History of Psychiatry, Ethics, Stigma, Prevention.

PAPER I
I. II. III. IV. The History of Psychiatry 2 Basic Ethics and Philosophy of Psychiatry. Stigma and Mental Illness 7 Prevention in Psychiatry 10 5

History of Psychiatry, Ethics, Stigma, Prevention.

I.

The History of Psychiatry

Mental illness, or its equivalent, has been recognised for as long as there have been records, and possibly before. Early Egyptian papyri contain references to mental disturbances. Cases of mental disorder are recorded in the Old Testament where they are often equated with possession by evil spirits (for example, Saul, David and Nebuchadnezzar). Greek writings began to propose mental aberrations as disease. Hippocrates appeared to regard mental illnesses as having bodily causes which required treatment. Plato proposed that the behaviour of a grown man could be affected by childhood experiences. It is important to recognise, however, that the conceptual framework within which psychopathological descriptions have been set has changed greatly over the years. It may not be justified to assume that terms such as mania, melancholia and hypochondria mean the same now as they did even a few hundred years ago. Aristotle labelled emotions and suggested people were drawn to positive experiences and avoided pain. Hippocrates classified mental illness into mania, paranoia, melancholia and epilepsy. He also coined the term hysteria, but was referring to a condition of women in which the womb wandered in the pelvis until cured by sexual intercourse! The Romans were generally more punitive towards mental illness, advocated whipping or ducking to purge the body of ghosts. The Christian Church dominated thinking on mental illness in the Middle Ages, producing the extremes of charity and cruelty to those afflicted. Islamic psychiatry in the Middle Ages used hospital treatment for the mentally ill, who were revered as messengers from God. Art and literature from the Renaissance era suggests an attitude of ridicule or fear towards the mentally ill in this period. Search for a physical site for psychological and spiritual entities commenced in the 17th century. At this time, institutions for the insane such as Londons Bethlem Hospital did exist, but conditions and treatments were unpleasant. Physicians such as Pinel in France in the 18 th century began to advocate kinder treatments and the removal of chains. Pinel began the definition of psychological phenomenology by describing mood swings, hallucinations and flight of ideas. The recurrent mental disorder suffered by King George III in the 18 th century aroused public interest and led to parliamentary consideration of the care of the mentally ill through Britain. Hypnosis was introduced by Mezmer and explored further by Charcot and Freud in the 19th century. The preoccupation with classification was continued by Kraepelin and Bleuler. Kraepelin developed the concept of dementia praecox (later more commonly known by Bleulers term of schizophrenia) and its separation (by virtue of poor prognosis) from manic-depressive insanity (with a better prognosis). The First World War, and cases of shell shock led to interest in the idea that exposure to stress and untoward events could cause illness and nervous symptoms. After the First World War, there was expansion of psychiatric facilities and a broadening of their scope. In the 1920s and 1930s, physical treatments were introduced such as malarial treatment for

History of Psychiatry, Ethics, Stigma, Prevention.

neurosyphilis, insulin coma therapy for schizophrenia, electroconvulsive therapy and psychosurgery. The 1950s heralded the introduction of psychotropic medication such as lithium, chlorpromazine, tricyclic and MAOI antidepressants. This revolutionised treatment of psychiatric illness, with greater optimism about treating mental illness and a reduction of psychiatric beds from 150,000 in the 1950s to around 45,000 in the 1990s. Another reason for the decline in beds was a change in social attitudes, fulled by Goffman (1961) who wrote a highly critical review of large psychiatric institutions in the USA, terming them total institutions. The origins of asylums in the 19th century as places of safe haven for people with mental illness were rooted in social concerns of the day. Their demise and subsequent fall similarly reflected change in public opinion driving policy with respect to community care. In the 21 st century, recent debate suggests that we are witnessing re-institutionalisation, with an increasing number of secure forensic beds, an increase in compulsory admissions to hospital, and an increase in supported housing run by private facilities.

