Psychiatry

comes from the ancient Greek for soul or butterfly. The fluttering elusive insect appears in the coat of arms of Britain's Royal College of Psychiatrists]]

Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities. The term was first coined by the German physician Johann Christian Reil in 1808, and literally means the 'medical treatment of the mind' (: mind; from Ancient Greek psykhē: soul; : medical treatment; from Gk. iātrikos: medical, iāsthai: to heal). A medical doctor specializing in psychiatry is a psychiatrist.

Psychiatric assessment typically starts with a mental status examination and the compilation of a case history. Psychological tests and physical examinations may be conducted, including on occasion the use of neuroimaging or other neurophysiological techniques. Mental disorders are diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases (ICD), edited and used by the World Health Organization. The fifth edition of the DSM (DSM-5) is scheduled to be published in 2013, and its development is suspected to be of significant interest to many medical fields.

Psychiatric treatment applies a variety of modalities, including psychoactive medication, psychotherapy and a wide range of other techniques such as transcranial magnetic stimulation. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.

History

Although one may trace its germination to the late eighteenth century, the beginning of psychiatry as a medical specialism is dated to the middle of the nineteenth century. Prior to this point one is considering the history of pre-institutionalised psychiatry.

Ancient times

Starting in the 5th century BC, mental disorders, especially those with psychotic traits, were considered supernatural in origin. This view existed throughout ancient Greece and Rome. In the 4th century BC, Hippocrates theorized that physiological abnormalities may be the root of mental disorders.

In the 11th century, another Persian physician, Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West as Avicenna, recognized "physiological psychology" in the treatment of illnesses involving emotions, and developed a system for associating changes in the pulse rate with inner feelings. The third section of Avicenna's monumental text Cannon of Medicine (Al-Qanun fi al-Tibb) dealt with disorders of the psyche and the nervous systems and expounded on topics such as sexology, lovesickness, delusion, apoplexy, hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo, spasm and tremor.

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment. Founded in the 13th century, Bethlem Royal Hospital in London is one of the oldest lunatic asylums. It is now part of the National Health Service and is an NHS Foundation Trust. to be the father of modern psychiatry.]]

Early modern period

In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was being applied. Thirty years later the new ruling monarch in England, George III, was known to be suffering from a mental disorder. It inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living).

19th century

At the turn of the century, England and France combined only had a few hundred individuals in asylums. By the late 1890s and early 1900s, this number skyrocketed to the hundreds of thousands. Due to the relationship between the universities and asylums, scores of competitive psychiatrists were being molded in Germany. This deficit hindered the diffusion of new ideas in medicine and psychiatry. By 1840, asylums as therapeutic institutions existed throughout Europe and the United States. studied and promoted ideas of disease classification for mental disorders.]]

However, the new and dominating ideas that mental illness could be "conquered" during the mid-nineteenth century all came crashing down. Increases in asylum populations may have been a result of the transfer of care from families and poorhouses, but the specific reasons as to why the increase occurred is still debated today. No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions and the reputation of psychiatry in the medical world had hit an extreme low.

20th century

Disease classification and rebirth of biological psychiatry

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities. While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation.

Following Sigmund Freud's death, ideas stemming from psychoanalytic theory also began to take root. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disease, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. Genetics were once again thought to play a role in mental illness. Molecular biology opened the door for specific genes contributing to mental disorders to be identified. Psychiatry's shift to the hard sciences had been interpreted as a lack of concern for patients. Others in the movement argued that psychiatry was a form of social control and demanded that institutionalized psychiatric care, stemming from Pinel's thereapeutic asylum, be abolished.

Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated. They alleged that ECT damaged the brain and was used as a tool for discipline. there are some citations that ECT does cause damage. Sometimes ECT is used as punishment or as a threat and there have been isolated incidents where the use of ECT was threatened to keep the patients "in line". The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.

Medicalization of deviance

According to Kittrie, a number of phenomena considered "deviant", such as alcoholism, drug addiction and mental illness, were originally considered as moral, then legal, and now medical problems. As a result of these perceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control. According to Franco Basaglia and his followers, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups.

