Delirium can occur in many febrile diseases. Confusion is prominent in typhoid fever, rickettsiosis, cerebral malaria, viral encephalitis (rabies, herpes, Japanese encephalitis, West Nile and other arboviroses), Naegleria fowleri encephalitis (amoebae), acute meningitis and cerebral abscess (tuberculous, pyogenic or amoebiasis). Endocarditis can cause septic cerebral emboli. Cerebritis and cerebellitis with ataxia can occur in Q-fever and also very rarely in Mycoplasma infections.

Syphilitic cerebral gumma, West African trypanosomiasis and cerebral toxoplasmosis cause a subacute to chronic condition. Differentiation from dementia is important. Melarsoprol used in the treatment of African trypanosomiasis can cause an acute reactive encephalitis. Chronic or subacute meningitis due to tuberculosis or cryptococcosis, can occur in AIDS.

Worm infestations of the central nervous system tend to provoke severe symptoms. Infection with Angiostrongylus cantonensis, cysticerci, Echinococcus, Gnatostoma sp, Toxocara sp and ectopic migrations of schistosomes or Paragonimus sp usually cause acute symptoms. The cerebrospinal fluid can contain eosinophils. Schistosoma japonicum especially affects the brain during ectopic migration. S. haematobium and S. mansoni more often cause lesions in the spinal cord, though these findings are not proven.

Caisson disease. In acute confusion, stupor, neurological problems or shock occurring after diving, one should consider decompression problems or caisson disease resulting from too rapid ascent to the surface (often occurs in panic situations).

Rupture of the lung with pneumothorax can occur due to rapid ascent to the surface without adequate expiration. For example, the pressure amounts to 3 atmospheres at a depth of 20 metres while on the water surface it is only one atmosphere so that the lungs’ volume would have to increase threefold. The air in the lungs expands as the pressure falls.

Envenomation by certain marine animals can have hyperacute and very serious consequences. The sea wasp [Chironex fleckeri] is a small, translucent, but extremely venomous jellyfish that is found in Australasian seawater. Coneshells [Conus sp] can likewise deliver a highly venomous sting (nerve toxin). The bite of the so called “blue ringed octopus” [Hapalochlaena lunulata and H. maculosa], a name given to two related species of small cephalopods (15 cm) found in the seas between Northern Australia to Japan, is likewise notorious. Acute confusion and stupor are among the clinical symptoms. Irukandji syndrome occurs in North Australia following stings by Carukia barnesi, a small box jellyfish.

• Hypoglycaemia. Rapid recovery after administration of glucose. Check for any use or administration of antidiabetic medication and consumption of Akee fruit (syn. Ackee fruit, Blighia sapida; contains toxic hypoglycines A and B).

• Severe ketoacidosis, usually in diabetes

• Wernicke-Korsakoff’s disease (frequent with alcohol abuse). Acute deterioration can be triggered by intravenous glucose administration. Paresis of the eye muscles, together with ataxia in a patient with confusion and apathy, with recovery after injection of thiamine (vitamin B1), is diagnostic. (cf. beriberi)

• Severe hyponatraemia, such as is occasionally seen in SIADH (Syndrome of Inappropriate Secretion of Antidiuretic Hormone) and in Addisonian crisis (adrenal failure, e.g. after a bite from a Russell’s viper).

• Heat stroke and dehydration. Definitely increased risk in the tropics. Heat illness may be viewed as a continuum of illnesses relating to the body’s inability to cope with heat. It includes minor illnesses, such as heat edema, heat rash (ie, prickly heat), heat cramps, and tetany, as well as heat syncope and heat exhaustion. Heatstroke is the most severe form of the heat-related illnesses and is defined as a body temperature higher than 41°C associated with neurologic dysfunction. Two forms of heatstroke exist. Exertional heatstroke generally occurs in young individuals who engage in strenuous physical activity for a prolonged period of time in a hot environment. Classic nonexertional heatstroke more commonly affects sedentary elderly individuals, persons who are chronically ill, and very young persons. Classic nonexertional heatstroke occurs during environmental heat waves and is more common in areas that have not experienced a heat wave in many years. Both types of heatstroke are associated with a high morbidity and mortality, especially when therapy is delayed. Hypoglycemia, convulsions and rhabdomyolysis can occur as complications of heatstroke.

• Severe hypothyroidism with possible myxoedemic coma. Thyroid problems can get worse after using iodine for drink water decontamination.

• Drunkenness. Beware of methanol contamination of home-brewed liquors.

• Intoxication: acute e.g. CO, cocaine (crack), chronic in e.g. mercury- or thallium intoxication (rat poison). Intoxication with thallium causes hair loss several weeks after the acute poisoning.

• Epilepsy, post-ictal confusion. Neurocysticercosis is a major cause of epilepsy in large parts of Central and South America.

• Cerebrovascular accident due to thrombosis or cerebral embolism (increased risk in Chagas’ disease, endocarditis, sickle cell crisis).

• Loasis (Loa loa infection) with high microfilariaemia can cause acute neurological symptoms, often just after commencement of therapy.

• Hypertensive encephalopathy is usually clinically manifest. It is a medical emergency. Blood pressure is very high and the eye fundus is typical.

