psychiatry - Psychiatry in professional practice, Treatment overview, Diagnostic systems of psychiatric disorders, History, Further considerations

A branch of medicine concerned with the study, diagnosis, prevention, and treatment of mental and emotional disorders. Its pattern of practice derives from many other disciplines (such as philosophy, psychology, biology, and ethology) and incorporates a wide range of treatment modalities. Within psychiatry, there is a range of sub-specialties including child psychiatry, liaison psychiatry (the study of patients with other physical illnesses concurrent with psychological and mental difficulties), forensic psychiatry (the study and treatment of patients who have broken the law), and psychotherapy. The range of conditions treated by psychiatrists is wide, and includes patients suffering from psychoses (in which there is a loss of contact with reality), neuroses (in which anxiety is a major component), eating disorders, disorders of dependence, mental retardation, and sleep disorders. The term psychiatry was coined in 1847. Society's attitude to the mentally ill has undergone a series of changes, and has often been influenced by those working outside of the psychiatric domain. Important contributors to modern attitudes concerning the mentally ill were the French physician Philippe Pinel (1745–1826) and the British philanthropist William Tuke (1732–1822). There has been a range of contributors to various aspects of psychiatry. Freud, Adler, Jung and many others have contributed to the psychological and psychoanalytic schools. Pavlov, Skinner, Solpe, and Beck have contributed to behavioural aspects. The German psychiatrist Emil Kraepelin (1856–1926) contributed the definition of clinical syndromes.

Psychiatry is a medical specialty dealing with the prevention, assessment, diagnosis, treatment, and rehabilitation of mental illness – both in itself and in bodily illness ('psychiatry in medicine') – such as clinical depression, bipolar disorder, schizophrenia and anxiety disorders.

Most psychiatric illnesses cannot currently be cured. Effectiveness of treatment for any given condition is also variable from patient to patient, with some patients having complete resolution of symptoms and others unfortunately having poor or minimal response to even the strongest measures.

Psychiatry in professional practice

Psychiatrists are the most well known of mental health professionals. They are medical doctors and one of the few professionals in the mental health industry who specialize and are certified in treating mental illness using the biomedical approach to mental disorders including the use of medications.

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. 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." These psychiatrists may only hold research degrees or a combination of psychiatry doctorates (such as an M.D.

Subspecialties

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

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

Some psychiatric practitioners specialize in helping certain age groups; Those who practise psychiatry in the workplace are called industrial psychiatrists in the US (occupational psychology is the name used for the most similar discipline in the UK). Psychiatrists working in the courtroom and reporting to the judge and jury (in both criminal and civil court cases) are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists and mental health professionals in the field of psychiatry may also specialize in psychopharmacology, neuropsychiatry, eating disorders, and early psychosis intervention.

See also: meta-semantics

Treatment overview

In general, psychiatric treatments have changed over the past several decades (see History section, below). In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, most psychiatric patients are managed as outpatients.

Individuals with mental illness are commonly referred to as patients but may also be called clients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician.

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.

Commencing treatment with medication requires the patient to agree to this treatment, although in many countries the law provides overriding circumstances, and that they will follow the dosage prescribed. Like all medications, psychiatric medications can have toxic effects in patients and hence often involve ongoing therapeutic drug monitoring, for instance full blood counts or, for patients taking lithium salts, serum levels of lithium.

Outpatient care

Psychiatric patients may be either inpatients or outpatients. Psychiatric outpatients periodically visit their clinician for consultation in his or her office, usually for an appointment lasting thirty to sixty minutes. These consultations normally involve the psychiatric practitioner interviewing the patient to update their assessment of the patient's condition, and to provide psychotherapy or review medication. The frequency with which a psychiatric practitioner sees patients varies widely, from days to months, depending on the type, severity and stability of each patient's condition, and depending on what the clinician and patient decide would be best

Inpatient care

Psychiatric inpatients are patients admitted to a hospital to receive psychiatric care, sometimes involuntarily.

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

Diagnostic systems of psychiatric disorders

ICD-10 (International Classification of Diseases)- the ICD 10 is published by the World Health Organisation and used world wide. In the United States, the standard system of psychiatric diagnoses is given in the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM), overseen and revised by the American Psychiatric Association.

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.

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.

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.

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. For many years, particularly during the mid-twentieth century, Freudian theories dominated psychiatric thinking.

In the 1950's and 1960's, the largely serendipitous discoveries of lithium carbonate as a treatment for bipolar disorder, chlorpromazine and other typical antipsychotics for treatment of schizophrenia and various antidepressant medications ushered in an "age of psychopharmacology". Followed by the development of fields such as molecular biology and tools such as neuroimaging, this led to psychiatry rediscovering its origins in physical and observational medicine and to search for the causes of mental illnesses within the brain.

During the 20th Century psychiatry was often used by totalitarian regimes as part of a system to enforce political control.

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.

Further considerations

Anti-psychiatry

Unlike most other areas of medicine, there exist movements opposed to the practices of – and, in some cases, the existence of – psychiatry.

Some mental health professionals sympathetic to anti-psychiatric views claim that there are no known biological markers for many if not all the disorders the DSM purportedly identifies. Also, though psychiatrists generally accept a medical model of mental disorders, some professionals and patients advocate alternative models that give more weight to environmental/social and psychological understandings.

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. Unfortunately, side effects to psychiatric drugs are common and sometimes severe. Critics also question whether psychiatric drugs are disorder- or problem-specific in the way that is claimed (Moncrieff and Cohen, 2005). Hirschfeld et al, 2003]), especially when comparing the criteria of the different psychiatric manuals (van Os et al, 1999). 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. Telepsychiatry

Lists

Famous figures in psychiatry Fictional psychiatrists Psychiatric drugs by condition treated Significant publications in: Medicine Psychiatry Psychology