Institutional Neurosis

Russell Barton

• Publisher: Butterworth-Heinemann
• Year: 2013
• Print ISBN:
  9780723603887
• eBook ISBN:
  9781483183411
• Edition: 3
• Topic: Medicine
• Subtopic: Neurology

Institutional Neurosis describes the clinical features of the disorder in mental hospitals, its differential diagnosis, etiology, treatment, and prevention. This book defines institutional neurosis as a disease characterized by apathy, lack of initiative, loss of interest in things and events not immediately personal or present, submissiveness, and sometimes no expression of feelings of resentment at harsh or unfair orders. The cause of institutional neurosis is uncertain, but it can be associated with many factors in the environment in which the patient lives. This text considers the factors associated with institutional neurosis such as loss of contact with the outside world; enforced idleness; brutality, browbeating and teasing; bossiness of staff; loss of personal friends, possessions and personal events; drugs; ward atmosphere; and loss of prospects outside the institution. This publication is a good reference for medical practitioners and students interested in the mental changes that may result from institutional life.

Chapter 1

Consideration, Clinical Features and Differential Diagnosis of Institutional Neurosis

Publisher Summary

This chapter describes institutional neurosis as a disease characterized by apathy, lack of initiative, loss of interest more marked in things and events not immediately personal or present, submissiveness, and sometimes no expression of feelings of resentment at harsh or unfair orders. There is also a lack of interest in the future and an apparent inability to make practical plans for it, deterioration in personal habits, a loss of individuality, and a resigned acceptance that things will go on as they are. Occasionally, the passive, submissive cooperation of the patient is punctuated by aggressive episodes that are casually attributed to mental illness but which are often provoked by some unkindness from another patient, a hospital employee, or visitors. It may be argued that the fact that treatment causes the disappearance of some of the symptoms ascribed to institutional neurosis is an insufficient evidence to justify formulating a disease entity. However, there is supporting evidence that suggests that a similar set of symptoms is sometimes found in people without mental disorders in other institutions.

Myerson (1939) claimed that the usual hospital care given to schizophrenic patients produced a ‘Prison Stupor’ or ‘Prison Psychosis’ which interacted with the social retreat of the original schizophrenia. The patient was put into a motivational vacuum.

Bettelheim and Sylvester (1948) used ‘Psychological Institutionalism’ to describe the detachment isolation, automaton-like rigidity, passive adjustment and general impoverishment of personality which they noted in emotionally disturbed children in an institution. They remarked: ‘Behaviour disorders in the common sense do not necessarily form part of this clinical picture.’

Martin (1955) used the term ‘institutionalization’ to denote the syndrome of submissiveness, apathy and loss of individuality that is encountered in many patients who have been some time in a mental hospital.

In 1956 I began using the term ‘institutional neurosis’ in various handouts to the nursing staff with whom I developed programmes of rehabilitation at Shenley Hospital.

Wing (1962) referred to the condition as ‘Institutionalism’ and Gruenberg (1962) introduced the term ‘social breakdown syndrome’. Vail (1966) discussed it under the title ‘Dehumanization’ and Wallace (1967) refers to ‘the syndrome of hospitalism’ to describe a patient’s loss of his outside identity as spouse, parent, worker or citizen for a new identity—that of a good, passive, chronic patient. It seems that the condition will continue to be discovered and renamed every few years.

I prefer the term ‘institutional neurosis’ because it promotes the syndrome to the category of a disease, rather than a process, thereby encouraging us to understand, approach and deal with it in the same way as other diseases.

The adjective ‘institutional’ does not imply that institutions are the only cause of the disorder, but signifies only that institutions are the places where it was first generally recognized, as the use of ‘Bornholm’ in Bornholm’s^* disease. By no means all people in institutions develop it, and probably hermits, some housewives and old age pensioners are afflicted with similar symptoms although living alone. ‘Oblomovism’, so often seen, and brilliantly depicted by Goncharov (1858), is probably a kindred disorder, an indolence and lethargy resulting from conditions in the environment in which the patient lives.

The term ‘neurosis’ is used rather than ‘psychosis’, since the syndrome itself does not interfere with the patient’s ability to distinguish between reality and fantasy. Indeed such passivity adjusts the individual to the demands of reality in the institution but, at the same time, it hampers or may prevent his return and adjustment to the world outside. ‘Neurosis’ is used in a general descriptive sense. It describes symptoms and signs, not psycho-dynamic hypotheses.

The purpose of this monograph is to describe the clinical features of the disorder in mental hospitals, its differential diagnosis, aetiology, treatment and prevention.

I feel sure that the term ‘institutional neurosis’ has been used already by workers in hospitals in this and other countries who recognize the condition. Furthermore, I claim no originality for most of the ideas presented; my purpose is to try to arrange them in an orderly manner so that they are more easily understood, more readily accepted, and more systematically treated.

Clinical Features

Institutional neurosis is a disease characterized by apathy, lack of initiative, loss of interest more marked in things and events not immediately personal or present, submissiveness, and sometimes no expression of feelings of resentment at harsh or unfair orders. There is also lack of interest in the future and an apparent inability to make practical plans for it, a deterioration in personal habits, toilet and standards generally, a loss of individuality, and a resigned acceptance that things will go on as they are—unchangingly, inevitably and indefinitely.

These signs vary in severity from the mute stuporose patient who sits in the same chair day after day, through the ward worker who has without protest surrendered the rest of her existence to the institution, to the active cheerful patient who enjoys the facilities available, often does some handicraft during the day, but shows no desire to leave the hospital, shows no interest in plans for a future in the world outside, and raises numerous difficulties and objections when anyone tries to help her to be discharged.

