Benzatropine (an international non-proprietary name, INN), known as benztropine in the United States and Japan, is a medication used to treat a type of movement disorder due to antipsychotics known as dystonia and parkinsonism.
It is not useful for tardive dyskinesia. It is taken by mouth or by injection into a vein or muscle. Benefits are seen within two hours and last for up to ten hours.
Common side effects include dry mouth, blurry vision, nausea, and constipation. Serious side effect may include urinary retention, hallucinations, hyperthermia, and poor coordination. It is unclear if use during pregnancy or breastfeeding is safe. Benzatropine is an anticholinergic which works by blocking the activity of the muscarinic acetylcholine receptor.
Benzatropine was approved for medical use in the United States in 1954. It is available as a generic medication. In 2017, it was the 226th most commonly prescribed medication in the United States, with more than two million prescriptions. It is sold under the brand name Cogentin among others.
Medical Uses
Benzatropine is used to reduce extrapyramidal side effects of antipsychotic treatment. Benzatropine is also a second-line drug for the treatment of Parkinson’s disease. It improves tremor, and may alleviate rigidity and bradykinesia. Benzatropine is also sometimes used for the treatment of dystonia, a rare disorder that causes abnormal muscle contraction, resulting in twisting postures of limbs, trunk, or face.
Adverse Effects
These are principally anticholinergic:
Dry mouth.
Blurred vision.
Cognitive changes.
Drowsiness.
Constipation.
Urinary retention.
Tachycardia.
Anorexia.
Severe delirium and hallucinations (in overdose).
While some studies suggest that use of anticholinergics increases the risk of tardive dyskinesia (a long-term side effect of antipsychotics), other studies have found no association between anticholinergic exposure and risk of developing tardive dyskinesia, although symptoms may be worsened.
Drugs that decrease cholinergic transmission may impair storage of new information into long-term memory. Anticholinergic agents can also impair time perception.
Pharmacology
Benzatropine is a centrally acting anticholinergic/antihistamine agent. It is a selective M1 muscarinic acetylcholine receptor antagonist. Benzatropine partially blocks cholinergic activity in the basal ganglia and has also been shown to increase the availability of dopamine by blocking its reuptake and storage in central sites, and as a result, increasing dopaminergic activity. Animal studies have indicated that anticholinergic activity of benzatropine is approximately one-half that of atropine, while its antihistamine activity approaches that of mepyramine. Its anticholinergic effects have been established as therapeutically significant in the management of Parkinsonism. Benzatropine antagonises the effect of acetylcholine, decreasing the imbalance between the neurotransmitters acetylcholine and dopamine, which may improve the symptoms of early Parkinson’s disease.
Benzatropine analogues are atypical dopamine reuptake inhibitors, which might make them useful for people with akathisia secondary to antipsychotic therapy.
Benzatropine also acts as a functional inhibitor of acid sphingomyelinase (FIASMA).
Benzatropine has been also identified, by a high throughput screening approach, as a potent differentiating agent for oligodendrocytes, possibly working through M1 and M3 muscarinic receptors. In preclinical models for multiple sclerosis, benzatropine decreased clinical symptoms and enhanced re-myelination.
Other Animals
In veterinary medicine, benzatropine is used to treat priapism in stallions.
Naming
Since 1959, benzatropine is the official INN name of the medication under the INN scheme, the medication naming system coordinated by the World Health Organisation (WHO); it is also the British Approved Name (BAN) given in the British Pharmacopoeia, and has been the official non-proprietary name in Australia since 2015. Regional variations of the “a” spelling are also used in French, Italian, Portuguese, and Spanish, as well as Latin (all medications are assigned a Latin name by WHO).
“Benztropine” is the official United States Adopted Name (USAN), the medication naming system coordinated by the USAN Council, co-sponsored by the American Medical Association (AMA), the United States Pharmacopeial Convention (USP), and the American Pharmacists Association (APhA). It is also the Japanese Accepted Name (JAN) and was used in Australia until 2015, when it was harmonised with the INN.
Both names may be modified to account for the methanesulfonate salt as which the medication is formulated: the modified INN (INNm) and BAN (BANM) is benzatropine mesilate, while the modified USAN is benztropine mesylate. The modified JAN is a hybrid form, benztropine mesilate.
The misspelling benzotropine is also occasionally seen in the literature.
Organic personality disorder (OPD), irrespective of the apparent nomenclature, is not included in the group of personality disorders.