Important names and their contribution to psychiatry: 1. Description & Diagnosis

Name Morel (1852) Kahlbaum (1863) Emil Kraepelin (1855-1926) Contribution Proposed mental illnesses could be separated and classified, based on aetiology. Described dmence prcoce Described catatonia with characteristic motor features (also described hebephrenia and dementia paranoides) Proposed division into dementia praecox and manic-depressive psychosis. Dementia praecox further divided into 3 subtypes: catatonic, hebephrenic and paranoid. Then later added 4th subtype: simple Defined paraphrenia separately (started middle life, free from changes in emotion and volition seen in dementia praecox) Proposed the name schizophrenia to denote splitting of psychic functions. The 4 As: Disturbances of Associations (thought disorder), Affective flattening, Autism (social withdrawal) & Ambivalence (apathy). Accessory symptoms: He believed these to be derived from loosening of associations: Hallucinations, Delusions, Catatonia & Abnormal behaviour Identified symptoms characteristic of schizophrenia (First Rank Symptoms). FRS - not supposed to have central psychopathological role and not necessary nor sufficient for the diagnosis. Nor do they have prognostic significance. Described schizoaffective disorder Separated schizophrenia from cycloid psychoses (non-affective psychoses with good outcome) Further sub-divided schizophrenia into systemic (catatonia, hebephrenia, paraphrenia) and non-systemic (affect-laden paraphrenia, schizophasia and periodic catatonia) Differentiated schizophreniform states from true schizophrenia, associated with better prognosis

Eugen Bleuler (1857-1939)

Kurt Schneider (1887-1967) Kasanin (1933) Leonard (1957)

Langfeldt (1961)

History of Psychiatry, Ethics, Stigma, Prevention.

2.

Treatment: Contribution Lithium Synthesis of Chlorpromazine Chlorpromazine for psychosis Reserpine, MAOIs Imipramine ECT Efficacy of Clozapine in resistant schizophrenia

Name John Cade (1949) Paul Charpentier (1950) Delay & Dineker Nathan Kline (1950, 1954) Roland Kuhn (1957) Ugo Cerletti & Lucio Bini (1938) John Kane (1987)

3. Psychology & related fields: Name Sigmund Freud Contribution Theory of psychoanalysis, structure of personality, topography of mind, ego-defense mechanisms, concept of anxiety & Psychoanalytical psychotherapy Prinicples of classical conditioning Behaviourism Client centred psychotherapy Cognitive theory of depression Attachment & Bonding Objects relation theory (Paranoid schizoid position etc.) Learned helplessness

Pavlov Watson & Skinner Carl Rogers Aaron Beck John Bowlby Melanie Kline Seligman

History of Psychiatry, Ethics, Stigma, Prevention.

II.

Basic Ethics and Philosophy of Psychiatry.

There are two fundamental approaches to ethics: The Duty-based approach most familiar to doctors. Originates from general obligations, codified by professional organisations, laying down rules of professional conduct. Utilitarianism concerned with broad judgements of benefit and harm. Assumes that the right action is the one that has the best foreseeable consequence.

Both these approaches to ethics can conflict at times. The Four-Principle Approach Respect for the autonomy of the patient the obligation for doctors to respect patients rights to make their own choices in accordance with their beliefs and responsibilities. This requires the doctor to help patients to come to their own decisions and then to respect and follow those decisions. This principle can clearly be at odds with the principle of beneficence, for example when a patient refuses treatment. Beneficence a fundamental commitment to doing good. When this principle overrules that of autonomy, it is seen as resulting in paternalism. Non-maleficence the avoidance of harm. A principle that is largely the reverse side of the coin to the principle of beneficence. Justice the requirement for doctors to act justly and fairly (for example in the allocation of resources). Moral philosophy is a huge discipline and an important academic subject. It is possible to identify two broadly competing camps within the subject the deontological and the teleological traditions. Deontology is by far the older, taking its roots from Judeo-Christian and Ancient Greek philosophy. The term derives from the Green deon for duty. The main feature is rules, where rights and duties determine action. The consequences are irrelevant. However, there is no procedure to resolve conflicts of rights, and to determine who/what kind of things have rights, and why. Teleology derives its name from the Greek teleon for purpose. The general principle is that actions are determined by the greatest good for the greatest number i.e. it is outcomebased. The consequences are all-important. However, there is no common scale for measuring outcome, and individual interests easily get overridden for the greater good. Virtue theory is different from deontology and utilitarianism as it is focused more on the individual, and their characteristics, rather than focusing on the actions. This theory defines virtues that people should aspire towards in order to lead a good life, rather than defining actions. Aristotle identified moral and intellectual virtues, which would enable one to attain the state of eudaimonia a state translated as happiness or human flourishing.

