Psychiatry --3

Personality Disorders

Self Harm Self Harm

Bi-polar Bi-polar

Personality Disorders

Anxiety

Schizophrenia Schizophrenia

Anxiety

Forensic

Eating Disorders

Eating Disorders

Dependence

Forensic

Dependence

Depression

Depression

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EDITORIAL

The Dark Art of Medicine

doi: 10.4201/lsjm.psy.011 Many medical students still regard psychiatry as the dark art of medicine. Even though Psychiatry now occupies a prized position as a compulsory module during the latter stages of clinical training at most medical schools many still leave wondering what a psychiatrist actually does for his patients. Although he often coordinates a team that discusses a patient’s treatment, how much time if any does he actually spend with the patients themselves?

For the medical student, early exposure to the schedule of a working psychiatrist undoubtedly sheds light on the role of a psychiatrist. But many are still left with the uneasy feeling that this is simply to assess patients at presentation, before passing them on to the other mental health professionals in the team. These other professionals are the ones that truly get to know the patient and his condition, that directly observe the effect, positive or negative, that treatment and his circumstances are having on him.

Psychiatrists are viewed simply as walking prescription pads, who aside from a basic understanding of psychopharmacology need only a copy of the ICD 10 or DSM close at hand to perform their roles.

This attitude poses an important question about the role of the psychiatrist. Has the demise of psychoanalysis as the main vehicle of psychotherapy resulted in loss of patient contact for psychiatrists? Since newer, evidence-based, therapies such as CBT are often provided by clinical psychologists and other health care workers, doesn’t this mean that psychiatrists are left with less and less actual time to spend with their patients? It’s not that we are arguing for the return of psychoanalysis, but the return of some of the time that this therapeutic role contributed to the patient-doctor relationship. A relationship that is surely vital for anyone making decisions about patient care.

The decline in therapeutic work is not for lack of training in psychotherapeutic theory and methods. Post graduate training, in the UK and USA, incorporates both technical and practical psychotherapeutic training. During the three “Core Training” years FRCPsych candidates, “must deliver basic psychological treatments in at least two modalities of therapy over both longer and shorter durations”.1 Since 2001 the US board responsible for accrediting post graduate training courses stipulated that those training in general psychiatry must show competence in five types of psychotherapy. 2 There is potential then for the new generation of psychiatrists to spend time with their patients using psychotherapeutic methods.

But is this training enough? Even if a psychiatrist wants to spend time with patients using evidence based methods like CBT, will this benefit the patient? Wouldn’t this time be better spent with someone, such as a clinical psychologist, who was better trained in the therapeutic method?

Unfortunately there is very little research on this topic, although the research that exists is not positive. A small study by Whitfield et al. asked a group of 51 Scottish psychiatrists who had received CBT training about their use of and training in CBT. 3 Although the majority said they used CBT type therapy in their practice less, than half received supervision in the method and less than half supervised others in their training. The main reason for not using or training in the method was lack of ‘protected time’ in their ‘job plans’.

Even in the US, where psychotherapy still forms a large proportion of training, there seems to be little motivation to develop these skills in younger psychiatrists. In a survey of 102 trainees, only 31% thought that training in psychotherapy was well integrated into their training with the number of patients actually treated and the level of assessment varying widely from course to course.4 Given these discrepancies in experience it is reasonable that psychological therapy is provided by those more experienced to do

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EDITORIAL so. However, it is difficult to see where and when a psychiatrist gets to know his patient as their treatment progresses. Certainly he will receive feedback from others, but as he is often the person responsible for integrating their care , is this ‘feedback’ enough?

The question that remains is whether psychotherapy still has a role in communication and care between patient and psychiatrist. The training of psychiatrists in psychotherapy may well be only to leave trainees with an awareness of these methods, but in using this training in this way aren’t we missing a chance to claim more ‘protected time’ with our patients?

Samuel Ponnuthurai & Alexander Ross Section Editor Psychiatry References 1.

2.

3.

4.

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Royal College of Psychiatrists. A competency based curriculum for

specialist training in psychiatry. London: Royal College of Psychiatrists; 2009. Available from http://www.rcpsych.ac.uk/PDF/Core_Feb09.pdf` Plakun, E. M. Finding psychodynamic psychiatry’s lost generation. Journal of the American Academy of Psychoanalysis & Dynamic Psychiatry. 2006; 34 (1): pp. 135 – 150.

Whitfield, Graeme, Connolly, Moira, Davidson, Alan, Williams, Chris. Use of cognitive-behavioural therapy skills among trained psychiatrists.

Psychiatric Bulletin. 2006; 30(2): pp. 58-60.

Khurshid, Khurshid A, Bennett, Jeffrey I, Vicari, Sandy, Lee, Karen L, Broquet, Karen E. Residency programs and psychotherapy competencies: A survey of chief residents. Academic Psychiatry. 2005; 29(5) : pp. 452-458.

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These questions relate to the ongoing debate between the biological model of mental illness and the psychosocial model – a debate we have tried to represent in previous issues of this journal. For those who stand wholly on the biological side of this divide, it must be difficult to see how such time can be well spent. Whilst for those who stand wholly on the psychosocial side it must be difficult to see how, given the current levels of training in therapy, and the time set aside for it in a psychiatrist’s job, a psychiatrist can actually usefully practice these methods.

But surely, we argue, there is a simpler matter at stake here.

Surely this time is also an important opportunity to get to know each patient’s specific circumstances and response to treatment. Surely this information is vital wherever one stands in this debate.

Is there method in madness after all?

It is an idea that first rose to infamy in the late 18th century with the Romantic Movement, and its appeal has cantankerously refused to dissipate. I am talking of course, of the link between madness and genius. The recent flurry of headlines has two root stories.

Psychiatrist Professor Michael Fitzgerald has been publicizing his new book, in which he claims luminaries as diverse as Kurt Cobain, Lord Byron, Clark Gable, Oscar Wilde and Picasso may all have been suffering from ADHD. He hopes that highlighting the possible positives of the condition, will help reduce stigma amongst sufferers.