• Inflammation of the brain and/or meninges . Cerebral vasculitis can occur in a systemic disease such as systemic lupus erythematosus. Immunosuppression in SLE-patients, e.g. by therapy with steroids, increases the risk of some complications, such as tuberculosis, including meningeal tuberculosis (not infrequent in India). Beware of Strongyloides hyperinfection when people use corticosteroids.

• Head injury, with concussion or subdural haematoma.

Pathophysiology

• ED is essentially a vascular disease often associated with diabetes, hypertension, and CAD. Other conditions include neurologic disorders, endocrinopathies, BPH, and depression.

• Conditions associated with reduced nerve and endothelium function, such as aging, smoking, and hypercholesterolemia cause circulatory and structural changes in penile tissues, resulting in arterial insufficiency and defective smooth muscle relaxation. Sexual dysfunction may be the presenting symptom of these disorders.

• ED is often an adverse effect of many commonly prescribed medications such as psychotropic and antihypertensive agents.

Frequency

• In the Massachusetts Male Aging Study (MMAS), a community-based survey of men aged 40-70 years, 52% of the respondents reported some degree of erectile difficulty. Complete ED, defined as (1) the total inability to obtain or maintain an erection during sexual stimulation and (2) the absence of nocturnal erections, occurred in 10% of the respondents. Lesser degrees of mild and moderate ED occurred in 17% and 25% of responders, respectively.

• An estimated 18-30 million men in the US are affected by ED. Long-term predictions based on an aging population suggest a large increase in the number of men with ED.

Causes

• ED is divided into organic and psychogenic impotence, but most men with organic etiologies usually have an associated psychogenic component. Pure psychogenic ED is an uncommon disorder.

• Diabetes is a well-recognized risk factor, with approximately 50% of diabetic men experiencing ED.

• Cigarette smoking has been shown to be an independent risk factor, increased by a factor of 1.5

• A sedentary lifestyle is a contributing factor to ED. Exercise has a beneficial effect on the cardiovascular system, and men who exercise regularly have a lower risk of ED.

• Vascular diseases account for nearly half of all cases of ED in men older than 50 years. Vascular diseases include atherosclerosis, peripheral vascular disease, myocardial infarction, and HTN.

Medication	Advantages	Disadvantages
Hormonal (testosterone) therapy	May restore sexual desire Patches now available	Useful only in the few patients with abnormal hormone levels Significant adverse effects (eg, fluid retention, liver damage) Limited effectiveness
Vasodilators (nitroglycerine)	Painless May use treatment only when desired	No reports on long-term use Possibly common adverse effects (eg, headaches) Very high failure rate Very limited effectiveness
Yohimbine (Yocon)	Adverse effects uncommon May increase sexual desire Success rate of 20-25%	Need to take medication every day No reports on long-term use Adverse effects, including nervousness, headache, dizziness, and nausea Limited effectiveness
Pentoxifylline (Trental)	Adverse effects uncommon Success rate of 50%	Adverse effects, including headache, dizziness, and stomach upset May only help with marginal penile blood
Trazodone (Desyrel)	Adverse effects uncommon Estimated success rate of 25%	No reports proving benefit No reports on long-term use Adverse effects, including lethargy and drowsiness Limited effectiveness
Intraurethral pellet therapy (MUSE)	May use treatment only when desired Success rate of 45% Reasonably effective	Pellet must be inserted directly into penis through urethra Requires refrigeration Mild burning or discomfort experienced by 30% of patients Can cause mild dizziness, faintness, or low blood pressure

Basic definition and background of Erectile Dysfunction:

Erectile Dysfunction is the inability to achieve and/or maintain an erection satisfactorily for sexual intercourse. It is an incredibly common problem in the United States; there are an estimated 30 million men who suffer from ED, with up to 52% of men aged 40 to 70 experiencing some degree of ED and increasing rates with age. Causes of ED are divided into organic (ie vascular, neurologic, hormonal, or structural), psychogenic, or mixed etiologies, with roughly 80% of men with ED having an organic cause.

Relevance of ED to primary care:

The relevance of ED to primary care is profound, as ED adversely affects patients’ quality of life, relationships, and personal self-esteem. ED is also seen a variety of common medical conditions (see table). ED can also be a sign of an underlying illness such as those named above; in fact, up to 60% of healthy patients presenting with ED were found to have abnormal cholesterol levels, and 15% of healthy patients with ED had elevated blood glucose levels.

Treatment of ED as a primary care physician:

Firstly, as with any encounter, a thorough medical and sexual history, and physical examination should be conducted. Many patients will not volunteer information about their ED; directed questions such as “Are you satisfied with your sexual function and relationship?” should be asked. Standard questionnaires, such as the International Index of Erectile Function (IIEF) or the abbreviated Sexual Health Inventory for Men (SHIM, see chart below), can be used to effectively screen for ED or to elucidate the nature of sexual dysfunction. Relevant lab studies (CBC, Chemistry panel, UA, Lipid profile, Thyroid function, and Testosterone level) should also be examined.

Once ED has been established and discussed with the patient, initial management should follow along the following steps:

1. Etiology should be assessed and addressed – Possible underlying medical, hormonal, or other problems should be optimally managed and relevant medications should be changed or discontinued.

2. Lifestyle modification – diet, exercise, stress reduction, eliminating alcohol and drug intake, and smoking cessation.

3. First-line therapy – oral pharmologic agents (1st line oral agents are phosphodiesterase-5 inhibitors, which have reported success rates of 69%, other oral agents include Yohimbine, Phentolamine, L-arginine, Apo-morphine), vacuum constriction devices, and sexual or couples therapy.

