Tattoos - true love will never fade

What is the motivation or psychology behind obtaining a tattoo? Tattooing as a form of decorative body art has moved out of the realm of cults and organisations into mainstream society. It is increasingly common to see patients sporting a new tattoo. "Just like that, doctor. My friends were getting one". The Pune magazines reflect this new found art form through full page articles every other week. Driving through the some parts of Pune takes you past at least three studios specialising in the art of tattooing.

Here we are concerned with the psychological aspects of tattooing. As compared to body-piercing, a tattoo is relatively permanent and more deliberate operation. For the moment set aside doubts over hygiene, HIV, and hepatitis.

10 reasons people get a tattoo

1. Beauty, art, and fashion. Tattoos are a means of decorating the body with a permanent fashion accessory. Many tattooed individuals refer to their tattoos as a piece of art. 
2. Individuality. A tattoo fulfils the desire to create a distinct self-identity. The symbols or words embellishing the skin creates a special message that distinguishes the person from others. The individual gains a sense of control over their appearance and identity. We see this especially in teenagers brought in by their parents.
3. Personal narrative. Women recovering from abuse create a new understanding of the injured part of the body. They reclaim possession through the deliberate and painful procedure of body modification. Tattoos have a self-healing effect in this reclamation of the body. 
4. Physical endurance. For some tattoos are a statement about testing their threshold for pain endurance.  
5. Group affiliations and commitment. Body ornaments are a permanent sign of love and commitment. The wish to belong to a certain community or to show affiliation to a particular group is a common reason for getting a tattoo. 
6. Resistance. Tattoos are a provocative protest against parents and society, especially in college students. Body modification has long been associated with subcultural movements and criminal tendencies. Until recently most studies on tattooing were done on prison populations.
7. Spirituality and cultural tradition. Body modifications emphasise personal affiliation to cultures and their spirituality. Esoteric symbols that convey special meaning are tattooed as a permanent reminder.
8. Addiction. Tattoos and piercings possess an addictive character through the release of endorphins. These substances are released in brain areas in association with painful penetration of the body.
9. Sexual motivation. Tattooing is a form of expressing sexual affectations and of emphasising ones own sexuality. 
10. No specific reason. A tattoo may be obtained impulsively on the spur of the moment. Some individuals may be under the influence of alcohol or drugs while acquiring their piece of body art.

Reasons people have a tattoo removed

People are mostly satisfied with the actual design of their tattoo.

Most want their tattoo removed for personal reasons. This occurs when the quest for uniqueness turns into stigma, negative comments, and clothes problems. Poor decision making and subsequent personal regret seem to be frequent motivations for tattoo removal.

An improved sense of self and maturity is another factor. Especially for those who obtained their tattoos for internal expectations of self-identity at an early age. Many are still trying to dissociate from the past and improve self-identity. More than 40% of persons who choose a tattoo to feel unique are disillusioned when their unique product loses its luster and excitement.

Professional/social reasons account for another third of those motivated for tattoo removal. A new job or career is a major motivation. Negative workplace attitudes toward tattoos and perceived interference for a tattooed individual’s achievement is common. There is a perception of lowered credibility, competence, and sociability that diminishes the image of tattoo wearer in the workplace.

The possession risks are more for women than for men. More than two thirds of those seeking tattoo removal are women. Society support for women with tattoos is not as strong as for men. Strong tattoo support from significant others and friends is counterbalanced by negative remarks about the tattoos from fathers, physicians, and the public. Negative responses are also documented among career-oriented women with tattoos. Women still need to deliberately think about controlling the body placement of their tattoos to avoid the possession risks and to increase their own psychological comfort.

References

1. Armstrong ML, Roberts AE, Koch JR, Saunders JC, Owen DC, Anderson RR. Motivation for contemporary tattoo removal: a shift in identity. Arch Dermatol. 2008 Jul;144(7):879-84.
2. Silke Wohlrab, Jutta Stahl, Peter M. Kappeler. Modifying the body: Motivations for getting tattooed and pierced. Body Image 4 (2007) 87–95.

Discrimination of psychiatrically ill persons by hospitals

Discrimination of mentally ill persons by hospitals

A young woman with psychiatric illness was refused admission at a leading tertiary care hospital in Pune. The reason - “mentally unstable patients are known to cause harm not only to themselves but to others as well. The hospital lacks facilities and infrastructure for catering to psychiatric patients.” A similar unwritten policy of denying inpatient care on grounds of psychiatric illness exists in at least one other large corporate hospital in Pune.

We have already stressed the importance of access to healthcare for persons with mental illness. We will now further explore the stereotype of harm in mental illness. The stigma associated with this stereotype has an adverse impact on timely delivery of healthcare to persons with psychiatric illness.

Are mentally ill persons likely to harm other hospital inpatients?

Hospital and healthcare settings have the highest levels workplace related violence across all industry sectors (CDC 2002).  The place where patient perpetrated violence is most likely to occur is the Emergency or Casualty department not the wards (Farooq 2009). Patients of all categories mostly attack staff or junior doctors - the ones they are in regular and direct contact with. In most cases violence is perpetrated by arrogant patient attendants not the patients themselves, whatever their diagnosis. For the rest violence is a result of unacceptable staff behaviour, and dissatisfied patients or attendants. It is rare for patients of any diagnosis to physically attack and harm each other in a hospital. Even in acute inpatient psychiatry units violence towards other patients or staff is less than 3% of total incidents of violence (Biancosino 2009). So much for psychiatric illness being “known to cause harm”.

