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. 'Asylums for the Fearful' were maintained by Jain ascetic scholars during the medieval Chola period (848-1279) in Tamil Nadu, India as evidenced by stone inscriptions from that time.

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
8. Somasundaram O, Raghavan V. Asylum for the fearful: A Jain innovation of the early Tamil land. Indian J Psychiatry [serial online] 2020 [cited 2020 Feb 3];62:107-8.

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

Multiple Illnesses and Multiple Prescriptions—Clarify safety with prescribing doctor

People with a serious psychiatric ailment fall ill, just like anyone else does. They develop colds and coughs, fevers and stomach ailments. They may sprain their ankles, have headaches, develop indigestion after having too good a meal, rashes after trying a new cosmetic and food poisoning after eating some unhygienic street food. Like anyone else, they do one of two things: they buy an OTC medicine; or they consult a general physician.

Precautions with other prescriptions

Be careful with OTC preparations. Not all OTC medications are benign or free from side effects. Avoid drug combinations. Cough syrups (even ‘safe’ herbal ones) usually have a combination of many ingredients, including substances which are highly addictive.

It is usually better and safer to go for option two – visit your GP. It is a good idea to establish a trusted professional relationship with one particular GP who knows your medical history thoroughly. However, this may not always be possible.

Very often, the distress of the current ailment takes precedence in the mind of both the patient and the doctor; because of immediate discomfort, pain or distress involved.  It is all too common for a busy GP, to misguidedly tell you to stop your psychiatric medication, attribute your symptoms to your medication or to simply waive the responsibility - ‘tell your psychiatrist to change your medication.’ Also, don't stop any long term medication on the advice of a person who is not a qualified medical practitioner.

Many psychiatric illnesses are serious, long-term, and may be life-threatening; just like chronic medical illnesses like hypertension, diabetes, epilepsy or heart disease are. No doctor will ever ask you to stop the medications for these illnesses abruptly while he treats your fever or loose motions. He will prescribe a medicine which will not react adversely with those you are already taking. Insist that your illness be treated similarly.

Medications for psychiatric illnesses are relatively few, as compared to the number of antibiotics, pain relievers or cough medicines available in the market. They also have to be started at low doses and built up gradually until you have the most benefits with the least side-effects. It is a slow process, for which you have had to follow-up regularly with your psychiatrist usually over months. It is important that this process should not be derailed without due consideration.

Stopping your psychiatric medication abruptly

1. May cause the distressing symptoms to return i.e you may relapse.
2. More seriously, you may find that the original medication, on which you were stable and symptom-free has now become ineffective, and you may require stronger medicines and/or multiple drugs to treat your illness.
3. Even more seriously, you may wrongly attempt to restart your psychiatry medication at its full strength when you recover from your viral fever after a week. Do not do so. Serious side-effects may follow.

What to do when consulting another doctor

• Always take your previous prescription with you when you need to consult another doctor. The prescription from our clinic has the dose and generic name of the medicine you are taking (as best practices worldwide demand and as mandated by the govt).
• Check with your doctor that he has prescribed a medicine which does not react with what you are already taking. Numerous apps are available to check drug interactions, which most doctors are conversant with. It takes only a couple of minutes to do so and prescribe a suitable drug. It can take months to find a new psychiatric medication that suits you and is as effective as the one you are on presently.
• In case, there is still a doubt, ask him to speak to your psychiatrist. Professional courtesy demands so.
• If you have stopped your medication, do not resume it without guidance. Seek an early appointment with your psychiatrist.

World Mental Health Day 2018

World Mental Health Day

World Mental Health Day is observed every year on the 10th of October to take awareness of mental health issues into the community. The theme for 2018 was Young People and Mental Health in a Changing World^[1].

Pathfinder Clinic WMHD2018 Event

On World Mental Health Day 2018 Pathfinder Clinic psychologists manned a desk for the day in the atrium at Magarpatta City, Pune. They used a short mental health quiz to pique the interest of anyone entering the shopping complex and rewarded all participants with an origami patronus! They were also administered a test of their current resilience. Our psychologists engaged in over-the-counter discussions on what constituted mental health issues. People brought out their own family and interpersonal problems, and to many it was an eye-opener that mental health issues could be contributory.

Why focus on young people?

Young people don't vote. They often don't have a voice and depend upon others to champion their right to health justice. The growing prevalence of youth mental health problems is a tsunami, and parents, the community and governments float in a small boat, named “denial”, on the quiet sea^[2]. Most mood and anxiety disorders, and schizophrenia have their onset in this age group[3]. Investing in early intervention programs is not only beneficial for patients, but also cost-effective[4].

What is changing in the young persons world?

The increasing use of online technologies and growing connectivity to virtual networks through the day and night add to pressures faced by adolescents. It is unclear whether some of these changes affect normal aspects of human behavior and cause psychiatric disorders. At the other end of the spectrum are young people caught in humanitarian crises due to conflict and environmental disasters that can overwhelm the coping ability of the individual.

