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