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PAPER%A%
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Social%Psychology%&%Socio1cultural%Psychiatry%

Table&of&Contents&

I.% Social%Psychology%..............................................................................................%2%

II.% The%History%of%Psychiatry.%................................................................................%6%

III.%Basic%Ethics%and%Philosophy%of%Psychiatry.%.....................................................%11%

IV.%Stigma%and%Mental%Illness%...............................................................................%18%

V.% Culture%and%Mental%Illness%..............................................................................%19%

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 Paper!A:!Social!Psychology!&!Socio3cultural!Psychiatry!

I.& Social&Psychology&

Attitudes% are! beliefs! or! feelings! towards! objects/events.! They! have! an! affective,!
cognitive!and!conative!component!(feeling,!thought,!and!behaviour).!Attitude!change!
may!be!brought!about!by!cognitive!dissonance!and!persuasion.!Persuasion!is!effective!
in! people! with! an! openness! to! change,! and! by! strong! attributes! of! the! person!
persuading! change.! Attitudes! can! be! positive! or! negative! and! are! closely! tied! to! the!
concepts! of! beliefs,! biases,! and! judgements.! Attitudes! vary! in! terms! of! centrality,!
consistency,! and! intensity! and! could! be! implicit! or! explicit.! As! attitudes! have! the!
potential! for! influencing! behaviour,! measurement! of! attitudes! can! help! understand! a!
person’s!standing!on!a!particular!event!or!situation.!
Measurement%of%attitudes:%Attitudes!can!be!measured!by!direct!observation,!direct!
questioning! or! by! using! scales.! The! Likert' scale! (5! point! scale! assessing! agreement!
/disagreement),! Thurstone’s! equal! appearing! interval! Scale! (usually! 11! intervals)! and!
Osgood’s!Semantic!Differential!Scale!(rating!the!variable!according!to!qualities!such!as!
curable! –! incurable)! are! used! for! measuring! attitudes.! Other! examples! include!
Bogardus’! Social! Distance! Scale! (attitudes! towards! ethnic! groups),! Guttman’s!
Scalogram!(measures!degree!of!unidimensional!attitudes).!
!
Attribution%theory%
Attribution!theory!deals!with!the!general!principles!governing!how!we!select!and!use!
information! to! arrive! at! causal! explanations! for! behaviour.! Initial! theories! were!
developed! by! Fritz! Heider! (1958).! People! offer! explanations! about! why! things!
happened;! we! can! make! one! of! two! types! of! attributions:! we! can! make! an! external!
attribution! or! we! can! make! internal! attribution.! An! external! attribution! ! assigns!
causality! to! an! outside! agent! or! force.! An! internal! attribution! claims! that! the! person!
was!directly!responsible!for!the!event.!The!term!‘fundamental'attribution'error’!is!used!
to! refer! to! the! tendency! to! underestimate! situational! influences! on! behaviour! and!
assume! that! some! personal! characteristic! of! the! individual! is! responsible.! i.e.,! the!
behaviour! of! others! is! normally! considered! dispositional,! whereas! the! behaviour! of!
oneself!is!considered!constrained!or!enabled!by!context.!
For!example,!if!your!friend!fails!the!examination!it!is!his!fault!(internal!attribution);!if!
you! fail,! it! is! because! the! examination! was! unfair! (external! attribution)!! Attributions!
can! affect! self3perception,! people3perception! and! event! or! object! perception.!
Attribution! needs! processing! of! information! presented! from! environment! (who! does!
what)! and! evoking! internal! judgements! (positive! or! negative)! which! are! cognitive!
functions.!!
Self! perception! was! studied! by! Bem;! person! perception! was! extensively! studied! by!
Heider.! Kelly! developed! an! elaborate! theory! for! object! perception.! His! ‘co! variation!
principle’! establishes! attribution! with! the! use! of! three! factors:! consensus,!
distinctiveness,!and!consistency.!
Attributional!styles,!proposed!by!Abramson!and!colleagues,!refer!to!people’s!styles!of!
making! attributions! for! the! events! in! their! lives.! Pessimistic! attributional! styles! have!
been!linked!with!stress!and!lowered!immune!system!functioning.!
Friendship%and%interpersonal%attraction:%
Increased!by!!

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 Paper!A:!Social!Psychology!&!Socio3cultural!Psychiatry!

• Proximity!(but!not!invasion!of!personal!space)!
• Exposure!(increased!opportunity!for3!
• Familiarity!
• Physical!attractiveness!
• Perceived!relative!competence!
• Reciprocal!liking!
• Reciprocal!self3disclosure!
• Similarity!of!views,!interests!and!values.!!Similarity!outweighs!complementarity!
in!the!initial!stages!of!a!relationship!but!the!importance!of!complementarity!
increases!with!time,!though!it!does!not!exceed!similarity.!
!
Self%in%the%social%context:%
Obedience%(to%authority)%is%compliance!with!instruction.!It%was!studied!by!Milgram!
who! reported! that! it! is! influenced! by! social! norms,! and! perceived! surveillance.! A!
surprising! potency! of! obedience! to! perceived! authority! was! revealed! by! Mailgram’s'
famous! experiments.! ! Naïve! subjects! were! instructed! by! a! white3coated! ‘professor’! to!
administer!increasingly!severe!(fake)!electric!shocks!to!stooges!when!these!failed!on!a!
learning! task.! ! Obedience! to! the! point! of! delivering! a! clearly! lethal! shock! to! a!
protesting! ‘learner’! was! observed! in! 2/3! of! subjects!! ! Relative! proximity! to! the! victim!
decreased! compliance! and! an! increase! the! perceived! authority! of! the! instructor!
increased!compliance!(the!belief!that!a!legitimate!authority!gave!the!instruction!was!a!
key! feature).! ! Compliance! fell! off! dramatically! when! there! was! only! one! dissenting!
voice! present.! (this! study! is! also! important! as! stringent! ethical! guidelines! were!
formulated!as!a!result!of!the!backlash!from!this!experiment)!
!
Conformity:%this!is!different!from!compliance.'It!refers!to!the!tendency!for!people!to!
agree! with! others! in! a! group! situation.! E.g.! Cash’s! line! judgement! experiment.! It! the!
process! of! yielding! to! pressure! from! others! through! power! of! persuasion! or! example.!!
Ash'showed!this!effect!in!the!case!of!perceptual!judgements!where!subjects!tended!to!
increase!the!number!of!false!judgements!of!line!length!if!several!other!judges!(stooges)!
had!given!false!judgements!previously.!Conformity!pressure!increased!with!an!increase!
in!the!number!of!stooges.!Vulnerability!to!group!pressure!is!low!in!individuals!scoring!
high! on! measures! of! intelligence,! social! effectiveness,! expressiveness,! breadth! of!
thinking,!internal!locus!of!control!and!self3reliance.!
Group%polarisation%is!the!tendency!for!groups!to!make!extreme!decisions!than!what!
individuals!do.!
Groupthink:!Groupthink!is!a!concept!that!was!identified!by!Irving!Janis!that!refers!to!
faulty!decision3making!in!a!group.!Groups!experiencing!groupthink!do!not!consider!all!
alternatives!and!they!desire!unanimity!at!the!expense!of!quality!decisions.!Groupthink!
occurs! when! groups! are! highly! cohesive! and! when! they! are! under! considerable!
pressure!(E.g.!start!a!war!against!another!country)!to!make!a!quality!decision.!It!is!thus!
the! tendency! for! individuals! within! a! group! to! strive! towards! a! consensus.! Leads! to!
alternatives! being! inadequately! explored! (dissenting! opinions! are! suppressed),! the!
benefits,! and! potential! risks! of! preferred! choice! of! action! inadequately! explored! and!
alternative/secondary/contingency!choices!of!action!being!inadequately!explored.!!
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Ingoup/outgroup% effects:% % People! perceive! outgroups! as! homogenous! and! ingroups!