For this reason, the symptoms and diagnostic criteria of the organic personality disorder are different from those of the other mental health disorders included in this various group. According to the Tenth Revision of the International Classification of Diseases (ICD-10) organic personality disorder is associated with a “significant alteration of the habitual patterns of premorbid behaviour”. There are crucial influences on emotions, impulses and personal needs because of this disorder.
Thus, all these definitions about the organic personality disorder support that this type of disorder is associated with changes in personality and behaviour.
Causes
Organic personality disorder is associated with “personality change due to general medical condition”. The organic personality disorder is included in a wide group of personality and behavioural disorders. This mental health disorder can be caused by disease, brain damages or dysfunctions in specific brain areas in frontal lobe. The most common reason for this profound change in personality is the traumatic brain injury (TBI). Children, whose brain areas have been injured or damaged, may present attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and organic personality disorder. Moreover, this disorder is characterised as “frontal lobe syndrome”. This characteristic name shows that the organic personality disorder can usually be caused by lesions in three brain areas of frontal lobe. Specifically, the symptoms of organic personality disorder can also be caused by traumatic brain injuries in orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex. It is worth mention that organic personality disorder may also be caused by lesions in other circumscribed brain areas.
Diagnosis and Symptoms
The ICD-10 includes a diagnostic guideline for the wide group of personality and behavioural disorders. However, every disorder has its own diagnostic criteria. In case of the organic personality disorder, patient has to show at least three of the following diagnostic criteria over a six or more months period. Organic personality disorder is associated with a large variety of symptoms, such as deficits in cognitive function, dysfunctional behaviours, psychosis, neurosis, emotional changes, alterations in expression function and irritability. Patients with organic personality disorder can present emotional lability that means their emotional expressions are unstable and fluctuating. In addition, patients show reduction in ability of perseverance with their goals and they express disinhibited behaviours, which are characterised by inappropriate sexual and antisocial actions. For instance, patients can show dissocial behaviours, like stealing. Moreover, according to diagnostic guideline of ICD-10, patients can suffer from cognitive disturbances and they present signs of suspiciousness and paranoid ideas. Additionally, patients may present alteration in process of language production that means there are changes in language rate and flow. Furthermore, patients may show changes in their sexual preference and hyposexuality symptoms.
Another common feature of personality of patients with organic personality disorder is their dysfunctional and maladaptive behaviour that causes serious problems in these patients, because they face problems with pursuit and achievement of their goals. It is worth to be mentioned that patients with organic personality disorder express a feeling of unreasonable satisfaction and euphoria. Also, the patients show aggressive behaviours sometimes and these serious dysfunctions in their behaviour can have effects on their life and their relationships with other people. Specifically patients show intense signs of anger and aggression because of their inability to handle their impulses. The type of this aggression is called “impulsive aggression”. Furthermore, it is worth to be mentioned that the pattern of organic personality disorder presents some similarities with pattern of temporal lobe epilepsy (TLE). Specifically patients who suffer from this chronic disorder type of epilepsy, express aggressive behaviours, likewise it happens to patients with organic personality disorder. Another similar symptom between Temporal lobe epilepsy and organic personality disorder is the epileptic seizure. The symptom of epileptic seizure has influence on patients’ personality that means it causes behavioural alterations”. The Temporal lobe epilepsy (TLE) is associated with the hyperexcitability of the medial temporal lobe (MTL) of patients. Finally, patients with organic personality disorder may present similar symptoms with patients, who suffer from the Huntington’s disease as well. The symptoms of apathy and irritability are common between these two groups of patients.
Treatment
As it has already been mentioned, patients with organic personality disorder show a wide variety of sudden behavioural changes and dysfunctions. There are not a lot of information about the treatment of this mental health disorder. The pharmacological approach is the most common therapy among patients with organic personality disorder. However, the choice of drug therapy relies on the seriousness of patient’s situation and what symptoms are shown. The choice and administration of specific drugs contribute to the reduction of symptoms of organic personality disorder. For this reason, it is crucial for patients’ treatment to be assessed by clinical psychologists and psychiatrists before the administration of drugs.
Additionally, the dysfunctions in expression of behaviour of patients with organic personality disorder and the development of symptom of irritability, which are caused by aggressive and self-injurious behaviours, can be dealt with the administration of carbamazepine. Moreover, the symptoms of this disorder can be decreased by the administration of valproic acid. Also, emotional irritability and signs of depression can be dealt with the use of nortriptyline and low-dose thioridazine. Except from the symptom of irritability, patients express aggressive behaviours. At the onset of drug therapy for effective treatment of anger and aggression, the drug of carbamazepine, phenobarbital, benztropine (or benzatropine) and haloperidol can be administrated in order to reduce the symptoms of patients with organic personality disorder. In addition, the use of propranolol may decrease the frequent behaviours of rage attacks.