Additionally, the researchers at the Karolinska Institute in Sweden in association with Kings College London, have found students who excelled at school age 16, were almost four times more likely to develop bipolar disorder as adults. The study carries particular weight as it is one of the first to survey such a substantial population, with a total of 713,876 study participants. It is thought the mild advantages of hypomania may account for this; hypomania provides a cognitive state of increased innovation and piquant wit, heightened emotional intelligence, and oft associated with an extraordinary stamina and boost in concentration. Researchers propose that these cognitive styles present a double-edged sword, improving school performance during adolescence but simultaneously predisposing students to significantly increased risk of bipolar disorder in later life. Another conclusion reached, however, will ground any Romantics firmly in reality. Students with notably poor school performance are at twice the risk of developing the condition compared to the general population, as a consequence of the darker cognitive styles of the disorder such as deep depression which is frequently accompanied by other disturbed behaviour such as substance misuse.

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PANELS PAGE

Psychiatry through the ages Nicola Hood

Year 4 Medicine, King’s College, London nicola.hood@lsjm.co.uk

Psychiatry is currently defined by the Concise Oxford English Dictionary as, “the branch of medicine concerned with the study and treatment of mental illness and emotional disturbance.” Whilst history suggests that madness in man is no modern affliction (note Shakespeare’s merry medley of meshuggenehs) the incorporation of psychiatry under the esteemed umbrella of medicine is more recent, as is the accompanying application of scientific standards to its theories and practise. Yet still, there is hesitation in the air. Public opinion lurches precariously from a heartfelt embrace of the American ‘therapist’ culture, in which we warble weekly about our issues, to a rejection of all mental illness as a problem of the weak, and dash it all chaps, thoroughly un-British to boot. This fickle mentality to an issue of such pertinence can no longer be tolerated. It is the duty of the next generation of medics to remember to respect our future colleagues equally, regardless of the specialty selection. Accepting the fundamental value of mental health maintenance is the cornerstone of whole-patient-centred-care, and we owe it to our patients to sharpen up our act. Psychiatry must not, cannot be belittled; ignoring its importance is nothing short of negligence.

Three News Items of Note

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Daring to Redefine- DSM V By the time you read this article the American Psychiatric Association will have released a draft version of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders- the psychiatrists’ Bible.

Whilst officially only diagnostic to America- where it defines not only diagnosis and treatment but who will pay for said treatment- it nevertheless has a trickle-down effect to the views of mental health held by society as a whole. The first DSM was published in 1952, and this version will not be finally released until 2013 (by which time this author hopes to be pacing the wards). Over time, the editions have reflected a flavour of what’s fashionable, drifting from a highly Freudian standpoint across to a more heavily biomedical approach.

Much has been written about concerns over transparency and the influence of the drug giants such as Pharma, but perhaps a more apposite debate should be had over the applications of the final product. The brain remains little-understood, people even less so.

The DSM does not diagnose, it is only an aid to diagnosis, and we need psychiatrists to carefully analyze and appraise each and every individual, before slapping on a label, which may remain with them for life.

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Banishing Baby Brain You might expect that new discoveries in psychiatry to relate to previously unknown biochemical mechanisms underlying common conditions, or perhaps novel aetiological factors. What is most unexpected is to read that a team lead by Helen Christensen from the Australian National University are declaring a condition does not exist at all. Colloquially referred to as ‘baby brain’ it has been traditionally thought that motherhood and pregnancy reduce women’s cognitive powers. The latest research though, banishes this belief as little more than another old wives’ tales, a superstition similar to swirling a wedding ring to discover if it’s a boy or a girl. The axiom may have wormed its way into the apple of popular culture but can actually be explained as a combination of a pre-partum change in women’s attributional style and an (evolutionarily adaptive) shift in attentional focus to the child. The researchers aspire that their results challenge the view that mothers are less effectual in the workplace than their colleagues, by dint of a change in attitudes of obstetricians, midwives and healthcare visitors, as well as the publication of their conclusions in the wider media.

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Schizophrenia through History Kaanthan Jawahar, BSc (Hons) Year 4 Medicine, King’s College London kaanthan.jawahar@kcl.ac.uk doi: 10.4201/lsjm.psy.009

Introduction Schizophrenia is viewed as a mental disorder, characterised by abnormalities in perception and expression of reality. Disturbances occur in thought, behaviour and emotion, and can affect all sensory modalities1.

Schizophrenia tends to occur equally amongst men and women, with a typical age of onset of 20 to 28 years in males and 26 to 32 years in females2. The point prevalence of Schizophrenia has been shown to be 0.46%, the period prevalence to be 0.33%, the lifetime prevalence to be 0.4% and the lifetime morbid risk to be 7.2%3.

Currently, there is no laboratory test to confirm a diagnosis of schizophrenia. Nor does a sign or symptom exist, which is considered to be pathognomonic of the disorder. Instead, a diagnosis is made using the DSM-IV-TR4 or ICD-10 criteria5.

The debate rages on over the aetiology of schizophrenia. Genetic predispositions, the dopamine theory, environmental factors, glutamate dysregulation and congenital factors all seem to play a part1. In the absence of a tangible pathological marker, one must question why these criteria are used. How did they come into existence and what is the underlying thinking behind them? To begin to answer these questions, one must look back at the initial conception of schizophrenia itself.

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Early Views The earliest evidence of the disorder can be traced back to Ancient Egypt (circa 1500 BC). The Book of Hearts within the Eber papyrus, describes in detail disorders that resemble modern day depression, dementia and the thought disturbances found in schizophrenia6.

Brief descriptions consistent with psychoses and schizophrenia also appear in Hindu Ayurvedic texts (circa 1400 BC)7. In medieval times, hallucinations and delusions were interpreted as proof that the individual was possessed, leading to several women being executed on the assumption that they were witches6.

The 19th Century Wilhelm Griesinger (1817-1869) spoke of ‘einheitspsychose’ (unitary psychosis) and believed that all psychoses were caused by a single pathological process in the brain. A disorder of the ‘mental reflex’ resulted in the symptoms of psychosis (e.g. a retardation resulted in melancholia and a hyperactive state resulted in mania)8.

Bénédict Morel (1809-1873), a French physician described a disorder mainly affecting males in adolescence, in which withdrawal, odd mannerisms, self-neglect and mental deterioration were present, coining the term ‘démence precoce’ in 1853 (premature dementia). In contrast to Griesinger’s ‘einheitspsychose’, Morel wanted to classify disorders based on their cause, symptoms and outcomes9.