Building resilience in young people

Resilience in young people is determined by their personal and social resources. Engaging young persons in therapy builds resilience through processes of bouncing back and personal growth[5]. Resilience is also built through the process of enhancing immunity to stress by 'innoculation', especially if the prior stress occurs early in life, is mild in its magnitude, and is controllable by the individual[6].

References

1. WHO. World Mental Health Day 2018. Accessed 2018-11-03
   
2. Helen Christensen, 1 Charles F. Reynolds, 3rd, 2 and Pim Cuijpers. Protecting youth mental health, protecting our future. World Psychiatry. 2017 Oct; 16(3): 327–328. Published online 2017 Sep 21. doi: [10.1002/wps.20437]. Accessed 2018-11-03
   
3. Cornelius LR, van der Klink JJ, de Boer MR, Brouwer S, Groothoff JW. High prevalence of early onset mental disorders among long-term disability claimants. Disabil Rehabil. 2016;38(6):520-7. doi: 10.3109/09638288.2015.1046566. Epub 2015 May 14. Accessed 2018-11-05
4. Celso Arango. First-Episode Psychosis Research: Time to Move Forward (by Looking Backwards). Schizophr Bull. 2015 Nov; 41(6): 1205–1206. Published online 2015 Sep 20. doi: [10.1093/schbul/sbv126]. Accessed 2018-11-05
5. Ayed N, Toner S, Priebe S. Psychol Psychother. Conceptualizing resilience in adult mental health literature: A systematic reviewand narrative synthesis. 2018 Jun 11. doi: 10.1111/papt.12185. [Epub ahead of print]. Accessed 2018-11-16.
6. Ashokan A, Sivasubramanian M, Mitra R. Seeding Stress Resilience through Inoculation. Neural Plast. 2016;2016:4928081. doi: 10.1155/2016/4928081. Epub 2016 Jan 5. Accessed 2018-11-16.

Parenting an Adolescent

Adolescence is a time of transition. Most parents find themselves bewildered by the changes in their previously affectionate and obedient children. Mood changes, withdrawal, monosyllabic answers and arguments find most parents asking, “What have we done wrong?”

Adolescence is marked by profound changes brought about by the hormonal surge at puberty. The physical changes are accompanied by emotional, behavioural and intellectual changes to which the child has to adapt rapidly.

“As their bodies, brains and worlds rearrange themselves, you (parents) will need to do your own reshuffling.”

Changing role of parenting adolescents

The need for autonomy, independence and a search for one’s own unique identity is an essential part of adolescence. Often, this is achieved by questioning and testing existing rules and norms. Make space for this quest. Handle an occasional error of judgement with explanations rather than with accusations and confrontation.

The essentials of parenting at this age are

1. Trust
2. Empathy
3. Respect
4. Support

Trust is important in all relationships. Trust your teen to do what is right. As far as possible, avoid correcting them and pointing out mistakes. Allow them to learn on their own.

Empathise. Your adolescent child is often plagued by self-doubts and insecurities. Remember you were an adolescent once, and do not trivialise their problems.

Respect their need to be away from you, alone or with friends. Listen to their opinions and try not to be dismissive of their views and values.

Support. Assure them of your love and support without being intrusive; this will encourage them to come to you in need.

Parenting styles

An authoritative parenting style provides the adolescent with opportunities to become self-reliant within a set of rules, limits and guidelines appropriate for his/her developmental age. The personality and temperament of the child may also influence your parenting style (a co-operative and responsible teen requiring much less supervision). The environment (e.g an unsafe neighbourhood) can also dictate your parenting style. Privileges and limits may be set with the active participation of the child. It helps to state your expectations without ambiguity (what is acceptable behaviour and what is not), set clear limits and enforce consequences (loss of privileges) when limits are not adhered to.

When parents differ in their parenting styles.

One parent (often a father who is away a great deal) may tend to be permissive in his parenting. Adolescents (and children!) are quick to take advantage of differences between parents. It is important for the parents to arrive at a consensus privately and present a united front when dealing with limits and consequences.

Autonomy vs Monitoring

There are no hard and fast rules. Monitoring does not mean constant surveillance. Safety concerns entail knowing about the whereabouts of the adolescent outside school hours, friends they are with and contact information. A schedule to return home should be worked out. Similar limits should be set for time spent on social media. Be honest in communicating your concerns and avoid doing things behind their backs. It only leads to lack of trust and a tendency to conceal things from you.

Do not seek to control. Often, clashes between parents and adolescent children are about who has control. Adolescents struggle for control over what they feel is their own life, while parents struggle to hold onto the control they had earlier.

Peers

Sometimes, you may be uncomfortable with the company your adolescent keeps. Do not rush into judgements and accusations. Observe for yourself if there is a genuine cause for concern. Teach your adolescents to say ‘no’ to what they feel uncomfortable about. Explain the harmful effects of risky behaviour (alcohol, drugs, sexual activity) at a young age.

When to seek help

Repetitive problem behaviours and high-risk behaviours require professional help and guidance. Aggressive and violent behaviour, progressive academic deterioration, school refusal or truancy, lying or cheating demand immediate attention. Increasing moodiness, lack of communication, inattention to personal hygiene are other warning signs of psychological distress.