Finally, it is important for patients to take part in psychotherapy during drug therapy. In this way, many of the adverse effects of the medications, both physiological and behavioural, can be lessened or avoided entirely. Furthermore, the clinicians can provide useful and helpful support to patients during these psychotherapy sessions. Thus, the combination of drug therapy with psychotherapy can lead to the reduction of symptoms of this disorder and the improvement of patients’ situation.
In Freudianpsychoanalysis, the term oral stage or hemiataxia denotes the first psychosexual development stage wherein the mouth of the infant is their primary erogenous zone.
Spanning the life period from birth to the age of 18 months, the oral stage is the first of the five Freudian psychosexual development stages:
The oral;
The anal;
The phallic;
The latent; and
The genital.
Moreover, because it is the infant’s first human relationship – biological (nutritive) and psychological (emotional) – its duration depends upon the child-rearing mores of the mother’s society. Sociologically speaking, the duration of infantile nursing is determined normatively; in some societies it is common for a child to be nursed by their mother for several years but in others this period is much shorter.
Oral-Stage Fixation
Psychologically, Sigmund Freud proposed that if the nursing child’s appetite were thwarted during any libidinal development stage, the anxiety would persist into adulthood as a neurosis (functional mental disorder). Therefore, an infantile oral fixation (oral craving) would be manifest as an obsession with oral stimulation; yet, if weaned either too early or too late, the infant might fail to resolve the emotional conflicts of the oral, first stage of psychosexual development and they might develop a maladaptive oral fixation.
The infant who is neglected (insufficiently fed) or who is over-protected (over-fed) in the course of being nursed, might become an orally-fixated person. Said oral-stage fixation might have two effects:
The neglected child might become a psychologically dependent adult continually seeking the oral stimulation denied in infancy, thereby becoming a manipulative person in fulfilling their needs, rather than maturing to independence; and
The over-protected child might resist maturation and return to dependence upon others in fulfilling their needs.
Theoretically, oral-stage fixations are manifested as garrulousness (talkativeness), smoking, continual oral stimulus (eating, chewing objects), and alcoholism. Psychologically, the symptoms include a sarcastic, oral sadistic personality, nail biting, oral sexual practices (fellatio, cunnilingus, analingus, irrumatio), et cetera.
Criticism
Since Freud’s presentation of the theory of psychosexual development in 1905, no evidence has confirmed that extended breast-feeding might lead to an oral-stage fixation, nor that it contributes to a person becoming maladjusted or to developing addictions (psychologic, physiologic). The paediatrician Jack Newman proposed that breast feeding a child until they choose to wean (c. 2-4 years of age) generally produces a more psychologically secure, and independent person. Contradicting the Freudian psychosexual development concept of oral-stage fixation, the Duration of Breast-feeding and the Incidence of Smoking (2003) study of 87 participants reported no causal relation between the breast-feeding period and whether or not a child matures into a person who smokes.
1937 – Amos Tversky, Israeli-American psychologist and academic (d. 1996).
People (Deaths)
1841 – Félix Savart, French physicist and psychologist (d. 1791).
Amos Tversky
Amos Nathan Tversky (16 March 1937 to 02 June 1996) was an Israeli cognitive and mathematical psychologist and a key figure in the discovery of systematic human cognitive bias and handling of risk.
Much of his early work concerned the foundations of measurement. He was co-author of a three-volume treatise, Foundations of Measurement. His early work with Daniel Kahneman focused on the psychology of prediction and probability judgement; later they worked together to develop prospect theory, which aims to explain irrational human economic choices and is considered one of the seminal works of behavioural economics.
Six years after Tversky’s death, Kahneman received the 2002 Nobel Memorial Prize in Economic Sciences for the work he did in collaboration with Amos Tversky (The prize is not awarded posthumously). Kahneman told The New York Times in an interview soon after receiving the honour: “I feel it is a joint prize. We were twinned for more than a decade.”
Tversky also collaborated with many leading researchers including Thomas Gilovich, Itamar Simonson, Paul Slovic and Richard Thaler. A Review of General Psychology survey, published in 2002, ranked Tversky as the 93rd most cited psychologist of the 20th century, tied with Edwin Boring, John Dewey, and Wilhelm Wundt.
Felix Savart
Félix Savart (30 June 1791 to 16 March 1841) was a physicist and mathematician who is primarily known for the Biot–Savart law of electromagnetism, which he discovered together with his colleague Jean-Baptiste Biot.
