Healing the Mind Through the Body

MENTAL HANDICAP VOL. 21 SEPTEMBER 1993 __I__ ___ _I______________.- _I__-

Healing the Mind Through the Body

John Corbett

This paper is based on the Gerry Simon Lecture given at the 20th Annual Meeting of the British Institute for Mental Handicap at Herriot Watt University, Edinburgh on 16 September, 1992.

I was glad when Mrs Simon and her family agreed that we might best remember Professor Simon by setting up a fund to endow a lecture. The Institute is his greatest memorial and it is appropriate that we are gathered here to celebrate our coming of age and to reflect on Gerry’s contribution to the study of learning disability.

I suppose I am in a good position to start the ball rolling, for it is now seven years since I was elected to the Chair which Professor Simon held with distinction at Birmingham University. I was fortunate in sharing an office at Lea Castle with GBS and his secretary and I am grateful to Mrs Jane Lawrence, now our Section Co-ordinator, for her help in preparing this lecture.

Gerry and I qualified as doctors in the same year, but as with many of those who served in the last war, there seems to have been a greater sense of purpose and urgency about his career. Our lives often seem serendipitous, the pattern laid down by nature being constantly modified by nurture and enriched by chance meetings and events which sometimes seem pre-ordained. I was reminded of Lord Cheshire, who also died in 1992, when I learnt from the Simon family that Gerry met a man in the queue at the Labour Exchange after the war who asked him what sort of a job he would like to do. Gerry replied that he had always wanted to be a doctor, and the man replied that he should not waste time but go and get on with it. (Leonard Cheshire had opened his home after the war to a stranger with disability who had nowhere else to go.) I wonder who these strangers were or what apparent chance took Gerry to hospital in Sri Lanka, after escaping from the Japanese in Burma, where he met Marjorie Simon who was to help him achieve his dream.

Although more chances must have intervened, in reviewing Gerry’s published work, one can see a pattern emerging. Gerry wrote, in his own obituary, that he went into the field of disability because this was one way of supporting a young family and remaining in contact with people and more chances must have supervened. Reviewing his published work, however, a pattern emerges which suggests careful planning of a time-limited professional life.

In his postgraduate career Gerry first worked at Borocourt and Smith Hospitals with Dr Gerry O’Gornian. Smith was one of the first residential facilities for autistic children and the first links with the topic of my lecture today can be detected in his early publications on autism which continued after his move to Lea and Lea Castle Hospitals as Consultant.

Autistic children have a strange interest in sensory stimulation which underlies their stereotyped behaviour and which serves in their adaptation to environmental demands. Whether through this interest or because he had lost his own vision for a period in childhood from an arrow in his eye, Gerry began to write about and develop services for people with sensory impairment. I recollect visiting his first unit at Lea which was in the bungalow he and his family lived in when he first came to Bromsgrove and Kidderminster as a Consultant.

In 1971, Gerry welded the multidisciplinary group in Kidderminster into the Institute, developing for it a regional arid national reputation. Soon after this, Professor Peter Mittler was chosen by Richard Crossman, Minister of Health, to chair the National Development Group in response to Sir Geoffrey Howe’s report on the conditions at Ely Hospital in Wales, and GBS became his deputy and Director of the National Development Team. Their annual reports and pamphlets survive as blueprints for contemporary planning.

Gerry believed that disability was a reason for explaining, in the words of Dr Ronnie MacKeith, ‘more things to more people’ and his books on drugs for teachers and on the ‘Modern Management of

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Mental Handicap’, directed at a multidisciplinary professional readership, have not been bettered today.

Perhaps Gerry’s most outstanding academic contribution lay in the manual ‘The Next Step on the Ladder’ written with colleagues from the Institute. This is part of a tradition of such guides to careful developmental assessment with steps for practical intervention which have remained the most popular publications of the Institute and which empower both parents and professionals working with children and adults with the knowledge required to make things better.

The theme of my lecture today follows from this example of trying to explain and integrate medical knowledge with our increasing understanding of the behavioural psychology of learning disability. It arises from my own interest in self-injurious behaviour which led to my first referrals from Gerry and has been enriched by his own teachings on sensory stimulation and autism.

There is a long tradition for the use of ‘stimulation’ in the therapy and education of children with development disability. This arises from a more general ethos in educational practice and child care that stimulation, both of a general and specific kind, is desirable in the maturation of the nervous system and can offset the effects of early developmental deprivation and generally promote personal development.