History of Psychiatry, Ethics, Stigma, Prevention.

Immanuel Kant was an 18th century German philosopher who developed the concept on moral philosophy. Kant believed that there was a single moral obligation, derived from the concept of duty. William David (W.D.) Ross was a Scottish philosopher at the turn of the 20th century, who was a moral realist. He argued about the existence of moral truths. Where consequentialist theories suggest that actions may be determined by what results in the most good, Ross argued that maximizing the good was only one of several prima facie obligations which play a role in determining what a person ought to do. Other obligations include: fidelity, reparation, gratitude, non-maleficence, justice, beneficence, self-improvement.

Abuses of Psychiatry
Paternalism was the key ethical principle underpinning the establishment of the county asylums in the mid-19th century in Britain. There was little legislation to govern the workings of asylums and their forerunner, the mad-houses. There were many publicised examples of abusive practices, especially involving the use of mechanical restraint and seclusion. 1 The activities of some German psychiatrists during the Second World War show how easily a benevolent paternalistic model may turn malevolent. Psychiatrists were at the forefront of the Nazi euthanasia campaign those patients deemed lebensunwertesleben (lives unworthy of life) were taken aside and murdered.2 From the 1950s to the 1980s the Soviet Union systematically abused psychiatry for political ends.3 A new diagnosis, sluggish schizophrenia, was defined so as to medicalise politically unacceptable dissident or reformist behaviour, and detain such individuals in psychiatric hospitals and medicate them against their will.

Antipsychiatry
A group of psychiatrists went beyond the rejection of paternalism to deny altogether the validity of psychiatric diagnoses and therefore of treatment. Thomas Szasz is the foremost of these individuals. His central argument is that mental illness, as a concept, has no validity.4 It is simply wrong in his view to medicalise mental distress and abnormal behaviour with a diagnostic label, and then to treat it those who profess to do so are acting as unwitting agents of social control. These antipsychiatry views were also influenced heavily by the study of institutional psychiatric practice in America by Goffman. Fulford has argued against the antipsychiatry movement by showing that medical and psychiatric diagnoses are equally value-laden, and are no less scientifically invalid.5

Common ethical issues Negligence

1
2

Barham (1992) Closing the asylum: the mental patient in modern society. England Books, London Lifton (1986) The Nazi doctors: medical killing and the psychology of genocide. Basic Books, New York 3 Block, Reddaway (1977) Russias political hospitals : the abuse of psychiatry in the Soviet Union. Gollancz, London 4 Szasz (1961) The myth of mental illness. Harper & Row, New York 5 Fulford (1989) Moral theory and medical practice. Cambridge University Press, Cambridge

History of Psychiatry, Ethics, Stigma, Prevention.

The most common reason for doctors to be taken to Court is because they are being sued for negligence. This requires the plaintiff to prove: That the patient owed a duty of care to the particular patient That the doctor was in breach of the appropriate standard of care imposed by the law That the breach in duty of care caused the patient harm, meriting compensation

Doctor/patient relationship
Doctors have obligations to respect the patients wishes and best interests. Unfortunately, psychiatrists have occasionally taken personal advantage of their patients in various ways: to satisfy their own psychological needs, imposing their own values and beliefs on their patients, financial exploitation, sexual exploitation, putting the interests of third parties who provide or fund medical care above those of the patient.

Confidentiality
Confidentiality is fundamental in medical practice. In most circumstances, the psychiatrist should not disclose confidential patient information without the patients consent. Doctors may be obliged to disclose information to a third party in the public interest for example, there are statutory obligations in relation to communicable disease, certain controlled drugs, unfitness to drive, suspicion of child abuse, by order of a Court or where disclosure may assist in prevention, detection or prosecution of a serious crime.

