Wednesday, October 30, 2019

Humanity and Psychiatry | Prehistory to Pinel

Prehistoric human skull with trepanations (Monte Albán, Mexico)

Six to seven millenia ago in the Neolithic age it was understood that abnormal behaviours originated in the brain. However, the cause was ascribed to 'confined demons' and holes were drilled in the skull (trepanation) to let them out (Faria 2015). Later, the ancient Greeks and Egyptians developed an illness model of abnormal moods and behaviours, though they believed it was the heart and not the brain that controlled them. Texts that survive indicate formal psychiatric history taking and evaluation, prescription physical therapies like sleep, fever, and music alongside what would fit in with present day supportive and lifestyle and stress management therapies (Lambrini K, 2018). This care was confined to religious temple complexes some of which specialised in treatment of mental health disorders.

The 1st Millennium

Organised medical care in hospitals originated in the near and middle eastern regions. They were the first purely medical centres that developed outside of religious influence. Mental illness was also treated at these centers. The peak of this phase was in the academic medical centre (bimaristan) at Jundi-Shapur, Iran in the 6th century (Miller, 2006). Evidence based medicine may owe its first tentative roots to this centre. The crusaders, most notably the knights of St John brought back this model of aid to the ill and wounded on their return to Europe. Their legacy persists in the St John's Ambulance Brigade.

In the 'Dark Ages' 

The 'dark' ages are considered as symbolizing everything malign about mental health treatments. However, medieval authors were mostly aware that diet, alcohol, overwork, and grief contributed to mental illness. The association with sin and punishment was probably propaganda that was used in a minority of cases (Kroll J, Bachrach B 1984). In 1487 Heinrich Kramer published the Malleus Malleficarum that became a paradigm for the treatment of  'witchcraft' and by extension of social and mental deviations from the norm of the time. The invention of the printing press and religious turmoil that occurred at the same time may have served to preserve what may otherwise have been an obscure book. Treatment of the 'insane' then became confined to asylums typified by the descent of Bethlehem Hospital into Bedlam by the early 15th century. In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of 'wanting in humanity' towards his patients.

Pinel in the age of reason

Philippe Pinel (1745–1826) initiated humanitarian reforms in the treatment of the mentally ill at the Pitié-Salpêtrière Hospital for women in Paris. He observed a strict nonviolent management of mental patients that came to be called moral treatment. He was dramatised in portraits as liberating the insane from their chains. His psychological approach was well thought out, behavioural, and tailored to the individual rather than the diagnosis. He assembled detailed case histories and a natural history of the progress of his cases. Pinel is seen as the physician who established the field that would come to be called psychiatry.

The empirical age

We are now in the age of evidence based medicine. Fortunately there is a mountain of evidence to support a humane, individualised approach to treatment of mental health disorders (Knoll 2013). The benefits of a pollution-free environment, nurturing homes, and safe schools and workplaces has a positive impact on mental health. Individual factors like regular exercise, moderation in diet, adequate rest, and recreation are still shown to improve mental health outcomes. Physical treatments and humanity still go hand in hand for the management of mental illness.


References:
  1. Faria MA. Violence, mental illness, and the brain - A brief history of psychosurgery: Part 1 - From trephination to lobotomy. Surg Neurol Int. 2013 Apr 5;4:49. doi: 10.4103/2152-7806.110146. Print 2013. Accessed 03-Aug-2019
  2. Lambrini K et al. Care for Patients with Mental Illness inAncient Greece. Top 10 Contributions on Nursing & Health Care: 2nd Edition. Chapter 1. 2018. Accessed 03-Aug-2019
  3. Miller A. Jundi-Shapur, bimaristans, and the rise of academic medical centres. 2006. Accessed 20-Aug-2019
  4. Kroll JBachrach Bhttps://www.ncbi.nlm.nih.gov/pubmed/6387755 1984. Accessed 13-Sep-2019
  5. Wikipedia. https://en.wikipedia.org/wiki/Bethlem_Royal_Hospital . Accessed 02-Oct-2019
  6. Wikipedia. https://en.wikipedia.org/wiki/Philippe_Pinel . Accessed 08-Oct-2019
  7. Knoll JL. The Humanities and Psychiatry: The Rebirth of Mind. 2013-03-05. Accessed 2019-10-19

Tuesday, July 30, 2019

Parenting After Divorce

Almost half of all couples divorcing have a child under the age of 16 years. Parental separation results in a major upheaval in the life of a child. Apart from the loss created by the absence of one parent, there are usually major changes in living conditions, home, neighbourhood and school. Added to this are the psychological hazards of insecurity, loss of trust, anxiety, guilt and fear.

