Psychiatry

Psychiatry is a medical specialty dealing with the prevention, assessment, diagnosis, treatment, and rehabilitation of mental illness – both in itself and in bodily illness ('psychiatry in medicine') – such as clinical depression, bipolar disorder, schizophrenia and anxiety disorders. Its primary goal is the relief of mental suffering and improvement of mental well-being. This is sometimes done by first doing a thorough diagnostic assessment of the person from a biological, psychological, and social/cultural perspective. An illness or problem can then be managed by medication or various forms of psychotherapy. 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 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 unfortunately having poor or minimal response to even the strongest measures. The majority of patients will fall somewhere in between.

Psychiatry in professional practice

Psychiatrists are the most well known of mental health professionals. They are medical doctors and one of the few professionals in the mental health industry who specialize 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 and cognitive behavioral therapy; however psychologists and clinical psychologists specialize in the research and clinical application of these techniques. The amount of training a psychiatrist holds in providing these types of therapies varies from program to program and also differs greatly based upon region.

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. However, a study of the CAT scans of 397 psychiatric patients found no anomaly clinically related to the patients' psychiatric condition and concluded, "the pretest probability of finding a space-occupying lesion or other pertinent abnormality in patients presenting with psychiatric illnesses in this retrospective study appears not to be greater than that of the general population. The outcome of this study could be implemented to develop a clinical pathway for limiting assessment by CT for possible organic pathology in acute psychiatric illness." [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.).

Subspecialties

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

• Child and adolescent psychiatry
• Adult psychiatry
• Psychiatry of Old Age (Psychogeriatrics)
• Learning disability
• Behavioral medicine
• Consultation-liaison psychiatry
• Emergency psychiatry
• Addiction psychiatry
• Forensic psychiatry

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

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.

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. ECT has drawn criticism from anti-psychiatry groups despite evidence for its efficacy.

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.

Inpatient care

Psychiatric inpatients are patients admitted to a hospital 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.

Once in the care of a hospital, patients are assessed, monitored, and often given medication and receive care from a multidisciplinary team, including physicians, nurses, psychologists, occupational therapists, psychotherapists, social workers, and other medical professionals. If necessary, they are prevented from harming themselves or others.

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). 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 are diagnosed to a greater extent in the U.S than the U.K.

The intention has been to create a set of diagnoses that is replicable and meaningful, although the categories 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 to enhance research into both diagnosis and treatment, 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 and lacking proper scientific foundation .

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.

History

Psychiatric illnesses are sometimes characterized as disorders of the mind rather than the brain, although the distinction is not always obvious and has changed in the last few decades as understanding of the treated illnesses grew. Many conditions have been linked to biological or chemical abnormalities in the brain's psychology, but for some conditions the etiology and pathogenesis are still the subject of intense research.

For a long period of history, neurology and psychiatry were a single discipline, and following their division the tremendous advances in neurosciences (especially in genetics and neuroimaging) recently are bringing areas of the two disciplines back together. Indeed, in a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote that "the separation of the (neurological versus psychiatric disorders) is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway." One example of this is the overlap between the two fields in the treatment of illnesses such as Alzheimer's disease.

Psychiatry was at first a pragmatic discipline that was part of general medicine, combining medicine and practical psychology. The work of Emil Kraepelin laid the foundations of scientific psychiatry. A neurologist, Sigmund Freud, used these same powers of medically based observation to develop the field of psychoanalysis. For many years, particularly during the mid-twentieth century, Freudian theories dominated psychiatric thinking.

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". Followed by the development of fields such as molecular biology and tools such as neuroimaging, this led to psychiatry rediscovering its origins in physical and observational medicine and to search for the causes of mental illnesses within the brain.

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]. It is apparently still used that way in China [4] and other countries.

Deinstitutionalization

During the last 40 years, the institutional confinement of people with the most severe and persistent forms of mental illness has been steadily declining. Among the reasons for this trend are 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 is the preference of the majority of the chronically mentally ill.

Further considerations

Anti-psychiatry

Main article: Anti-psychiatry

Unlike most other areas of medicine, 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, Thomas Szasz and R. D. Laing. In 1999, psychiatrist Peter Breggin founded a scholarly journal devoted exclusively to criticism of bio-psychiatry, Ethical Human Psychology and Psychiatry.

Some mental health professionals sympathetic to anti-psychiatric views claim that there are no known biological markers for many if not all the disorders the DSM purportedly identifies. Also, though psychiatrists generally accept a medical model of mental disorders, some professionals and patients advocate a trauma model, especially as regards schizophrenia.

Other criticisms

• Criticism has been made regarding the need for improvement in psychiatric medications, as illustrated by studies of pharmacogenetic polymorphism showing that people of various ethnicities, for example one third of African American and Asian groups, have an increased risk of side effects and toxicity.

• As in any medical specialty, different individuals respond differently to a given drug. Unfortunately, side effects to psychiatric drugs are common and sometimes severe. Combined with the time period of therapeutic effect which generally takes between two and six weeks (but can draw out to several months), this can lead to prolonged periods where patients are sufferring distressing side effects.

• Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2005).

• The high rate of methylphenidate (Ritalin) use among school children in the U.S. has come under greater scrutiny. However this may be partly due to the shortage of child and adolescent psychiatrists (A Report of the Surgeon General, 2001) who are able to regulate such prescriptions.

• Critics claim that there are problems in terms of 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.

• 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.

Related terms

• "Alienist" was a somewhat derogatory and now obsolete term for a psychiatrist or psychologist.
• Mental health professional
• "Shrink", taken from "head shrinker", is a slang term for a psychiatrist or psychotherapist, sometimes treated as derogatory or offensive.
• Telepsychiatry

References

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

• Hirschfeld et al 2003, "Perceptions and impact of bipolar disorder: how far have we really come?", J. Clin. Psychiatry vol.64(2), p.161-174.

• 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

• MedFriendly.com, Psychologist, Viewed 20 September, 2006

• Moncrieff J, Cohen D. (2005). Rethinking models of psychotropic drug action. Psychotherapy & Psychosomatics, 74, 145-153

• 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

• 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.

See also

• Anti-psychiatry
• Biological psychiatry
• Chemical imbalance theory
• Cognitive neuropsychiatry
• Ethnopsychopharmacology
• International Center for the Study of Psychiatry and Psychology
• Neurology
• Neuropsychiatry
• Mental health
• Psychiatric survivors movement
• Psychoanalysis
• Psychopathology
• Psychopharmacology
• Psychotherapy
• Scientology and psychiatry

Lists

• Famous figures in psychiatry
• Fictional psychiatrists
• Psychiatric drugs
  • by condition treated

• Significant publications in:
  • Medicine
  • Psychiatry
  • Psychology

External links

• World Psychiatric Association
• Culture and Ethnicity, National Mental Health Information Center, SAMHSA
• American Psychiatric Association
• DSM-IV-TR online
• The Journal of Clinical Psychiatry
• The American Journal of Psychiatry
• American Academy of Child and Adolescent Psychiatry
• Journal of Child and Adolescent Psychopharmacology
• Child Mental Health - Addresses mental disorders, behavioral disorders, child abuse, trauma, disaster and medication issues
• On-Line Psychiatry Journal Club (via JournalReview.org)
• PSYCHOMEDIA The First Italian Portal on Psychiatry Psychology Psychoanalysis Psychotherapy
• Resources for Child and Adolescent Psychiatry
• ICD 10 "Blue Book"
• Internet Mental Health
• The Royal College Of Psychiatrists
• Shrink Rap Blog