4. Second line therapy – intraurethral alprostadil (MUSE), intracavernosal self-injection of alprostadil; Referral to a specialist.

5. Third-line therapy – surgical prosthesis or other necessary surgery.

Adverse effects of Phosphodiesterase-5 Inhibitors:

Important considerations for the primary care physicians to remember when prescribing phosphodiesterase-5 inhibitors, such as Viagra, Cialis, and Levitra, include side-effect profile. The most common side effects are headache (15%), facial flushing (14%), nasal congestion (4%), dizziness (2%), and visual disturbances (2%). These adverse reactions are generally not severe enough to cause discontinuation.

Response rate to Phosphodiesterase-5 Inhibitors:

Response rate to the drug should occur within 3-4 uses. If there is inadequate response, the dose should be titrated upwards, or additional uses up to 6-8 times should be considered. If failure of therapy persists, referral to a specialist should be considered.

When to refer to a specialist?

Primary care physicians should consider referral to a specialist at any point where they feel lack of comfort with treatment/management. In general, indications for referral include failure of oral pharmacologic therapy/1st line therapy as aforementioned, patients with complex etiologies (such as Peyronie’s disease, history of pelvic/perineal trauma), or young patients who have never achieved erection, which suggests primary ED.

Tables:

Common medical problems with increased risk of ED: CAD or PVD Diabetes Depression Hypertension Hyperlipidemia Smoking Alcohol/drug abuse Anemia Medications, esp anti-hypertensives and psychotropics

SHIM Score: >22 no ED, 17-21 Mild ED, 12-16 Mild-Moderate ED, 8-11 Moderate, <7>

References:

Abnormal perceptions: abnormalities in the way information from the outside world is sensed and processed, i.e. hallucinations, illusions.

Acute intoxication: changes in physiological and psychological responses due to the administration of a psychoactive substance.

Affect: the behaviour a person exhibits, which reflects the underlying mood/ emotions.

Agitation: feelings of tension combined with excessive physical activity.

Agnosia: patient cannot interpret sensations properly although there is nothing wrong with the sensory organs.


Ambivalence: simultaneous opposing impulses towards something.


Amnesia: inability to recall past experiences/events.

Anhedonia: no longer finding pleasure in previously enjoyable activities. Not being able to enjoy anything.


Attention: the ability to focus on a specific activity.

Blunted affect: reduced expression of emotion.

Cathartic colon: atonic colon due to chronic laxative abuse.

Choreiform movements: jerky involuntary movements, particularly affecting the head, face or limbs. Usually due to a disease of the basal ganglia, but may result from drugs used to treat Parkinson’s disease, or withdrawal of phenothiazines. They are characteristic of Huntington’s disease.

Circumstantiality: a form of thought disorder characterised by speech in which the main point of what is being communicated is lost in a sea of unnecessary trivial details.

Clouding of consciousness: the patient is drowsy and does not respond completely to stimuli. There is disturbance of attention, concentration, memory, orientation and thinking.

Cognition: mental processes by which knowledge is acquired and acted on. Includes perception, reasoning, creativity and problem-solving.

Compulsion: repetitive stereotyped act performed, despite knowing it is senseless, in order to reduce anxiety, and in response to obsessional thoughts.

Concentration: the ability to maintain attention.

Concrete thinking: lack of abstract thought. Normal in children. Occurs in adults with schizophrenia or organic brain disease, e.g. ‘People in glass houses shouldn’t throw stones – because they would break the windows.’

Conditioning event: establishment of a new behaviour by modifying the associations between a stimulus and a response.

Confabulation: gaps in memory are unconsciously filled with false memories/explanations.

Coprolalia: the repetitive speaking of obscene words.

Counter-transference: the therapist’s emotions and attitudes to the patient.

Defence mechanism: mental mechanisms that protect the consciousness from the affects, ideas and desires of the unconscious.

De´ ja` vu: illusion of familiarity of a situation.

Delirium: disorder of consciousness in which the patient is acutely disorientated, restless and confused. May also experience hallucinations and anxiety.

Delusion: a firm, fixed belief which is held unshakeably and is out of keeping with the patient’s cultural/social background.

Delusional perception: new and delusional significance is attached to a familiar real perception without any logical reason.

Dementia: chronic, progressive, global organic impairment of intellectual functioning without change in consciousness.

Denial: refusal to accept that something is true. Sometimes a psychological reaction to bad news, used as a defence mechanism.

Dependence: psychological and/or physical effect of habitual use of a drug/substance. Leads to compulsion to keep taking the drug. In physical dependence there are withdrawal symptoms if the drug is stopped. Psychological dependence means the person feels the need to keep taking it for well-being, but there are no physical withdrawal effects.

Depersonalisation: an unpleasant sensation where the person feels unreal or strangely altered, or feels that the mind has become separated from the body. Mild forms can occur in normal individuals under stress.

Derealisation: a feeling of unreality in which the environment is experienced as unreal and as flat, dull or strange. Can be very frightening. Often occurs at the same time as depersonalisation.

Displacement: defence mechanism in which thoughts and feelings about one person or object are transferred onto another.

Diurnal mood variation: variation in mood during the course of the day.