Are patients with psychiatric illnesses the only ones that harm other patients? At the height of the swine-flu scare in 2009 no patient suspected of having the disease was denied treatment or admission. Yet swine-fly is known to be highly contagious and lethal. Special protocols and facilities were drawn up and earmarked overnight. So the potential for harm is not the overriding factor in denial of treatment.

Patients with psychiatric illness require minimal investigation, and respond rapidly to cheap and effective medication. Return on investment may be what it is all about. Psychiatrically ill pateintsdo not make much money for a hospital. It is more lucrative to provide skewed facilities for a liver transplant that would require weeks of ICU care, extensive investigation and invasive procedures. It would also make news for all the right reasons.

Mental illness accounts for 80-90% of completed suicides. Serious suicide attempts by poisoning or jumping result in emergency hospital admissions. Treatments would entail stay in the Intensive Care Unit, utilisation of the Operation Theatre, mechanical ventilation, and extensive monitoring and investigations. All this translates into large cash transactions over a short period of time. No hospital administrator would deny admission to these critically ill patients - ethical considerations, policy and stigma not withstanding.

Is it really possible to exclude patients with psychiatric illness from the hospital healthcare system?

The dichotomy between soma and psyche, physical and mental is artificial. This was formally enunciated in Para 1 of the WHOs Alma-Ata declaration (1978) and is the accepted definition of health for medical students since decades. Psychiatric and somatic illnesses coexist with and impact eachother. Ignoring this interaction is adversely affecting the outcomes of chronic illnesses like diabetes, heart disease, cancer and respiratory disease. The World Mental Health Day 2010 document specifically evaluates the evidence and stresses the urgent need to integrate mental heatlhcare for these chronic illnesses which account for 60% of the worlds deaths.

Walk into any hospital ICU and you will see at least one delirious patient strapped to the bed with physical restraints. Psychological aspects of critical illness are given the short shrift only because the mindset is one of discrimination and disrespect for the individual. Psychiatric and physical health problems do not exist in isolation. Their physical basis and vice versa cannot be excluded by artificial dichotomies.

Is it desirable to treat persons with mental illness in a general hospital setting?

Integration of mental healthcare delivery with existing facilities is a major thrust of the WHO (2008). Hospitals need to provide an accessible and acceptable location for treatment of acute exacerbations of mental health disorders in the same way that they currently do for physical health disorders. This would also enable access to services for physical health problems that arise during the inpatient stays of persons with mental health problems.

Deinstitutionalisation of psychiatric and mental health care has been stressed as a human right since the mid 20th century. A step in this direction for Pune's hospitals would be to draw up and implement guidelines to prevent and manage hospital violence. These guidelines already exist (CDC 2002, OSHA 2004).

References

1. Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009 Oct;197(10):772-82.
2. CDC. Violence - occupational hazards in hospitals.  DHHS (NIOSH) Publication No. 2002–101. April 2002
3. J Farooq, A Mustafa, D Singh, GH Yattoo, A Tabish, GJ Qadiri. Violence in hospitals. Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009; 16-20
4. Occupational and Safety Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R
   
5. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001 Jan;52(1):75-80.
6. World Federation for Mental Health (WFMH). Mental health and chronic physical illness - the need for continued and integrated care. World mental health day. 10 October 2010.
7. World Health Organisation (WHO) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
8. WHO/Wonca.  Integrating mental health into primary care: a global perspective. World Health Organisation and World Organization of Family Doctors (Wonca). 2008.

Attempted suicide prosecuted in Pune

Woman booked for attempting suicide

A 21-yr woman attempted suicide by jumping from the fourth floor of the gynaecology ward she was admitted in. She could not stand the pain of complications after a Caesarean Section. Section 309 of the Indian Penal Code was slapped against her by the police. 612 people committed suicide in Pune in 2008. This gives a documented suicide rate in Pune of 16.3 persons per 100,000 population. The national suicide rate is 10.8/100,000. This data is based on police records. A verbal autopsy study (1994-99) estimated an actual suicide rate of 95.2/100 000 population —nine times the national average.

This tragic incident and its background needs further analysis

How common is attempted suicide in a 21 year old woman during and after pregnancy?
The suicide rate for 15–24 year females is 109/100000. This exceeds the male rate of 78/100 000. Suicide is responsible for 49% of all deaths in women at these ages. During pregnancy attempted suicide is about 40 per 100,000 pregnancies. Women that attempted suicide during pregnancy had increases in caesarean delivery. One percent of people who attempt suicide complete it within a year

Why are official suicide rates gross underestimates?
Attempted suicide is a symptom associated with the stigma of mental illness and also the stigma of crime. To avoid this double stigma patients and we doctors collude to label the suicide attempt as accidental. Another verbal autopsy study (1997-98) of all deaths in a rural area showed that half the deaths ascribed to injuries were actually suicides. The real suicide rates are distorted depending on the degree of under-reporting.

So what if official suicide rates are gross underestimates?
80-95% of suicide is associated with treatable physical problems (including unremitting pain) and psychiatric problems (including post partum depression). When under-reported - resources meant for treatment of psychiatric disorders, including those for knowledge dissemination and manpower, are diverted to other problems.  A California study found that a psychiatric disorder increased the risk of postpartum suicide attempts 27.4-fold. The discrimination against females with mental illness is raised to a national level. People are left unaware that the conditions resulting in suicide attempts are disorders that are treatable; doctors and paramedical staff are not trained to recognise conditions that could lead to suicide; primary care doctors are unaware of simple, effective and available psychiatric treatment options. 

Why is the suicide rate in Pune one-and-a-half times the national average?
Among the many social factors associated with suicide, addressing suicide attempts humanely would contribute more to bringing down the actual suicide rate – definitely more so than prosecution. This high suicide rate in Pune may also have a flip side – we may have a better reporting system.