There is extensive literature on the relationship between stereotyped behaviour and generalised sensory stimulation but there is apparent disagree- ment on the issue of whether stimulation increases or decreases stereotyped behaviour in people with learning disability. The most convincing theory to explain this apparent conflict derives from one of the oldest sustained findings in experimental psychology and concerns the relationship between environmental stimulation and arousal. The experiments of Yerkes and Dodson who showed in 1907 that motivation to learn increases with arousal produced by environmental stimulation. Beyond a certain point, a decrease occurs giving rise to the so-called ‘cue arousal curve’. This has been interpreted as suggesting that, at low levels of environmental stimulation, for example in deprived institutionalised settings, people with severe learning disability will show low arousal stereotypies such as rocking to increase arousal, while beyond an optimal level of arousal, high arousal stereotypies will occur: for example, in autistic children who are unable to cope with excess stimulation (Goodall & Corbett, 1982).

In recent years, interest has shifted to specific types of stimuli and pathways of sensory input and claims have been made for therapeutic results in the treatment of brain damage, cerebral palsy and other forms of developmental disability. Some

of these approaches such as Sensory Integration Therapy (Ayres, 1975) have an established place in management while others, such as patterning therapy, are more controversial and lack both a sound neurological basis and scientific confirmation of their efficacy. Recent innovations like ‘gentle teaching’ fit particularly well with this arousal theory.

In this paper the anecdotal and neurophysiological evidence for such claims will be reviewed. To illustrate these issues a case vignette may assist. This case has been reported by Dossetor et al. (1991) but I will briefly recount the essential details. LH was a 14 year old girl with a ten year history

of severe self injurious behaviour. She was diagnosed as suffering from Cornelia de Lange syndrome at the age of three and a half years. She suffered from middle ear infections leading to conductive deafness which was treated surgically. At this time she was said to have ar, I& of 30, her motor development being at a two year level, with social skills at an eighteen month level and a more severe language deficit with no speech or evidence of symbolic use of language and response only to a limited number of commands given in context. From an early age she had suffered from major behavioural problems with overactivity and aggression. These placed severe stress on her parents’ maniage which broke up when she was five years of age. She was then admitted to a local mental handicap hospital and shortly afterwards suffered from impetigo of the scalp and began to iqjure herself with hand to head and, later, head to object banging. She tended to seek out sharp corners on which to bang. She also tried to restrain herself in her clothing or the furniture. At the age of twelve years she was transferred to a local community-based unit of ten children.

She had been treated, over the years, with most psychotropic drugs, including dopamine blockers, lioresal, lithium and naltrexone and she also had received behavioural treatment. She was aged fourteen when I was asked to see her as an emergency and she was being nursed separately to the other children in the home in a room with padded furniture.

I suggested that her arms were splinted, that she have adequate head protection and massage to the hands and feet with the splints removed for twenty minutes twice a day. One of her care staff who undertook this had experience of aromatherapy and aromatic oils were used for the massage.

After three months, she was managing without splints and eighteen months later, although she had suffered minor relapses of the self-injury, she was integrated with the other children, was attending school again and was managing without any protection or medication.

There are three possible hypotheses which might be invoked to explain the therapeutic success of the peripheral aromatherapy in this case.

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(1) That it was the result of spontaneous remission, although such a point had not been reached in the previous eight years.

(2) That there had been some subtle change in the interpersonal dynamics so that the treatment had enabled staff who were concerned about approaching L, for fear of precipitating self-injury, to resume contact with her.

(3) That there was some specific effect from the peripheral stimulation.

Various therapies involving stimulation have had a vogue recently and include acupuncture, aromatherapy, reflexology, the use of vibration or other sensory stimuli and massage. They have in common fairly specific techniques compared with the more general forms of environmental Stimulation which used to be advocated for children with profound and severe learning disability. Many people seem to be using them and claiming benefit, but as with other complementary therapies, scientific evidence for beneficial effects in people with a learning disability is weak. They do, however, reflect a contemporary and understandable enthusiasm for a holistic approach to therapy and for blending Eastern and Western traditions in healing.

At best, these therapies provide personal contact and stimulation, which we know from research and clinical experience severely disabled people lack as they get older. At worst, these may be imposed on people with learning disability, as with other specific medical and psychological treatments, without criti- cal scrutiny of their therapeutic value and as an alternative to other much needed improvements in their quality of life. In order to explore the scientific basis for such therapies, I would like to briefly review the therapies which involve specific forms of peripheral stimulation.