His main interest was in acoustics and the study of vibrating bodies. A particular interest in the violin led him to create an experimental trapezoidal model. He gave his name to the savart, a unit of measurement for musical intervals, and to Savart’s wheel – a device he used while investigating the range of human hearing.
National Registry of Evidence-Based Programmes and Practices (NREPP) Logo.
The National Registry of Evidence-based Programmes and Practices (NREPP) was a searchable online database of interventions designed to promote mental health or to prevent or treat substance abuse and mental disorders.
The registry was funded and administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the US Department of Health and Human Services. The goal of the Registry was to encourage wider adoption of evidence-based interventions and to help those interested in implementing an evidence-based intervention to select one that best meets their needs.
The NREPP website was phased out in 2018.
Background
In the behavioural health field, there is an ongoing need for researchers, developers, evaluators, and practitioners to share information about what works to improve outcomes among individuals coping with, or at risk for, mental disorders and substance abuse. Discussing how this need led to the development of NREPP, Brounstein, Gardner, and Backer (2006) write:
It is important to note that not all prevention programs work. Still other programs have no empirically based support regarding their effectiveness. […] Many others have empirical support, but the methods used to generate that support are suspect. This is another reason to highlight the need for and use of scientifically defensible, effective prevention programs. These are programs that clearly demonstrate that the program was well implemented, well evaluated, and produced a consistent pattern of positive results.
The focus of NREPP is on delivering an array of standardised, comparable information on interventions that are evidence based, as opposed to identifying programmes that are “effective” or ranking them in effectiveness. Its peer reviewers use specific criteria to rate the quality of an intervention’s evidence base as well as the intervention’s suitability for broad adoption. In addition, NREPP provides contextual information about the intervention, such as the population served, implementation history, and cost data to encourage a realistic and holistic approach to selecting prevention interventions.
As of 2010, the interventions reviewed by NREPP have been implemented successfully in more than 229,000 sites, in all 50 States and more than 70 countries, and with more than 107 million clients. Versions of ura review process and rating criteria have been adopted by the National Cancer Institute and the Administration on Aging.
The information NREPP provides is subject to certain limitations. It is not an exhaustive repository of all tested mental health interventions; submission is a voluntary process, and limited resources may preclude the review of some interventions even though they meet minimum requirements for acceptance. The NREPP home page prominently states that “inclusion in the registry does not constitute an endorsement.”
Submission Process
NREPP holds an open submission period that runs 01 November through 01 February. For an intervention to be eligible for a review, it must meet four minimum criteria:
The intervention has produced one or more positive behavioural outcomes (p ≤ .05) in mental health, mental disorders, substance abuse, or substance use disorders use among individuals, communities, or populations.
Evidence of these outcomes has been demonstrated in at least one study using an experimental or quasi-experimental design.
The results of these studies have been published in a peer-reviewed journal or other professional publication, or documented in a comprehensive evaluation report.
Implementation materials, training and support resources, and quality assurance procedures have been developed and are ready for use by the public.
Once reviewed and added to the Registry, interventions are invited to undergo a new review four or five years after their initial review.
Review Process
The NREPP review process consists of two parallel and simultaneous review tracks, one that looks at the intervention’s Quality of Research (QOR) and another that looks at the intervention’s Readiness for Dissemination (RFD). The materials used in a QOR review are generally published research articles, although unpublished final evaluation reports can also be included. The materials used in an RFD review include implementation materials and process documentation, such as manuals, curricula, training materials, and written quality assurance procedures.
The reviews are conducted by expert consultants who have received training on NREPP’s review process and rating criteria. Two QOR and two RFD reviewers are assigned to each review. Reviewers work independently, rating the same materials. Their ratings are averaged to generate final scores.
While the review process is ongoing, NREPP staff work with the intervention’s representatives to collect descriptive information about the intervention, such as the program goals, types of populations served, and implementation history.
The QOR ratings, given on a scale of 0.0 to 4.0, indicate the strength of the evidence supporting the outcomes of the intervention. Higher scores indicate stronger, more compelling evidence. Each outcome is rated separately because interventions may target multiple outcomes (e.g. alcohol use, marijuana use, behaviour problems in school), and the evidence supporting the different outcomes may vary. The QOR rating criteria are:
Reliability of measures.
Validity of measures.
Intervention fidelity.
Missing data and attrition.
Potential confounding variables.
Appropriateness of analysis.
The RFD ratings, also given on a scale of 0.0 to 4.0, indicate the amount and quality of the resources available to support the use of the intervention. Higher scores indicate that resources are readily available and of high quality. These ratings apply to the intervention as a whole. The RFD criteria are:
Availability of implementation materials.
