Amin A Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, 300-Prince Philip Dr, St. John's, NL A1B 3V6, Canada. )

Personal space by definition is an approximate area surrounding an individual in which other people should not physically violate in order for them to feel comfortable and secure.¹ The idea comes from Edward T. Hall secondary to influence from studies of behaviour of zoo animals.² Personal space may also be defined as the area immediately surrounding the individual in which the majority of his interactions with others take place; it has no fixed geographical reference points, moves about with the individual, and expands and contracts under varying conditions.³ A person\'s comfort zone is highly variable and difficult to measure; the estimate is about 24.5 inches on side, 27.5 inches in front and 15.75 inches behind for an average westerner.² The concept of personal space varies across the globe and in most cases it is culturally determined. A number of other factors can influence the personal space like: mood state, nature of relationship, illness, level of intimacy, societal norms, gender, psychological make-up, population density, housing architecture, race, ethnicity and social status. As per research, amygdala deals with emotional reactions to proximity to other people. It has been observed that those with bilateral damage to their amygdala lack a sense of personal space boundary. This finding was consistent with monkeys with bilateral amygdala lesions.⁴ The amygdala may be required to trigger the strong emotional reactions normally following personal space violations, thus regulating interpersonal distance in humans. Anthropologists noted that human spatial use was an important variable in studying cultural patterns. The psychiatric literature rarely refers to space but it is used by psychotherapists in the therapeutic sessions. It has been recorded that in certain schizophrenic patients, personal space distance would be relatively increased.⁵ From this observation, a hypothesis emerged that each human being has, as part of his body-image, an internal projection of the space immediately around him. This is called body-buffer zone. The size, shape, and penetrability of this buffer zone probably depend on immediate interpersonal events, current ego and drive states, and the individual\'s psychologic and cultural history.⁵ When it comes to physician-patient relationship, application of universal norm in terms of personal space is applicable. Erosion of personal space in this relationship comes under the subject of \'Boundary violations\' which the regulatory bodies of respective countries vehemently disapprove under their ethical guidelines.⁶ In Pakistan, we come across reports about personal intimacy with patients that lead to bad reputation of the profession. There are vulnerability factors among the patients like the psychiatric disorders, transference phenomena, social circumstances, low I.Q. and emotional immaturity. Likewise, doctors may also harbour certain vulnerability factors like: personality traits, promiscuous nature, alcohol/drug dependence, emotional immaturity and social disinhibition. Media reports are replete with the incidents of patient abuse by physicians and so far no exemplary sanctions are carried out by the local medical regulatory body that could deter such practices.
In terms of general human behaviour, a number of interesting studies were conducted. It was observed that the use of personal space by persons in interactions involving stigmatized individuals especially epileptics was that of less proximate as compared to non-stigmatized individuals.⁷ In terms of cultural influence, a study revealed that Anglo Saxons used the largest zone of personal space, followed by Asians, then Caucasians, the Mediterraneans and Latinos used the shortest distance.⁸ A research suggests broadening of the notion of social control beyond formal and informal human resources to include the physical features of spaces. The said study⁹ advises that inanimate objects and the spaces that comprise them are informative for and relevant to behaviours of human interactants. Having considered the findings of studies and commentaries on different aspects of human behaviour, the issue of social bindings and restriction are applicable in physician-patient relationships. It is important to understand this issue in the local context. Cultural permissiveness in warmer expression of emotions while obliterating the personal space is not always the best thing to follow. Hence, general awareness in this regard may prevent a number of social complications in such situations. Is it important for the local regulatory body to provide some guidelines in terms of preserving the personal space in doctor-patient relationship? Will incorporation of some suggestions/recommendation in current good practice guideline help?

1.WiseGeek. What is Personal Space? (Online) (Cited October 15, 2009). Available from URL: www.wisegeek.com/what-is-personal-space.htm.
2.Wikipedia. Personal Space. (Online) (Cited October 15, 2009). Available from URL: http://en.wikipedia.org/wiki/Personal_space.
3.Little, KB. Personal Space. J Experiment Soc Psychol 1965; 1; 237-47.
4.Kennedy DP, Glascher J, Tyszka JM, Adolphs R. Personal space regulation by the human amygdala. Nature Neuroscience, 2009; 12: 1226-7.
5.Horowitz MJ, Duff DF, Stratton LO. Body-Buffer Zone-Exploration of Personal Space in Archives of General Psychiatry. (Online) (Cited October 15, 2009). Available from URL: http://archpsyc.ama-assn.org/cgi/content/summary/11/6/651.
6.Gadit AM, Patel S. Boundary violations in medical practice: What should be done? J Pak Med Assoc 2008; 58: 211-3.
7.K Robert et al. American Psychological Association. Effects of stigmatizing conditions on the use of personal space. (Online) (Cited October 26, 2009). Available from URL: http//:psycnet.apa.org/?fa=main.doiLanding&uid=1969-06832-001.
8.Beaulieu, CMJ. Intercultural Study of Personal Space: A case study. J Appl Soc Psychol 2006; 34: 794-805.
9.Manzo J. Social Control and the Management of "Personal" Space in Shopping Malls. Space and Culture 2005; l: 83-97.