Karl Ludwig Kahlbaum (1828-1899) placed importance on the course and clinical outcome of the disorder. He differentiated between disorders with and without an organic aetiology and coined several new terms for newly described symptoms and syndromes, including paraphrenia, dysthymia, and cyclothymia10. Like Morel, Kahlbaum also described a psychosis in the young - ‘jugendliche irresein’ (juvenile madness). However, he is better known for his description of ‘katatonie’ (catatonia) – a disturbance in motor functionality as a phase in a progressive illness, comprised of psychosis and depression, commonly ending in dementia11.

Kahlbaum was also the mentor of Ewald Hecker. Together, their studies on psychotic patients at Kahlbaum’s clinic resulted in Hecker adding ‘hebephrenia’ (a disorder with an onset in adolescence and continuing mental decline – ‘hebephrenia’ literally translates as ‘silly mind’) and ‘cyclothymia’ (a cyclical mood disorder) to psychiatry12.

Emil Kraepelin & Dementia Praecox Emil Kraepelin (1856-1926) studied medicine in Leipzip and Wuerzburg between 1874 and 187813. Unlike his contempories, Kraepelin had little interest in identifying pathological markers in brain samples. Instead, he had a profound curiosity in human psychology as a dimension of psychiatric illness. He was a great admirer of the experimental psychologist Wilhelm Wundt. In 1882, he took up a post Leipzig to study with Wundt in his newly established psychological laboratory14.

In 1883 his work with Wundt spawned the first edition of his ‘Compendium der Psychiatrie’ (Compendium of Psychiatry), in which he argued that psychiatry was a branch of medical science and so must be subject to investigation and research like the other natural sciences. With respect to psychiatry, this involved identifying discrete disorders and then to map out a corresponding progression of the illness, taking into account individual differences in personality in the case histories15.

In 1890, Kraepelin took a professorship of psychiatry at Heidelberg.

It was here that Kraepelin was free to research as he had wanted, without the pressure to implement neurology14. Within 4 weeks of admission, patients were assigned a diagnosis and their progression

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was vigorously followed up. Kraepelin had all of this information on ‘zahlkarten’ (data cards) - each one unique to each patient and updated during each interaction16.

By focussing on clinical psychopathological research based on data about the course of an illness, Kraepelin aimed to define nosological boundaries in psychiatry.

Kraepelin found that a large proportion of his patients progressed through to dementia, despite their differing clinical presentations.

He postulated that one illness was the cause of this. Naturally, he pursued this finding to identify indicators for this new disorder17. With the use of his ‘zahlkarten’, he had created a database from which reliable data could be extracted and interpreted.

The fourth edition of Kraepelin’s ‘Lehrbuch der Psychiatrie’ introduced dementia praecox to the scientific community in 1893, under the category of ‘Psychic Processes of Degeneration’14.

Symptoms included auditory hallucinations, delusions, autism, abnormal thought associations, flattening of affect, lack of insight, stereotypy and negativism, with onset typically in adolescence18.

Kraepelin also felt that there was a definitive pathological cause of his dementia praecox and he was sure that it would be discovered in the future - a departure from his initial repulsion of biological psychiatry19.

The sixth edition of Kraepelin’s ‘Lehrbuch’ (1899) saw him split the vast world of psychotic disorders largely into two main groups. The first was ‘Manic-Depressive Psychosis’, whose central symptom was a disorder of affect and the course was cyclical, with patients often going into remission following acute episodes, and in some cases recovering completely. The second was ‘Dementia Praecox’, where psychosis was present in the absence of an affective component, with patients suffering from uniformly progressive cognitive decline.

Dementia praecox consisted of the catatonic, hebephrenic and paranoid types. The current DSM-IV-TR criteria speaks of these types as well (renaming the hebephrenic type as ‘disorganised’)20.

Kraepelin had initiated a change in the way that psychotic symptoms were interpreted. The presence and not the content of symptoms was now the focus.

Eugen Bleuler & Schizophrenia Eugen Bleuler (1857-1939) was a Swiss psychiatrist who followed Kraepelin’s work closely throughout his career. But his focus lay more on the mechanisms of the symptom formation in dementia praecox, as opposed to the prognosis. He coined the term ‘schizophrenia’ in 1908 (literally ‘splitting of the mind’) as he felt the underlying pathology was a cognitive loosening of association14.

He also felt that schizophrenia was a heterogeneous entity and, as such, had a variable course and did not inevitably enter a deteriorating progression. Complete recovery was also possible. In this way, Bleuler felt that ‘dementia’ was not appropriate21.

Bleuler postulated the existence of ‘fundamental’ symptoms and

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‘accessory’ symptoms. The fundamental symptoms have come to be known as the ‘four A’s’: Ambivalence, flattening of Affect, Autism and loosening of Associations. The accessory symptoms were the more positive, psychotic features of the disorder: hallucinations, delusions, catatonia, abnormal behaviours etc.9.

Bleuler felt that his four A’s were found in every case of schizophrenia, whilst the more overt accessory symptoms could be found in other disorders. If loosening of associations occurred in the individual’s mind, then the accessory symptoms would invariably ensue, resulting from the cognitive impairment. Therefore, one could argue that his fundamental symptoms were pathognomonic of schizophrenia22.

Bleuler’s views held sway for a substantial amount of time, especially in the USA. But his fundamental and accessory symptoms and his new categories (‘latent’ and ‘simple’ schizophrenia) led to problems in diagnosis, as discussed by Stefan et al:

“

... this confusion was confounded by the clinical heterogeneity of schizophrenia, the lack of clear prognostic features and the failure to discover any definitive pathological abnormalities, and led to an expansion of the concept of schizophrenia to the extent that it became a vague symptom for severe mental illness with different meanings in different countries3.

”

Kurt Schneider & 1st Rank Symptoms Kurt Schneider was born in 1887 in Württemberg, Germany. He studied medicine in Türbingen and Berlin. In 1945, he was appointed to the chair of psychiatry and neurology at the University of Heidelberg, where he stayed until he retired in 195524.

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Schneider was concerned with improving diagnostic methods in psychiatry. His beliefs were similar to that of Karl Jaspers (1883 – 1969), who believed that the essence of psychoses was that the content was ‘non-believable’ by normal individuals (i.e. they were unable to understand and relate to it). This made Schneider move away from trying to interpret symptom content and instead to understand the symptom form20. He argued that the content of psychoses were of little importance in diagnosis. Instead, one must look at the form of the psychosis (e.g. how a delusional belief is held and how a hallucination is experienced)20.