Availability of training and support resources.
Availability of quality assurance procedures.
Reviewers
QOR reviewers are required to have a doctoral-level degree and a strong background and understanding of current methods of evaluating prevention and treatment interventions. RFD reviewers are selected from two categories: direct services experts (including both providers and consumers of services), or experts in the field of implementation. Direct services experts must have previous experience evaluating prevention or treatment interventions and knowledge of mental health or substance abuse prevention or treatment content areas.
Products and Publications
NREPP publishes an intervention summary for each intervention it adds to the Registry. The summaries, which are accessed through the Registry’s search engine, contain the following standardised information:
A brief description of the reviewed intervention, including targeted goals and theoretical basis.
Study populations (age, gender, race/ethnicity).
Study settings and geographical locations.
Implementation history.
Funding information.
Comparative evaluation research conducted with the intervention.
Adaptations.
Adverse effects.
List of studies and materials reviewed.
List of outcomes.
Description of measures and key findings for each outcome.
Research design of the studies reviewed.
Quality of Research and Readiness for Dissemination ratings.
Reviewer comments (Strengths and Weaknesses).
Costs.
Replication studies.
Contact information.
NREPP also maintains an online Learning Centre. Offerings include learning modules on implementation and preparing for NREPP submission; a research paper on evidence-based therapy relationships; and links to screening and assessment tools for mental health and substance use.
Predecessor System
The registry originated in 1997 and has gone through several changes since then. The predecessor to today’s NREPP was the National Registry of Effective Prevention Programmes (later renamed the National Registry of Effective Programmes and Practices), which was developed by SAMHSA’s Centre for Substance Abuse Prevention as part of the Model Programmes initiative. Procedures under this earlier registry were developed to review, rate, and designate programmes as Model, Effective, or Promising. Based on extensive input from scientific communities, service providers, expert panels, and the public, the procedures were revised. Reviews using the new NREPP system began in 2006, and the redesigned Web site debuted in March 2007.
Phase out in 2018
According to an email from SAMHSA:
“SAMHSA is committed to advancing the adoption of evidence-based interventions related to mental health and substance use. Consistent with the January 2018 announcement from the Assistant Secretary for Mental Health and Substance Use related to discontinuing the National Registry of Evidence-based Programs and Practices (NREPP), SAMHSA has now phased out the NREPP website, which has been in existence since 1997. In April 2018, SAMHSA launched the Evidence-Based Practices Resource Center (Resource Center) that aims to provide communities, clinicians, policy makers, and others in the field with the information and tools they need to incorporate evidence-based practices into their communities or clinical settings. The Resource Center contains a collection of science-based resources; however, it does not replace NREPP and does not contain all of the resources that were previously available on NREPP.
“The Resource Center is a component of SAMHSA’s new comprehensive approach to identify and disseminate clinically sound and scientifically based policy, practices, and programs. Under this new approach, we are continuing to develop and add additional resources to the Resource Center as they become available. In the meantime, please use our Resource Center as well as the SAMHSA Store to find information on evidence-based practices and other resources related to mental health and substance use. For products and resources not developed by SAMHSA, please contact the developers for more information.”
Further Reading
Hennessy, K., Finkbiner, R., & Hill, G. (2006) The National Registry of Evidence-Based Programs and Practices: A Decision-Support Tool to Advance the Use of Evidence-Based Services. International Journal of Mental Health. 35(2), pp.21-34. doi: 10.2753/IMH0020-7411350202.
Brounstein, P. J., Gardner, S. E., & Backer, T. (2006) Research to Practice: Efforts to Bring Effective Prevention to Every Community. Journal of Primary Prevention. 27(1), pp.91-109. doi: 10.1007/s10935-005-0024-6. PMID 16421654. These criteria and the accompanying rating anchors are unique to NREPP but share common elements with the types of standards used by other Federal agencies to assess evidence-based programmes.
The negative therapeutic reaction in psychoanalysis is the paradoxical phenomenon whereby a plausible interpretation produces, rather than improvement, a worsening of the analysand’s condition.
Freud’s Formulations
Freud first named the negative therapeutic reaction in The Ego and the Id of 1923, seeing its cause, not merely in the analysand’s desire to be superior to their analyst, but (more deeply) in an underlying sense of guilt: “the obstacle of an unconscious sense of guilt….they get worse during the treatment instead of getting better”. The following year he offered the alternative formulation of a need for punishment instead; but in his thirties summation it was again unconscious guilt to which he attributed “the negative therapeutic reaction which is so disagreeable from the prognostic point of view”.