Psychological impact of divorce on the child

The psychological impact of divorce on the child is a complex issue. Several factors such as the manner in which the parents separated; the age and maturity of the child, socio-economic factors and support of family members determine the effect of the separation on the child.

Emotional and behavioural problems in children have been found to occur more often when the separation has been hostile and accompanied by much unpleasantness. A little sensitivity, a great deal of love and understanding and reassurance goes a long way in preventing emotional and behavioural disorders in the child.

Child’s Emotional Experience

Irrespective of their age, the child may feel
  • A sense of loss.
  • Sudden unwelcome changes in his life – change of school, neighbourhood and friends.
  • Fearful (Who will look after me? What will happen if my mom leaves me?)
  • Angry – at one or both parents for failing to look after him.
  • Guilt and confusion – (Has this happened because of me? Am I responsible in some way?)
  • Insecure and rejected – their world has fallen apart.
  • Torn between feelings for both parents

Developmental Stage Reactions

A young child (less than 8-9 years) is more dependent on the parents for love, protection and security, and is likely to respond with more fearfulness and anxiety. There is also a greater tendency towards wishful thinking and hoping that the parents get back together. He/she may become more ‘clingy’ and dependent; and may have nightmares, stomach-aches, or may regress to bed-wetting. Attention-seeking behaviours may be aimed at getting the parents back may result in childish behaviours and tantrums. It is important to reassure the child, and establish a predictable routine to give him a sense of security and stability.

An older child or adolescent tends to respond with greater anger and may become oppositional or withdrawn. He may feel that his parents have failed to look after him, and start relying more on himself; and may retaliate by being more self-centred, independent and deliberately hurtful.
‘They don’t care about me, why should I care about them’
It may help to talk things over with an adolescent, and channelize his need for independence by giving him some responsibilities.

Strategies to Help Your Child

DOs

  • Be open. The child has the right to know what is going on and what to expect. It should be explained in simple terms why the parents are separating and who he he/she is going to stay with (without giving specific unpleasant details) and he/she should be given age appropriate answers to any questions they may have.
  • Reassure the child that he/she will always be loved and looked after by both parents.
  • Protect the child from the unpleasantness, conflicts and arguments which may arise between you and your spouse.
  • Take responsibility for the situation, and be careful not to blame the child.
  • Make as few changes as possible to the child’s daily routine and caregiving, though some changes are inevitable.
  • Get help from family members, friends and teachers. Social support gives a sense of security and belonging to your child and is equally important for you.

DON’Ts

  • Don’t pull your child into the conflict – do not use him as a weapon, messenger or spy. It only serves to build up resentment in the child.
  • Don’t ask your child to take sides.
  • Don’t criticise, abuse or argue with your ex in front of your child.
  • Don’t share your anger and frustration about your spouse with your child. If you need to vent your feelings, do it with a friend, family member or counsellor.
  • Don’t discuss mutual pending matters (e.g financial or legal issues) with your child.
Remember, your child has the right to be loved, cared for and protected. He has the right to know about changes which affect him. Above all, your child has the right to grow up like other children his age. Create an atmosphere of trust, where he/she can talk about his/her feelings, ask questions and expect truthful answers. A supportive and caring parent-child relationship has been found to greatly reduce the negative impact of divorce.

Ref:
  1. https://www.justice.gc.ca/eng/rp-pr/fl-lf/divorce/wd98_2-dt98_2/wd98_2.pdf
  2. https://link.springer.com/chapter/10.1007/978-1-4613-9811-0_7
  3. https://www.rcpsych.ac.uk/mental-health/parents-and-young-people/information-for-parents-and-carers/divorce-or-separation-of-parents---the-impact-on-children-and-adolescents-for-parents-and-carers