succes- sively added to the preceding structure so that it grows in only one direction. It usually relies on the medicinal chemist finding suitable protecting groups so that the reactions are selective. This design approach is useful if the product is a polymer (oligomer) formed from a small number of monomeric units. Alternatively, the synthesis can proceed in different directions from an initial building block known as a template, provided the template has either the necessary functional groups or they can be generated during the course of the synthesis (Figure 6. B C D A A− −B−C A−B−C−D (a) D A−B−C D A C D B A− −B−C A−B−C−D D (b) D−A−B−C Figure 6. In practice, it is not always possible to select reactions that meet all these criteria. However, condition 6 must be satisfied, otherwise there is little point in carrying out the synthesis. The degree of information available about the intended target will also influence the selection of the building blocks. If little is known, a random selection of building blocks is used in order to identify a lead. However, if a there is a known lead, the building blocks are selected so that they produce analogues that are related to the structure of the lead. In both cases synthesis usually proceeds using one of the strategies outlined in Figure 6. Both solid support and solution synthetic methods may be used to produce libraries that consist of either individual compounds or mixtures of compounds. Each type of synthetic method has its own distinct advantages and disadvantages (Table 6. It uses resin beads that have a large number of functional groups attached to the surface by a variety of structures known as either a handle or a linker (Figure 6. Each of these functional groups acts as the starting point for the synthesis of one molecule of a product. Since a bead will possess in the order of 6 Â 103 functional groups of the same type the amount of the product formed on one bead is often sufficient for structure determination and high throughput screening.
Help client explore angry feelings so that they may be di- rected toward the intended object or person buy discount amoxil 500 mg line. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues order amoxil 250 mg with amex. Help client discharge pent-up anger through participation in large motor activities (e purchase amoxil 250mg line. Physical exercise provides a safe and effective method for discharging pent-up tension. Explain to client the normal stages of grief and the behaviors associated with each stage. Help client to understand that feelings such as guilt and anger toward the lost entity are appropriate and acceptable during the grief process. Knowl- edge of the acceptability of the feelings associated with nor- mal grieving may help to relieve some of the guilt that these responses generate. With support and sensitivity, point out reality of the situation in areas where misrepresentations are expressed. Client must give up an idealized perception and be able to Adjustment Disorder ● 249 accept both positive and negative aspects about the painful life change before the grief process is complete. Knowledge of cultural inﬂuences speciﬁc to the client is im- portant before employing this technique. Help client solve problems as he or she attempts to determine methods for more adaptive coping with the experienced loss. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Encourage client to reach out for spiritual support during this time in whatever form is desirable to him or her. As- sess spiritual needs of client, and assist as necessary in the fulﬁllment of those needs. Spiritual support can enhance successful adaptation to painful life experiences for some individuals. Client is able to verbalize normal stages of grief process and behaviors associated with each stage. Client is able to identify own position within the grief pro- cess and express honest feelings related to the lost entity. Client will verbalize things he or she likes about self within (realistic time period). Client will exhibit increased feelings of self-worth as evi- denced by verbal expression of positive aspects about self, past accomplishments, and future prospects. Client will exhibit increased feelings of self-worth by setting realistic goals and trying to reach them, thereby demonstrat- ing a decrease in fear of failure. It is important for client to achieve something, so plan for activities in which success is likely. Promote understanding of your acceptance for him or her as a worthwhile human being. Unconditional positive regard and acceptance promote trust and increase client’s feelings of self-worth. Help client identify positive aspects of self and to develop plans for changing the characteristics he or she views as neg- ative. Individuals with low self-esteem often have difﬁculty recognizing their positive attributes. They may also lack problem-solving ability and require assistance to formulate a plan for implementing the desired changes. Encourage and support client in confronting the fear of failure by attending therapy activities and undertaking new tasks. Offer recognition of successful endeavors and positive reinforcement for attempts made. Enforce limit-setting in matter-of-fact manner, imposing previously established consequences for violations. Negative feedback can be ex- tremely threatening to a person with low self-esteem, pos- sibly aggravating the problem. Encourage independence in the performance of personal re- sponsibilities, as well as in decision-making related to own self-care. Help client increase level of self-awareness through criti- cal examination of feelings, attitudes, and behaviors. Help him or her to understand that it is perfectly acceptable for one’s attitudes and behaviors to differ from those of others as long as they do not become intrusive. As the client achieves self-awareness and self-acceptance, the need for judging the behavior of others will diminish. Client demonstrates ability to manage own self-care, make independent decisions, and use problem-solving skills. Client sets goals that are realistic and works to achieve those goals without evidence of fear of failure. Client will be able to interact with others on a one-to-one basis with no indication of discomfort. Client will voluntarily spend time with others in group ac- tivities demonstrating acceptable, age-appropriate behavior. Be honest; keep all promises; convey acceptance of person, separate from unac- ceptable behaviors (“It is not you, but your behavior, that is unacceptable. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Confront client and withdraw attention when interactions with others are manipulative or exploitative. Act as role model for client through appropriate interactions with him or her, other clients, and staff members. It is through these group interactions, with positive and negative feedback from his or her peers, that client will learn socially accept- able behavior. Client has formed and satisfactorily maintained one inter- personal relationship with another client. Client verbalizes reasons for inability to form close interper- sonal relationships with others in the past. Possible Etiologies (“related to”) Move from one environment to another [Losses involved with decision to move] Feelings of powerlessness Lack of adequate support system [Little or no preparation for the impending move] Impaired psychosocial health [status] Decreased [physical] health status Deﬁning Characteristics (“evidenced by”) Anxiety Depression Loneliness Verbalizes unwillingness to move Sleep disturbance Increased physical symptoms Dependency Insecurity Withdrawal Anger; fear Goals/Objectives Short-term Goal Client will verbalize at least one positive aspect regarding re- location to new environment within (realistic time period). Encourage individual to discuss feelings (concerns, fears, anger) regarding relocation. Exploration of feelings with a trusted individual may help the individual perceive the situation more realistically and come to terms with the inevitable change.