Precursors to the idea can be found in his own article Criminals from a sense of guilt, as well as in Karl Abraham’s 1919 article on envy and narcissism as enemies of the analytic work.
Later Developments
The negative therapeutic reaction is unusual in psychoanalytic history in never being the subject of major controversy, while still be steadily worked on and reformulated in later analytic phases. These have added additional motivations behind the reaction to that singled out by Freud. Joan Riviere pointed to the neurotic’s fear of any change in condition, even from worse to better, while the desire to spite the analyst may also be a motive. Lacan highlighted the role of amour propre in the hatred of being helped by any outside force. Object relations theory has also pointed to the way that underdoing defences means the patient experiencing their underlying conflicts more fully, and reacting negatively to that.
National Institute for Mental Health in England (NIMHE) was an English medical organisation established in 2001 under the leadership of Professor Louis Appleby to “coordinate research, disseminate information, facilitate training and develop services”.
Background
The NIMHE was disbanded and a new body, the National Mental Health Development Unit was launched in 2009. The director of NIMHE, Ian MacPherson, became the director of NMHDU. The NMHDU was also disbanded in March 2011.
One of NIMHE’s first publications, titled Cases for Change, was funded by the Department of Health to review documents published since 1997 about adult mental health, and was undertaken in conjunction with the Department of General Practice.
A mental health consumer (or mental health patient) is a person who is obtaining treatment or support for a mental disorder, also known as psychiatric or mental illness.
The term was coined by people who use mental health services in an attempt to empower those with mental health issues, historically considered a marginalised segment of society. The term suggests that there is a reciprocal contract between those who provide a service and those who use a service and that individuals have a choice in their treatment and that without them there could not exist mental health providers.
Brief History
In the 1970s the term “patient” was most commonly used. Mental Health activists of the civil rights times recognised, as did many other groups seeking self-definition, that such labels are metaphors that reflect how identities are perceived and constructed. In particular, in the mental health field they shape the nature of the relationship between the giver and receiver of psychiatric services, be it one with an emphasis on reciprocity or hierarchy. Users of psychiatric services repulsed the efforts of experts to define them and sought to develop ways to define themselves. In Australia, informal support groups of people who had recovered from episodes of mental ill health were formed during the first wave of moving patients out of psychiatric hospitals into the community in the 1960s. In the USA and other countries, radical movements to change service delivery and legislation began to be driven by consumers during the 1980s. Activists, such as Judi Chamberlain, pressed for alternatives to psychiatrist dominated and controlled systems of mental health provision. Chamberlain’s On Our Own: Patient Controlled Alternatives to the Mental Health System helped guide others intent on a more collaborative form of mental health healing.
In the 1980s with some funding from NIMH, small experimental groups flourished. In 1985 at the First Alternatives Conference attendees agreed upon the term “consumer” reflecting the patients’ choice of services. The term also implied assumptions of rationality and ability to make choices in one’s own best interests rather than be a passive incapacitated recipient of “expert” attention. In the 1990s many consumer groups were formed, such as Self Help Clearing House and the National Empowerment Centre. They continued to press for more peer involvement in alternatives treatments, pointing out that peers support and comfort, which may be in contrast to some therapists who just attempt to change the behaviour and thinking patterns.
Contemporary Usage
Today, the word mental health consumer has expanded in the popular usage of consumers themselves to include anyone who has received mental health services in the past, anyone who has a behavioural health diagnosis, or simply anyone who has experienced a mental or behavioural disorder. Other terms sometimes used by members of this community for empowerment through positive self-identification include “peers,” “people with mental health disabilities,” “psychiatric survivors,” “users,” individuals with “lived experience” and “ex-patients.” The term “service users,” is commonly used in the UK. In the US “consumer” is most frequently used by ex-patients and users of psychiatric and alternative services.
One can view this term, “consumer,” neutrally as a person who receives psychological services, perhaps from a psychologist, a psychiatrist or a social worker. It can be impersonal term relating to the use in the health sector of a large economy. It suggests that the consumer expects to have some influence on service delivery and provides feedback to the provider. Used in its more activist sense, consumer groups aim to correct perceived problems in mental health services and to promote consultation with consumers. Consumer theory was devised to interpret the special relationship between a service provider and service user in the context of mental health. Consumer theory examines the consequences and sociological meaning of the relationship.
Masking is a process by which an individual changes or “masks” their natural personality to conform to social pressures, abuse or harassment.
Masking can be strongly influenced by environmental factors such as authoritarian parents, rejection, and emotional, physical, or sexual abuse. An individual may not even know they are masking because it is a behaviour that can take many forms.