Acupuncture is perhaps the oldest and best rese- arched. It originated in China but is now practised in many parts of the world, chiefly for the relief of pain. The Chinese do not have a full explanation for its efficacy but have observed that inserting a needle at one point of the body sets up a reaction at a second point. It has recently been shown that acupuncture leads to the release of chemical messengers (neurotransmitters) in the brain, known as endogenous opiates or endorphins - these are morphine like substances which reduce pain. One dramatic example of this process is the relief of dental pain by acupuncture which may then be reversed by administering an opiate blocker or antagonist - naloxone (Corbett & Campbell, 1981).

Traditionally, acupuncture is considered to be a metaphysical treatment and in this tradition, illness is supposed to be the result of an imbalance of the body’s forces. An analogy from Western medicine might be blood letting which was claimed to control

the bodily ‘humours’, remove putrefactions and redirect the bodily fluxes. Acupuncture and Moxism, another ancient Chinese therapy involving the burning of a small cone or moxa at specific points on the skin to cause a blister, will, in this tradition, affect the distribution of the Yin and Yang in so- called burning spaces, hypothetical channels or meridians in the body. The Yin is the female principal which is active and light while the Yang, the male principle, is passive and dark; both have the need to be in harmony.

The humoral theory was only gradually replaced in Western medicine following William Harvey’s discovery of the circulation of the blood, five hundred years ago. Most texts on natural or complementary healing still include reference to oriental traditions of meridians of life force and chakras of Asian medicine, together with this explanation for the location of acupuncture, AH- SHI or literally ‘ouch points, although these largely defy conventional anatomical explanation.

Modern technology has been applied to the principles of acupuncture in the form of percu- taneous nerve stimulation (PNS) which involves the passage, without needles, of low intensity electrical current at acupuncture points or tender spots, or the electrical stimulation through acupuncture needles which is now used in China as an alternative to traditional acupuncture.

The ‘gate’ theory of pain has been invoked to explain the action of therapies based on acupuncture. This suggests that if impulse transmission in thick (that is, touch nerve) fibres can be increased, it will selectively block conduction in thin (pain nerve) fibres in the spinal cord by blocking the ‘gate’ there with a powerful endorphin which occurs naturally in the synapses (the junction between nerve cells in the spinal cord).

Although the theoretical basis for reflexology is less clear than acupuncture, it does involve more specific stimulation and massage of the hands and feet and it is tempting to wonder whether the gate theory might be invoked to explain the successes which are claimed, or whether it is just more widely used for people with a learning disability because it is more socially acceptable. Similar principles seem to be involved in Shiatsu, which originated in Japan and involves pressure (mainly with the thumbs) at particular points on the body.

Other related therapies include Acupressure, Zone or Corvo therapy and Rolfing. Peripheral massage of the hands and feet is often combined with aromatherapy, using essential oils which are either used in the massage or inhaled. An excellent account of this therapy is given by Sanderson, Harrison & Price (1991).

I would like to briefly describe some of the clinical and scientific evidence which might underpin

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the theoretical basis for the peripheral stimulation therapies. Two American psychologists, the Olds, published their work on the ‘Pleasure Area’ of the brain in 1954. They pointed out that before this time, any notion that emotions might have any specific localisation in the brain would have been dismissed as naive, akin perhaps to medieval anatomy or phrenology and until that time, classical mapping of the brain function had ranged mainly over the cortex and, particularly, the sensory and motor cortex (Corbett & Campbell, 1981).

Other areas, including the limbic system (the Rhinencephalon or smell brain of animals) were regarded as too difficult to investigate, because of the absence, until then, of suitable electrodes which would not damage the cortex and other superficial brain structures and secondly, the lack of any suitable means of measuring behaviour. The Olds used the newly developed electrodes of Hess to explore, as they thought, the arousal mechanisms of the reticular activating system. They also used the recently invented ‘Skinner box’ to modulate and measure behaviour. The animal in the experiments, a rat, was able to press a key to obtain a minute amount of current into the brain. The accidental placement of electrodes in areas of the limbic system, comprising some 35% of the brain substance, would result in the animal pressing the lever almost continuously, reaching rates of 5,000 times per hour. They called these parts of the brain the ‘pleasure areas’. When the electrodes were placed in other parts of the brain, making up about 5% of the brain volume, the animal would press the key once and then actively avoid it. With the electrodes placed at the junction between the two areas, the animals would run up to the switch and appear ambivalent about touching the switch - the ‘stop it, I like it’ reaction. The resemblance of this behaviour to that seen in addiction of exogenous opiates is striking.