Consent to medical treatment

In order to have capacity to decide on a specific decision, the patient must be able to understand and retain the knowledge necessary in order to make a decision, be able to weigh up the information and communicate the decision. The Mental Capacity Act 2005 essentially places into statute the key outcomes from case law, and has five key principles: A presumption of capacity, The right for individuals to be supported to make their own decisions, The right for individuals to make what might be seen as eccentric or unwise decisions, The obligation to act in the best interests of patients without capacity, The obligation to use the least restrictive intervention.

III.

Stigma and Mental Illness

Stigma can be defined as constituting three elements: A label that separates a person from others The linking of the marked person to undesirable characteristics The rejection and avoidance of the stigmatised person by others

Rejection may be experienced in a range of areas such as employment and housing, through to everyday minor insults. Stigma has been found to be highly prevalent among people with

History of Psychiatry, Ethics, Stigma, Prevention.

a serious mental health problem living in the community.6 The effects of labelling are mediated by social psychological mechanisms in which both former psychiatric patients and members of the general population internalise negative cultural conceptions and attitudes about people who have been diagnosed with a mental illness, leading to personal discrimination. For many former psychiatric patients a negative self-concept emerges from a combination of their primary disability and from the cumulative reaction of others. Social rejection is an ongoing and recursive experience in the community setting and a persistent form of social stress for discharged patients.

IIIb. Culture and Mental Illness

The culture of a particular population is the sum of work and thought expressed or produced by members of that population, including their social practices, beliefs, institutions, and arts.7 Although it is a reflection of people and the ecological and socioeconomic contexts in which they live, at the same time culture exerts a profound influence on individual behaviour, cognition and emotion.8 Culture can play an important role in the development and expression of mental disorder through pathogenic or pathoplastic mechanisms. While some mental disorders have a strong pan-cultural core (high degree of syndromal stability across cultures), others are specific or unique to a particular culture (culture-bound syndromes). Examples of culture-bound syndromes: Amok. Occurs in Malays and consists of a period of withdrawal, followed by a sudden outburst of homicidal aggression in which the sufferer will attack anyone within reach. The attack typically lasts for several hours until the sufferer is overwhelmed or killed. If alive, the person typically passes into a deep sleep or stupor for several days, followed by amnesia for the event. It almost always occurs in men. Koro. Common in South-east Asia and China. Involves the belief of genital retraction with disappearance into the abdomen, accompanied by intense anxiety and the fear of impending death. Dhat. Commonly recognised in Indian culture. Includes vague somatic symptoms and sometimes sexual dysfunction which the subject attributes to the passing of semen in urine as a consequence of excessive indulgence in masturbation or intercourse. Windigo. Described in North American Indians, and ascribed to depression, schizophrenia, hysteria or anxiety. It is a disorder in which the subject believes he or she has undergone a transformation and become a monster who practises cannibalism.

6
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Link et al (1997) Journal of Health and Social Behaviour 28: 177-190 Lopez & Guarnaccia (2000) Annual Review of Psychology 5: 571-598 8 Fiske (1995) The cultural dimensions of psychological research. Erlbaum, Hillsdale p271-294

History of Psychiatry, Ethics, Stigma, Prevention.

Latah. Usually begins after a frightening experience in Malay women. It is characterised by a response to minimal stimuli with exaggerated startles, coprolalia, echolalia, echopraxia and automatic obedience. Brain fag syndrome. Widespread low-grade stress syndrome described in many parts of Africa, commonly encountered among students. Pibloktoq or Artic hysteria is a culture bound syndrome appearing exclusively in Eskimos (Inuit) living within the Arctic Circle. It is more common in woman and tends to occur in winters. It is characterised by hysterical behaviours (screaming or uncontrolled behaviours), insensitivity to extreme cold, echolalia, depression and coprophagia. Often there is amnesia for the episode. It has been explained by a variety of theories: ecological, nutritional, biological-physiological, psychologicalpsychoanalytic, social structural and cultural, and possible implication of vitamin intoxication, namely, hypervitaminosis A.