DSM-IV: (Diagnostic and Statistical Manual of Mental Disorders, 4th edn.) published
by the American Psychiatric Association and used in the USA (see ICD-10).

Dysphasia: disorder of language as a result of cortical damage affecting the generation and content of speech. Aphasia is a complete absence of speech due to cortical damage.

Dysthymia: chronic low mood not meeting requirements for a depressive episode.

Dystonia: postural disorder caused by disease of the basal ganglia. Spasms in the muscles of the shoulders, neck, trunk and limbs.

Echolalia: pathological repetition of the words spoken by another person.

Echopraxia: pathological imitation of the actions of another person.

EEG (electroencephalogram): measures the electrical activity of the brain. Reflects the state of the patient’s brain and level of consciousness.

Ego: part of the mental apparatus that is present at the interface of the perceptual and internal demand systems. It controls voluntary thoughts and actions and, at an unconscious level, defence mechanisms.

Egodystonic: unpleasant/uncomfortable.

Egomania: pathological preoccupation with oneself.

Elated mood: more cheerful than normal. Not necessarily pathological.

Encopresis: incontinence of faeces.

Enuresis: involuntary passage of urine.

Erotomania: delusion that the individual is loved by some person, often a person of some importance.

Euphoria: exaggerated feeling of well-being. It is pathological.

Euthymia: normal mood.

Flight of ideas: speech consists of a stream of accelerated thoughts with abrupt changes from topic to topic. The connections between topics may be chance relationships, verbal associations, e.g. alliteration, but can usually be followed (unlike Knight’s move thinking). Associated with pressure of speech.

Formication: a somatic hallucination in which insects are felt to be crawling on/under skin.

Free association: articulation of all thoughts that come to mind.

Habituation training: training to decrease reaction and sensitivity to a fearful stimulus.

Hallucination:

• Sensory experience in the absence of a stimulus.
  
• May be auditory, visual, olfactory, gustatory, tactile.
  
• Occurs in normal people when falling asleep (hypnagogic) and waking (hypnopompic).
  
• A pseudohallucination is where the patient knows that the hallucination is coming from inside the mind.
  
• Visual/ tactile hallucinations may imply an organic problem.
  
• Auditory hallucinations suggest psychosis.

Hallucinosis: hallucinations occurring in clear consciousness, e.g. in alcoholic hallucinosis.

Hyperacusis: increased sensitivity to sounds.

Hyperaesthesia: sensations appear increased.

Hypoaesthesia: sensations appear decreased.

Hypochondriasis: fear of having a serious illness, in the absence of any real organic pathology.

ICD-10: (10th revision of the International Classification of Diseases) published by the World Health Organization, Geneva, 1992. Used in Europe (see DSM-IV).

Id: an unconscious part of the mental apparatus which is partly made up of inherited instincts and partly by acquired, but repressed, components.

Ideas of reference: patients feel that other people look at or talk about them, or that TV/media refers to them.

Illusion: false perception due to misinterpretation of a stimulus arising from an object.

Inappropriate affect: an affect that is inappropriate for the circumstances, e.g. giggling when talking about the death of a loved one.

Initial insomnia: difficulty falling asleep when first going to bed. Middle insomnia is waking in the middle of the night. Early morning insomnia (also known as late insomnia) is waking in the early hours and being unable to go back to sleep.

Insight: degree of correct understanding the patient has of the condition and its cause, as well as the willingness to accept treatment.

Jamais vu: illusion of failure to recognise a familiar situation.

Jargon aphasia: incoherent, meaningless, neologistic speech.

Knight’s move thinking: odd, tangential associations between ideas leading to disruptions in speech, which means that the connections between topics cannot be followed (unlike flight of ideas).

Labile affect: affect repeatedly and rapidly shifts, e.g. anger to sadness.


Life events: psychologically stressful events in life (such as bereavement, divorce, moving house, changing jobs, etc.), which may trigger onset/relapse of psychiatric conditions.

Logoclonia: the last syllable of the last word is repeated.

Loosening of associations: the connections between a patient’s sentences are difficult to follow.


Monomania: pathological preoccupation with a single object.


Mood: pervasive and sustained emotion that colours the person’s perception of the world.
Mutism: total loss of speech.

Negativism: motiveless resistance to commands and attempts to be moved.

Neologism: a new word invented by the patient, usually with a personal meaning.

Neurosis: a psychiatric disorder in which the patient has insight into the illness, and can distinguish between subjective experiences and reality.

Obsession: intrusive or unwanted thought, image or idea, which enters the patient’s consciousness despite attempts to suppress it.

Organic disorder: disorder due to change of structure of an organ or tissue, i.e. a physical disorder.

Overvalued idea: unreasonable and sustained intense preoccupation maintained with less than delusional intensity.

Palilalia: a word is repeated with increasing frequency.

Parasuicide: an act of self-harm in which the motive is not a wish to die. It is different from attempted suicide.

Passivity phenomenon: delusional belief that an external force is controlling aspects of the self, e.g. thoughts, impulses, actions.

Perseveration: mental operations, speech and behaviour carried on beyond the point at which they are appropriate.


Post-ictal: after a fit/seizure.

Posturing: an inappropriate or bizarre bodily posture adopted continuously over a long period.

Poverty of speech: very reduced speech.

Pressure of speech, pressure of thought: speech is very fast, as though there are too many ideas to verbalise all at one time. Occurs in mania and psychosis.