as!heterogenous.!
!
Bystander% effect:! Refers! to! a! tendency! toward! inaction! in! response! to! a! crisis3
situation! when! surrounded! by! a! crowd.! It! results! from! diffusion! of! responsibility!
(people! thinking! that! others! may! help)! and! inhibited! behaviour! in! front! of! an!
audience.!!
!
Altruism! refers! to! helping! behaviour.! Along! with! egoism,! collectivism,! and!
principlism,!it!contributes!to!pro3social!behaviour.!
Aggression:% is! any! behaviour! that! is! carried! out! with! an! intent! to! harm! others! (see!
more!details!in!the!section!on!‘observational!learning’).!Recent!studies!(e.g.,!Aronson,!
Wilson,!&!Akert,!2005)!have!revealed!that!viewing!violence!depicted!in!the!media,!or!
playing!video!games!that!have!components!of!aggressive!acts,!can!increase!aggressive!
behaviour! (but! an! alternative! argument! propounds! that! media/! games! etc.! depict!
variation!of!violence!that!is!already!present!in!society).!Other!factors!that!can!increase!
aggression! include! substance! use! (diminished! judgement! and! control),! poor!
frustration! tolerance,! and! physical! discomfort! (hunger,! very! hot! weather,! pain,! etc.).!
Presence! of! and! access! to! weapons! have! also! been! associated! with! violent! behaviour.!
The! drive! theory! is! based! on! the! frustration3aggression! hypothesis! (various! external!
sources! create! the! drive3or! motivation3for! aggression,! one! such! drive! results! from!
frustration! which! can! trigger! aggressive! acts;! the! ‘Yale! group:! Dollard,! Doob,! Miller,!
Mowrer,!&!Sears,!1939).!Berkowitz!proposed!that!emotions!interact!with!cognitions!to!
moderate! ! or! trigger! aggression.! Other! explanations! are! biological! (testosterone3
serotonin!balance),!and!psychodynamic!(the!‘death’!instinct).!
Stanford%prison%experiments%(Zimbardo,!1971)!:!A!study!of!‘captivity’!and!its!effects!
on! inmates! and! prison! authorities.! In! an! experimental! situation! ‘prison! guards’! acted!
more!brutally!than!expected,!while!‘prisoners’!accepted!and!suffered!sadistic!behaviour!
of! the! guards.! Situations! were! created! to! encourage! disorientation,! depersonalisation!
and! deindividuation! (i.e.! conditions! which! facilitated! movement! away! from! personal!
identity!and!resulting!responsibility!e.g.,!wearing!dark!glasses!to!prevent!eye!contact,!
guards!holding!batons,!prisoners!dressed!in!coarse!cloth!etc.).!Participants!were!found!
to!‘internalise’!their!roles!and!act!accordingly.!This!study!gave!strength!to!the!idea!that!
social' roles' compel' people' to' act' in' a' particular' way! even! if! it! may! be! extreme.! This!
increases!when!legitimised!by!society!or!an!institution.!
Locus% of% Control% (Rotter)! refers! to! an! individual's! perception! of! what! are! the! main!
causes! of! events! in! life.!A! locus! of! control! orientation! is! a! “belief! about! whether! the!
outcomes!of!our!actions!are!contingent!on!what!we!do!(internal!control!orientation)!or!
on! events! outside! our! personal! control! (external! control! orientation)”.! This! concept!
was!developed!by!Julian!Rotter!in!the!1960's!!

