Psychiatry

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Psychiatry is a medical specialty dealing with the prevention, assessment, diagnosis, treatment, and rehabilitation of mental illness. Its primary goal is the relief of mental suffering associated with disorder and improvement of mental well-being. This may be based in hospitals or in the community and patients may be voluntary or involuntary. Psychiatry adopts a medical approach but may take in to account biological, psychological, and social/cultural perspectives. Treatment by medication or, less often, various forms of psychotherapy may be undertaken. The word 'psychiatry' derives from the Greek for "healer of the spirit".

Most psychiatric illnesses cannot currently be cured. While some have short time courses and only minor symptoms, many are chronic conditions which can have a significant impact on a patients' quality of life and even life expectancy, and as such may be thought to require long-term or life-long treatment. Effectiveness of treatment for any given condition is also variable from patient to patient, with some patients having complete resolution of symptoms and others having poor or minimal response. The majority of patients will fall somewhere in between.[citation needed]

Contents

[edit] Psychiatry in professional practice

Psychiatrists are medical doctors and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis, and/or cognitive behavioral therapy, but it is their medical training that differentiates them from clinical psychologists and other psychotherapists. Psychiatric nurses and psychiatric social workers are also involved in the professional practice of psychiatry, with the former having limited prescription rights in some countries and the latter having a legal role in committing people to psychiatric facilities in some countries. A high proportion of patients presenting to general practice report mental health problems and family physicians frequently prescribe psychiatric medication and sometimes refer patients for psychiatric assessment.

Some departments of psychiatry, especially those with academic links, may have the name of "Psychological Medicine," which should not be confused with Medical Psychology, Health Psychology or Clinical Psychology.

As part of their evaluation of the patient, psychiatrists, Physician Assistants, and Nurse Practitioners are the only mental health professionals who may conduct physical examinations, order and interpret laboratory tests and EEGs, and may order brain imaging studies such as CT or CAT, MRI, and PET scanning. A medical professional must evaluate the patient for any medical problems or diseases that may be the cause of the mental illness, although findings of relevant brain abnormalities, for example via CAT scans, may be uncommon [1]

In addition to psychiatrists who practice clinically, some only perform research and/or work in an academic setting. These psychiatrists may only hold research degrees or a combination of psychiatry doctorates (such as an M.D. and Ph.D.).

[edit] Subspecialties

The field of psychiatry itself can be divided into various subspecialties. These include:

Some psychiatric practitioners specialize in helping certain age groups; child and adolescent psychiatrists work with children and teenagers in addressing psychological problems. Those who work with the elderly are called geriatric psychiatrists, or in the UK and Australia, psychogeriatricians. Those who practise psychiatry in the workplace are called industrial psychiatrists in the US (occupational psychology is the name used for the most similar discipline in the UK). Psychiatrists working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists and mental health professionals in the field of psychiatry may also specialize in psychopharmacology, neuropsychiatry, eating disorders, and early psychosis intervention.

See also: meta-semantics

[edit] Treatment overview

In general, psychiatric treatments have changed over the past several decades (see History section, below). In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, most psychiatric patients are managed as outpatients. If hospitalization is required, the average hospital stay is around two to three weeks, with only a small number of cases involving long-term hospitalization.

Individuals with mental illness are commonly referred to as patients but may also be called clients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a patient 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.

[edit] Initial assessment

Whatever the circumstance of their patient's referral, a psychiatrist first assesses their patient's mental and physical condition. This usually involves interviewing the patient and often obtaining information collated from other sources such as other health and social care professionals, relatives, associates, law enforcement and emergency medical personnel and psychiatric rating scales. 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 else other than the psychiatrist, especially if Blood tests and medical imaging are performed.

Commencing treatment with medication requires the patient to agree to this treatment, although in many countries the law provides overriding circumstances, and that they will follow the dosage prescribed. Like all medications, psychiatric medications can have toxic 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. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, especially those unresponsive to medication.

[edit] Outpatient care

Psychiatric patients may be either inpatients or outpatients. Psychiatric outpatients periodically visit their 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 patient to update their assessment of the patient's condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees patients varies widely, from days to months, depending on the type, severity and stability of each patient's condition, and depending on what the clinician and patient decide would be best.

[edit] Inpatient care

Psychiatric inpatients are patients admitted to a hospital or clinic to receive psychiatric care, sometimes involuntarily. In North America, the criteria for involuntary admission vary with jurisdiction. It may be as broad as having a mental disorder and being capable of mental or physical deterioration or as narrow as a patient being considered to be an immediate danger to themselves or others. In the UK, involuntary admission is limited to this narrow criterion. 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 favoured as safer.

Once in the care of a hospital, patients are assessed, monitored, and often given medication and receive care from a multidisciplinary team, which may include physicians, psychiatric nurses, clinical psychologists, occupational therapists, psychotherapists, psychiatric social workers, and other mental health professionals. If patients are 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. Inpatients may be allowed leave periods, either accompanied or on their own.

