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Rethinking madness

Posted by By Ikwunga Okogbule-Wonodi on 2006/07/10 | Views: 397 |

Rethinking madness

MADNESS, whether as a social phenomenon, the ostensibly generous description of intelligence or audacity has remained something of an enigma.....

MADNESS, whether as a social phenomenon, the ostensibly generous description of intelligence or audacity has remained something of an enigma in the history of all cultures. Depending on its use, some might wish to be referred to as a "mad this" or "mad that", and even be flattered by such a "compliment": A mad scientist, a mad or crazy guy, and so on and so forth. Then again on occasions some would spare no efforts to distance themselves and loved ones from associations with the mere insinuation of madness past or present. The latter is readily explained when madness is used in the context of disease. This will be the focus of the rest of this discussion.

A label of mental illness is one laden with stigma, and this stigma goes beyond the mentally ill to include those who care for the mentally ill at the family or professional level. Stigma tends to be similar across societies and cultures though the severity and social consequences differ. It is easier for one to accept the notion of pathology in the heart or the eyes, which would engender diagnoses of Hypertension or Short sightedness, respectively, than brain dysfunction. In these hypothetical examples, it is acceptable to be on Antihypertensive drugs or to wear corrective glasses for the rest of one's life than to consider some long-term approach to the treatment of a mental disorder. This article does not seek as its goal to be judgmental. Rather, it aims to invite the reader to rethink psychiatric disorders as disorders that are not the result of moral turpitude, retribution for past crimes or transgressions, or influence of spiritual attacks, but from a complex interplay of genes, environment and experiences. The outcome being symptoms that affect thoughts, emotions, feelings, memories and behaviors and several other subjective inner experiences that influence the way we think of ourselves, relate to others and our productivity as members of the societies we live in.

Psychiatric disorders were widely recognised in the ancient world. Melancholia and hysteria were identified in Egypt and Sumeria as early as 2600 BC. A psychiatric nosology, which classifies groups of mental disorders, was contained in the medical classification system of the Ayur-Veda in India written about 1400BC. Hippocrates and Plato, two great thinkers of their time whose empirical observations, hypotheses, and writings significantly impacted Western civilisation created systems to classify mental disorders in classical Greece. Hippocrates' nomenclature shaped medical thought in Rome and persisted into the European Middle Ages. The Middle Ages would find the mentally ill prosecuted and executed in the witch hunts of Europe with over 110,000 found guilty, tortured, and executed between 1450 and 1750.

During the European Renaissance and Enlightenment, systems of classification came to reflect the belief in the ordered and uniform character of nature while a separate school of thought urged the development of a theoretical framework for medical nosology. This tension between paradigms based on observation and theory continued into the nineteenth century with the establishment of mental asylums, which became the main recourse for the treatment of the psychiatrically ill. Psychiatric thinkers like Kraepelin and Freud attempted, through different approaches, to medicalize our understanding of mental disorders. This was the age of "Enlightened treatment". It heralded the introduction of the first medications for use in the treatment of psychiatric disorders in 1952 with the discovery of the therapeutic properties of Lithium salts in "Melancholia and Mania", and four years later, the serendipitous discovery of chlorpromazine for the treatment of psychiatric disorders with prominent psychotic symptoms. Since then, the mental health community has witnessed the addition of numerous medications, and non-medication-based techniques to their therapeutic armamentarium.

A main task in the past half-century has been to evolve an evidence-based diagnostic system for psychiatric disorders. However, "etiology unknown" remains the hallmark and bane of psychiatry. Nonetheless, diagnostic criteria have evolved with the resultant increase in the reliability of psychiatric diagnoses. The most widely used tool for psychiatric diagnoses worldwide is the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). The DSM has shown high reliability in arriving at psychiatric diagnoses. Reliability of a clinical diagnosis is defined as the likelihood that a given patient will consistently receive the same diagnosis when rated by the same or a different clinician. In psychiatry where there are no tissue-based diagnostic procedures as for example, in infectious diseases, the current DSM-IV guidelines have been a major and welcome advancement. Additionally, the increased sensitivity training and the resulting ability of behavioral clinicians and researchers to incorporate the role of culture in the experience and expression of mental pathology is a positive gain. In Africa, pace-setting academics like Professor A. Lambo generated a critical body of research evidence documenting the role of culture on manifestations of psychopathology and response to treatment.

Today we are learning more about how the complex interplay between environmental, cultural, and genetic factors leads to biochemical imbalances that negatively impact brain functioning leading to neurological and psychiatric disorders. We appreciate more clearly how disruptions in the way nerve cells in the brain communicate with each other result in symptoms of anxiety, depression, impairment of reasoning, insight and judgment, and dislocations from reality testing. In the past half-century the field of psychiatry has made gains from accumulated data on the prevalence rates of diagnostic entities, treatment modalities and implicated pathophysiological factors. The accumulated data is compelling:

1) one in four people will suffer from a psychiatric disorder severe enough to lead to deterioration in educational, work, social, and family function in their lifetime,

2) psychiatric disorders are non-fault medical conditions of the brain,

3) there are scientifically proven treatment modalities,

4) cultural factors should be taken into account in diagnostic evaluation and therapeutic interventions, and

5) mental health is a fundamental right of all individuals regardless of race, gender or creed.

In the developing countries of Africa, much of the gains in mental health services and research that exist in developed Western countries are yet to be actualized. Stigma is rife across all strata of the African social fabric. People with severe mental illness are often abandoned by nuclear family in poorly funded mental institutions or "hidden away" in their villages. Mental institutions are some of the most poorly funded medical facilities on the continent. The ratio of psychiatrists or allied mental health practitioners to citizens is abysmally disproportionate. In parts of Africa, only one psychiatric hospital serves the whole country. For instance, in Sierra Leone, it is reported that there is only one psychiatrist: in a nation that in addition to the base prevalence of psychiatric disorders, also has a multitude of people suffering the traumatic psychological effects of years of civil war. In many African countries, people with mental illness are misconceived as being somehow mentally subnormal or less than human, are subjected to degradation, beating, shackling, or are reduced to objects of public ridicule and entertainment.

The next series of articles on the topic of mental illness in Africa will address the plague of stigma and mental illness in Africa. But first, let's rethink a group of non-fault medical conditions of the brain that are not due to moral turpitude or spiritual attacks, and should not be given up to the empirical and ignorant therapeutic nonsense of untrained traditional and spiritual quacks - medical conditions of the brain that deserve treatment by trained medical personnel, and the people with mental illness and their relatives who should rightfully demand access to evidence-based care.

* Dr. Wonodi is an Afrobeat Poet and Assistant Professor of Psychiatry at the Maryland Psychiatric Research Center, University of Maryland School of Medicine, U.S.A.

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