Leadership:% % The! qualities! of! a! leader! depend! on! specific! situations.! Hence! different!
people!tend!to!become!leaders!in!different!situations.!!For!example,!most!groups!tend!
to! have! both! task3oriented! and! emotion3oriented! leaders,! with! the! two! roles! rarely!
being!filled!by!the!same!individual.!!%
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Lewin!distinguished!between!different!styles!of!leadership:!
!
! Democratic3! acts! with! support! of! the! group! and! takes! into! account! other!
opinions!
! Authoritarian'–!absolute!authority,!with!no!requirement!to!consult!others!
! Laissez@faire!–!a!relaxed,!informal!style!that!promotes!individuality!
!
In!the!original!experiment,!groups!with!autocratic!and!democratic!leaders!were!equally!
good!at!task!accomplishment!but!members!of!the!group!with!an!autocratic!or!laissez3
faire! leader! were! aggressive! to! each! other! and! abandoned! the! task! in! the! leader’s!
absence.! ! Fiedler’s' contingency' model! attempted! to! predict! leader! effectiveness! by!
balancing!leadership!style!against!context!variables.!!According!to!research!by!Alimo,!
characteristics!of!an!effective!leader!include!allocation!of!work.!
!
Social% influence% and% social% power:% % French' and' Raven! Established! 5! types! of! social!
power:%
!
! Authority/Legitimate'–!derived!from!role,!influence!due!to!status!and!position!
! Rewards3!the!ability!to!allocate!resources!or!confer!rewards!
! Coercive3!the!power!to!punish!
! Referent'–!liked,!admired!by!subjects,!charismatic!
! Expert'–!skills,!knowledge!and!experience,!often!useful!in!influencing!superiors.!
! Can!also!add!Information'–!access!to!info.!
!
Persuasive% communication:% improves! with! credibility,! expertise,!
attractiveness/likeability,! optimal! non3verbal! cues! (such! as! physical! proximity)! and!
similarity!of!the!communicator.!!A!tall!person!is!likely!to!be!more!positively!received.!
Elements! within! the! recipient! include! low! self3esteem! and! intelligence! (complex!
relationship,!prob!curvilinear).!!%
!
Conversation:%%It!has!been!proposed!that!conversation!have!a!very!clear!structure!in!
terms!of!‘conversational!turns’.!We!do!not!normally!speak!at!the!same!time!and!there!
are! clear! turn3governing! mechanisms,! which! ensure! this.! ! The! most! obvious! is! when!
we!ask!a!question!or!use!a!stereotypical!sequence!such!as!‘hello’.!!!We!can!convey!our!
readiness!to!‘yield!the!floor’!by!our!intonation.!!We!fill!our!pauses!with!‘ums’!and!‘ahs’!
when!we!wish!to!continue!speaking.!!The!direction!of!our!gaze!is!a!good!indicator!of!
our!readiness!to!yield!the!floor;!if!we!wish!to!carry!on!speaking!we!usually!look!away!so!
a!listener!is!more!to!interrupt!if!the!speaker!re3establishes!gaze.!
!
Telephone% conversation! is! mainly! functional,! therefore! is! associated! with! shorter!
utterances! than! face3to3face! conversations.! ! There! is! also! decreased! spontaneity! in!
telephone! conversations.! Facial! expressions! are! more! effective! at! conveying! emotion!
than!tone!of!voice.!!!
!
Primacy% effect:% % First! impressions! are! powerful! in! forming! person! schema! and! later!
ones! are! likely! to! be! discarded! if! they! are! discrepant! with! the! first.! ! It! is! especially!
strong!if!the!first!impression!is!negative.!

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!
The%congruity%theory!holds!that!if!one!does!not!agree!with!a!message!from!a!person!
he!likes,!he!will!change!both!the!attitude!towards!the!person!and!to!the!message.!
!
Stereotyping:% Are! beliefs! about! people! based! on! their! membership! to! a! particular!
group! (e.g.,! cultural3ethnic! group,! occupation,! geographic! location,! gender3based!
beliefs! etc.).! It! refers! to! making! inferences! about! a! person! by! placing! them! in! a!
category! derived! from! one! or! more! quickly! identified! characteristics.! ! Applies! to!
individuals! (e.g.! attractiveness)! and! groups! (e.g.! race).! ! Has! been! shown! to! result! in!
self3fulfilling!prophecy!where!an!individual!or!members!of!a!group!live!up!or!down!to!
the!expectations!of!others.!Stereotypes!are!not!easily!changed!as!people!tend!to!recall!
selective! information! that! adds! strength! to! their! beliefs! and! dismiss! contradictory!
findings! as! stemming! from! ‘exceptions! to! the! rule’.! Stereotypes! can! be! positive! or!
negative.!It!can!help!people!process!new!information!about!people!(faster,!by!drawing!
on! past! experiences)! and! helps! in! adapting! accordingly.! Negative! stereotyping! can!
distort! and! bias! perception.! Prejudice! refers! to! biased! judgements! made! prior! to!
reception! of! all! facts! about! the! person/event.! Stereotypes! can! give! rise! to! prejudices!
and!coupled!with!negative!attitudes,!it!can!lead!to!discriminatory!behaviour.!
!
Prejudice! is! defined! as! an! attitude! towards! members! of! some! group,! based! on! their!
membership! of! that! group.! This! may! be! developed! to! maintain! high! levels! of! self!
esteem!in!the!group,!but!not!necessarily!a!person’s!own!self!esteem.!
!
Norms%refer!to!expected!ways!of!behaving!in!specific!situations,!whereas!values!refer!
to!collective!beliefs!about!what!is!right,!good!and!desirable.!
!
Social%facilitation:%The!presence!of!others!improves!performance!on!simple!responses!
but!hinders!performance!on!complex!responses.!!
!
Normalisation!is!a!concept!developed!in!learning!disability!services.!!It!is!described!as!
‘making! available! to! all! [mentally! retarded! people]! patterns! of! life! and! conditions! of!
everyday!living!which!are!as!close!as!possible!to!the!regular!circumstances!and!ways!of!
life!of!society’.!!!
!
Positive% discrimination! is! a! process! of! inclusion! of! marginalised! groups! to! give! a!
more! representative! picture! of! the! population! as! a! whole! e.g.! recruiting! a! certain!
number!of!individuals!from!ethnic!minorities!into!the!police!force,!even!if!this!is!at!the!
expense!of!white!individuals.!
%
Sick% role! as! defined! by! Parsons’! is! the! role! taken! by! people! who! are! sick,! i.e.,! being!
exempt!from!normal!social!obligations!but!expected!to!seek!and!accept!treatment.!!
!
Illness% Behaviour! as! defined! by! Mechanic! refers! to! the! ways! in! which! given!
symptoms! may! be! differentially! perceived,! evaluated! and! acted! upon! by! different!
individuals.!

II.& The&History&of&Psychiatry.

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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!London’s!Bethlem!Hospital!did!
exist,! but! conditions! and! treatments! were! unpleasant.! Physicians! such! as! Pinel! in!
France! in! the! 18th! 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!18th!century!aroused!public!interest!and!led!to!parliamentary!
consideration!of!the!care!of!the!mentally!ill!through!Britain.!The!term!“Hypnosis”!was!
introduced!by!a!Scottish!surgeon!John!Braid!in!his!lectures!in!1841.!!Mezmer!explored!
hypnosis!further!as!did!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! Bleuler’s! term! of!
schizophrenia)!and!its!separation!(by!virtue!of!poor!prognosis)!from!manic3depressive!
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! 1920’s! and! 1930’s,! physical! treatments! were! introduced! such! as! malarial!
treatment!for!neurosyphilis,!insulin!coma!therapy!for!schizophrenia,!electroconvulsive!
therapy!and!psychosurgery.!!
The! 1950’s! heralded! the! introduction! of! psychotropic! medication! such! as! lithium,!
chlorpromazine,!tricyclic!and!MAOI!antidepressants.!This!revolutionised!treatment!of!