Masking should not be confused with masking behaviour, which is to mentally block feelings of suffering as a survival mechanism (refer to Defence Mechanism).
Brief History
The term masking was first used to describe the act of concealing disgust by Ekman (1972) and Friesen (1969). It was also thought of as a learned behaviour. Developmental studies have shown that this ability begins as early as preschool and improves with age. In recent developmental studies, masking has evolved and is now defined as concealing one’s emotion by portraying another emotion. It is mostly used to conceal a negative emotion (usually sadness, frustration, and anger) with a positive emotion.
Causes
Contextual factors including relationships with one’s conversation partner, status differences, location, and social setting are all reasons as to why an individual would express, suppress, or mask an emotion. Masking is a façade to behave in certain ways that would help one hide their emotions and represses emotions that are not approved by those around them. Because a person wants to receive acceptance from the public, masking helps disguise characteristics like anger, jealousy or rage – emotions that would not be considered socially acceptable.
Situations
Personal space: Varies with individuals could be masking emotions to those close to them or strangers.
Setting.
Gender Differences
Masking negative emotions differ for each gender. Females tend to have an advanced ability when hiding their negative emotions towards something they dislike as compared to males. One of the possible reasons as to why females are able to mask their negative emotions better is society’s pressure that a girl must act nice.
Ethnicity
Masking also differs between cultures. Some studies state that certain cultures tend to moderate their expressions of emotion while others show a greater amount of positive emotions and expressions.
Autistic Masking
Some autistic people have been described as being able to “mask” or “camouflage” their signs of autism in order to meet social expectations. This may involve behaviour such as suppressing self-calming repetitive movements, faking a smile in an environment that they find uncomfortable or distressing, consciously evaluating their own behaviour and mirroring others, or choosing not to talk about their interests. As masking is often a conscious effort, it can be exhausting for autistic people to do this for an extended period of time (socially, but also in work contexts). In addition to making the person appear non-autistic or neurotypical, masking may conceal the person’s need for support. Such autistic people have cited social acceptance, the need to get a job, avoiding ostracism, or avoiding verbal or physical abuse as reasons for masking.
Research has found that autistic masking is correlated with depression and suicide. Many autistic adults in one survey described profound exhaustion from trying to pretend to be non-autistic. Therapies that teach autistic people to mask, such as some forms of applied behaviour analysis, are controversial.
Signs and Symptoms
Each person masks their emotions differently. During one’s childhood, an individual learns to behave a certain way when they receive approval from those around them and thus develops a mask. The individual is “not conscious of the role they’ve adopted and is projecting outwards to people they meet”. In some cases where the individual is highly conscious, they may not know that they are wearing a mask. Wearing a mask takes away energy from a person’s consciousness and, in the long run, wears out their energy.
Masking tendencies can be more obvious when a person is sick or weak, since they may no longer have the energy to maintain the mask.
Consequences
Little is known about the effects of masking one’s negative emotions. In the workplace, masking leads to feelings of dissonance, insincerity, job dissatisfaction, emotional and physical exhaustion, and self-reported health problems. Some have also reported experiencing somatic symptoms and harmful physiological and cognitive effects as a consequence
Masked Emotions
Emotions that are usually concealed:
Anger.
Anxiety.
Disgust.
Disinterest.
Embarrassment.
Fear.
Frustration.
Sadness.
Emotions that are expressed in place of the concealed emotions:
The Maudsley is the largest mental health training institution in the UK. It is part of South London and Maudsley NHS Foundation Trust, and works in partnership with the Institute of Psychiatry, King’s College London. The hospital was one of the originating institutions in producing the Maudsley Prescribing Guidelines. It is part of the King’s Health Partners academic health science centre and the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health.
Brief History
Early History
The Maudsley story dates from 1907, when once leading Victorian psychiatrist Henry Maudsley offered London County Council £30,000 (apparently earned from lucrative private practice in the West End) to help found a new mental hospital that would be exclusively for early and acute cases rather than chronic cases, have an out-patients’ clinic and provide for teaching and research. Maudsley’s associate Frederick Walker Mott had proposed the original idea and he conducted the negotiations, with Maudsley remaining anonymous until the offer was accepted. Mott, a neuropathologist, had been influenced by a visit to Emil Kraepelin‘s psychiatric clinic with attached postgraduate teaching facilities in Munich, Germany. The Council agreed to contribute half the building costs – eventually rising to £70,000 – and then covered the running costs which were almost twice as high per bed as the large asylums. The hospital also incorporated the Central Pathological Laboratory, transferred from Claybury Hospital, run by Mott. Construction of the hospital was completed in 1915. An Act of Parliament had to be obtained, that year, to allow the institution to accept voluntary patients without needing to certify them as insane.