Transinstitutionalization and the aftermath

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Center's focus was diverted to provide psychotherapy sessions for those suffering from acute but mild mental disorders. Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned that pseudo-patients might be sent to their institutions, but none were actually sent. Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders.

Psychiatry, like most medical specialties has a continuing, significant need for research into its diseases, classifications and treatments. Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. It refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.

Those who practice psychiatry are different than most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories: mental illness, severe learning disability, and personality disorder. While the focus of psychiatry has changed little throughout time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from the field of medicine.

Scope of practice

for neuropsychiatric conditions per 100,000 inhabitants in 2002.]] While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Unlike other physicians and neurologists, psychiatrists specialize in the doctor-patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.

Ethics

Like other purveyors of professional ethics, the World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977, has been expanded through a 1983 Vienna update and, in 1996, the broader Madrid Declaration. The code was further revised in Hamburg, 1999. The World Psychiatric Association code covers such matters as patient assessment, up-to-date knowledge, the human dignity of incapacitated patients, confidentiality, research ethics, sex selection, euthanasia, organ transplantation, torture, the death penalty, media relations, genetics, and ethnic or cultural discrimination. In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry.

Subspecialties

Various subspecialties and/or theoretical approaches exist which are related to the field of psychiatry. They include the following:

Addiction psychiatry; focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders.

Biological psychiatry; an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system.

Child and adolescent psychiatry; a branch of psychiatry that specialises in work with children, teenagers, and their families.

Community psychiatry; an approach that reflects an inclusive public health perspective and is practiced in community mental health services.

Cross-cultural psychiatry; a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.

Emergency psychiatry; the clinical application of psychiatry in emergency settings.

Forensic psychiatry; the interface between law and psychiatry.

Geriatric psychiatry; a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in humans with old age.

Liaison psychiatry; the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry.

Military psychiatry; covers special aspects of psychiatry and mental disorders within the military context.

Neuropsychiatry; branch of medicine dealing with mental disorders attributable to diseases of the nervous system.

Social psychiatry; a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental wellbeing.

In the United States, psychiatry is one of the specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Approaches

Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry, but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment. Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence, but identifies cognition as an irreducible and independent realm in which disorder may occur. or (2) scientists in the academic field of psychiatry who are qualified as research doctors in this field. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis and cognitive behavioral therapy, but it is their training as physicians that differentiates them from other mental health professionals.]] Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological and psychological perspectives to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.

Clinical application

Diagnostic systems

See also Diagnostic classification and rating scales used in psychiatry images such as these may assist in a diagnosis by ruling out other conditions.]] Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organisation, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fourth revised edition and is also used worldwide.

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.

Treatment settings

General considerations

Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self- or referral by a primary-care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Whatever the circumstance of a person's referral, a psychiatrist first assesses the person's mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement and emergency medical personnel and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses, such as thyroid dysfunction or brain tumors, or identify any signs of self-harm; this examination may be done by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like all medications, psychiatric medications can cause adverse effects in patients and hence often involve ongoing therapeutic drug monitoring, for instance full blood counts or, for patients taking lithium salts, serum levels of lithium, renal and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs have been challenged.

The close relationship between those prescribing psychiatric medication and pharmaceutical companies has become increasingly controversial along with the influence which pharmaceutical companies are exerting on mental health policies.

Also controversial are forced drugging and the "lack of insight" label. According to a report published by the US National Council on Disability,

Involuntary treatment is extremely rare outside the psychiatric system, allowable only in such cases as unconsciousness or the inability to communicate. People with psychiatric disabilities, on the other hand, even when they vigorously protest treatments they do not want, are routinely subjected to them anyway, on the justification that they "lack insight" or are unable to recognize their need for treatment because of their "mental illness". In practice, "lack of insight" becomes disagreement with the treating professional, and people who disagree are labeled "noncompliant" or "uncooperative with treatment".