Mental illness among ethnic minorities

Schizophrenia The higher than expected rates of schizophrenia among Afro-Caribbean people born in Britain have been noted since the 1960s. Studies of hospital admissions have demonstrated high rates of schizophrenia in this group compared to British whites and Asians. These results have caused controversy, with criticisms of misdiagnosis due to unfamiliar culturally determined patterns of behaviour, acute psychotic reactions being mistaken for schizophrenia, or racism accounting for the observed differences. There is no evidence of increased rates of schizophrenia in the West Indies, and therefore no evidence that AfroCaribbeans carry a greater genetic loading for schizophrenia. Suicide Suicide rates are high among young Indian women at ages 15-24 and 25-34, but low among Indian men. Suicide rates are low in Caribbeans but high in young adult East Africans. Immigrant groups have a higher rate of suicide by burning, with a nine-fold excess among Indian women.9

Raleigh & Balarajan (1992) British Journal of Psychiatry 161: 365-368

History of Psychiatry, Ethics, Stigma, Prevention.

IV.

Prevention in Psychiatry

"Prevention psychiatry" is a paradigm within the psychiatric profession that focuses on reducing the incidence and prevalence of mental disorders and behavioral problems by identifying risk and protective factors and applying evidence-based interventions. Everyone knows that prevention is better than cure, yet preventive activities are given low priority among interventions undertaken by psychiatrists. Reasons for this include the argument that the evidence for effective preventive interventions is weak; that limited resources only allow assessment and treatment of the most severely ill; the training of psychiatrists contains little of relevance to prevention; and effective prevention requires changes in the structure of society and in organizations over which psychiatrists have little control. A recent critical review by the Royal College of Psychiatrists has shown that effective evidence-based preventive interventions do exist. Indeed, there have been several thousand published outcome studies of preventive intervention in this field. A significant number meet criteria for scientific rigor. The three types of prevention are: Primary prevention is directed at reducing the incidence (rate of occurrence of new cases) in the community. Primary prevention efforts are directed at people who are essentially normal, but believed to be at risk from the development of a particular disorder. The goal of primary prevention is to prevent development of psychiatric disorder by early intervention. Evidence from longitudinal studies have indicated that it is possible to identify help-seeking individuals with prodromal symptoms who are at greatly increased risk of developing full blown schizophrenia and psychosis at 1 year follow up. It has been shown that general practitioners (GPs) and counselors can, with minimal training, identify these 'at-risk mental states', 2540% of which will convert to psychosis over the next year. Substance misuse of street drugs is often a final risk factor in these or other individuals. The first RCTs of low dose drug treatment and/or cognitivebehavioural therapy in these prodromal cases indicate that transition to full psychosis can be postponed, ameliorated or perhaps in some cases prevented.10 Primary prevention may be subdivided into universal, selective and indicated prevention.

Universal prevention is defined as those interventions that are targeted at the general
public or to a whole population group that has not been identified on the basis of increased risk (e.g. seatbelts, encouragement of safe drinking, reduction of cigarette smoking, healthy eating and exercise).

Selective prevention targets individuals or subgroups of the population whose risk of

developing a mental disorder is significantly higher than average, as evidenced by
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Edwards, J. & McGorry, P. D. (2002) Implementing Early Intervention in Psychosis: A Guide to Establishing Early Psychosis Services. London: Martin Dunitz.

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History of Psychiatry, Ethics, Stigma, Prevention.

biological, psychological or social risk factors. Examples are good antenatal and perinatal

care in pregnant women; health interventions in young unsupported teenage mothers; and social support for socially-isolated elderly people. Indicated prevention targets high-risk people who are identified as having minimal but

detectable signs or symptoms foreshadowing mental disorder or biological markers indicating predisposition for mental disorder but who do not meet diagnostic criteria for disorder at that time. Secondary prevention involves efforts to reduce the prevalence of a disorder by reducing its severity and duration. Thus, secondary prevention programmes are directed at people who show early signs of disorder, and the goal is to shorten the duration of the disorder by early and prompt treatment. It is preventive in that by shortening the duration of illness it prevents chronic morbidity prevents some of the consequences of mental illness for other people, for example children and spouses, and it may prevent mortality. Tertiary prevention is designed to reduce the disability and handicap associated with a particular disorder. It is preventive in that by reducing disability and handicap, it prevents many of the associated sequelae of chronic illness.
Type Primary Prevention What it does Reduction of the incidence of a disorder. Sub-types Universal Intervention Selected Intervention Indicated interventions Example Media advertisements to reduce smoking in the population Providing good Antenatal care & postnatal care. Preventing the development of schizophrenia in people with subthreshold symptoms using CBT or low dose antipsychotics. Early treatment of people who have psychosis (Early intervention programs) to reduce symptoms. Prophylaxis treatment with lithium to prevent relapse of Bipolar illness

Secondary Prevention

Reduction of the prevalence of a disorder.