Prodrome: a symptom indicating the onset of a disease, e.g. strange feelings/ aura before an epileptic fit, periods of depression before first schizophrenic episode.

Projection: a defence mechanism in which repressed thoughts and wishes are attributed to other people or objects.

Prosopagnosia: inability to recognise faces.

Pseudodementia: clinically similar to dementia, but has a non-organic cause, e.g. depression, hypothyroidism.

Pseudohallucination: a form of imagery arising in the subjective mind, lacking the substantiality of normal perceptions.

Psychoactive substance: substance which acts on the brain to alter mood/state of arousal.

Psychomotor: muscular and mental activity. Muscular activities are affected by cerebral disturbance.

Psychomotor agitation: excess overactivity and restlessness, e.g. in agitated depression.

Psychomotor retardation: reduced muscular and mental activity. May occur in treatment with neuroleptics, but is characteristic of depression.

Psychosis: being out of touch with reality but with clear consciousness. Characterised by the presence of delusions and hallucinations.

Puerperal: relating to childbirth or the period that immediately follows it.

Regression: a defence mechanism in which there is a return to an earlier stage of development.

Repression: defence mechanism in which there is pushing away of unacceptable ideas and wishes, which remain in the unconscious.

Rumination: an obsessional type of thinking in which the same thoughts or themes are experienced repetitively, to the exclusion of other mental activity.



Sick role behaviour: activity by individuals who consider themselves ill.

Somatic symptoms: relating to the body rather than the mind.

Somatic passivity: delusional belief that one is a passive recipient of bodily sensations or movements from an external agency.

Stereotypy: repeated regular fixed pattern of movement or speech which is not goal-directed.

Superego: partly conscious and partly unconscious derivative of the ego that exercises self-judgement and holds ethical and moralistic values.

Tardive dyskinesia: involuntary chewing or grimacing movements due to longterm treatment with neuroleptics.

Thought blocking: a sudden interruption in the train of thought occurs, leaving a blank after which what was being said cannot be recalled.

Thought broadcast: the feeling/belief that thoughts are audible to others or are being broadcast on television/radio.

Thought insertion: feeling/belief that thoughts are being put into the mind, or are being altered by an external force.

Thought withdrawal: the feeling that thoughts/ideas are being taken out of the mind by an external force.

Tics: repeated irregular movements involving a particular group of muscles.


Transference: the unconscious process in which emotions and attitudes experienced in childhood are transferred to the therapist.

Word salad: the speech is an incoherent and incomprehensible mix of words and phrases.

Introduction

Moral behaviour means behaviour in conformity with the moral code of the social group. `Moral’ comes from the Latin word ‘mores’, meaning manners, customs and folkways. Moral behaviour is controlled by moral concepts. Moral development has both an intellectual and an impulsive aspect .Children must learn what is right and what is wrong. Then, as soon as they are old enough, they must be given explanations of why this is right and what is wrong.

Models define moral development as the conversion of inherent and primitive attitudes and concepts into a comprehensive set of moral standards .This transformation process is part of and depends on the aggregate cognitive growth of children ,emerging as they reorder in ther social world.Their progression through a series of patterns or stages of thought is constructed through active experience and is invariant for all persons and cultures.

Development of the theory

Theories of moral development began with Freud’s theory relating superego formation to castration anxiety.

Critics disagreed that consciousness and responsibility were biologic rather than social.Piaget’s view was that justice was the core of morality.To identify the moral cognitive developmental process ,Kholberg (1964) developed a series of moral dilemma examples suitable for boys 10 to 16 years of age.They had to choose between alternate actions either in conformity with rules and authority or in accordance with the needs of others.Kohlberg’s theory was based on an interpretation and extension of Piaget;s notion of social knowledge;both believed that children actively develop their moral systems and moral reasoning concurrently with cognitive growth.

Kohlberg’s Theory of Moral Development

Lawrence Kohlberg (1968) has formulated a theory of moral development. Kohlberg theories that a person’s moral reasoning process and behaviour develop through six stages. Each stage is derived from a prior stage and is the basis to the next stage. He defined three levels of moral development. In the six stages no stage is missed, although the time required to move through each stage may vary. Few people progress through all six stages.Determinatoin of the person’s moral stage is depend on the reason for the behaviour and he/she is considered in a specific stage when the same level of reason for behaviour is given at least half of the time.

It has been argued that the theory was derived from interviews with male adults and may not reflect feminine moral reasoning (Gilligan 1977)

Level 1: Pre conventional level

The person is responsive to cultural rules of labels of good and bad, right or wrong. Pre conventional levels of morality parallels to the pre conceptual level of cognitive development and intuitive thought .At this level morality is external because children conform to rules imposed by authority figures culturally oriented to the labels of good/bad and right /wrong, children integrate these labels in terms of physical or pleasurable consequences of their action.

Stage 1: Punishment and obedience orientation

At this stage, the individual is responsive to cultural guidelines of good and bad, right and wrong, but primarily in terms of the known related consequences. Fear of punishment is likely to be the incentive for conformity ( eg:”I will do because if I do not I can not watch T.V for one week”)

Average age toddler to seven years.