Schneider’s largest contributions to our understanding of schizophrenia were his ‘1st Rank Symptoms’ (auditory hallucinations, delusional perception, thought insertion, withdrawal and broadcast etc.)25.

Like Bleuler, Schneider wished to make a list of ‘fundamental’ symptoms. But Schneider’s focus was on clinically observable symptoms. He thought that the underlying component in schizophrenia was a loss of personal autonomy and the inability to distinguish between self and non-self 26.

“

Among the many abnormal modes of experience that occur in schizophrenia, there are some which are put in the first rank of importance, not because we of them as basic disturbances, but because they have this special value in helping us determine the diagnosis of schizophrenia... Symptoms of the first rank importance do not always have to be present for a diagnosis to be made26.

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”

Schneider had created a symptom cluster that can be reliably and objectively used to diagnose schizophrenia (much like the current DSM-IV-TR).

Schneider also spoke of second rank (negative) symptoms (e.g. flattening of affect, poverty of speech, social withdrawal), which he felt were highly suggestive of schizophrenia, but not specific to the disorder12.

DSM-III The Diagnostic and Statistical Manual of Mental Disorders 1st edition (DSM-I) was published by the American Psychiatric Association in 1952. Work had began for this in 1948, with the aim being to provide American psychiatry with a single national system of classification.

At that time, psychoanalysis was the predominant school of thought and this classification system reflected that. DSM-II became available in 1968 and further consolidated the psychoanalytical hold over American psychiatry27.

During the 1960s, Schneider’s 1st rank symptoms held sway in the UK and Europe, after British investigators translated his work20.

This global non-standardisation of diagnostic criteria prompted two studies to analyse if the differences had any implications. The US-UK Diagnostic Study28 compared diagnoses of psychiatric disorders between London and New York. A major finding was that schizophrenia seemed to have a much wider concept in the USA. Some patients, who received a diagnostic label of schizophrenia in the USA, would have been diagnosed with an affective disorder in the UK29. The International Pilot Study of Schizophrenia (IPSS – World Health Organisation)30 looked at several countries and concluded that broader criteria were used in the USA when compared to Europe.

Furthermore, it also suggested that a higher degree of consistency in the clinical picture of schizophrenia was found when using the strict diagnostic rules of Kraepelin and Schneider.

These differences were one of the main factors, which led to the creation of DSM-III and its publication in 1980.

The man in charge of the DSM-III task force was Robert Spitzer.

Born in 1932, and educated at New York University Medical School27, he sought to make diagnoses as precise as possible. His thinking was that all disorders had an underlying pathology and thus the use of stringent criteria for diagnoses would correspond better to an uncertain aetiology – a Kraepelinian way of thinking. The major innovation of DSM-III was the presence of a symptom checklist alongside the descriptive prose of the disorder. A patient would have to display symptoms on this checklist in order to be diagnosed31.

Spitzer had standardised psychiatric practice and research. He had created diagnostic criteria, which were nominally evidence based and had laid down testable hypotheses, which would ensure the continuing review of the criteria. DSM-IIIR (revised edition 1987), DSM-IV (1994) and DSM-IV-TR (text revision - 2000) have followed27.

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DSM-V DSM-V is currently being developed and is due to be released in 201232.

One would expect relatively few changes to be made to the diagnostic criteria, as they have remained largely unchanged since DSM-III. However, Van Os33 argues for a total overhaul of the existing criteria - “…scientific and societal developments point to a system of classification combining categorical and dimensional representations of psychosis in DSM and ICD. Furthermore, it is proposed to introduce…the diagnosis of salience dysregulation syndrome”.

In this syndrome, it is argued that positive psychotic experiences alter salience attribution (i.e. display other psychopathologies, such as mania and cognitive deficit). When these components rise above a threshold, intervention is required33.

This model is treatment based. It measures affected mental components and so provides therapeutic targets. It does not attempt to understand the underlying psychopathology, but it does not need to, as the underlying cause of Schizophrenia is still unknown.

Conclusion Mental illness has been present throughout time. Evidence of psychoses has been observed as far back as ancient Egypt. However, the concept of schizophrenia is a mere two hundred years old. The works of Griesinger, Morel, Kahlbaum and Hecker all made contributions, but it was Emil Kraepelin who changed not just our understanding of schizophrenia, but also our understanding of psychiatry.

He simplified the myriad of psychiatric disorders into two categories: manic-depressive psychosis and dementia praecox20. He felt that in the absence of pathological markers, one must make the diagnosis of the disorder as specific as possible – the same thinking of Robert Spitzer31 and DSM-III nearly a century later.

Bleuler and Schneider created lists of symptoms, which could be used to diagnose schizophrenia. Indeed, Bleuler’s beliefs were instrumental in DSM-I and DSM-II. But it is Schneider’s 1st rank symptoms25 that are present in the current DSM-IV-TR classification.

Before Kraepelin, diagnoses in psychiatry were largely descriptive.

He sought to add validity and reliability to psychiatric practice. With this new validity and reliability, psychiatric research became possible

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and served to increase our knowledge of disorders and subsequent treatment.

Even with the absence of definite pathophysiology and the arguments against diagnostic labels, nosology in psychiatry is needed for reliable communication in the research world. Without Kraepelin, we would not have this.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Kring AM, Davison GC, Neale JM, Johnson SL. “Schizophrenia” in Abnormal Psychology 10th ed. USA, John Wiley & Sons. 2007 Castle D, Wesseley S, Der G, Murray RM. The incidence of operationally defined schizophrenia in Camberwell 1965–84. British Journal of Psychiatry 1991;159:790–794 Bhugra D. The global prevalence of schizophrenia. PLoS Medicine.

2006;2(5):372–373 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th Edition Text Revision. Washington DC, American Psychiatric Association. 2000 World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Switzerland, WHO. 1992 Kyziridis TC. Notes on The History of Schizophrenia. German J Psychiatry, 2005;8:42-48 Lawrie SM, Johnstone EC. “Schizophrenia and Related Disorders” in Companion To Psychiatric Studies 7th ed. Johnstone EC, CunninghamOwens DG, Lawrie SM, Sharpe M, Freeman CPL (eds.). London, Churchill Livingstone. 2004 History of Psychiatry - Greisinger. http://bms.brown.edu/ HistoryofPsychiatry/griesinger.html. Accessed on 30/05/2009 Gelder M, Harrison P, Cowen P. “Schizophrenia” in Shorter Oxford Textbook of Psychiatry 5th ed. Oxford, Oxford University Press. 2006 Bräunig P, Krüger S. Karl Ludwig Kahlbaum, M.D. 1828–1899. Am J Psychiatry 1999;156:989

For references see thelsjm.co.uk.

