PSYCHIATRY is the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders . These include various abnormalities related to mood, behaviour, cognition , and perceptions.
Initial psychiatric assessment of a person typically begins with a case history and mental status examination . Physical examinations and psychological tests may be conducted. On occasion, neuroimaging or other neurophysiological techniques are used. Mental disorders are often diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA), and the International Classification of Diseases (ICD), edited and used by the World Health Organization (WHO). The fifth edition of the DSM ( DSM-5 ) was published in 2013, and its development was expected to be of significant interest to many medical fields.
The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment in current practice, but contemporary practice also includes a wide variety of other modalities, e.g., assertive community treatment , community reinforcement , and supported employment . Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, e.g., with epidemiologists , mental health counselors , nurses, psychologists , public health specialists, radiologists, and/or social workers .
* 1 Etymology
* 2 Theory and focus
* 2.1 Scope of practice * 2.2 Ethics * 2.3 Approaches * 2.4 Practitioners * 2.5 As a career choice * 2.6 Subspecialty * 2.7 Research
* 3 Clinical application
* 4 Treatment
* 4.1 General considerations
* 5 History * 6 Controversy and criticism * 7 See also
* 8 References
* 8.1 Notes * 8.2 Cited texts
* 9 Further reading * 10 External links
The word psyche comes from the ancient Greek for soul or butterfly . The fluttering insect appears in the coat of arms of Britain's Royal College of Psychiatrists
The term "psychiatry" was first coined by the German physician Johann
Christian Reil in 1808 and literally means the 'medical treatment of
the soul' (psych- "soul" from
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 ).
People who specialize in psychiatry often differ from most other
mental health professionals and physicians in that they must be
familiar with both the social and biological sciences . The
discipline studies the operations of different organs and body systems
as classified by the patient's subjective experiences and the
objective physiology of the patient.
SCOPE OF PRACTICE
Neurology § Overlap with psychiatry
Disability-adjusted life year
Though the medical specialty of psychiatry uses research in the field
of neuroscience , psychology , medicine , biology , biochemistry , and
pharmacology , it has generally been considered a middle ground
between neurology and psychology. Because psychiatry and neurology
are deeply intertwined medical specialties, all certification for both
specialties and for their subspecialties are offered by a single
board, the American Board of
See also: Ethical issues in psychiatry (other)
Like other purveyors of professional ethics , 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 during the organization's general assembblies in 1999, 2002, 2005, and 2011. 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, for example, surrounding the use of lobotomy and electroconvulsive therapy . Discredited psychiatrists who operated outside the norms of medical ethics include Harry Bailey , Donald Ewen Cameron , Samuel A. Cartwright , Henry Cotton , and Andrei Snezhnevsky .
Psychiatric illnesses can be conceptualised in a number of different
ways. The biomedical approach examines signs and symptoms and compares
them with diagnostic criteria.
Once a medical professional diagnoses a patient there are numerous ways that they could choose to treat the patient. Often psychiatrists will develop a treatment strategy that incorporates different facets of different approaches into one. Drug prescriptions are very commonly written to be regimented to patients along with any therapy they receive. There are three major pillars of psychotherapy that treatment strategies are most regularly drawn from. Humanistic psychology attempts to put the "whole" of the patient in perspective; it also focuses on self exploration. Behaviorism is a therapeutic school of thought that elects to focus solely on real and observable events, rather than mining the unconscious or subconscious. Psychoanalysis , on the other hand, concentrates its dealings on early childhood, irrational drives, the unconscious, and conflict between conscious and unconscious streams.
All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are physicians who specialize in psychiatry and are certified to treat mental illness . They may treat outpatients, inpatients, or both; they may practice as solo practitioners or as members of groups; they may be self-employed, be members of partnerships, or be employees of governmental, academic, nonprofit, or for-profit entities; they may treat military personnel as civilians or as members of the military; and in any of these settings they may function as clinicians, researchers, teachers, or some combination of these. Although psychiatrists may also go through significant training to conduct psychotherapy , psychoanalysis or cognitive behavioral therapy , it is their training as physicians that differentiates them from other mental health professionals .
