Thursday, March 15, 2018

Sanity vs Insanity


Dr. Ruwan M Jayatunge    

Insanity is the only sane reaction to an insane society  –Thomas Szas

Although sanity refers to the soundness, rationality and healthiness of the human mind there is no clear demarcation between sanity and insanity. Some view the difference between sanity and insanity as a few nanometers and measured by success. The causes for insanity are multifactorial. Genetics, life stressors, infections, injuries to the central nervous system, drug abuse and even society and culture can contribute to the progression of different mental disorders.

 Chemical Imbalance of the Brain
Deficits or defects in the structural or functional integrity of the nervous system could lead to insanity. For instanceNeurotransmitter imbalances can cause mental disorders. Neurotransmitters are endogenous chemicals that allow the transmission of signals from one neuron to the next across synapses. Acetylcholine, dopamine, GABA, serotonin, epinephrine, norepinephrine and endorphins are the most significant or crucial neurotransmitters found in the human brain and neurotransmitter imbalances within the brain   are the main causes of psychiatric conditions.

 Human Society and Mental Illnesses
Throughout the human history mental illnesses were considered as demonic possession or the presence of evil spirit. In the Medieval Europe psychiatric patients were burned at the stake accusing them as the agents of Satan. In 1247 London’s Bethlem asylum was found and the term “bedlam” became associated with chaos, confusion, and poor treatment, which reflected the general attitude toward mental illness. The mentally ill received harsh treatments. The 17th century English physician Thomas Willis declared that: “discipline, threats, fetters, and blows are needed as much as medical treatment for the mentally ill.

 Humane Way of Treating the Mentally Ill
Dr. Philippe Pinel – one of the founders of modern psychiatry introduced humane way of treating the mentally ill patients in Europe. In 1793 he was appointed the director of the BicƒÆ’†’ªtre Insane Asylum and took numerous revolutionary decisions. He unchained the mental patients and stopped ill treatments.   Dr.  Pinel treated the patient as well as his surrounding environment. His innovations in treating mentally ill patients are still used by the modern psychiatry.

 King Buddhadasa’s Approach to the Mentally Ill
Many centuries before Dr. Philippe Pinel the King Buddhadasa of Sri Lanka (398 AD) treated psychiatric patients with compassion. He was a prominent physician, surgeon as well as a psychotherapist. According to the history once an insane individual insulted the King  Buddhadasa in front of royal gathering  Instead of punishing him the King treated his mental illness successfully. The King Buddhadasa used herbals, empathetic words and healthy community atmosphere to treat the mentally ill.    

 Institutionalization of Psychiatric Patients
Institutions for the mentally ill were established beginning in the 14th century. Institutionalization is a deliberate process whereby a person entering the institution is reprogrammed to accept and conform to strict controls that enables the institution to manage a large number of people with a minimum of necessary staff. Until the end of 1960 s Institutionalization was considered as the viable option to treat psychiatric patients. In these institutions psychiatric patients were often subjected to humiliations and maltreatment. Prolonged years of Institutionalization diminished thesocial and life skills of the patients. This condition was identified as Institutionalization Syndrome which had the features of loss of independence, loss of self-confidence, erosion of desire and skills for social interaction, excessive reliance on institutions and fear of authority.

 The movie Girl Interrupted recounts the true personal story of the   writer Susanna Kaysen’s account of her 18-month stay at a mental hospital in the 1960s.  Diagnosed with Borderline personality disorder Susanna was institutionalized against her will. She questions the doctors the validity of her diagnosis and to what degree it could be applied universally to anyone showing nonconformist behavior. Deinstitualization or the removal of mentally ill occurred in late 1960 s and treating the mantel patients within the community began after the deinstitutionalization process. 

 Community Psychiatry and the Neelammahara Model
Under the Community mental health services mentally ill are treated in a domiciliary setting, instead of psychiatric hospitals or institutions.  This mode has been adopted and successfully maintained in Australia, UK , Belgium and many other Western countries.  This model of community mental health services were available in Sri Lanka some 300 years ago in a village named Neelammahara.  Neelammahara was prominent for Ayurvedic psychiatry and this model allowed psychiatric patients to live in the community and obtain treatment.

 Michel Foucalt and Anti-psychiatry Movement
The Anti-psychiatry Movement which was formed in 1960 questioned the fundamental assumptions and practices of psychiatry. Foucalt pointed out that the specific definitions of, or criteria for, hundreds of current psychiatric diagnoses or disorders are vague and arbitrary, leaving too much room for opinions and interpretations to meet basic scientific standards. In addition inappropriate and overuse of medical concepts and tools to understand the mind and society, including the miscategorization of normal reactions to extreme situations as psychiatric disorders. Hence Foucalt emphasized that prevailing psychiatric treatments are ultimately far more damaging than helpful to patients.  

 The Ambiguity of Psychiatric Diagnoses
The popular move One Flew over the Cuckoo’s Nest made a colossal impact on the ambiguity of psychiatric diagnoses. According to the movie Randle McMurphy charged with statutory rape, decides to avoid the prison by willfully presenting the psychiatric symptoms.  In the mental institution he was given ECT (Electroconvulsive therapy)and eventually forced to undergo    Lobotomy (a surgical procedure consists of cutting the connections to and from the prefrontal cortex   the anterior part of the frontal lobes of the brain).

  On Being Sane in Insane Places
Psychologist David Rosenhan conducted a study to check the validity of psychiatric diagnosis in 1973. Rosenhan’s study consisted of two parts. The first involved the use of healthy associates or ‘pseudo patients’, who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in 5 different states in various locations in the United States. The second involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. In the first case hospital staff failed to detect a single pseudo patient, in the second the staff falsely detected large numbers of genuine patients as impostors. The study is considered an important and influential criticism of psychiatric diagnosis.

  The Case of P.P. Jamis
The Case of P.P. Jamis gives some impression on being sane in insanity places. Mr. P.P. Jamis committed a minor offence in 1958 and he was sent to Mental Hospital Angoda , Sri Lanka for an evaluation.  His life changed unexpectedly. Jamis had to spend 50 years in the Mental Hospital and spent his entire youth inside a cubicle. After the interventions by the activists he was released on bail in 2008.

The Sane Society and the Mentally Ill
The Psychologist Eric Fromm proposed that, not just individuals, but entire societies “may be lacking in sanity”. Eric Fromm further says that “yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of  ”unadjusted’ individuals, and not of a possible unadjustment of the culture itself.

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