My colleague, the late Dr Bert Campbell at the Institute of Psychiatry, showed that it is not necessary to have electrodes implanted in the nervous system and the peripheral afferent or sensory nervous system is quite adequate for this purpose. He devised an apparatus which could be used by normal and profoundly handicapped young children to produce various forms of pleasurable stimulation. He found that children with different brain lesions would have different profiles of sensory stimulation and that these would vary over time. With my colleague, Dr Elizabeth Goodall, we extended this work to look at the effect of peripheral stimulation on sterotyped and self-injurious behaviour, using the apparatus invented by Dr Campbell. We also used it as a basis for the development of teaching equipment, using sensory reinforcement (Goodall & Corbett, 1982, Goodall et al., 1981 & 1982).

In some syndromes, stereotyped self-injurious behaviour is particularly frequent and in certain of these, notably Lesch Nyhan, Prader Willi, Tourette and Rett syndromes, there is further evidence to implicate abnormalities of neurotransmitter modu- lation. These involve dopamine, serotonin and neuro- peptides. At present it is not clear which combi- nations of these neurotransmitters are most important but further laboratory work suggests that the circuits in the limbic system which are primarily involved, lie deeply in the brain in the periaqueductal grey matter.

It is of interest that both in animals and humans, self injury often seems to have a characteristic topography, frequently involving biting or injury to the extremities (in the case of Lesch Nyhan, of the fingers and of the lips) and it is tempting to wonder whether, as in the cortex, these have a disproportionate representation in the pleasure areas of the limbic system. It is also relevant that many repetitive behaviours and interests in normal subjects involve peripheral stimulation (clapping, thumbsucking, nailbiting and interest in perfumery). If this were so, peripheral stimulation of the extremities might be an alternative way of manipul- ating the neurotransmitter systems of the limbic pleasure areas.

The obvious clinical situations in which therapies based on peripheral. stimulation are likely to be of value are those involving self-injury, other repetitive or stereotyped behaviours and, perhaps, addiction states, but there is also increasing evidence for their efficacy in pervasive developmental disorders of autistic and other types.

Firmer scientific underpinning of these and related therapies would allow claims for new therapies to be subjected to cost-benefit analysis and limit their possible abuse. Sigmund Freud, who was a neurologist by training, attempted to integrate theor- ies of the brain and mind in his ‘Project’ and ended his monograph ‘Beyond the Pleasure Principle’, commenting on the slow road to scientific progress, with the following quotation from Ruckerts Maka- mendes Hariri ‘Whither we cannot fly, we must go limping but the scripture saith that limping is no sin’.

I would like to suggest that we will continue to limp in this as in other areas of knowledge until we open our minds to the benefits of the multidisciplinary approach to research and practice which Gerry Simon advocated.

Acknowledgements Grateful thanks are due to Dr Beryl Smith, Dr David Clarke and Ms Jane Harrison for comments on this paper and to Mrs Jane Lawrence and Mrs Liz Hares for assistance with typing and continued support throughout the preparation of this paper.

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Appendix: Original publications by Professor G. B. Simon, MB. ChB. FRCPsych.

Some Physical Characteristics of a Group of Psychotic Children. Brit. J. Psychiatry. January, 1964, 110, 104-107.

Where Biochemistry Can Help. Special Education. Nov- ember, 1966, Vol. 55, No. 4, 17-21.

Anomalies of Growth in a Group of Children Exhibiting Psychotic Features. Journal of Mental Subnormality. June, 1966, 12 part 1, No. 22, 42-44.

The Early Development of Psychotic Children and Their Sibs. H. Whittam, G. B. Simon, P. J. Mittler. Developmental Medicine and Child Neurology. October, 1966, Vol. 8, No. 5, 552-560.

Insulin Tolerance in Psychotic Children. American Jour- nal of Mental Defiiency. May, 1966, Vol. 70, No. 6, 829-834.

Sensory Handicap, Development and Mental Retardation. Teaching and Training. 1967, Vol. V, No. 2, 40-46.

Biochemical Factors in Subnormality. M. E. Burns, G. B. Simon. Chapter in Modern Trends in Mental Health and Subnormality. 1968, 119-150.

The Needs of the Visually and Mentally Handicapped Child: Part 1. New Beacon. February, 1972, Vol. LVI, No. 658, 3133.

The Needs of the Visually and Mentally Handicapped Child: Part 2. New Beacon. March, 1972, Vol. LVI, No. 659, 63-66.

Into the Community - Through Many Doors. A. Brain, G. B. Simon. Apex. June, 1973, Vol. 1, No. 1, 10-11.