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psychiatric! illness,! with! greater! optimism! about! treating! mental! illness.! There! was! a!
significant!reduction!of!psychiatric!beds!from!150,000!in!the!1950’s!to!around!45,000!in!
the! 1990’s.! Though! there! is! a! misconception! that! this! is! due! to! the!
‘psychopharmacological! revolution’! in! reality! beds! in! some! countries! began! to! fall!
before!the!introduction!of!medication!while!in!others!the!bed!numbers!remained!the!
same!despite!medications.!It!is!thought!that!a!number!of!reasons!led!to!this!decrease.!
Amongst!them!are:!expansion!of!talking!treatments!in!community!settings!and!move!
away! from! biomedical! models,! decreasing! popularity! of! segregation! following! World!
War! II,! cost! cutting! (asylums! were! expensive),! ideas! that! institutionalization! was! not!
helpful!(see!‘antipsychiatry’)!and!pressure!from!mental!health!users!critical!of!hospital!
based! treatment.! Another! reason! for! the! decline! in! beds! was! a! change! in! social!
attitudes,!fuelled!by!Erving!Goffman!(1961)!who!wrote!a!highly!critical!review!of!large!
psychiatric! institutions! in! the! USA,! terming! them! ‘total! institutions’.! He! also! wrote!
about!stigma!(see!below)!
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!21st!century,!recent!debate!suggests!that!we!are!witnessing!re3
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.!
Antipsychiatry'
A! group! of! psychiatrists! went! beyond! the! rejection! of! paternalism! to! deny! altogether!
the! validity! of! psychiatric! diagnoses! and! therefore! of! treatment.! The! term! was! first!
coined! by! David! Cooper,! a! British! psychiatrist! in! his! book! “Psychiatry! and! anti3
psychiatry”! 1967.! Thomas! Szasz! is! the! foremost! of! the! antipsychiatrists.! .! His! central!
argument!is!that!mental!illness,!as!a!concept,!has!no!validity.1!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!Erving!Goffman.!He!described!4!main!
characteristics!of!institutions:!
!
• Batch!living!(absence!of!boundaries!between!work!and!leisure!for!‘inmates’)!
• Binary! management! (staff! controlling! the! ‘inmates’! while! living! in! a! different!
world)!
• Inmate!role!
• Institutional!perspective!
He!also!describes!the!processes!as:!
• Passing!through!the!funnel!of!betrayal!
• Civil!death!(as!they!lose!all!their!freedoms)!
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
1 "Szasz"(1961)"The"myth"of"mental"illness."Harper"&"Row,"New"York"

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• Mortification! of! the! self! (admission! process,! ritual! stripping,! examination! and!
acquiring!institutional!clothes)!!
Fulford!has!argued!against!the!antipsychiatry!movement!by!showing!that!medical!and!
psychiatric!diagnoses!are!equally!value3laden,!and!are!no!less!scientifically!invalid.2!
!
Important%names%and%their%contribution%to%psychiatry:%
1.%Description%&%Diagnosis%
Name! Contribution!
Morel!(1852)!! Proposed! mental! illnesses! could! be! separated! and! classified,! based!
! on!aetiology.!!Described!démence!précoce!
Kahlbaum! Described! catatonia' with! characteristic! motor! features! (also!
(1863)!! described!dementia!paranoides)!
Ewald! Hecker! A! mentee! of! Kahlbaum! with! whom! he! did! research.! He! described!
(1843!1909)! hebephrenia!and!cyclothymia!!
Emil! Kraepelin! Proposed! division! into! dementia! praecox! and! manic3depressive!
(185531926)!!! 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)!
Eugen! Bleuler! Proposed! the! name! schizophrenia' to! denote! ‘splitting’! of! psychic!
(185731939)!!! functions.! The! 4! ‘A’s:! 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!
Kurt!Schneider! Identified! symptoms! characteristic! of! schizophrenia! (First! Rank!
(188731967)!! Symptoms).!FRS!3!not!supposed!to!have!central!psychopathological!
role!and!not!necessary!nor!sufficient!for!the!diagnosis.!!Nor!do!they!
have!prognostic!significance.!
Paul3Maurice! Bouffee!delirante!to!mean!a!rapid!onset!psychosis!of!short!duration.!
Legrain! and! This! was! initially! suggested! by! a! French! psychiatrist! Valentine!
Honore! Saury! Magan,!but!brought!to!completion!by!his!two!students.!!
(1886)!
Jacob! Kasanin! Described!schizoaffective'disorder!
(1933)!!
!
Mapother! Coined!the!term!derealization!
(1935)!
Leonard!(1957)!!! Separated! schizophrenia! from! cycloid' psychoses! (non3affective!
! psychoses!with!good!outcome)!
Further! sub3divided! schizophrenia! into! systemic' (catatonia,!
hebephrenia,! paraphrenia)! and! non@systemic' (affect3laden!
paraphrenia,!schizophasia!and!periodic!catatonia)!
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
2 "Fulford"(1989)"Moral"theory"and"medical"practice."Cambridge"University"Press,"Cambridge"

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Langfeldt! Differentiated! schizophreniform' states' from! true! schizophrenia,!

