Psychiatry

From The Book of THoTH (Leaves of Wisdom)

Psychiatry refers to the practice of medicine relating to the mind and behaviour, coming from Greek words meaning "healer of the mind". It has parallels with the work "physiatry", which is used to refer to the practice of medicine within a rehabilitation framework but, given its reliance on medication as the primary or sole means of treatment, psychiatry rarely works within a rehabilitative framework. Some academics advocate the use of patient-centred terms that embrace prevention, diagnosis, treatment, and rehabilitation, rather than just diagnosis and certain forms of treatment. Although, traditionally, psychiatrists are psychiatric physicians, the term "psychiatrist" would be used to refer to what a clinician does rather than the type of training received: "psychiatry" would therefore refer to the activities of all clinicians who treat mental illness, including not only psychiatric physicians but also psychiatric psychologists, psychiatric nurses, psychiatric social workers, and psychiatric counselors. At present, the plethora of terms to describe many related medical professions is more about meeting clinicians' needs for professional protectionism and prestige rather than the public's need for clarity.

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, and psychosocial interventions.

1 Practice of psychiatry
2 The DSM system
3 Contrast with psychology
4 Professional requirements
5 History
6 Further considerations
- 6.1 Anti-psychiatry
- 6.2 Other criticisms
7 Related terms
8 Footnotes
9 References
10 See also
- 10.1 Lists
11 External links

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Practice of psychiatry

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 a significant number of 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
Elderly psychiatry (Geriatric psychiatry)
Learning disability
Consultation-liaison psychiatry
Emergency psychiatry
Addiction and substance abuse 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 especially in a hospital or clinical setting (particularly in the UK) but may also be called clients, especially when treated privately. 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 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 and their associated medical specialists consulted. 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<ref>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.</ref>, 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. Many 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.

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. In North America, some jurisdictions give psychiatrists the sole authority to admit patients forcibly, while others require a trial.

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.

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The DSM system

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 <ref>http://www.apa.org/books/431668A.html</ref>.

ICD-10 (International Classification of Diseases-10), the main alternative to the DSM, is less specific in its criteria for each illness. It is used primarily in Europe.

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Contrast with psychology

In academic departments of US medical schools, there has long been flexibility in professional labels and many professors of psychiatry are often actually psychologists. However, in terms of training programs for the practice of forms of clinical medicine, there are different rules: increasingly, medical schools are combining physicians and psychologists in their departments and renaming them "departments of psychological medicine", rather than admitting that psychologists practice a form of psychiatry and altering the structure of the professions. This reflects an attempt to exclude clinical psychologists from the arena of medical practice, even though that is what they do. Given the vast overlap between psychiatry and clinical psychology, it is useful to try and draw some distinctions.

The current rule internationally is that psychiatry is practised by physicians who specialize in mental illness. They are trained in the biomedical approach to disorders and in the use of medications. Some (but not all) psychiatrists are also trained to conduct psychotherapy, which is a separate skill. Psychiatrists are usually not taught to evaluate patients from a biopsychosocial perspective before prescribing treatment, even though this is ideal.

Psychology is the larger 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. Psychologists cover a vast range of sub-disciplines and the clinical care of people with mental and physical illness is only one specialty. Relatively few choose to complete the rigorous training required of clinical psychologists.

Clinical psychology is the branch of psychology that specializes in understanding and helping those experiencing mental distress or behavioral problems in the clinic and/or community; it has a number of specialties in itself, including medical psychology, neuropsychology, clinical health psychology, forensic psychology, and clinical psychophysiology. Clinical psychologists have extensive postgraduate training in mental health, psychological assessment, psychotherapy, and psychosocial interventions, with some choosing additional advanced training in physiology, physical health, and pharmacology. They are often found working in similar settings and with the same kinds of patients or clients as psychiatric physicians. Clinical psychologists start with training in general psychology rather than a training in general physiology (as psychiatric physicians do), before going onto postgraduate clinical courses in forms of psychological medicine. Depending on the country, psychiatrists' training lasts 6-8 years from start to finish, while psychologists training lasts 5-10 years. Psychologists do not always assume a medical model or so-called 'neo-Kraepelinian' categories (named after the psychiatrist Emil Kraepelin, the father of descriptive psychiatry). While individual psychiatrists may (unreasonably) claim exclusive expertise in medication-based interventions and the general physical context, individual clinical psychologists may (equally unreasoably) claim particular expertise in psychosocial interventions and the general psychosocial context, even though the two are not always separated in this way. The distinction between clinical psychology and psychiatry is primarily and increasingly one of professional identification, rather than substance.

In order to prescribe medications in certain States of the US, clinical psychologists must complete a postdoctoral training program in clinical psychopharmacology and practicum, and pass a licensing examination prior to doing so); this specialty is called medical psychology and the turf battle in the US over prescribing privileges is ongoing. The American Psychological Association argues that there is an inadequate number of psychiatrists for the number of people with mental health problems, and that focused education in psychopharmacology is adequate to provide medication management. The American Psychiatric Association has long argued that a full training in physical medicine is necessary to make the diagnostic, therapeutic and potentially life-threatening decisions that accompany the pharmacologic treatment of those with serious mental health problems. Above all, there is a lot of ignorance on both sides as to what the public actually needs and what sort of training is sufficient and necessary to meet those needs, while the turf battle is colored primarily by professional self-interest.

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Professional requirements

In the United States, psychiatrists can be board certified as specialists in their field. After completing four years of medical school, physicians practise as psychiatry residents for four years. Psychiatry residents are required to complete at least four months of medicine (internal medicine or pediatrics) and two months of neurology during these four years. After completing their training, psychiatrists take written and then oral board examinations, each of which has a failure rate that approaches 50%, before becoming board certified.

In the United Kingdom, people gain a four-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 (this is a term used in the US but not the UK), although this begs the question of the relevance of a physician's training to the work environment. 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.

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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." <ref name="Martin 2002">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.</ref> 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, Freudian theories dominated psychiatric thinking.

The discovery of lithium carbonate as a treatment for bipolar disorder (and shortly thereafter after 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.

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Further considerations

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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<ref>http://www.springerpub.com/journal.aspx?jid=1523-150X</ref>.

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<ref>http://www.mindfreedom.org/mindfreedom/hungerstrike1.shtml#final</ref>. Also, though psychiatrists generally accept a medical model of mental disorders, some professionals and patients advocate a trauma model, especially as regards schizophrenia<ref>http://primal-page.com/ps2.htm</ref><ref>http://www.rossinst.com</ref><ref>http://www.schizosavant.com/</ref>.

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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<ref name="Wells, 1998"/>.

As in any medical specialty, different individuals respond differently to a given drug. However, given the long periods (up to several months) needed for adqeuate trials of many psychiatric medications, this can lead to some patients experiencing a prolonged trial-and-error process involving numerous serious adverse effects.

Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2004).

The high rate of methylphenidate (Ritalin) use among school children in the U.S. has come under greater scrutiny{{fix

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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).

Another concern centers on the issue of involuntary treatment, which touches on issues of civil liberties and personal freedoms. In the U.S. there are many restrictions in place to protect the rights of the patients. The laws regarding the involuntary treatment of children vary widely from state to state<ref>http://www.psychlaws.org/LegalResources/Index.htm</ref>.

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Related terms

"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.

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