Services: Hospital Provision. Chapter 7 in The Young Retarded Child. Churchill Livingstone, 1973, 71-80.

Deafness and the Mentally Retarded. I. Tempowski, H. Felstead, G: B. Simon. Apex. September, 1974, Vol. 2, No. 2, 4-5.

Educational Needs of the Severely Subnormal. Paper presented at Seminar at West Midlands College, Walsall 8.9.74. Reprinted in Teaching and Training. 1974, Vol. XII, No. 4, 110-115 and 140.

A Service for the Mentally Handicapped. Mental Handicap and the Community Health Council (Conference Proceedings). Kidderminster: Institute of Mental Sub- normality. 1976, 1-11.

Development Team for the Mentally Handicapped: First Report. London: Her Majesty’s Stationery Office. 1976-1977, 58 pp.

The Way Ahead in Mental Handicap. Bulletin of the British Journal of Psychiatry. 1977, 11-13.

Edge View: A Community Unit in Practice. B. Hibberd, G. B. Simon. Apex. June, 1977, Vol. 5, No. 1, 20-22.

Rewarding Behaviour (toilet training programmes for the mentally handicapped). Health & Social Service Journal. 25th November, 1977, 16-26.

Role, Functions and Influence of the Subnormality Hospital. The British Society f o r the Study of Mental Subnormality Newsletter. March, 1977. Vol. 2, No. 3,

Joint Planning and Utilisation of Resources to Meet the Needs of the Mentally Handicapped. British Institute of Mental Handicap. 1977, 58pp.

Meeting the Needs of Mental Disorder for the Mentally Handicapped. Health & Hygiene, April-June, 1978, Vol. 1, No. 4, 197-200.

6 PP.

The Mentally Handicapped - Is Community Care the Best Solution? The Psychiatrist’s Viewpoint. Royal Society of Health Journal. August, 1978, Vol. 98, No. 4, 181-182.

Services in the United Kingdom. Chapter in Mental Retardation and Development Disabilities: An Annual Review. Joseph Wortis (ed.). New York: Brunner/Mazel Publishers. 1978, Vol. 10.

Development Team for the Mentally Handicapped - Second Report. London: Her Majesty’s Stationery Office. 1978-1979, 60 pp.

The National Development Group and the Development Team for the Mentally Handicapped. Regional Review. 1979, 65, 8-10.

inster: British Institute of Mental Handicap. 1980. The Next Step on the Ladder (Revised Edition). Kidderm-

Edited and contributed to: Modern Management of the Mentally Handicapped: A Manual of Practice. Lancaster: MTP. 1980.

Local Services f o r Mentally Handicapped People. Kidderminster: British Institute of Mental Handicap. 1981.

Psychiatric Illness in the Blind. Insight. 1982, Vol. 4, No.

A Teacher’s Guide to Drugs. Special Education: Forward 1, 1-5.

Trends. March, 1974, Vol. 1, No. 1, 25-28.

REFERENCES Ayres, J. (1975) Sensory Integrative Therapy. Los

Angeles, CA: Western Psychological Services. Corbett, J. A. and Campbell, H. G. (1981) Causes

of severe self injurious behaviour. In P. Mittler and J. de Jong (eds) New Frontiers in Mental Retardation: Vol. 2. Biomedical Aspects. New York: University Park Press.

Dossetor, D. R., Couryer, S. and Nicol, A. R. (1991) Massage for very severe self injurious behaviour in a girl with Cornelia de Lange Syndrome. Deuelopmental Medicine and Child Neurology 33, 636-644.

Freud, S. (1922) Beyond the Pleasure Principle. London: International Psychoanalytic Press.

Goodall, E. and Corbett, J. A. (1982) Relationships between sensory stimulation and stereotyped behaviour in mentally retarded and autistic children. Journal of Mental Defiiency Research 26, 163-175.

Goodall, E., Murphy, G., Callias, M. and Corbett, J.A. (1981) Sensory reinforcement table for severely retarded and multiply handicapped children. Apex: Journal of the British Institute of Mental Handicap 9, 96-97.

Goodall, E., Murphy, G., Callias, M. and Corbett, J. A. (1982) Sensory reinforcement table: An evaluation. Mental Handicap 10, 52-54.

Sanderson, H., Harrison, J. and Price, S. (1991) Aromatherapy and Massage fo r People with Learning Dimult ies . Birmingham: Hands On Publishing & Training.

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Healing the Mind Through the Body