Tertiary Prevention

Reduction of the disability associated with a disorder.

Risk and Protective Factors: It is important to be aware of the specific risk and protective factors in different stages of life starting from the prenatal period to the older adult stage to consider prevention strategies. Risk factors: Risk factors predate the associated disorder. They are highly associated with the disorder. Some risk factors are malleable, or subject to change via a preventive intervention. Biological

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History of Psychiatry, Ethics, Stigma, Prevention.

Expression of genetic vulnerability, adverse prenatal event (traumatic, toxic, infectious) Psychological/Psychosocial Family discord, parenting skill deficits Social/Environmental Availability of drugs and firearms, extreme economic and social deprivation.

Protective factors: Protective factors predate the associated disorder. They reduce the risk of developing a disorder or adverse outcome. Some are malleable, or subject to enhancement via a preventive intervention (i.e., promoting resiliency). Support from caring adults Parents, relatives, professionals Good school performance Conflict resolution skills Positive role models and positive peers Clear and consistent discipline in the family In general prevention programs need to: Address factors that play causal roles. Reverse or reduce risk factors. Enhance protective factors to increase competency in multiple domains. Age-specific, developmentally appropriate, and culturally sensitive. The Report by the College11 on prevention in psychiatry and the WHO document 12 is an exhaustive document containing risk and protective factors in each stage of life and the possible preventative strategies. Some of the specific risk factors relevant to the exam are below, but the list is not in any way exhaustive. Specific risk factors for postnatal depression: family history of depression previous episode of depression Traumatic pregnancy or delivery. Specific risk factors for child abuse and neglect: young age of parents parental history of unhappy or disrupted childhood history of persistent aggressive behaviour in one or both parents domestic violence child born with a congenital or developmental disorder Persistently crying baby. Specific risk factors for early development of behaviour problems:
Prevention in Psychiatry: Council Report CR104 February 2002. http://www.rcpsych.ac.uk/files/pdfversion/cr104.pdf
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Prevention of Mental Disorders: Effective Interventions and Policy options. WHO report 2004. http://whqlibdoc.who.int/publications/2004/924159215X.pdf
12

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History of Psychiatry, Ethics, Stigma, Prevention.

maternal depression adverse temperamental characteristics in the baby, such as negative mood and irregularity developmental delay or disorder large family size. Specific for delayed language development: smoking in pregnancy more than occasional consumption of alcohol in pregnancy inadequate cognitive stimulation behaviour problems in the child large family size. Specific for single gene or chromosomal disorder: advanced maternal age previous birth of a child with a congenital anomaly family history of a genetically determined anomaly. Specific risk factors for premature death: schizophrenia drug and alcohol misuse anorexia nervosa learning disabilities adolescents with severe conduct disorders. Specific risk factors for suicide: schizophrenia severe depressive disorders bipolar disorders anorexia alcohol and drug misuse adolescents with severe conduct disorders recent discharge from hospital. REFERENCES Companion to Psychiatric Studies, 7th edition, eds Johnstone, Cunningham Owens, Lawrie, Sharpe, Freeman Shorter Oxford Textbook of Psychiatry, eds Gelder, Harrison, Cowen, 5th Edition Revision Notes in Psychiatry, 2nd edition, eds Puri, Hall Textbook of Psychiatry, 2nd edition, eds Puri, Laking, Treasaden Prevention in Psychiatry. Report of the Royal College of Psychiatrists Public Policy Committee Working Party, 2002. Prevention of Mental Disorders: Effective Interventions and Policy options. WHO report 2004. http://whqlibdoc.who.int/publications/2004/924159215X.pdf.

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