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The Mental Health Team in Britain: Past, Present and Future Tariq Shafi

Year 4 Medicine, University of Nottingham tariqshafi@btinternet.com doi: 10.4201/lsjm.psy.008 The mental health team is, like any team in medical care, the crux of provision of care for, in this case, patients with psychiatric difficulties. The twentieth century has seen a great change in the provision of mental health care and, accordingly, the mental health team. This article will discuss how society impacts on mental health care, and compares the components of a mental health team from 50 years ago to that of today. It will also hypothesise what the mental health team will look like 50 years from now.

Impact of Society on Psychiatric Care There is little doubt that society affects not only science but healthcare. The latter half of the twentieth century saw a shift in psychiatric care from inpatient to outpatient care, a process termed ‘deinstitutionalization’. Immediately after the end of World War II, Britain underwent considerable economic and social change. The country was bankrupt after the war as a result many industries and services were nationalised, including the health service. The move to community-based treatments probably derived from a change in social philosophy, new and effective forms of psychopharmacology and the rundown state of the asylum buildings 1.

The Mental Health Team in 1960 Fifty years ago, society in Britain was markedly different than it is now. Television had hit British homes and the nuclear family unit was more commonplace than today.2 The majority of women did not work outside the home and the proportion of people attending church was several fold higher than today.3 On the political front, the great enemy was Communism and the threat of the atom bomb pervaded the air. The main autonomous source at that time, the BBC, paled in comparison with the independent and diverse media of today.

In 1960 the focus of psychiatric care was beginning to shift from long-term, often indefinite inpatient stay in an asylum to a more diverse, outpatient system of care. Physical treatments such as electroconvulsive therapy and lobotomy were relatively new and used commonly. Day hospitals had begun to be established, providing more flexible psychiatric services and reducing the number of hospital beds. The use of neuroleptic drugs allowed more patients to be managed in the outpatient setting. The focus from inpatient to outpatient care was also illustrated by the appointment of outpatient psychiatric nurses, first deployed in Warlingham Park Hospital in Croydon in 1954, whose role was to facilitate rehabilitation and help former patients seek jobs and accommodation. Furthermore, the Percy report in 1957

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recommended that, ‘the majority of mentally ill patients do not need to be admitted to hospital as inpatients. Patients may receive medical treatment from general practitioners or as hospital outpatients and other care from community health and welfare services.’4 The Mental Health Team Today Society today is almost unrecognisable in comparison to fifty years ago. Whilst wars are more numerous and prevalent today, Britain is not in its recovery phase from a world war. Stigma regarding mental illness is less prevalent, not least because information is more accessible in the Internet age. People are less reluctant to seek help for medical problems than previously, with GP attendances per patient increasing by 50% since 1971. 5 Today, many people with mental health problems never see a psychiatrist, and are managed by their GP who may prescribe medications or refer them for counselling/psychotherapy. The factors predisposing to mental illness are more fully appreciated than they were in 1960. A mental health team today addresses these areas such as relationship problems, housing problems or benefits, and as such are quite large. Most people recover from mental health problems without coming into hospital,6 and the mental health teams are thus called Community Mental Health Teams.

Psychiatrists today put greater emphasis on emotional problems than previously. Clinical psychologists are trained in psychological treatments. The number of clinical psychologists has increased four-fold since 1995.7 Community psychiatric nurses can give and monitor medicines, and many have special training in themes such as eating disorders or behaviour therapy. The community psychiatric nurse is commonly the care coordinator assigned to the patient. As the key worker, the community psychiatric nurse often also provides the role of the occupational therapist, helping people get back to doing things and regaining or gaining self-confidence; and that of the social worker, helping people with money, housing and childcare issues.

A greater number of staff without a professional qualification may work with the team because of their special experience. These include people who have experienced mental health problems, advocates, and workers from day centres or housing organisations.

Specialist old age psychiatry teams may include other professionals such as speech therapists or physiotherapists. Such workers may also see people in their own homes. Most teamwork is done outside hospital although the team may have a base in a clinic.

Families and friends are involved, and advocates can be employed.

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The patient has a greater role in his or her care, and whether they should proceed with pills or counselling.

The Mental Health Team in 50 Years It is always difficult to envisage what society will be like in the future, especially as distant as 2060. Technological advances may be overestimated, illustrated by films such as Back to the Future II where hovering skateboards and automated clothing were standard in 2015. Conversely, there may be a regression in society post a nuclear war, seen in films like The Postman and the Mad Max movies. However based on trends, it is predictable that in 2060 Britain will be almost entirely secular and less conservative. The question however, is whether this trend will apply to the stigma of mental illness?

Although recent research has shown that the older population have a more sympathetic view of mental illness and, although people are more aware of mental health issues, views such as people with mental illness having less right to a job than others and being more prone to violence are becoming more common.8 The Moving People campaign has had a considerable effect in counteracting stigma in Scotland, where it has considerable backing by the Scottish Executive.

I believe that in 2060 there will be several changes to the mental health team. A dietician is already a common component of the mental health team but is likely to play an even greater role if trends in diet continue. Obesity in both men and women increased by 10% between 1994 and 2004. Food not only affects physical appearance, but also psychological health. For instance, complex carbohydrates as well as certain food components such as folic acid, omega-3 fatty acids, selenium and tryptophan are thought to decrease the symptoms of depression.9 Furthermore, people with mental health problems are more likely to develop or compound a weight problem, due for instance in lethargy, a feature of depression. Weight gain, impaired glucose tolerance (leading to diabetes) and osteoarthritis may also be a side-effect of some treatments such as antipsychotics.

I believe there will be a greater input from expert patients who have been through mental illness. An expert-patient Self Management Training Programme has been in place for manic depression since 1998, with good outcomes demonstrated in an ongoing randomised controlled trial.10 There may also be a role of a geneticist, as genotyping may initially be introduced to inform more tailored prescription of psychotropic medications. For instance, research has shown that patients with genotypes giving rise to extremes of activity of a particular cytochrome had an alteration in response to certain antipsychotics.11 Alcohol intake has increased two-fold in the last 50 years 12 and is likely to rise further and substance abuse, although declining

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in recent years nevertheless had an incidence of 25% amongst young adults in a recent study.13 The high rate of homelessness and substance abuse are factors relating to patient non-compliance and an assertive outreach worker can play a key role in the mental health team.

