Psychiatry
Psychiatry is a
medical speciality whose primary goal is to improve people's mental well-being. This can be by managing and improving the symptoms of specific
mental illness, as well as assisting people to gain insight into themselves and their relationships with others.
The name derives from the
Greek for "healer of the spirit". In the United States, it is practised by people, termed
psychiatrists, holding
M.D. or
D.O. degrees.
While all clinicians encounter patients with mental illnesses and any of them may treat it, psychiatrists specialize in these areas. They are specifically trained in the
differential diagnosis (the distinguishing of various forms) and treatment of mental illness. Treatment can involve medication, psychotherapy (such as
cognitive behaviour therapy,
interpersonal therapy, and
psychodynamic psychotherapy), and psychosocial interventions.
Psychiatry is one of the clinical medical disciplines that involve the diagnosis, treatment and prevention of mental and behavioral disorders such as
clinical depression,
bipolar disorder,
schizophrenia and
anxiety disorders.
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. Efficacy 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.
In general,
psychiatric treatments have improved over the past several decades, beginning with the advent of modern
psychiatric medications (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.
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*
Consultation-liaison psychiatry* Emergency psychiatry
* Addiction psychiatry
* Forensic psychiatry
Practicing psychiatrists may specialize in certain areas of interest such as
psychopharmacology,
mood disorders,
neuropsychiatry, eating disorders, psychiatric rehabilitation, crisis assessment and treatment, early psychosis intervention, community psychiatry (home treatment and outreach) and various forms of psychotherapy such as
psychodynamic therapy and
cognitive behavioral therapy.
Individuals with mental illness are commonly referred to as
patients when seen by physicians but may also be called
clients, especially when treated
privately by allied healthcare professionals. They may come under the care of a psychiatrist 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.
Whatever the circumstance of their patient's referral, a psychiatrist first assesses their patient's mental and somatic 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 (e.g. thyroid dysfunction or brain tumors) or identify any signs of
self-harm.
Blood tests and
medical imaging may be also performed. 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]
Various forms of medication, therapy and counseling deal with mental and behavioral conditions.
Psychotherapy may be used for many conditions, either exclusively or in combination with medication. In the
United States, only physicians, medical psychologists
[Medical psychologists are clinical psychologists with advanced training in physiology and psychopharmacology and those who practise in New Mexico, Louisiana, Guam or the military may also prescribe medication.], nurse practitioners, or physician assistants may prescribe mental health
medication. In some countries, mental health medication may only be prescribed by physicians. 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 produce
side-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.
Psychiatric patients may be either inpatients or outpatients. Psychiatric outpatients periodically visit their psychiatrist for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatrist interviewing the patient to update their assessment of the patient's condition and management of any medication. The psychiatrist may also provide psychotherapy. The frequency with which a psychiatrist 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 psychiatrist and patient decide would be best.
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 monitored, given medication and tested by a psychologist. If necessary, they are prevented from harming themselves or others. Hospitalized patients are increasingly being managed in a multidisciplinary fashion, meaning patients may encounter a variety of
nursing staff,
occupational therapists, psychotherapists,
social workers and other healthcare professionals.
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 based on 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 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.
The intention is to create a set of diagnoses that are replicable and meaningful, although the categories are broad and many of the symptoms overlap. 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
[http://www.apa.org/books/431668A.html].
ICD-10 (-10), the main alternative to the DSM, is less specific in its criteria for each illness. It is used primarily in Europe.
Main articles: Psychology, Clinical PsychologyPsychology is the study of human behavior and thought processes. Psychology is as much a field of academic study (like
biology or
sociology) as a profession, and as a whole, is concerned with the whole range of everyday human behavior as much as it is the study of mental illness. Clinical psychology is the application of psychology to problematic mental distress in a health and social care context.
In general, being a qualified medical practitioner is a prerequisite for entering training to become a psychiatrist, though the process and time spent may vary from country to country.
In the
United States, psychiatrists can be board certified as specialists in their field. After completing four years of college, then 4 years of medical school, these physicians practise as psychiatry residents for another four years. Psychiatry residents are required to complete at least four post-graduate months of internal medicine or pediatrics and two months of neurology during the first year. After completing their training, psychiatrists take written and then oral board examinations administered by the American Board of Psychiatry and Neurology (ABPN).
In
Australia, after completing a medical degree and two years of experience as a junior doctor (intern, then RMO or Resident Medical Officer), doctors must complete five years as a psychiatry registrar, including six month rotations in child and consultation-liaison psychiatry, and pass written and clinical exams prior to gaining qualifications as a Consultant Psychiatrist. The professional body of psychiatrists is known as the
RANZCP (Royal Australian and New Zealand College of Psychiatrists).
In the
United Kingdom, people gain a five-year bachelor's degree in general physical medicine, after which they are allowed the title 'doctor'; then they work as a
senior house officer (SHO) in psychiatry for 2-3 years while sitting postgraduate exams, after which they may apply for a
specialist registrar post, which may be in any one of several areas of specialization within psychiatry. There are several different areas of specialization in which one may train as a specialist registrar (the 3-4 years of career advancement required before becoming a senior physician or
consultant), which are general adult psychiatry, child and adolescent psychiatry, psychogeriatrics, forensic psychiatry, and psychotherapy. After this period as a specialist registrar, one has to be approved by the
Royal College of Psychiatrists as a specialist in the chosen field before going on to apply for a consultant post in that field. In other countries, similar rules usually apply.
Some psychiatrists 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, 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.
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."
[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.] 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.
The discovery of
lithium carbonate as a treatment for
bipolar disorder (and, shortly thereafter, by the development of
typical antipsychotics for treatment of
schizophrenia), followed by the development of fields such as
molecular biology and tools such as
neuroimaging has led to psychiatry re-discovering its origins in physical and observational medicine without losing sight of its humane dimension.
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].
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.
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[http://www.springerpub.com/journal.aspx?jid=1523-150X].
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
[http://www.mindfreedom.org/mindfreedom/hungerstrike1.shtml#final]. Also, though psychiatrists generally accept a medical model of mental disorders, some professionals and patients advocate a
trauma model, especially as regards schizophrenia
[http://primal-page.com/ps2.htm][http://www.rossinst.com][http://www.schizosavant.com/].
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
[http://www.psychlaws.org/LegalResources/Index.htm].
*
Telepsychiatry* "
Alienist" was a somewhat derogatory and now obsolete term for a psychiatrist or psychologist.
* "Shrink", taken from "
head shrinker", is a slang term for a psychiatrist or psychotherapist, sometimes treated as derogatory or offensive.
* 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
* 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.
*
Anti-psychiatry*
Biological psychiatry*
Chemical imbalance theory*
Cognitive neuropsychiatry*
Ethnopsychopharmacology*
International Center for the Study of Psychiatry and Psychology*
Neurology*
Neuropsychiatry*
Mental health*
Mental health professional*
Psychiatric survivors movement*
Psychoanalysis*
Psychopathology*
Psychopharmacology*
Psychotherapy*
Scientology and psychiatryLists
*
Famous figures in psychiatry*
Fictional psychiatrists*
Psychiatric drugs**
by condition treated* Significant publications in:
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Medicine**
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Psychology*
World Psychiatric Association *
Culture and Ethnicity, National Mental Health Information Center, SAMHSA*
American Psychiatric Association*
American Academy of Child and Adolescent Psychiatry*
Child Mental Health*
On-Line Psychiatry Journal Club (via JournalReview.org)*
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