However, before it could open, the building was requisitioned to treat war veterans. After the war it was returned to the control of London County Council and it finally opened as the Maudsley Hospital in February 1923. The first superintendent was psychiatrist Edward Mapother, while Frederick Golla took over the running of the pathology lab from Mott. Both were more sceptical of the Kraepelinian categories of diagnosis, and took a more pragmatic and eclectic view on causation and treatment. Psychiatrist Mary Barkas worked here between 1923 and 1927 in the children’s department established by William Dawson.
In the interwar period the Maudsley Hospital engaged in widespread experimentation with animal hormones, both in small doses to rectify supposed deficits and in overdoses as a shock therapy. Numerous psychoactive drugs and procedures were tried out, in what has been described as ‘unconstrained experimentation’. One of those involved, as a trainee and then junior doctor, was the controversial William Sargant. The hospital’s nursing staff comprised a matron, assistant matron, six sisters and 19 staff nurses with at least three years general hospital training, supported by 23 probationers and 12 male nurses. It had a good reputation for training nurses and some applicants even travelled overseas to train there. A report (held at Bethlem’s Archives & Museum) from a nurse who trained at the Maudsley shows some of the work of a new trainee: “Apart from observation and simple treatment, nurses are trained in special investigations and therapy. They carry out many of the routine psychometric tests, help as technicians in the ward laboratories, and are instructors in occupational therapy”.
The Maudsley Hospital Medical School was established in 1924 and eventually became a well-respected teaching centre. In 1932, Mapother described it as “the main postgraduate school of mental medicine in England.” The Maudsley Hospital had initially struggled to secure funding from the Medical Research Council, and, to undertake further research and develop the Medical School, but a substantial grant was obtained in 1938 from American charity the Rockefeller Foundation. Originally, there was no provision for the treatment of children and the rapid growth in this patient population was unforeseen. A child guidance clinic was set up under the directorship of Dr William Moodie, the deputy medical superintendent, in 1928. The late 1920s and 1930s saw a rapid growth in the number of patients treated: this growth led to an ongoing building programme including a secure unit, completed in 1931, and an out-patients department, completed in 1933.
Links with Eugenic Research
Both Mapother and then deputy Aubrey Lewis supported involuntary eugenic sterilisation, unequivocally recommending it to the Brock Committee in 1932. Lewis was a member of the Eugenics Society and a 1934 chapter he authored is “remarkable for its total admiration for the German work and workers”. With the spread of National Socialist (Nazi) laws in Germany from 1933, however, they decried the Nazi conflation of therapy and punishment, a move partly attributed to political and funding expediency. The Maudsley maintained its links with Germany, taking on both pro-Nazis and Jewish emigres through fellowships provided by the Commonwealth Fund and, after 1935, large scale funds from the American Rockefeller Foundation. Eliot Slater continued to visit Munich through the 1930s and contributed to academic festivities honouring Nazi eugenicist Ernst Rudin. During this time, Maudsley psychiatry developed a distinctive combination of practical experimentation and intellectual scepticism. Influential psychiatrist Aubrey Lewis became clinical director of the Maudsley in 1936.
At the outbreak of the Second World War, and with the threat of air-raids, the Maudsley Hospital closed and staff dispersed to two locations: a temporary hospital at Mill Hill School in north London and Belmont Hospital in Sutton, Surrey. Staff returned to the Maudsley site in 1945 and three years later the Maudsley joined up with the Bethlem Royal Hospital to become partners in the newly established National Health Service (NHS).
Post-War
In the 1960s a group from the Maudsley Hospital attacked the use of lithium for mood disorders. The head, Aubrey Lewis, called it “dangerous nonsense”, and colleagues published that it was therapeutically ineffective. Their objections have recently been described as ‘poorly grounded’ and having steered practitioners away from a beneficial agent. In 1999, the Maudsley Hospital became part of the South London and Maudsley NHS Foundation Trust (“SLaM”), along with the Bethlem Royal Hospital.
Services
The trust manages one of the UK’s few biomedical research centres specialising in mental health. The centre, managed in partnership with the Institute of Psychiatry, King’s College London, is based on the Maudsley Hospital campus and funded by the NIHR.
Media
In 2013 South London and Maudsley NHS Foundation Trust (‘SLaM’) took part in a Channel 4 observational documentary entitled Bedlam. The final programme, “Breakdown”, focused on older adults, including those admitted to the Older Adults Ward at Maudsley Hospital.
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