Finally, in terms of targeting specific groups early intervention services will become more common. Comprised of the members of the community health team these teams are already placed to play a key role in diagnosing psychosis early, enabling a faster recovery and reducing the incidence and severity of relapses. Due to the additional roles in the future mental health team outlined above, I believe that the clinical psychologist will still play an integral but lesser role, cognitive behavioural therapy remaining the predominant method.

Conclusions Since the 1950s the focus of psychiatric care has shifted from the centuries-old system of inpatient care to care within the community.

There are more members of a mental health team than previously, and the mainstay of treatment focuses on pharmacological, psychological and social therapy and rehabilitation. We are approaching an age of gene therapy and awareness of the link of diet to disease, and practitioners expert in these fields as well as expert patients can be future members of the mental health team.

It is unlikely that psychiatric care will be practised entirely in the community but, like society, in time psychiatric care will bear even less resemblance to what it was like in 1960.

References 1.

2.

3.

4.

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Turner T. The history of deinstitutionalization and reinstitutionalization.

Psychiatry 2004 Sep;3(9):1-4.

Office for National Statistics: http://www.statistics.gov.uk/cci/nugget.asp?id=1865.

London [updated 2007 Oct; cited 2010 Mar 19].

Whychurch.org.uk: http://www.whychurch.org.uk/trends.php [updated 2007 Apr; cited 2010 Mar 19].

Lord Percy. Report of the Royal Commission on the Law relating to Mental Illness and Mental Deficiency. London: HMSO, 1957.

Office for National Statistics: http://www.statistics.gov.uk/cci/ nugget.asp?id=827. London [updated 2004 Apr; cited 2010 Mar 19].

The Mental Health Team: http://www.rcpsych.ac.uk/ mentalhealthinfo/communityteam.aspx. London: Royal College of Psychiatrists [updated 2009 Dec; cited 2010 Mar 19].

Migration Advisory Committee Shortage Report – Clinical Psychologists, SOC2212. NHS Workforce Review Team, 2009.

Psychminded.co.uk: http://www.psychminded.co.uk/news/ news2007/July07/stigma003.htm. Leamington Spa [updated 2007 Jul; cited 2010 Mar 19].

Feeding Minds: the impact of food on mental health, p8. From http:// www.mentalhealth.org.uk/campaigns/food-and-mental-health.

London: Mental Health Foundation [updated 2007 Mar; cited 2010 Mar 19].

The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. London: Department of Health, 2001.

For references see thelsjm.co.uk.

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RESEARCH

The Mental Health of Mental Health Staff: Psychological distress and burnout in DSPD units Mohammed Al-Hairi,BSc (Hons) Year 5 Medicine, Imperial College School of Medicine mohammed.al-hairi@nhs.net doi: 10.4201/lsjm.psy.010 Clinical burnout and psychological morbidity amongst prison officers and mental health professionals in psychiatric institutions is at alarming levels. Emotionally exhausted and physically drained forensic staff harm the practitioner-patient relationship and the rehabilitative therapeutic climate. As part of the larger MEMOS project assessing the organisation of the nationwide Dangerous and Severe Personality Disorder (DSPD) programme, this exploratory cross-sectional study will investigate the levels of burnout and psychological distress in all frontline workers employed in the four maximum security DSPD units delivering the new service. Of the total 749 members of staff, 356 (47.5%) completed a questionnaire that assessed their psychological wellbeing. Perhaps surprisingly, data analysis revealed that, on average, care of violent offenders only provoked moderate levels burnout. However, a quarter of the workforce was experiencing some degree psychiatric distress, a minority seriously so, and many had a particularly low sense of work-related productivity and achievement. These results provide food for thought for programme administrators and an impetus for further research to explore potential supportive strategies.

Keywords: • Burnout • Forensic • Mental health • Psychiatric • Nurses • Prison officers • Maslach Burnout Inventory • General Health Questionnaire • Dangerous and Severe Personality Disorder 226

Background Stress and Burnout Occupational stress has been well documented across the spectrum of healthcare specialities 1. Generic organisational factors repeatedly highlighted as major workplace stressors include a lack of resources, responsibility without authority, limited role autonomy 2, 3 and most importantly the risk inherent in a deep emotional investment in the wellbeing of vulnerable patients 4. Forensic psychiatric professionals are presented with a particularly demanding work environment in both context and purpose. Numerous studies have demonstrated that the occupational stressors for correctional staff can be broadly categorised into the difficulties intrinsic in treating incarcerated psychiatric patients and those that revolve around perceived bureaucratic practices.

Delivering therapy in a forensic setting entails coping with, and adapting to, potentially stressful patient encounters. Sullivan showed that psychiatric nurses had to deal with challenging behaviours, untoward incidents and violent confrontations on a regular basis 5. Correctional nurses and officers who lack the necessary skills to intervene appropriately can begin to view their patients as untreatable, difficult behaviours as intractable and work demands as unmanageable. Such attitudes may lead to feelings of inadequacy, frustration and psychological exhaustion 6. Psychologist Herbert Freudenberger was the first to identify this phenomenon and coined the term burnout which is still used colloquially to this day 7.

Freudenberger’s pioneering investigations were advanced by Maslach who refined the concept and developed the Maslach Burnout Inventory (MBI) where burnout is conceptualised as a complex multidimensional construct defined by emotional exhaustion, depersonalisation and reduced personal accomplishment (Figure 1). Professionals suffering from burnout feel emotionally and physically drained, develop dehumanised, callous or cynical feelings towards patients, while their sense of professional productivity and achievement diminish 8. The burnout phenomenon has been eloquently described as an enduring sense of helplessness and hopelessness 9 and has been linked with absenteeism 10 high employee turnover, and even alcohol abuse 11. Healthcare work itself should not be psychologically hazardous and as such, burnout

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RESEARCH

is increasingly being regarded as a major cause for concern for NHS policy makers.

Figure 1: Schematic diagram of the burnout phenomenon.

Chronic emotional and interpersonal occupational stressors instigate or exacerbate Emotional Exhaustion and Depersonalisation leading to diminishment of one’s sense of Personal Accomplishment.