(1961)!! associated!with!better!prognosis!
!
!
2.% Treatment:%
Name! Contribution!
John!Cade!(1949)! Lithium!
Paul!Charpentier!(1950)! Synthesis!of!Chlorpromazine!
Delay!&!Dineker! Chlorpromazine!for!psychosis!
Nathan!Kline!(1950,!1954)! Reserpine,!MAOIs!
Roland!Kuhn!(1957)! Imipramine!
Ugo! Cerletti! &! Lucio! Bini! ECT!
(1938)!
John!Kane!(1987)! Efficacy!of!Clozapine!in!resistant!schizophrenia!
!
3.%Psychology%&%related%fields:%
Name% Contribution%
Sigmund!Freud! Theory! of! psychoanalysis,! structure! of! personality,! topography! of!
mind,! ego3defence! mechanisms,! concept! of! anxiety! &!
Psychoanalytical!psychotherapy!
Pavlov! Principles!of!classical!conditioning!
Watson! &! Behaviourism!
Skinner! Skinner! in! particular! is! associated! with! operant! conditioning!
principles!
Carl!Rogers! Client!centred!psychotherapy!
Aaron!Beck! Cognitive!theory!of!depression!
John!Bowlby! Attachment!&!Bonding!
Jean!Piaget!! Cognitive!Development!theory!!
Lev!Vygotsky! Lev! Vygotsky! is! generally! associated! with! observations! on! play! and!
the!‘zone!of!proximal!development’.!!
Lawrence! Moral!development!theory!
Kohlberg!
Melanie!Kline! Objects!relation!theory!(Paranoid!schizoid!position!etc.)!
Seligman! Learned!helplessness!
Paul!Eckman! Listed!6!basic!emotions!which!are!recognized!across!cultures:!anger,!
disgust,!fear,!happiness,!sadness!and!surprise!
4.%Famous%cases%
!
Phineas!Gage!(1835)! 1st! described! case! of! frontal! lobe! injury.! Following! an!
explosion! an! iron! rod! penetrated! his! frontal! lobe,! leading!
to!a!change!in!personality!without!memory!or!intelligence!
being!affected.!!
Anna!O.!(1895)! Treated!by!Bruer,!her!case!was!written!up!in!collaboration!
with!Sigmund!Freud!and!is!thought!to!mark!the!beginning!
of!psychoanalysis!

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Auguste!D!(1906)! First!patient!described!with!dementia!by!Aloi!Alzheimer!
Little!Albert!(1920)! Albert!was!chosen!by!John!Watson!and!his!partner!Ryaner!
at! the! age! of! 9! months! for! a! classical! conditioning!
experiment,!where!they!induced!a!fear!of!a!rat!by!pairing!it!
with!a!loud!noise.!!
!
!
5.%Famous%publications%
!
Treatise%on%madness%(1758)% William% Battie.% A% critique% mostly% aimed% at%
Bethlem%Hospital.%%
The! Interpretation! of! Dreams! Book! by! Sigmund! Freud,! where! he! proposed! the!
(1899)! topographical!model!of!the!psyche!
Beyond! the! Pleasure! Principle! Essay! by! Sigmund! Freud,! describes! the! id,! ego! and!
(1920)! superego.!!
“On! the! Characteristic! of! Total! by!Erving!Goffman!
Institutions”! (1957)! –! essay! and! Canadian!sociologist!
“Asylums”!(1961)!3!book!
“The! Myth! of! Mental! Illness”! Thomas!Szasz!(born!1920)!
(1960)! and! “The! manufacture! of! American!Psychiatrist!and!academic!
madness”!(1970)!
“Madness! and! civilization”! Michael!Foucault!(1926!–!1984)!
(1964)! French!philosopher!and!social!theorist!
“The! divided! self”! (1960)! and! R.D.!Laing!(192731989)!!
“Sanity,! Madness! and! the! Scottish!psychiatrist!
Family”!(1964)!
“The!institution!denied”!(1968)! Franco!Basaglia!(1924!–!1980)!
Italian!Psychiatrist!and!neurologist!

III.& Basic&Ethics&and&Philosophy&of&Psychiatry.

Key%Theories%
!
There!are!two!fundamental!approaches!to!ethics:!
1. The%Duty1based%approach%(Deontology)!–!most!familiar!to!doctors.!
Originates!from!general!obligations,!codified!by!professional!
organisations,!laying!down!rules!of!professional!conduct.!
!
2. Utilitarianism%(Teleology)!–!concerned!with!broad!judgments!of!
benefit!and!harm.!Assumes!that!the!right!action!is!the!one!that!has!the!
best!foreseeable!consequence.!
'
1.'Duty'based'approach:'

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Deontology!(aka!absolutism)!is!by!far!the!older,!taking!its!roots!from!Judeo3Christian!
and! Ancient! Greek! philosophy.! The! term! derives! from! the! Green! deon! for! duty.!
Immanuel! Kant! is! considered! to! be! the! founding! father! of! modern! deontological!
thinking.! 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.!
2.'Utilitarianism:''
Teleology% (aka! Utilitarianism/consequentialism)% 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! outcome3based.! These! theories! were!
propagated! by! Jeremy! Bartham! and! John! Stuart! Mills! in! the! 19th! century.! The!
consequences! are! all3important.! However,! there! is! no! common! scale! for! measuring!
outcome,!and!individual!interests!easily!get!overridden!for!the!greater!good.!Different!
theories! mainly! differ! in! what! is! considered! a! desirable! outcome,! however,! the!
principle!of!‘the!greatest!good!for!the!greatest!number’!persists.!!!
!
3.'Modern'ethics:'
!The!duty!and!utilitarianism!approaches!to!ethics!can!conflict!at!times.!
Tom! Beauchamp! and! James! Childress,! two! American! philosophers,! developed! the!
Four3Principle!Approach,!which!is!now!widely!used:!
• 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.!
• Non1maleficence! –! 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.!
%
4.'Other'ethics'theories:'
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’.!

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Narrative%ethics%takes!into!account!the!actual!lives!of!people!before!deciding!what!is!
correct! and! incorrect! for! them.! It! does! not! value! rules! and! principles! and! focuses! on!
the!context!for!moral!decision!making.!The!aim!is!to!make!a!very!personal!decision.!!
Key%historical%figures%
In'Medical'ethics'
Hippocrates%is!considered!to!be!the!father!of!medicine!and!was!the!first!to!create!an!
ethical! code! of! conduct! for! physicians! in! the! form! of! the! Hippocratic! Oath.! This!
encouraged! teaching! medicine,! being! honest,! maintaining! patient! confidentiality! and!
abstaining!from!things!that!may!be!detrimental.!!
!
Ishaq%bin%Ali%Rahawi%was!a!Muslim!physician!who!wrote!‘Adab!al3Tabib’!(‘Conduct!of!
a!Physician’)!in!the!9th!century.!It!consisted!of!20!chapters!and!included!topics!such!as!
what!the!physician!must!avoid,!the!dignity!of!the!medical!profession,!the!examination!
of!doctors!and!removing!corruption!in!the!medical!profession.!It!is!thought!to!be!based!
on! ideas! of! Hippocrates! and! Galen! and! is! considered! to! be! the! first! bo0k! of! medical!
ethics.!3!!
!
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! and! that! this! moral! principle! should! be! a! principle! for! all!
people!
%
Thomas%Percival%was!an!English!physician!who!is!considered!to!be!the!first!person!to!
draw!up!a!modern!code!of!medical!ethics.!He!published!!‘The!Code!of!Medical!Ethics’!
in! 1803,! an! expanded! version! of! a! pamphlet! he! had! created! in! 1794.! Percival! is! also!
known! for! his! interest! in! and! campaigning! for! public! health,! especially! in! relation! to!
factory!workers.!4!!!!
%
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,! non3maleficence,! justice,!
beneficence,!self3improvement.!