Stage 2: Instrumental relativist orientation

The right behaviour consist of that which satisfies the child’s own needs.Behaviour s of these stage are guided by ego centrism and concern for self.ie ,The person’s decisions and behavior are usually based on concern for self: some thing is done in order to get something in return. Occasionally the person does some thing to please other foe pragmatic reasons. There is no feeling of justice, loyalty or gratitude. These concepts are expressed physically (eg: I will do something if I get something for it or because o pleases you)

CONVENTIONAL LEVEL

The person is concerned with maintaining expectations of the family, group, nation or society. A sense of guilt has developed and affects behaviour. The person values conformity. Loyalty and active maintenance of social order and control. Conformity means good behaviour or what pleases or helps another and is approved. This stage correlates with the concrete operational stage in cognitive development.

Stage 3: Interpersonal Concordance Orientation

A) Decisions and behaviour are based on concerns about others reactions; the person wants others approval or record. The person has moved from egocentricity to consideration of others as a basis for behaviour. Behaviour is judged by the persons intensions (I will do some thing because it will please you or because it is expected)

B) An empathetic response , based on understanding of how another person feels , is a determinant for decisions and behaviour ( I will do something because I know how it feels to be with out; I can put myself in your shoes)average age: school age through adult hood . Most American women are found to be in his stage.

Stage 4: Law and Order Orientation

The person ants established rules from authorities, and the reason for decisions and behaviour is that social and sexual rules and traditions demand the response. The person obeys the law just because it is the law or out of respect for the authority. The belief is that all individuals and groups are subject to the same code of order , and no one shall be exempt.( eg: I will do it because it is the law)

Average age: Adolescence and adulthood, most men are found in this stage; 80% of adults do not move past this stage.

Level 3: Post conventional level, autonomous or principle level

The person lives autonomously, defines moral values and principles that are distinct from his own identification with group values. He/ she live according to the principles that are universally agreed upon and that the person considers appropriate for life

Stage 5: Social Contract Legalistic Orientation

The social rules are not the sole basis for decisions and behaviour because the person believes a higher moral principle applies, such as equality. Justice or due process. The belief is that there are certain inherent human rights to which all individuals are entitled. Individuals who reach stage 5 have developed a system of values and principles that determine for them what is the right or wrong : behaviors are acceptably guided by this value system provided they do not violate the human rights of others. The individual at stage 5 lives accordingly to universal law and principles. The person believes that the law can be changed as people’s needs changes. Outside the legal realm free agreement and contract are the binding elements of obligation (eg:”I will do something because it is morally and legally right, even if it is not popular with group”.)

Average age: middle age or older adults.

Stage 6: Universal Ethical Principle Orientation

Decision and behaviour are based on internalized rules on conscience rather than on social laws, and on self chosen ethical and abstract principles that are universal, comprehensive and consistent. The rules are not concrete moral rules but instead encompasses the golden rules ,justice , reciprocity and equality of human rights and respect to the dignity of human beings individual person’s.Humam life is inviolable. The person believes there is a higher order than social order has a clear concept of civil disobedience and will use self as an example to right a wrong. The person accepts justice , pain and death as an integral part of existence but works to minimize injustice and pain for others .(e.g. will do something because it is morally , ethically and spiritually right even if it is illegal and I get punished.)

Average age: middle age to older adult.

Conclusion

. Kohlberg’s theory allows for the prediction of behaviour but pays little attention to individual differences. Children can learn to behave in a socially approved manner through trial and error through direct teaching or through identification.

References

1. Mary C Townsend (1993) Psychiatric Mental Health Nursing, F.A Davis Company Philadelphia.

2. Hurlock (1993) Child Development, Mc Graw Hill Book Company.

3. Herald Kaplan and Sadok JB (2002) Synopsis of Psychiatry Behavioral Science, A Clinical approach, 6th edition Willions and Wilkins publishers Ballimore

This is a brief introduction about common Psychological tests that are indicated for various reasons on our patients. the specific uses differ according to the college, setup & psychologist conducting it.

This is just a brief review of the tests & indications :

Psychological tests are given in nearly all custody evaluations in order to assess each parent's mental and emotional health, as well as to identify any abnormal psychological conditions (personality disorders, neurotic behaviors, etc).

The most common test by far is the MMPI-2, with other tests like the MCMI-III and the Rotter Incomplete Sentence Blank used to confirm the MMPI-2 results.

"Classic" tests such as the Rorschach are not used as frequently in custody evaluations since the advent of more specialized tests, such as the Thematic Aperception Test (TAT) and the series of tests developed by Barry Bricklin of Bricklin Associates (Bricklin Perceptual Scales (BPS), Perception Of Relationship Test (PORT), Parent Awareness Skills Survey (PASS), Parent Perception of Child Profile (PPCP), etc).

This list is provided to familiarize you with the most common kinds of tests you may be given during the course of a custody evaluation. Specifics on the test scales, ranges, and administration are not detailed here in order to preserve the test's validity. Providing information on how the tests are scored, or what are considered "acceptable" responses would invalidate the purpose of these tests.

Minnesota Multiphasic Personality Inventory-2TM

The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) instrument, the restandardized version of the original MMPI® instrument, is an empirically-based assessment of adult psychopathology. The MMPI-2 instrument, provided by NCS, is the standard that mental health professionals use to help measure psychopathology across a broad range of client settings. The MMPI-2 instrument is used by clinicians in hospitals, clinics, counseling programs, and private practice to assist with the diagnosis of mental disorders and the selection of an appropriate treatment method.