Chronic Occupational Stressors:

Reduced Personal Accomplishment Depersonalisation Emotional Exhaustion Dangerous and Severe Personality Disorder The origin of the Dangerous and Severe Personality Disorder (DSPD) diagnosis can be traced back to a UK government “white paper” which described a putative criminogenic mental disorder for which broadened commitment criteria was proposed 12. The authors noted that “individuals who present a risk to others because of their severe personality disorder are rarely detained under the [existing] Mental Health Act 1983 because they are assessed as being unlikely to benefit from the sorts of treatment currently available in hospital” 13. Citing the importance of public protection, the government passed legislation that would eliminate this treatability criterion and enable the involuntary hospitalisation of severely personality disordered persons shown capable of causing serious harm and who presented an unacceptable risk to society.

The new proposals generated controversy almost immediately with leading psychologists voicing concern over the conversion of psychiatric facilities into instruments of social control without explicit therapeutic intent 14. Many remain unconvinced that these people are treatable or their antisocial behaviours amenable to change. As such, the issue of whether the government’s DSPD proposals strike the right balance between individual liberty and public safety remains open.

Nevertheless, as a result of the landmark publication four pilot DSPD units were opened; two within HM Prison Service (HMP Whitemoor and HMP Frankland) and two based in secure NHS psychiatric hospitals (Rampton and Broadmoor hospitals).

Ongoing concerns that working with this challenging population

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has an adverse impact on the health and welfare of staff lead to the creation of the Multi-method Evaluation of Management, Organisation and Staffing (MEMOS) project.

Study Objectives As part of the MEMOS project, this descriptive observational study will: Examine the levels of burnout and psychological distress in the DSPD workforce.

Compare the results between healthcare nurses and prison guards, therapists and non-therapists.

Materials and Method Design and Sample A self-report multi-variate cross-sectional survey utilising the Maslach Burnout Inventory (MBI) 15 and General Health Questionnaire (GHQ-12) 16 was administered to all frontline personnel employed in the four pilot DSPD units.

These units share common clinical guidelines and provide longterm residential psychiatric care to adult patients with a diagnosis of DSPD. Nurses, psychiatrists and certain trained prison officers deliver therapy sessions. Frontline employees were defined as “any professional who carries out therapeutic, medical or educational activities or is in regular contact with patients/prisoners in a supervisory capacity”.

The study was approved by NHS COREC (Central Office for Research Ethics Committees).

Instruments A demographic datasheet was included in the questionnaire pack with questions on personal details and occupational variables such as length of time in post and previous experience in a forensic setting. These where then treated as independent or explanatory variables.

The MBI is a validated 22 item self-report scale widely used in occupational studies of human services workers. It comprises three separate subscales examining Emotional Exhaustion (EE), Depersonalisation (DP) and Personal Accomplishment (PA).

Respondents are asked to rate items on a six-point Likert-type scale ranging from 0, ‘never’, to 6 ‘every day’ and mean scores are then calculated using these frequencies. While high scores for EE and DP indicate a high degree of burnout, the PA subscale measures a protective personal quality and so higher scores indicate lower levels of burnout.

The GHQ-12 assesses the current level of experienced mental

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RESEARCH stress of respondents. It includes items such as ‘Have you recently been feeling unhappy and depressed?’ and is rated on a four-point scale (scored 0-3). Total scores over 3 are considered above the threshold for psychiatric “caseness” and indicate probable psychiatric distress.

Procedure The survey was distributed with an information letter attached in which assurances of the confidential, voluntary and anonymous nature of the investigation were explicit. The questionnaires were unnamed but did include an identification code to enable researchers to follow up non-responders. Members of staff were instructed to return the completed questionnaire directly to the research team in the pre-paid envelope provided or post it into a sealed box on the unit for hand collection by the researcher.

To boost response rates, employees were reminded about the MEMOS project in staff meetings, organisational newsletters and directly by email. Negotiations with the line managers enabled unit wards to provide protected time during working hours to encourage

Gender Male Female Age 20 - 29 30 - 39 40 - 49 50 - 59 60 + Therapy?

Yes No

Prisons (%)

Hospitals (%)

Total (%)

68.3 31.7

47.4 52.6

56.3 43.7

15.4 28.2 32.9 20.8 2.7

19.4 38.3 27.8 13.3 1.1

17.6 33.7 30.1 16.7 1.8

61.8 38.2

60.6 39.4

61.2 38.8

Table 1. The demographic characteristics of the sample population by site.

Involved Therapy (%) 27 29 26

All Staff Prison Officers Psychiatric Nurses

Not Involved Therapy (%) 25 23 25

All Cases (%) 26 26 25

Table 2. The percentage of staff who crossed the GHQ-12 psychiatric “caseness” threshold for likely psychiatric distress

All Staff

Officers

Nurses

MBI Subscales Mean

SD

Depersonalisation

14.9

4.6

10.0

5.9

12.9

9.4

14.7

3.7

10.5

4.1

12.4

17.3

Personal Accomplishment

27.0

9.6

15.7

27.7

9.4

13.3

Emotional Exhaustion

% High Mean

SD

% High Mean

SD

% High

14.9

6.3

8.2

5.8

10.3

18.8

23.6

8.7

10.3

Table 3. The means and standard deviations of the 3 subscales of the Maslach Burnout Inventory for nurses, prison officers and the total staff sample. The proportion of participants who scored highly under each subscale is also listed.

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staff to complete the questionnaire. In addition, three follow-up letters were sent to all non-responders requesting consent.

Analysis The data collected was analysed using the Statistical Package for Social Sciences (SPSS) software, version 14. Chi-Square analysis was used to assess the significance of variation in subgroup proportions while differences between the mean scores on the three MBI indices was examined using the Students t-test.

Results Of the total 749 members of staff, 356 completed the questionnaire pack giving a reasonable if disappointing response rate of 47.5%.

This was fairly constant across all 4 sites (41% - 52%).

The sample comprised of 79 (20%) prison officers, 108 (28%) psychiatric nurses, 28 (7%) senior managers, 37 (10%) psychologists or psychiatrists and several other smaller healthcare specialities.

The demographic characteristics of the entire study population are summarised in Table 1.

Despite the greatest effort and numerous strategies to increase the return rate, only 50% of the eligible population participated.