AS A CAREER CHOICE
The field of psychiatry has many subspecialties (also known as
fellowship ) that require additional training which are certified by
the American Board of
* Clinical neurophysiology * Forensic psychiatry * Addiction psychiatry * Child and Adolescent Psychiatry * Geriatric psychiatry * Hospice and palliative medicine * Pain management * Psychosomatic medicine (also known as consultation-liaison psychiatry ) * Sleep medicine
Further, other specialties that exist include:
* Cross-cultural psychiatry * Emergency psychiatry * Learning disability * Neurodevelopmental disorder * Cognition diseases as in various forms of dementia * Biological psychiatry * Community psychiatry * Global Mental Health * Military psychiatry * Social psychiatry
Addiction psychiatry ; focuses on evaluation and treatment of
individuals with alcohol, drug, or other substance-related disorders,
and of individuals with dual diagnosis of substance-related and other
Biological psychiatry ; an approach to
psychiatry that aims to understand mental disorders in terms of the
biological function of the nervous system. Child and adolescent
psychiatry ; the branch of psychiatry that specializes in work with
children, teenagers, and their families.
Community psychiatry ; an
approach that reflects an inclusive public health perspective and is
practiced in community mental health services . Cross-cultural
psychiatry ; a branch of psychiatry concerned with the cultural and
ethnic context of mental disorder and psychiatric services. Emergency
psychiatry ; the clinical application of psychiatry in emergency
Forensic psychiatry ; the interface between law and
Geriatric psychiatry ; a branch of psychiatry dealing with
the study, prevention, and treatment of mental disorders in humans
with old age.
Global Mental Health ; the area of study, research and
practice that places a priority on improving mental health and
achieving equity in mental health for all people worldwide. Liaison
psychiatry ; the branch of psychiatry that specializes in the
interface between other medical specialties and psychiatry. Military
psychiatry ; covers special aspects of psychiatry and mental disorders
within the military context.
In larger healthcare organizations, both public and private, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well.
In the United States, psychiatry is one of the few specialties which qualify for further education and board-certification in pain medicine , palliative medicine , and sleep medicine .
Psychiatric research is, by its very nature, interdisciplinary; combining social, biological and psychological perspectives in attempt to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards , psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.
See also: Diagnostic classification and rating scales used in psychiatry
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, with pathological , psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.
Three main diagnostic manuals used to classify mental health
conditions are in use today. The
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.
The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms ; the use of artificial dividing lines between categories and from 'normality '; possible cultural bias; medicalization of human distress and financial conflicts of interest , including with the practice of psychiatrists and with the pharmaceutical industry ; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement . The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.
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NIMH federal agency patient room for Psychiatric research, Maryland, USA.
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 .
Persons who undergo a psychiatric assessment are evaluated by a psychiatrist for their 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 personnel, 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 that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm ; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.
Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring , for instance full blood counts serum drug levels, renal function, liver function, and/or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient.
For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on the treating physician's recommendations without requiring consent from the patient.
Mental health issues such as mood disorders and schizophrenia and
other psychotic disorders were the most common principle diagnoses for
Medicaid super-utilizers in the
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.
People 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, pharmacists, 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. Even in developed countries, programs in public hospitals vary widely. Some may offer structured activities and therapies offered from many perspectives while others may only have the funding for medicating and monitoring patients. This may be problematic in that the maximum amount of therapeutic work might not actually take place in the hospital setting. This is why hospitals are increasingly used in limited situations and moments of crises where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centers or "rehab" as popularly termed.
Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy." This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.
Main article: History of psychiatry
The earliest known texts on mental disorders are from ancient India and include the Ayurvedic text, Charaka Samhita . The first hospitals for curing mental illness were established in India during the 3rd century BCE.
The Greeks also created early manuscripts about mental disorders. In
the 4th century BCE,
The Islamic Golden Age fostered early studies in Islamic psychology and psychiatry, with many scholars writing about mental disorders. The Persian physician Muhammad ibn Zakariya al-Razi , also known as "Rhazes", wrote texts about psychiatric conditions in the 9th century. As chief physician of a hospital in Baghdad, he was also the director of one of the first psychiatric wards in the world. Two of his works in particular, El-Mansuri and Al-Hawi, provide descriptions and treatments for mental illnesses.