[edit] Main theoretical tenets of modern psychiatry

Modern mainstream psychiatric theory sees psychiatry as a branch of medicine that should be scientific in theory and practice. It argues that there is a distinct boundary between the mentally healthy and the mentally ill and that there are specific types of mental illness which psychiatry can medically differentiate, understand and treat. Currently the field adopts a primarily biomedical paradigm, with most theoretical work focused on the role of genetics and neurochemical processes in the brain, and on medication. Modern psychiatry is also based on a statistically codified diagnostic classification scheme dubbed 'neo-Kraepelian' (Klerman, 1978). This view is represented in diagnostic manuals such as the DSM and the psychiatric section of the ICD which are based on patterns of so-called 'Feighner criteria' (lists of symptoms with rules on the combinations required for different diagnoses)

[edit] Diagnostic systems of psychiatric disorders

ICD-10 (International Classification of Diseases)- the ICD 10 is published by the World Health Organisation and used world wide. In the United States, the standard system of psychiatric diagnoses is given in the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM), overseen and revised by the American Psychiatric Association. It is currently in its fourth revised edition (IV-TR, published 2000) and is also used world-wide, perhaps more so than the ICD-10. The ICD-10 and the DSM are considered roughly on par with one another although the lack of a case example version of the ICD-10 is considered a problem by some. They are comparable in accuracy of diagnoses excepting certain categories which are more due to social differences in the countries themselves. For example disruptive disorders of childhood and multiple personality disorder are diagnosed to a greater extent in the U.S than the U.K.

The stated intention was to create a set of diagnoses that would be replicable and clinically useful whilst being atheoretical as regards etiology, although the categories are based on psychiatric theory, are broad, and many of the symptoms overlap. The two systems were designed to be compatible generally but there are inherent anomalies in both. While the system was originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now one of two standards widely used by clinicians, administrators and insurance companies in many countries. However, it has been critiqued for being vague, poorly defined, stigmatizing and lacking proper scientific foundation [1].

The DSM has five axes:

  • Axis I: Psychiatric disorders
  • Axis II: Personality disorders / mental retardation
  • Axis III: General medical conditions
  • Axis IV: Social functioning and impact of symptoms
  • Axis V: Global Assessment of Functioning (described using a scale from 1 to 100)

Common axis I disorders between the two systems include substance dependence and abuse (e.g. alcohol dependence); mood disorders (e.g. depression, bipolar disorder); psychotic disorders (e.g. schizophrenia, schizoaffective disorder); and anxiety disorders (e.g. post-traumatic stress disorder, obsessive-compulsive disorder). Axis II disorders include borderline personality disorder, schizotypal personality disorder, avoidant personality disorder and antisocial personality disorder.

[edit] History

Psychiatry developed as a profession during the 19th Century (although its origins go back further), particularly in Germany. The name was coined by Johann Christian Reil, from the Greek 'psyche' (soul) and 'iatros' (doctor). Teaching began in Leipzig in 1811, with the first psychiatric department established in Berlin in 1865. The field sought to apply concepts and tools from general medicine and neurology to the study and treatment of mental distress and disorder. For a long time psychiatry formed a single discipline with neurology. It was associated with insane asylums and involuntary commitment. Benjamin Rush is considered the "Father of American Psychiatry", publishing the first textbook on the subject in the United States, Medical Inquiries and Observations upon the Diseases of the Mind (1812).

At the turn of the century, Neurologist Sigmund Freud developed the field of psychoanalysis (Carl Jung also worked on related ideas) and for many years during the mid twentieth century, Freudian and neo-Freudian theories dominated psychiatric thinking. However, it was the work of Emil Kraepelin that laid the foundations of modern psychiatry by developing ideas of distinct categories of mental illness. Others who notably developed this line of work included Karl Jaspers, Eugen Bleuler, Kurt Schneider and Karl Leonhard. Adolf Meyer was one of the most influential figures in psychiatry in the first half of the twentieth century, combining biological and psychological approaches.

From the 1930s, psychiatry adopted a number of treatment practices including inducing seizures (by ECT, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). In the 1950's and 1960's, the largely serendipitous discoveries of lithium carbonate as a treatment for bipolar disorder, chlorpromazine and other typical antipsychotics for treatment of schizophrenia and various antidepressant medications ushered in an "age of psychopharmacology".

During the 20th Century psychiatry was often used by totalitarian regimes as part of a system to enforce political control. Typical examples include Nazi Germany[2], the Soviet Union under the name of Psikhushka, and the apartheid system in South Africa[3].

Coming to the fore during the 1960s, the field attracted an anti-psychiatry movement challenging its theoretical, clinical and legal legitimacy. Psychiatrists notably associated with critical challenges to mainstream psychiatry included RD Laing and Thomas Szasz.