While the sample obtained can be said to be representative as the proportions above correspond well with institutional records, the poor response rate may skew the results; professionals who feel particularly dejected or despondent or burned-out as a result of chronic work-related stress may be less inclined to participate.

Table 2 shows the proportion of psychiatric nurses and prison officers who fulfilled the criteria for psychiatric “caseness” on the GHQ-12. In total, 26% of respondents were suffering from some degree of psychiatric morbidity and this was similar for every discipline; there was no statistically significant difference between the nursing and security workforce or between staff involved and not involved in delivering therapy.

Maslach conceptualised burnout, and its constituent components, as continuous variables and categorised high, moderate and low levels based on the results of a normative sample of 730 mental health professionals 15. Using this breakdown, it can be calculated that 13% of staff employed in the DSPD service are positive for a high level of EE, 9% positive for high DP and 16% positive for an abnormally low sense of PA (Table 3).

There is a statistically significant difference between the mean PA score for nurses and prison officers (p=0.04), whereas the same cannot be said for the 2 other subscales, (EE, p=0.9; DP, p=0.07). Moreover, many more nurses and prison officers felt particularly depersonalised by their work than the total staff average, 17% and 19% fell in the high burnout level for DP compared to only 9% of the sample taken as a whole.

Further data itemisation and univariate analyses revealed a weak correlation between age and burnout, particularly EE (r=0.344), but this did not reach the level of statistical significance (p=0.245). Likewise, there was no significant relationship between age and GHQ-12 result, or between gender and the MBI subscales. Furthermore, and somewhat surprisingly, neither experience in a general forensic setting or on the DSPD unit itself correlated significantly with either one of the two assessment

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RESEARCH tools.

Discussion In terms of the concerns raised over the DSPD workforce, it seems that, on average, the care of violent offenders provoked only moderate levels of burnout. In fact staff appear relatively resilient to depersonalisation and emotional exhaustion despite the fact that are charged with the task of supervising and securing an unwilling and potentially violent population.

On the other hand, the majority of frontline forensic staff reported work as moderately stressful in all components of the MBI while about 13% felt physically and emotionally depleted (high EE) and almost one in ten had developed callous, indifferent and insensitive attitudes toward patients (high DP). This figure was a lot higher in psychiatric nurses and prison officers, at about one in five. Moreover, the overall prevalence of psychological distress in the DSPD workforce was high with approximately one quarter suffering from psychiatric ill health, a minority seriously so. This represents a major cause for concern in terms of the recruitment and retention of skilled staff.

The PA subscale of the MBI essentially measures ones belief in their work-related competence, and hence a low PA reflects a strong tendency to evaluate ones work negatively 17. In the context of the DSPD programme, the particularly low PA score, significantly in prison officers, may be attributable to the limited patient progress observed. “Burnout is most evident in work situations that inhibit mental health workers’ capacity to realise their values through their work” 18.The argument that personality and behaviour is largely immalleable in the DSPD population may be accurate.

Study Limitations The findings from this study must be treated with some caution since only 50% of the eligible study population participated. Differences between the sample group and the study population, beyond their demographic characteristics, are impossible to evaluate. The questionnaire method of data collection is particularly susceptible to recall bias and ignores the dynamic and idiosyncratic nature of workplace stress. Moreover it is likely that overall job satisfaction and burnout are influenced by unmeasurable local factors that are difficult to quantify such as leadership style, communication flow and organisational culture. Another important consideration is that sources of stress outside the workplace were not accounted for in this study. Domestic strains and traumatic life events can independently contribute to the experience of burnout or may make it more difficult for employees to function well at work and therefore represent a potential confounder 23.

In Conclusion, this study represents one of the first quantitative investigations of its kind with DSPD workforce and its results provide food for thought for the programme administrators. Overall, it appears that the emotional demands of human service provision combined with the significant challenges of the DSPD population have an adverse impact on the psychological health and wellbeing of many employees. In order to ensure the longevity of the DSPD service, the units must create a working environment that is considered healthy and secure by both prisoners and treatment staff.

References 1.

It is unclear why young and inexperienced members of the DSPD workforce reported the same levels of psychological distress and clinical burnout as senior colleagues. Many studies have reported young age and forensic inexperience as risk factors for occupational burnout 19; 20, while the effect of gender is uncertain 18. As DSPD units are perceived as the forefront of forensic psychiatry, they may attract the most enthusiastic, trained and skilled young professionals who are more resilient to the burnout process 21; 22. Another possible explanation is that the cross-departmental, multidisciplinary team approach in these units protects junior recruits from the most distressing aspects of patient care. Melchior discovered that work experience at the group level had a much higher association with burnout than that at single nurse level 19.

2.

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The importance of the practitioner-patient relationship on professional burnout has long been suggested. Maslach posited that nurses would develop clinical burnout if their patients did not respond to them on a personal level, give positive feedback or show progress 15. It has since been shown that burnout follows perceived inequity in the therapeutic relationship where nurses feel little improvement has been generated from the large emotional investment made 19. Indeed, working with psychiatric patients with a poor prognosis can lead to feelings of helplessness, weariness and frustration that can initiate the burnout process 6. Mental health professionals who work with long-term psychiatric patients need to recognise that such patients often have a limited potential for rehabilitation 19. Unrealistic expectations can lead to feelings of disappointment and dissatisfaction that exacerbate the damaging burnout spiral.

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Weinberg, A., Creed, F., (2000). Stress and psychiatric disorder in healthcare professionals and hospital staff. The Lancet, 355(9203):533537.

Fagin, L., Carson, J., Leary, J., De Villiers, N., Bartlett, H., O’Malley, P., West, M., McElfatrick, S., Brown, D., (1996). Stress, coping and burnout in mental health nurses: findings from three research studies. International Journal of Social Psychiatry, 42(2):102-111.

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Freudenberger, H.J., (1974). Staff burnout. Journal of Social Issues, 30(1):159-165.

Maslach, C., Jackson, S.E., (1981). Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press.

Sørgaard, K.W., Ryan, P., Hill, R., Dawson, I., (2007). Sources of stress and burnout in acute psychiatric care: inpatient vs. community staff. Social Psychiatry and Psychiatric Epidemiology, 42(10):794-802.

Neveu, J.P. (2007). Jailed resources: Conservation of resources theory as applied to burnout among prison guards. Journal of Organizational Behaviour, 28, 21–42.

For full references see thelsjm.co.uk.

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