In'Psychiatry:'
William%Tuke!opened!the!York!Retreat!in!1796!and!developed!a!moral!treatment!for!
insanity.!!!
%
Philippe%Pinel%popularized!methods!of!treatment!that!did!not!involve!restraint!in!the!
early!19th!century!
!
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
3
"Islam"Today."Greaves"R."2010."p."54"
4
"Wikipedia."http://en.wikipedia.org/wiki/Thomas_Percival"

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!
!

Key%Historical%events%and%their%consequences%
!
% ! • Geneva%Declaration%(1948)%–!a!
% ! declaration!similar!to!Hippocratic!
% ! oath!for!doctors!pledging!to!work!
% Trials!following!the!second! towards!humanitarian!goals!and!
Nuremberg% world!war!that!looked!at! not!abuse!medicine%
war%trials% physicians!who!conducted!
• Nuremberg%Code%(1947)!–!a!set!of!
(194611947)5% research!on!a!range!of!people!
research!ethical!principles!for!
inc.!Jews,!homosexuals!and!the!
human!experimentation.%
disabled!and!were!involved!in!
euthanasia.! • Helsinki%Declaration%(1964)%–!
! Leading!on!from!the!Nuremberg!
code,!a!set!of!ethical!principles!re:!
human!experimentation!%
% A!student,!Prosenjit!Poddar,!
% planned!and!carried!out!the! • This!trial!and!its!rehearing!
% murder!of!Tatiana!Tarasoff,!a! concluded!that!it!was!the!clinicians!
Tarasoff%case% girl!he!had!befriended,!but! duty!to!protect!those!at!risk,!even!
(197411976)% who!did!not!wish!to!be!in!a! if!they!are!not!his/her!patients.!!
relationship!with!him.!He!had! • Hence!the!psychologist!should!
confided!his!plan!his! have!broken!confidentiality!to!
psychologist,!who!did!inform! ensure!safety!of!the!victim.!!
the!police,!but!did!not!warn!
Tatiana!or!her!parents!of!the!
possible!attack.!!
!
!
Summary%of%unethical%experiments%conducted%on%humans6%
These!are!all!post!Nuremberg!code!studies!involving!abuse!and!exploitation.!

%
% Description%
Study%
! The!U.S.!Public!Health!Service!conducted!a!research!
! project!from!1932!to!1972!to!document!the!natural!
Tuskagee!syphilis! progression!of!syphilis.!Six!hundred!low3income!African3
experiment!(1932!–!1972)! American!males,!399!of!whom!were!infected!with!
syphilis,!201!were!not!infected,!were!recruited!for!the!
study.!Participants!were!given!free!medical!examinations,!

""""""""""""""""""""""""""""""""""""""""""""""""""""""""
5
"Wikipedia."http://en.wikipedia.org/wiki/Nuremberg_Trials"
6
"Wikipedia."http://en.wikipedia.org/wiki/Unethical_human_experimentation_in_the_United_States"

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free!meals,!and!burial!insurance;!however,!they!were!not!
told!about!their!disease.!The!physicians!conducting!the!
study!told!the!participants!they!were!being!treated!for!
bad!blood.!The!physicians!deliberately!denied!these!men!
treatment!for!syphilis!and!also!attempted!to!prevent!
treatment!from!other!sources.!This!led!to!the!Office!for!
human!research!protection!being!set!up!in!the!US!along!
with!federal!laws!that!would!protect!human!subjects!
! A!CIA!experiment!where!whooping!cough!bacteria!were!
Tampa!Bay!(1955)! released!from!boats!in!Tampa!Bay!leading!to!a!whooping!
cough!epidemic.!!
! Willowbrook!State!School,!situated!in!New!York!State,!
Willowbrook!State!School! was!an!institution!for!children!with!learning!disabilities.!
Hepatitis!studies!(1963366)! Parents!of!children!in!the!institution!gave!consent!for!
their!children!to!participate!in!a!study.!The!intent!of!the!
research!study!was!to!follow!the!course!of!viral!hepatitis!
and!study!the!effectiveness!of!an!agent!for!inoculating!
against!hepatitis.!Parents!were!provided!with!study!
information!describing!the!drug!administration!as!
vaccinations.!However,!the!children!were!deliberately!
infected!with!the!hepatitis!virus.!There!is!evidence!that!
the!school!only!admitted!children!to!the!school!whose!
parents!gave!permission!for!them!to!be!in!the!study.!!

Tearoom!Trade!Study!(mid! For!his!PhD!dissertation,!Laud!Humphries,!a!sociologist,!
1960s)! was!interested!in!learning!what!motivates!men!who!have!
anonymous!sex!in!public!washrooms.!He!was!interested!
in!determining!their!personal!characteristics!and!also!the!
nature!of!the!sexual!activity.!There!were!two!parts!to!the!
study.!In!the!first!part,!he!befriended!the!men!by!acting!
as!a!lookout.!Since!the!public!washroom!was!in!a!park!
the!researcher!was!able!to!take!down!some!of!the!mens!
licence!plate!numbers.!He!then!obtained!identifying!
information!on!these!men!by!tracing!their!car!license!
plates!via!a!policeman.!A!year!later,!in!the!second!part!of!
the!study,!the!researcher!utilized!the!identifying!
information!he!obtained!to!contact!and!subsequently,!
interview!the!men!in!their!homes.!To!avoid!being!
recognized,!he!altered!his!appearance!and!claimed!he!
was!conducting!a!study!on!health!issues.!The!concerns!
with!this!study!were!the!use!of!deception!upon!deception!
and!the!lack!of!opportunity!for!participants!to!provide!
informed!consent.!!