Along with the development of fields such as genetics and tools such as neuroimaging, psychiatry moved away from psychoanalysis back to a focus on physical medicine and neurology[2] and to search for the causes of mental illnesses within the genome and the neurochemistry of the brain. Social Psychiatry became marginalised relative to biopsychiatry. Psychiatric categories were further codified in diagnostic manuals which became widely adopted. Robert Spitzer was notable in this development. Psychiatry became more closely linked to pharmaceutical companies.

Developments in psychotherapy also occured, generally away from long-term psychanalysis to more evidence-based therapies. Particularly notable was the development of Cognitive Behavioral Therapy from the work of Aaron Beck.

During the last third the 20th century, the institutional confinement of people with the most severe and persistent forms of mental illness steadily declined. Among the reasons for this trend were campaigns for more humane care, advances in psychopharmacology, increases in public financial assistance for people with severe disabilities, and developments in community mental health treatment (for example, see psychosocial rehabilitation and assertive community treatment). Finally, this was said to be the preference of the majority of those diagnosed with mental health conditions.

[edit] Further considerations

[edit] Anti-psychiatry

Main article: Anti-psychiatry

There exist movements opposed to the practices of – and, in some cases, the existence of – psychiatry. These movements mostly originated in the 1960s and 1970s, led by figures such as David Cooper, Peter Breggin, Thomas Szasz and R. D. Laing. Modern antipsychiatry encompasses a broad range of professional views, including a scholarly journal devoted exclusively to criticism of psychiatry, Ethical Human Psychology and Psychiatry[3]. The movement is also driven by users and ex-users of psychiatric services and disability rights campaigners.

[edit] Main criticisms

  • A lot of criticism and debate has focused on the efficacy, adverse effects and routine usage of psychiatric medications. The close relationship between psychiatry (and those prescribing psychiatric medication such as general physicians) and pharmaceutical companies has become increasingly controversial. Studies of pharmacogenetic polymorphism indicate that people of various ethnicities, for example one third of African American and Asian groups, have an increased risk of side effects and toxicity[4]. Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2005). ECT, termed electroshock by critics, is also much criticised, with concerns centred on evidence of long-term adverse effects and inefficacy, despite evidence of short-term benefits, and on how ECT is actually administered in routine practice.
  • Critics highlight findings of problems with diagnostic reliability, including misdiagnosis (Williams et al, 1992; McGorry et al, 1995; Hirschfeld et al, 2003]), especially when comparing the criteria of the different psychiatric manuals (van Os et al, 1999). Some critics add that the criteria for many "mental illnesses" are openly culturally biased, or are extremely subjective and create essentially random diagnoses. See Schizophrenia. Rapid rises in the number diagnosed with particular disorders, sometimes relating to expanding of diagnostic criteria and increased prescribing of medication, for example with regard to childhood ADHD and ritalin, have also been criticised. Some critics claim that there are no established biological markers for many if not all the disorders the DSM purportedly identifies[5]. Although psychiatrists generally accept a medical model of mental disorders, some critics advocate alternative models that give more weight to environmental/social and psychological understandings and treatments.
  • Another concern centers on the issue of involuntary commitment, which centers on issues of civil liberties and personal freedoms. In the U.S. someone may be involuntarily detained for psychiatric examination for a period of time (usually 24 to 72 hours depending on the state) if a government official declares the subject to be a danger to himself or others. With the attestation of an examining physician that a patient meets strict criteria of dangerousness to himself or others resulting from symptoms of mental illness, a judge may extend this commitment. Opposition to involuntary commitment is diverse and includes simple arguments that involuntary commitment is now or is inherently unconstitutional. The laws regarding the involuntary treatment of children vary widely from state to state[6].

[edit] See also

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[edit] Related terms

[edit] Lists

[edit] Footnotes

  1. ^ http://www.apa.org/books/431668A.html
  2. ^ Martin J. B. "The integration of neurology, psychiatry and neuroscience in the 21st century". Am. J. of Psychiatry 2002; 159:695-704. Fulltext. PMID 11986119
  3. ^ http://www.springerpub.com/journal.aspx?jid=1523-150X
  4. ^
  5. ^ http://www.mindfreedom.org/mindfreedom/hungerstrike1.shtml#final
  6. ^ http://www.psychlaws.org/LegalResources/Index.htm

[edit] References

  • Ford-Martin, Paula Anne Gale (2002), "Psychosis" Gale Encyclopedia of Medicine, Farmington Hills, Michigan
  • McGorry PD, Mihalopoulos C, Henry L et al (1995) Spurious precision: procedural validity of diagnostic assessment in psychiatric disorders. American Journal of Psychiatry 152 (2) 220-223
  • Moncrieff J, Cohen D. (2005). Rethinking models of psychotropic drug action. Psychotherapy & Psychosomatics, 74, 145-153
  • 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
  • Williams, J.B., Gibbon, M., First, M., Spitzer, R., Davies, M., Borus, J., Howes, M., Kane, J., Pope, H., Rounsaville, B., and Wittchen, H. (1992). The structured clinical interview for DSM-III-R (SCID) II: Multi-site test-retest reliability. Archives of General Psychiatry, 49, 630-636.

[edit] External links


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