psychoanalytic psychiatry

Psychiatry

[si-kahy-uh-tree, sahy-]
Psychiatry is a medical specialty which exists to study, prevent, and treat mental disorders in humans. Psychiatric assessment typically involves a mental status examination and taking a case history, and psychological tests may be administered. Physical examinations may be conducted and occasionally neuroimages or other neurophysiological measurements taken. Diagnostic procedures vary but official criteria are listed in manuals, the most common being the ICD from the World Health Organization and the DSM from the American Psychiatric Association. Psychiatric medication is a central treatment option, which is largely unique to psychiatry along with rarer procedures such as Electroconvulsive therapy. Psychotherapy is also a major treatment option in psychiatry, although it is also the speciality of other mental health professions. Psychiatric services may be provided on an inpatient or outpatient basis. In certain authorized cases this may be done on an involuntary basis. Both the research and clinical application of psychiatry are considered interdisciplinary. Because of this, various subspecialties and theoretical approaches exist. Psychiatrists can be considered physicians who specialize in the doctor-patient relationship utilizing some of medicine's newest classification schemes, diagnostic tools and treatments.

Psychiatry can be said to have originated in the 5th century BC, while the first hospitals for the mentally ill were created in the Middle Ages. The 18th century saw the development of psychiatry as a recognized field and mental health institutions came to utilize more elaborate, as well as some more humane, treatments. The 19th century saw a massive increase in patient populations. The 20th century saw a rebirth of a biological understanding of mental disorders as well the introduction of disease classifications and psychiatric medications. An anti-psychiatry movement emerged in the 1960s and a shift led to the dismantling of state psychiatric hospitals in favor of community treatment. There have been changes in psychiatric diagnoses and treatments and in the balance between the biological and social sciences. Research has continued looking into the origins, classification, and treatment of mental disorders.

Theory and focus

"Psychiatry, more than any other branch of medicine, forces its practitioners to wrestle with the nature of evidence, the validity of introspection, problems in communication, and other long-standing philosophical issues" (Guze, 1992, p.4).

The term psychiatry (ψυχιατρική), coined by Johann Christian Reil in 1808, comes from the Greek “ψυχή” (soul or mind) and “ιατρός" (healer or doctor). 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. The discipline is interested in the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. 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

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 therepautic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and the entirety of their post-graduate training is revolved around the field of medicine. Psychiatrists can therefore prescribe medication, order laboratory tests, utilize neuroimaging in a clinical setting, and conduct physical examinations.

Ethics

Like other professions, 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:

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

History

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. Early manuals written about mental disorders were created by the Greeks. In 4th century BC, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. However further explorations of this perspective ceased shortly thereafter following the fall of the Roman Empire. Religious leaders and others returned to using early versions of exorcisms to treat mental disorders which often utilized cruel, harsh, and other barbarous methods.

Middle Ages

The first psychiatric hospitals were built in the medieval Islamic world from the 8th century. The first was built in Baghdad in 705, followed by Fes in the early 8th century, and Cairo in 800. Unlike medieval Christian physicians who relied on demonological explanations for mental illness, medieval Muslim physicians relied mostly on clinical observations. They made significant advances to psychiatry and were the first to provide psychotherapy and moral treatment for mentally ill patients, in addition to other forms of treatment such as baths, drug medication, music therapy and occupational therapy. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi (Rhazes) combined psychological methods and physiological explanations to provide treatment to mentally ill patients. His contemporary, the Arab physician Najab ud-din Muhammad, first described a number of mental illnesses such as agitated depression, neurosis, priapism and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb).

In the 11th century, another Persian physician 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, which is seen as a precursor to the word association test developed by Carl Jung in the 19th century. Avicenna was also an early pioneer of neuropsychiatry, and first described a number of neuropsychiatric conditions such as hallucination, insomnia, mania, nightmare, melancholia, dementia, epilepsy, paralysis, stroke, vertigo and tremor.

Psychiatric 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 psychiatric hospitals. By 1547 the City of London acquired the hospital and continued its function until 1948.

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. In 1758 English physician William Battie wrote the Treatise on Madness which called for treatments to be utilized in asylums. Thirty years later the new ruling monarch in England, George III, was known to be suffering from a mental disorder. Following the King's remission in 1789, mental illness was seen as something which could be treated and cured. By 1792 French physician Philippe Pinel introduced humane treatment approaches to those suffering from mental disorders. William Tuke adopted the methods outlined by Pinel and that same year Tuke opened the York Retreat in England. That institution became known as a model throughout the world for humane and moral treatment of patients suffering from mental disorders. 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. The United States housed 150,000 patients in mental hospitals by 1904. German speaking countries housed more than 400 public and private sector asylums. These asylums were critical to the evolution of psychiatry as they provided a universal platform of practice throughout the world.

Universities often played a part in the administration of the asylums. Due to the relationship between the universities and asylums, scores of competitive psychiatrists were being molded in Germany. Germany became known as the world leader in psychiatry during the nineteenth century. The country possessed more than 20 separate universities all competing with each other for scientific advancement. However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums or psychiatry. Britain, like Germany, also lacked a centralized organization for the administration of asylums. This deficit hindered the diffusion of new ideas in medicine and psychiatry.

