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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, although recovery may occur. 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 individual to individual.

Psychiatry in professional practice

Psychiatrists are doctors of medicine (MD) or osteopathy (DO) and are board certified in most states 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]

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 practice 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.

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 or more recently consumers. 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.

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.

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 or clinic to receive psychiatric care, sometimes involuntarily, in which case they could be involuntarily committed to a standard, otherwise non-psychiatric prison. 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 favored 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.

Theory and Focus

Mainstream psychiatry is considered a branch of medicine that is, or should aim to be, evidence-based in theory and practice. Psychiatric diagnosis is based on the concept of a distinct boundary between the mentally healthy and the mentally ill, and between different kinds of mental illness that can be medically differentiated, understood and treated. This is commonly done through standardized categories dubbed 'neo-Kraepelian' (Klerman, 1978), based on patterns of so-called 'Feighner criteria' (lists of symptoms with rules on the combinations required for different diagnoses).

Psychiatry is often described as being based within, or dominated by, a biomedical paradigm, although there are different theoretical approaches:

Diagnostic systems of psychiatric disorders

DSM-IV
The Latest Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association.
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Two main classifications of mental disorders are in use today. The ICD-10 (International Classification of Diseases) is produced and published by the World Health Organisation and includes a section on mental disorders, and is used to some extent worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM), produced and published by the American Psychiatric Association, is solely focused on mental disorders and is the main classification tool in the United States. 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 a par with one another, and an explicit concern in the development of the DSM-IV was compatiblity with the diagnostic categories and codes of the ICD. The lack of a case example version of the ICD-10 is considered a problem by some[How to reference and link to summary or text]. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders (CCMD).

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data, they are 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. 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.

History

Physicians in Ancient Egypt and Ancient Greece sought to explain and treat mental disturbance, notably melancholy and hysteria, but medieval thought focused on the concept of demonic possession or supernatural spirits. The first hospital wards for the mentally disturbed opened from the 8th century in the Middle East, notably at Baghdad Hospital under Rhazes, with the first dedicated asylums opening from the 15th Century in Egypt, Spain and then the rest of Europe, notoriously at Bedlam in England.

In the 16th century, Johann Weyer argued that some cases of alleged witchcraft were actually mental illness, as others had argued before him. Different categories of mental illness became systematically considered by physicians in the context of neurology, a term coined in the 17th century from the work of Thomas Willis. In 1758, William Battie gave impetus to the study and treatment of mental disturbance as a medical speciality. From the late 18th Century, the moral treatment movement sought to make asylums more humane and therapeutic as well as custodial, an approach developed partly from the work of physicians, notably Philippe Pinel, who also developed new ways of categorizing mental disorders.

Psychiatry developed as a clinical and academic profession in the early 19th Century, particularly in Germany. The field sought to systematically apply concepts and tools from general medicine and neurology to the study and treatment of abnormal mental distress and disorder. The term psychiatry was coined in 1808 by Johann Christian Reil, from the Greek “psyche” (soul) and “iatros” (doctor). Official teaching first began in Leipzig in 1811, with the first psychiatric department established in Berlin in 1865. Benjamin Rush pioneered the approach in the United States. The American Psychiatric Association was founded in 1844. Psychiatric nursing developed as a profession.

Early in the 20th Century, neurologist Sigmund Freud developed the field of psychoanalysis and Carl Jung popularized related ideas. Meanwhile Emil Kraepelin developed the foundations of the modern psychiatric classification and diagnosis of mental illnesses. Others who notably developed this approach included Karl Jaspers, Eugen Bleuler, Kurt Schneider and Karl Leonhard. Adolf Meyer was an influential figure in the first half of the twentieth century, combining biological and psychological approaches. Women were admitted as members of the profession for the first time[2]

Psychiatry was used by some totalitarian regimes as part of a system to enforce political control, for example in Nazi Germany [3], the Soviet Union under Psikhushka, and the apartheid system in South Africa [4]. For many years during the mid-20th century, Freudian and neo-Freudian thinking dominated psychiatric thinking. Social Psychiatry developed.

From the 1930s, a number of treatment practices came in to widespread use in psychiatry, including inducing seizures (by ECT, insulin or other drugs) or cutting connections between parts of the brain (leucotomy or lobotomy). In the 1950s and 1960s, lithium carbonate, chlorpromazine and other typical antipsychotics and early antidepressant and anxiolytic medications were discovered, and psychiatric medication came in to widespread use by psychiatrists and general physicians.

Coming to the fore in 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 R.D. 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[5] 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. “Neo-Kraepelinian” categories were codified in diagnostic manuals, notably the ICD and DSM, which became widely adopted. Robert Spitzer was notable in this development. Psychiatry became more closely linked to pharmaceutical companies. New drugs came in to common use, notably SSRI antidepressants and atypical antipsychotics.

Psychiatry was involved in the development of psychotherapies. Neo-Freudian ideas continued, but there was a trend away from long-term psychoanalysis to more cost-effective or evidence-based approaches, particularly cognitive therapy from the work of Aaron Beck. Other mental health professions, particularly clinical psychology, were becoming more established and competing with or working with psychiatry.

During the last third the 20th century, the institutional confinement of people diagnosed with mental illness steadily declined, particularly in more developed countries. Among the reasons for this trend of deinstitutionalization were pressure for more humane care and greater social inclusion, advances in psychopharmacology, increases in public financial assistance for people with disabilities, and the Consumer/Survivor Movement. Developments in community services followed, for example psychiatric rehabilitation and Assertive Community Treatment.

It has been argued that different methods of historical analysis, for example focusing on individual/technical achievements or focusing on social factors and social constructs, can lead to different histories of psychiatry[6]

Further considerations

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. Presently antipsychiatry encompasses a broad range of professional views, including a scholarly journal devoted exclusively to criticism of biopsychiatry, Ethical Human Psychology and Psychiatry[7], published by ICSPP. The movement is generally driven by former consumers of psychiatrically-related services and disability rights campaigners, who have found minimal assistance or outright iatrogenesis with current methodologies.

Main criticisms

  • A lot of criticism and debate has focused on the efficacy, adverse effects and the widespread and growing use 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[8]. Although psychiatrists generally accept a medical model of mental disorders, some critics advocate alternative models that in some cases give more weight to environmental/social and psychological understandings and treatments, and disagree on the existence of a biological cause for mental illnesses by the fact that it has never been proven. This makes psychiatry in the opinion of critics a pseudoscience and not a true science.
  • 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[9].

See also

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Footnotes


References

  • Andreasen NC. (1995)The validation of psychiatric diagnosis: New models and approaches. Am J Psychiatry ; 152:161–162.

Bracken, P. and Thomas, P. (2005). Postpsychiatry: Mental Health in a Postmodern World. Oxford: Open University Press.

  • Detre T, McDonald MC.(1997) Managed care and the future of psychiatry. Arch Gen Psychiatry ; 54:201–204,.
  • Guze SB. Why psychiatry is a branch of medicine. New York: Oxford University Press; 1992.
  • Ludwig AM. The psychiatrist as physician. J Am Med Ass 1975; 234:603–604.
  • Martin J. B.(2002) "The integration of neurology, psychiatry and neuroscience in the 21st century" . Am. J. of Psychiatry 159:695-704. Fulltext. PMID 11986119.
  • 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

External links

Psychiatric Watchdogs and Anti-Psychiatry Groups


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