Derived from the original MMPI instrument, the MMPI-2 instrument preserves the most valuable features of the original assessment while addressing contemporary concerns to provide better descriptive and diagnostic information for clients today. The MMPI-2 instrument contains items appropriate and relevant to current test-takers. Special effort has been made to eliminate sexist wording and outmoded content. Duplicate items and items with objectionable content have also been eliminated.


The MMPI-2 consists of 567 statements to which the subject responds with true, false, or cannot say. It was designed primarily for adults and has not yet been used for children (although the 1992 MMPI-A was designed for adolescents). The items cover a wide range of topics, including attitudes on religion and sexual practices, perceptions of health, political ideas, information on family, education, and occupation, and displays of symptoms known to be exhibited by certain groups of mentally disturbed people.


The normative sample of the MMPI-2 instrument consists of 1,138 males and 1,462 females between the ages of 18 and 80 from several geographic regions and diverse communities within the U.S. The sample is much larger and more nationally representative than that of the original MMPI instrument.

Millon™ Clinical Multiaxial Inventory-III

The Millon Clinical Multiaxial Inventory-III instrument is a self-report instrument designed to help the clinician assess DSM-IV-related personality disorders and clinical syndromes. A significant revision of the MCMI-IITM instrument, this instrument incorporates new items, a new item-weighting system, and new scales to provide insight into 14 personality disorders and 10 clinical syndromes.


The instrument is useful in assessing Axis I and Axis II disorders based on the new DSM-IV classification system, identifying the personality disorders that underlie a patient's presenting symptoms, and designing appropriate and efficient treatment programs.

Millon™ Adolescent Clinical Inventory

The Millon Adolescent Clinical Inventory instrument is a brief self-report personality inventory with a strong clinical focus. Evolving from the Millon Adolescent Personality Inventory (MAPI™) instrument, the MACI instrument was designed with a more focused normative sample consisting of adolescents in various clinical treatment settings. Through a series of contemporary questions, it helps the clinician assess an adolescent's personality, along with self-reported concerns and clinical syndromes.

The MACI instrument is used for adolescent assessment in outpatient, inpatient, or residential treatment settings. The MACI instrument can be used by psychologists, psychiatrists, school psychologists, juvenile justice professionals, and other mental health professionals. It can be useful in initial evaluation of troubled adolescents to confirm diagnostic hypotheses, in planning individualized treatment programs, and in measuring treatment progress.

Millon™ Adolescent Personality Inventory

The Millon Adolescent Personality Inventory (MAPI) instrument is a brief self-report inventory designed specifically for assessing adolescent personality characteristics including coping styles, expressed concerns, and behavioral patterns. The MAPI instrument was normed on both normal adolescents and adolescent patients.
The MAPI instrument is used in clinical, correctional, and educational settings by psychologists, psychiatrists, and school counselors as well as other mental health and guidance professionals. It can be very useful in the initial evaluation of typical and troubled adolescents and in diagnosis and treatment planning.

Millon™ Behavioral Health Inventory

The Millon Behavioral Health Inventory instrument is a brief self-report personality inventory designed to help the clinician assess the psychological coping factors related to the physical health care of adult medical patients. The MBHI instrument provides valuable information about the patient's style of coping and the patient's perceptions of the kinds of stress that may be affecting his or her medical condition.

The MBHI instrument is used in health care and counseling settings by psychologists and psychiatrists who work with patients in hospitals, clinics, and private practice. It is useful in:
• Evaluation and screening of physically ill, injured, and surgical patients to help identify possible psychosomatic complications or help predict response to illness or treatment.
• Workers' compensation evaluations to help assess stress-related claims. For claims related to physical injuries, the MBHI instrument can help in the development of effective rehabilitation programs.
• Evaluation and screening of individuals in specialty clinics or programs (e.g., pain, stress, headache) who have problems that may stem from a psychological disorder or an unidentified stressor.

Quality of Life Inventory

The QOLI assessment can help clinicians assess problems in living in 16 areas of life for an individual and the degree to which the individual is satisfied or dissatisfied with each area in his or her own life. The assessment also includes an overall score.
Assessment Areas: health, self-esteem, goals and values, money, work, play, learning, creativity, helping, love, friends, children, relatives, home, neighborhood, community.
Providing a nonpathological measure of an individual's mental health, the QOLI assessment was designed to augment measures of negative affect and psychiatric symptoms.

Applications of the QOLI assessment include:
• Outcome assessment and treatment planning for mental and physical disorders
• Non-heath related personal counseling settings such as organizational development, EAPs and college counseling centers to help people focus on improving their quality of life
• Tracking patient treatment progress and documenting change
• Helping to identify people at risk for developing health problems or disorders
• Assisting in gathering information to help establish the efficacy of different treatments or services
• Substance abuse treatment and assessment
• Behavioral medicine assessment

Derogatis Psychiatric Rating Scale

The Derogatis Psychiatric Rating Scale (DPRS) instrument, formerly known as the Hopkins Psychiatric Rating Scale, is a multidimensional psychiatric rating scale provided by NCS. The DPRS was designed for use with the SCL-90-R® instrument or BSI® self-report instruments. It is often used to validate patients' self-reports.

Designed for use by clinicians trained in psychopathology, the DPRS instrument enables the clinician to rate his or her observations of a patient's psychological symptomatic distress on the same nine primary dimensional scales as the SCL-90-R and BSI instruments. With the DPRS instrument, the clinician can also rate the patient on eight additional dimensions that are important to accurate clinical assessment but that are not amenable to patient self-report.