Occasionally the passive, submissive cooperation of the patient is punctuated by aggressive episodes which are casually attributed to mental illness but which, if carefully investigated, often seem to be provoked by some unkindness from another patient, a hospital employee or visitors. At other times an apparently similar provocation may produce no such response.

The patient often adopts a characteristic posture (Frontispiece), the hands held across the body or tucked behind an apron, the shoulders drooped and the head held forward. The gait has a shuffling quality, movements at the pelvis, hips and knees are restricted, although physical examination shows a full range of movement at these joints. The muscular power is found to be good when the patient cooperates in testing it. It may be that this posture develops through prolonged sitting and too little exercise. It was evident in chronic populations of hospitals and workhouses long before the introduction of phenothiazines in 1953, drugs which produce a somewhat similar posture known as Parkinsonism.

New patients arriving at the hospital may notice this posture. One patient in hospital for two months said: ‘I’m terrified of being sent where the women walk about with their hands under their aprons with no sign of life in them.’

Further evidence that an institutional neurosis is present may be found in patients’ notes (Martin, 1955). A severe neurosis will often have resulted in entries such as: ‘Dull, depressed and solitary’, or ‘Simple, mute and dirty’, or ‘Dull, apathetic and childish’, or ‘Remains uncommunicative, withdrawn and unoccupied’, or ‘Sits about all day and is quite lost’.

And in a mild example of the syndrome may be found remarks such as: ‘Unoccupied and lacking in initiative’, or ‘Works well but has no spontaneity’, or ‘Has settled down well’, or ‘Is cooperative and gives no trouble’.

Permutations of these words and phrases, ‘institutionalized’, ‘dull’, ‘apathetic’, ‘withdrawn’, ‘inaccessible’, ‘solitary’, ‘unoccupied’, ‘lacking in initiative’, ‘lacking in spontaneity’, ‘uncommunicative’, ‘simple’, ‘childish’, ‘gives no trouble’, ‘has settled down well’, ‘is cooperative’, should always make one suspect that the process of institutionalization has produced a neurosis. Such remarks were often found in the notes of chronic patients who had been in hospital for many years but who were sufficiently improved after one year’s treatment to leave hospital and lead an independent life outside and others who were considerably improved but remained in hospital. When reviewing such a case one must persistently ask oneself to what extent and to whom do such remarks apply. To the patient? To medical staff? To nurses? To attendants? To administrators? To those ultimately responsible for the psychiatric service?

Differential Diagnosis

Only in the past few years has it been recognized that the symptoms described above indicate a disorder separate from the one first responsible for bringing the patient into hospital, and that the disease is produced by methods of looking after people in mental hospitals and is not part of the mental illness preceding and sometimes existing with it.

The condition may be indistinguishable from the later stages of schizophrenia. Often it is complicated by residual schizophrenic features such as delusions or hallucinations. In such cases the diagnosis can only be made retrospectively after subjecting the patient to an intensive course of rehabilitation.

Depressive illnesses have many features in common with institutional neurosis, but the gloominess, sadness, guilt, agitation and despondency of depression are absent in institutional neurosis.

Organic dementias, such as arrested general paralysis of the insane and those of arteriopathic and allegedly arteriopathic origin, are easy to diagnose when neurological signs are present, but it may be difficult to realize that a supervening institutional neurosis is complicating and sometimes largely responsible for the mental picture. Again the only way to decide is retrospectively; to try an intensive rehabilitation programme directed at re-establishing the work habit on one hand and resocialization on the other.

Myxoedema may be distinguished by the typical face, croaking voice, constipation, and raised serum cholesterol, SGOT, LDH and CPK with lowered serum thyroxine, T₃, P.B.I., radioactive iodine uptake and so forth. The tendency to bury oneself under the bedclothes is common to both conditions.

It may be argued that the fact that treatment causes the disappearance of some of the symptoms ascribed to institutional neurosis is insufficient evidence to justify formulating a disease entity. However, other supporting evidence is that a similar set of symptoms is sometimes found in people without mental disorders in other institutions—prisoner-of-war camps, displaced persons camps, orphanages, tuberculosis sanatoria, prisons and convents. The symptoms are also encountered as an end result of many different disorders and, as Martin remarks, ‘It can hardly be argued that mental illness in general, regardless of its type produces an end state similar to institutionalization’. Asher (1947) described the effect of prolonged bed rest on some patients with physical, not psychiatric disorders: ‘At a later stage a dismal lethargy overcomes the victim. … The end result can be a comatose vegetable existence in which, like a useless but carefully tended plant, the patient lies permanently in tranquil torpidity.’

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^*Bornholm is a Danish island in the Baltic Sea. In 1933 a Danish physician, Sylvest, described an outbreak there of epidemic pleurodynia, a virus infection of the pleura characterized by severe chest pain—which one patient described as the Devil’s grip—fever and headache. Although the illness had been recognized and described in Germany, Norway, Iceland and the U.S.A. during the preceding 200 years the name ‘Bornholm’ has been applied since Sylvest’s monograph appeared—but of course the disease occurs all over the world.

Chapter 2

Aetiology or Factors associated with Institutional Neurosis

Publisher Summary

This chapter discusses the factors as...

Table of contents

• Cover image
• Title page
• Table of Contents
• Inside Front Cover
• Copyright
• Preface to the Third Edition
• Preface to the Second Edition
• Preface to the First Edition
• Inside Front Cover
• Foreword to the First Edition
• Chapter 1: Consideration, Clinical Features and Differential Diagnosis of Institutional Neurosis
• Chapter 2: Aetiology or Factors associated with Institutional Neurosis
• Chapter 3: Consideration of the Factors associated with Institutional Neurosis
• Chapter 4: Treatment of Institutional Neurosis
• Chapter 5: Wider Implications of Institutional Neurosis
• Summary
• References
• Index