Milgram!Obedience!Study! Stanley!Milgram,!a!social!psychology!researcher!at!Yale!
(early!1960s)! University,!wondered!why!defendants!in!the!Nuremberg!

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Trials!justified!their!unethical!actions!by!saying!they!
were!just!following!orders.!Even!though!his!studies!were!
designed!to!learn!about!conditions!of!obedience!and!
disobedience,!Milgram!used!deception!to!recruit!
participants!by!calling!his!projects!learning!and!memory!
studies.!Nave!participants!believed!they!were!applying!
punishment,!escalating!electric!shock,!to!a!learner,!in!
response!to!incorrect!answers!to!word3pair!matching!
questions.!Actually,!the!learner!was!a!confederate!(i.e.,!
was!working!for!the!researcher)!and!was!not!being!
shocked.!The!deception!was!revealed!at!the!end!of!the!
study.!

! 3.!Jewish!Chronic!Disease!Hospital!(1963):!Studies!were!
Jewish!Chronic!Disease! conducted!at!the!Jewish!Chronic!Disease!Hospital!in!New!
Hospital!Case!(1963)! York!City!to!develop!information!on!the!nature!of!the!
human!transplant!rejection!process.!Chronically!ill!
patients!who!did!not!have!cancer!were!injected!with!live!
human!cancer!cells.!The!physicians!did!not!inform!the!
patients!as!to!what!they!were!doing.!The!physicians!
rationalization!for!their!actions!was!as!follows:!(i)!they!
did!not!want!to!scare!the!patients!and!(ii)!they!thought!
the!cells!would!be!rejected.!!

%
%%
Abuses&of&Psychiatry%
Paternalism! was! the! key! ethical! principle! underpinning! the! establishment! of! the!
county!asylums!in!the!mid319th!century!in!Britain.!There!was!little!legislation!to!govern!
the! workings! of! asylums! and! their! forerunner,! the! ‘mad3houses’.! There! were! many!
publicised! examples! of! abusive! practices,! especially! involving! the! use! of! mechanical!
restraint!and!seclusion.!7!
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.8!From!the!
1950’s! to! the! 1980’s! the! Soviet! Union! systematically! abused! psychiatry! for! political!
ends.9! 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.&

Common%ethical%issues%
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
7
"Barham"(1992)"Closing"the"asylum:"the"mental"patient"in"modern"society."England"Books,"London"
8"Lifton"(1986)"The"Nazi"doctors:"medical"killing"and"the"psychology"of"genocide."Basic"Books,"New"
York"
9"Block,"Reddaway"(1977)"Russia’s"political"hospitals":"the"abuse"of"psychiatry"in"the"Soviet"Union."

Gollancz,"London"

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Negligence'
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!patient’s!
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,!where!the!patient!continues!to!drive!despite!adequate!advice!
• suspicion!of!child!abuse,!or!abuse/neglect!of!an!incompetent!patient!
• by!order!of!a!Court!!
• where!disclosure!may!assist!in!prevention,!detection!or!prosecution!of!a!serious!
crime.!
• Where!deemed!appropriate!during!an!investigation!into!a!colleagues!fitness!to!
practice.! However,! in! these! cases! patient! consent! should! be! sought! and! if!
refused! further! consideration! is! required! to! appreciate! whether! disclosure!
would!be!in!the!public!interest.!
If! disclosure! of! the! information! is! not! in! the! public! interest! you! do! NOT! have! to!
routinely!disclose!information!to:!
• Solicitors!
• Police!officers!
After! the! patient’s! death! your! obligation! to! maintain! patient! confidentiality! persists.!
Attempts! should! be! made! to! anonymise/code! information! if! at! all! possible! (e.g.! for!
audit).!!You!are!obliged!to!disclose!information!about!patients!who!have!died:!
• For!a!coroner’s!report!

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• For!national!and!local!confidential!enquiries!and!audits!
• For!public!health!surveillance!(but!most!cases!would!be!anonymised)!
• To!parents!who!are!seeking!to!understand!the!cause!of!a!child’s!death!
• For! partners/close! relatives! of! an! adult,! wishing! to! understand! the! cause! of!
death,!!if!you!believe!the!patient!would!not!have!objected!!
• When!the!person!enquiring!has!the!right!to!access!records!under!the!Access'to'
Health'Records'Act'1990!

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.!
!
In!order!to!seek!consent,!the!professional!doing!so!must!be:!
• Suitably!qualified!to!do!so!
• Has!sufficient!knowledge!of!the!proposed!investigations/treatment!and!the!risks!
• Understands!the!guidance!provided!by!the!GMC!and!will!act!in!!keeping!with!it.!!
!
Consent!may!be!given!orally!(i.e.!verbally!agreeing!to!procedure),!may!be!implied!(i.e.!
by!complying!with!procedure)!or!may!be!written!(i.e.!consent!form!signed).!In!some!
cases!e.g.!fertility!treatment,!written!consent!is!required!by!law.!Written!consent!
should!also!be!sought!if:!
• If!treatment/investigation!is!complex!and!involved!significant!risks!
• There!may!be!significant!consequences!for!the!patient’s!work!or!social!life!
• Clinical!care!is!not!the!primary!purpose!of!the!proposed!procedure!
• It!is!part!of!a!research!programme!or!is!innovative.!!
!

IV.% Stigma%and%Mental%Illness%

Stigma!can!be!defined!as!constituting!four!elements:!
• !Labelling.%In!which!the!characteristic!that!are!considered!to!be!indicative!of!an!
important!difference!are!named.!!
• Stereotyping.!The!linking!of!the!differences!to!undesirable!characteristics!
• Separating.!Clear!distinction!between!a!‘normal’!group!and!a!‘labelled’!
person/group!as!being!different.!