Inpatient treatment

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization.

Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the USA and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves and/or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically-certified cases of mental disorder, and adds a right to timely judicial review of detention.

are one of many ways to administer psychiatric medication.]] Patients may be admitted voluntarily if the treating doctor considers that safety isn't compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision, and may be physically restrained or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.

In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason.

Outpatient treatment

People may receive psychiatric care on an inpatient or outpatient basis. Outpatient treatment involves periodic visits to a clinician for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatric practitioner interviewing the person to update their assessment of the person's condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees people in treatment varies widely, from days to months, depending on the type, severity and stability of each person's condition, and depending on what the clinician and client decide would be best. Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications) with little or no time devoted to psychotherapy or "talk" therapies, or behavior modification. Psychiatrists who serve the lower end of the market, which is dependent on insurance reimbursements, do not receive insurance payments for lengthy psychotherapy sessions which is competitive with that offered for the brief consultations needed for prescribing and monitoring medication. Psychotherapy in such situations is performed by a lower paid psychologist or social worker. The role of psychiatrists is changing in community psychiatry, with many assuming more leadership roles, coordinating and supervising teams of allied health professionals and junior doctors in delivery of health services.

See also

Biopsychiatry controversy

Mental health

Psychiatric assessment

Telepsychiatry

Anti-psychiatry - Criticism against psychiatry

Bullying in psychiatry

References

Notes

Cited texts

Gask, L. (2004). A Short Introduction to Psychiatry. London: SAGE Publications Ltd., p. 113 ISBN 978-0-7619-7138-2

Guze, S.B. (1992). Why Psychiatry Is a Branch of Medicine. New York: Oxford University Press, p. 4. ISBN 978-0-19-507420-8

Leigh, H. (1983). Psychiatry in the practice of medicine. Menlo Park: Addison-Wesley Publishing Company. ISBN 978-0-20-105456-9

Lyness, J.M. (1997). Psychiatric Pearls. Philadelphia: F.A. Davis Company, p. 3. ISBN 978-0-80-360280-9

Shorter, E. (1997). A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, Inc. ISBN 978-0-47-124531-5

Syed, Ibrahim B. (2002). "Islamic Medicine: 1000 years ahead of its times", Journal of the International Society for the History of Islamic Medicine, (2): 2-9 [7-8].

Further reading

Berrios G E, Porter R (1995) The History of Clinical Psychiatry. London, Athlone Press

Berrios G E (1996) History of Mental symptoms. The History of Descriptive Psychopathology since the 19th century. Cambridge, Cambridge University Press

Ford-Martin, Paula Anne Gale (2002), "Psychosis" Gale Encyclopedia of Medicine, Farmington Hills, Michigan

MedFriendly.com, Psychologist, Viewed 20 September 2006

C. Burke, Psychiatry: a "value-free" science? Linacre Quarterly, vol. 67/1 (February 2000), pp. 59–88. Cormacburke.or.ke

National Association of Cognitive-Behavioral Therapists, What is Cognitive-Behavioral Therapy?, Viewed 20 September 2006

van Os J, Gilvarry C, Bale R et al. (1999) A comparison of the utility of dimensional and categorical representations of psychosis. Psychological Medicine 29 (3) 595-606

Hiruta, Genshiro. (edited by Dr. Allan Beveridge) "Japanese psychiatry in the Edo period (1600-1868)." History of Psychiatry, Vol. 13, No. 50, 131-151 (2002).

External links

World Psychiatric Association

Journal of Clinical Psychiatry

American Psychiatric Association

The Royal College of Psychiatrists

Royal Australian and New Zealand College of Psychiatrists

Asia-Pacific Psychiatry, official journal of the Pacific Rim College of Psychiatrists.

Early Intervention in Psychiatry, official journal of the International Early Psychosis Association.">International Early Psychosis Association.

Psychiatry and Clinical Neurosciences, official journal of The Japanese Society of Psychiatry and Neurology.

E-Psychiatry Blog

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