Thematic Aperception Test

The Thematic Aperception Test assesses personality through projective technique focusing on dominant drives, emotions, sentiments, complexes, attitudes and conflicts. The subject is shown pictures one at a time and asked to make up a story about each picture.

Subject age range: 7+ years.

Normally given in two sessions, one day apart. (Approximately 60 minutes per session.)

House - Tree - Person Projective Drawing Technique

Designed to aid clinician in obtaining information concerning an individual's sensitivity, maturity, flexibility, efficiency, degree of personality integration, and interaction with the environment. Subject is asked to draw pictures of a house, a tree, and a person. Subject is given an opportunity to explain the drawings.

In common with other projective measures of personality (e.g. the Rorschach, or TAT), the H-T-P provides a structured context for the projection of unconscious material. Like a specific ink blot or TAT card, the subject is always presented with blank paper (or a standardized drawing form) and standard instructions as to what is to be drawn (the house, the tree, the person). Combining an ease of administration with a maximum of projective potential, the H-T-P allows the clinician to gather information that might not otherwise be available in a structured, verbal interview.

Unlike the Rorschach or TAT, the H-T-P presents a maximum of ambiguity for the subject. Whereas the Rorschach and TAT present a stimulus card which does not change over time, the H-T-P presents the subject with a completely blank field onto which they are asked to draw and project. Every subject will draw a house, but every house will differ. The result is a collection of projective material organized around standard themes. The H-T-P can claim a great deal of freedom from stimulus bias.

Parent Perception of Child Profile

The PPCP elicits an extensive portrait of a parent's knowledge and understanding of a specific child. It helps the Evaluator assess the degree to which a parent's perception:

(1) are accurate;
(2) compare to other sources;
(3) reflect genuine interest in a child.

The PPCP also assesses the irritability potential of a parent towards a specific child. The Parent Perception of Child Profile offers a parent an opportunity to express what he or she knows about a particular child in a wide variety of important life areas.

Responses are gathered in eight categories:

• Interpersonal Relations
• Daily Routine
• Health History
• Developmental History
• School History
• Fears
• Personal Hygiene
• Communication Style

The PPCP can be Evaluator-administered or self-administered. One main use of the PPCP is to compare the responses of selected respondents, e.g., the two parents. Comparisons can be made in several ways, including accuracy and depth of knowledge in any given life area, especially one (or several) deemed critical to a particular child, and the feelings and attitudes expressed.

Amnesia is a term used to cover the partial or complete loss of memory. Amnesia can be caused by many things; such as, psychological trauma, brain damage, brain tumor, or seizures. Characteristics of Amnesia include having difficulty learning new information or recalling previously learned information.

Memory loss of Amnesia includes everything from a person’s past and the other times. Most cases of Amnesia are temporary, lasting a few seconds to hours. Duration depends on the severity of disease or trauma. As Amnesiacs recover they first recall older memories first then recent memories. Memories that occurred around the time of the accident are usually never recovered.

There are many different types of Amnesia, such as:

• Anterograde Amnesia
• Emotional/hysterical Amnesia
• Korsakoff Amnesia
• Retrograde Amnesia
• Transient Global Amnesia

The most common types of Amnesia are Anterograde and Retrograde Amnesia. Anterograde Amnesia is when the person can’t recall incidents that happened after onset of Amnesia.

Retrograde Amnesia is the type of amnesia most people think of when they hear the term. People with retrograde amnesia find it hard to remember things that occurred prior to an incident in which they incurred damage to the head. Sometimes people never remember the seconds leading up to the incident.

Transient Global Amnesia is so-called because it last a short period of time, but affects a large portion of the memory. It leaves the person confused because they may be without their memory for 24 hours or more. Transient Global Amnesia is the sudden appearance of severe, forgetful confusion lasting from as little as 30 to60 minutes to as long as 12 hours or more. It is an unusual but not uncommon syndrome. During severe attacks, there is total disorientation except for one’s identity, combined with a retrograde memory deficit that can extend back for several years, but with gradually resolves as the attack subsides. Patients generally have a rapid, total recovery; therefore no treatment is indicated. However, since this event may involve poor cerebral circulation due to atherosclerosis, further testing in indicated. If there is a personal or family history of cerebrovascular disease, it is suggested that the recommendation for atherosclerosis within the Cardiovascular Disease protocol be followed and consideration given to therapy.

Wernike-Korsakoff's Psychosis is memory loss caused by extended alcohol abuse. This tends to be a progressive disorder and is usually accompanied by neurological problems, such as uncoordinated movements and loss of feeling in the fingers and toes.

Infantile/Childhood Amnesia refers to a person's inability to recall events from early childhood. Some say this type of amnesia could be linked to language development or the fact that some areas of the brain linked to memory were not fully mature.

Emotional/Hysterical (fugue) Amnesia is usually triggered by a traumatic event that the person's mind is unable to properly handle. Usually, the memory slowly or suddenly returns a few days later, although memory of the trauma itself may remain incomplete.

Posthypnotic Amnesia is memory loss sustained from a hypnotic state. It can include inability to recall an event that occurred during hypnosis or information stored in the long term memory.

Lacunar Amnesia is the inability to remember a specific event.