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• Status%loss%and%discrimination.%The!devaluation,!rejection!and!avoidance!of!
the!stigmatised!person/group!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! a! serious! mental! health! problem! living! in! the! community.10! 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!self3concept!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.!
Erving!Goffman!(1963)!identified!three!forms!of!social!stigma:!
1. Experience!of!mental!illness!(or!being!labelled!mentally!ill)!
2. Physical!illness/deformity!
3. Belonging!to!a!particular!group!(race,!religion!etc)!
Patrick!Corrigan!and!Amy!Watson!(2002)11!wrote!that!Western!countries!have!more!
stigma!regarding!mental!illness,!than!Asian!and!African!counties.!They!identified!2!
types!of!stigma:!Public%Stigma!in!which!the!public!have!misconceptions!about!mental!
illness!and!thus!stigmatise!sufferers.!The!impact!of!this!may!take!4!forms:!withholding!
help,!avoidance,!coercive!treatment,!and!segregated!institutions.!They!also!identified!3!
ways!of!dealing!with!public!stigma:!
1. Protest!
2. Education!
3. Contact!
The!other!type!of!stigma!identified!is!Self1stigma.%This!is!a!process!by!which!sufferers!
internalize!the!stigmatizing!ideas!of!the!public,!which!leads!them!to!believe!that!they!
are!less!valued,!leading!to!low!self!esteem.!!

V.& 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.12! 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.13!

""""""""""""""""""""""""""""""""""""""""""""""""""""""""
10
"Link"et"al"(1997)"Journal"of"Health"and"Social"Behaviour"28:"177^190"
11"Understanding"the"impact"of"stigma"on"people"with"mental"illness."Corrigan"P,"Watson"A."World"
Psych."2002."Feb"1(1)."16^20."http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832/"
12"Lopez"&"Guarnaccia"(2000)"Annual"Review"of"Psychology"5:"571^598"
13
"Fiske"(1995)"The"cultural"dimensions"of"psychological"research."Erlbaum,"Hillsdale"p271^294"

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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! pan3cultural! core! (high! degree! of! syndromal! stability! across!
cultures),! others! are! specific! or! unique! to! a! particular! culture! (culture3bound!
syndromes).!
Examples!of!culture3bound!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.! Also! known! as! Suo% Yang! in! China.! Common! in! South3east! 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.! In! China! there! is! a! similar! culture! bound!
syndrome!known!as!Shen1k’uei.!
• Wendigo.! 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.!
• 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! low3grade! stress! syndrome! described! in!
many!parts!of!Africa,!commonly!encountered!among!students.!
• Pibloktoq% or% Arctic% 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,!
biological3physiological,! psychological3psychoanalytic,! social! structural! and!
cultural,! and! possible! implication! of! vitamin! intoxication,! namely,!
hypervitaminosis!A.!
• Susto:%This!is!condition!seen!in!Latin!America!whereby!the!person!believes!they!
have! lost! their! soul! through! fight! or! other! experience.! This! leads! to! illness!
behaviour.!

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• Hwabyung:!is!a!Korean!word!meaning!“firesickness”!it!is!based!on!the!Chinese!
concept! of! five! elements.! It! is! used! to! describe! distress! with! accompanying!
somatic!and!emotional!symptoms.!
• Ataques%de%nervios:!Literally!means!“attack!of!the!nerves”.!It!refers!to!a!stress!
induced!emotional!reaction!with!mixed!anxiety!and!hysterical!features.!!
• Tajin%kyofusho:!Is!a!Japanese!culture3bound!syndrome!which!takes!the!form!of!
social!anxiety!with!sufferers!worrying!about!offending!or!harming!people.!!
• Bouffee% deliriante:% seen! in! West! Africa! and! Haiti.! Sudden! outbursts! of!
aggressive!behaviour,!agitation,!confusion!and!psychomotor!excitement.!!

Mental%illness%among%ethnic%minorities%
Schizophrenia%
The!higher!than!expected!rates!of!schizophrenia!among!Afro3Caribbean!people!born!in!
Britain!have!been!noted!since!the!1960’s.!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!Afro3Caribbeans!carry!a!greater!genetic!loading!for!
schizophrenia.!
Suicide%
Suicide!rates!are!high!among!young!Indian!women!at!ages!15324!and!25334,!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!nine3fold!
excess!among!Indian!women.14!
World1wide%differences%in%mental%illness%
!
Schizophrenia:!Patients!with!this!diagnosis!in!developing!countries!have!a!better!
outcome!than!those!in!developed!countries!
!
Bipolar!disorder:!Psychotic!experiences!of!mania!are!more!common!among!Nigerian!
and!Afro3Caribbean!patients,!than!in!European!ones.!!
!
Eating!disorders:!Are!infrequent!in!developing!countries,!despite!rise!in!incidence!in!
developed!countries!
!
Neuroses:!There!is!an!increased!prevalence!of!conversion!disorder!in!developing!
countries.!!
%
%
%
""""""""""""""""""""""""""""""""""""""""""""""""""""""""
14"Raleigh"&"Balarajan"(1992)"British"Journal"of"Psychiatry"161:"365^368"

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References:%
%
Atkinson,!R.L.,!Atkinson!R.!C.,!Smith,!E.E.,!Bem,!D.J.,!Nolen3Hoeksema,!S.!(1999)!
Hilgard’s!introduction!to!psychology!(13th!Ed.)!Harcount!College!Publishers.!

Gross,!R.!D!(2005)!Psychology:!The!science!of!mind!and!behaviour!(5th!Ed)!Hodder!&!
Stoughton.!

Thambirajah,%M.%S.%(2005).%Psychological%Basis%of%Psychiatry.%Elsevier%Churchill%
Livingstone,%Edinburgh.%

Companion!to!Psychiatric!Studies,!8th!edition,!2010.!eds!Johnstone,!Cunningham!
Owens,!Lawrie,!McIntosh,!Sharpe.!

Shorter!Oxford!Textbook!of!Psychiatry,!eds!Gelder,!Harrison,!Cowen,!5th!Edition!

The!Encyclopaedia!of!schizophrenia!and!other!disorder.!Noll!R.!2007.!!

Revision!Notes!in!Psychiatry,!2nd!edition,!eds!Puri,!Hall!

Textbook!of!Psychiatry,!2nd!edition,!eds!Puri,!Laking,!Treasaden!

Medical!Ethics!and!Law.!2nd!ed.!Baxter!C,!Brennan!M!G,!Coldicott!Y,!Möller!M.!2005.!!

Confidentiality.!Guidance!for!Doctors.!GMC.!2009.!http://www.gmc3
uk.org/Confidentiality_0510.pdf_32611802.pdf!

!Consent.!Patients!and!doctors!making!decisions!together.!Guidance!for!doctors.!GMC.!
2008.!http://www.gmc3uk.org/Consent_0510.pdf_32611803.pdf!!

%
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