In the United States in 1834, Anna Marsh, a physician's widow, deeded the funds to build her country's first financially-stable private asylum. The Brattleboro Retreat marked the beginning of America's private psychiatric hospitals challenging state institutions for patients, funding, and influence. Although based on England's York Retreat, it would be followed by speciality institutions of every treatment philosophy.

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. By 1840, asylums as therapeutic institutions existed throughout Europe and the United States.

However, the new and dominating ideas that mental illness could be "conquered" during the mid-nineteenth century all came crashing down. Psychiatrists and asylums were being pressured by an ever increasing patient population. The average number of patients in asylums in the United States jumped 927%. Numbers were similar in England and Germany. Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity. 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. The different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin somewhat model this hiatus of psychiatry between the different disciplines. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his acceptance for a professorship of psychiatry, and later his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan of a more comprehensive psychiatry. Kraepelin also began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that these different disorders were all biological in nature, evolved into a new idea of "nerves" and psychiatry became a sort of rough neurology or neuropsychiatry. 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 asylums. However the progress of psychiatry by the 1970s turned psychoanalytic theory into a marginal school of thought within the field.

This period of time saw the reemergence of biological psychiatry. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the first neurotransmitter, acetylcholine. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. 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. While psychosocial issues were still seen as valid, psychotherapy was seen to be their "cure." Genetics were once again thought to play a role in mental illness. Molecular biology opened the door for specific genes contributing mental disorders to be identified. By 1995 genes contributing to schizophrenia had been identified on chromosome 6 and genes contributing to bipolar disorder on chromosomes 18 and 21.

Anti-psychiatry and deinstitutionalization

The introduction of psychiatric medications and the use of laboratory tests altered the doctor-patient relationship between psychiatrists and their patients. Psychiatry's shift to the hard sciences had been interpreted as a lack of concern for patients. Anti-psychiatry had become more prevalent in the late twentieth century due to this and publications in the media which conceptualized mental disorders as myths. 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. Incidents of physical abuse by psychiatrists took place during the reign of some totalitarian regimes as part of a system to enforce political control with some of the abuse even continuing to our present day. Historical examples of the abuse of psychiatry took place in Nazi Germany , in the Soviet Union under Psikhushka, and in the apartheid system in South Africa.

Electroconvulsive therapy was one treatment that the anti-psychiatry movement wanted eliminated. They alleged that electroconvulsive therapy damaged the brain and it was used as a tool for discipline. While there is no evidence that brain damage was a result of electronconvulsive therapy, there have been isolated incidents where the use of electroconvulsive therapy was threatened to keep the patients "in line." The prevalence of psychiatric medication helped initiate deinstitutionalization, the process of discharging patients from psychiatric hospitals to the community. The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained. Mental health professionals envisioned a process wherein patients would be released into communities where they could participate in a normal life while living in a therapeutic atmosphere.

Transinstitutionalization and the aftermath

In 1963, United States 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 and/or mild mental disorders. Ultimately there were no arrangements made for actively ill patients who were being discharged from hospitals. Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails. 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 analyzing 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. Rosenhan's study concluded that individuals with no presence of mental disorders could not be distinguished from those suffering from mental disorders. While critics such as Robert Spitzer placed doubt on the validity and credibility of the study, they also conceded that the consistency of psychiatric diagnoses needed improvement.

Psychiatry, like many medical specialties, has a continuing, significant demand for research investigating its related diseases, classifications, origins, and treatments. Psychiatry falls into 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 relational elements. In addition to external factors, the human brain must recognize or organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is the attempt to envelop the understanding of these factors so that they can be studied both clinically and physiologically.

Industry and academia

Practitioners

As with most medical specialties, all physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are physicians who specialize in psychiatry and are certified in treating mental illness using the biomedical approach to mental disorders. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis, and/or cognitive behavioral therapy, but it is their medical training, access to medical laboratories, and ability to prescribe medication that differentiates them from other mental health professionals.

Research

Psychiatric research is, by its very nature, interdisciplinary. From a general perspective it studies and combines social, biological and psychological approaches and how those perspectives cause mental disorders. While practicing psychiatrists and other psychiatric researchers study outcomes from such a wide variety of fields, research institutions and publications exist that are dedicated to the interdisciplinary study of mental disorders within the psychiatric context. Under the supervision of institutional review boards, psychiatric researchers look at a variety of topics such as neuroimaging, genetics, and psychopharmacology, which in turn help enhance diagnostic consistency, discover new treatment methods, and classify new mental disorders. On the basis of Tinbergen's four questions a framework of reference or "periodic table" of all fields of anthropological research and humanities can be established. It helps to structure interdisciplinarity in Psychiatry, e.g. how Neurology, Psychiatry and Psychotherapy might be connected with other fields of anthropological research.

Clinical application

Diagnostic systems

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 and psychosocial histories obtained, neuroimages or other neurophysiological measurements are taken, and personality tests or cognitive tests may be administered. In addition psychiatrists are beginning to utilize genetics during the diagnostic process. Some endophenotypes being researched may predispose certain individuals to certain conditions.

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 Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.

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-referral 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 efficacity 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 U.S. 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.

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 less time devoted to psychotherapy or "talk" therapies, or behavior modification. 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

References

Notes

General 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
  • C. Burke, Psychiatry: a "value-free" science? Linacre Quarterly, vol. 67/1 (Feb. 2000), pp. 59-88.
  • 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.

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