Abu Zayd al-Balkhi , known to the west as "Avicenna", was a Persian polymath during the 9th and 10th centuries and one of the first to classify neurotic disorders. He pioneered cognitive therapy in order to treat each of these classified neurotic disorders. He classified neurosis into four emotional disorders: fear and anxiety , anger and aggression , sadness and depression , and obsession . Al-Balkhi further classified three types of depression: normal depression or sadness (huzn), endogenous depression originating from within the body, and reactive clinical depression originating from outside the body.
Specialist hospitals were built in
The beginning of psychiatry as a medical specialty is dated to the
middle of the nineteenth century, although its germination can be
traced to the late eighteenth century. In the late 17th century,
privately run asylums for the insane began to proliferate and expand
in size. In 1713 the Bethel Hospital Norwich was opened, the first
purpose-built asylum in England. In 1656,
Louis XIV of France
During the Enlightenment attitudes towards the mentally ill began to change. It came to be viewed as a disorder that required compassionate treatment. In 1758 English physician William Battie wrote his Treatise on Madness on the management of mental disorder . It was a critique aimed particularly at the Bethlem Hospital , where a conservative regime continued to use barbaric custodial treatment. Battie argued for a tailored management of patients entailing cleanliness, good food, fresh air, and distraction from friends and family. He argued that mental disorder originated from dysfunction of the material brain and body rather than the internal workings of the mind. Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury . Pinel ordering the removal of chains from patients at the Paris Asylum for insane women.
The introduction of moral treatment was initiated independently by
the French doctor
Philippe Pinel and the English
Although Tuke, Pinel and others had tried to do away with physical restraint, it remained widespread into the 19th century. At the Lincoln Asylum in England, Robert Gardiner Hill , with the support of Edward Parker Charlesworth , pioneered a mode of treatment that suited "all types" of patients, so that mechanical restraints and coercion could be dispensed with — a situation he finally achieved in 1838. In 1839 Sergeant John Adams and Dr. John Conolly were impressed by the work of Hill, and introduced the method into their Hanwell Asylum , by then the largest in the country.
The modern era of institutionalized provision for the care of the
mentally ill, began in the early 19th century with a large state-led
effort. In England, the
Lunacy Act 1845 was an important landmark in
the treatment of the mentally ill, as it explicitly changed the status
of mentally ill people to patients who required treatment. All asylums
were required to have written regulations and to have a resident
qualified physician . In 1838, France enacted a law to regulate both
the admissions into asylums and asylum services across the country. In
the United States, the erection of state asylums began with the first
law for the creation of one in New York, passed in 1842. The Utica
State Hospital was opened approximately in 1850. Many state hospitals
At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. However, the idea that mental illness could be ameliorated through institutionalization ran into difficulties. Psychiatrists were pressured by an ever-increasing patient population, and asylums again became almost indistinguishable from custodial institutions,
In the early 1800s, psychiatry made advances in the diagnosis of mental illness by broadening the category of mental disease to include mood disorders , in addition to disease level delusion or irrationality . The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of "nerves", and psychiatry became a rough approximation of neurology and neuropsychiatry. Following Sigmund Freud 's pioneering work, ideas stemming from psychoanalytic theory also began to take root in psychiatry. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. Otto Loewi 's work led to the identification of the first neurotransmitter, acetylcholine .
By the 1970s, however, the psychoanalytic school of thought became
marginalized within the field.
Biological psychiatry reemerged during
In 1963, US president
John F. Kennedy introduced legislation
National Institute of Mental Health
CONTROVERSY AND CRITICISM
Main article: Controversy surrounding psychiatry
Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by psychiatrist David Cooper in 1967. The anti-psychiatry view is that psychiatric treatments are ultimately more damaging than helpful to patients, and psychiatry's history involves what may now be seen as dangerous treatments, such as lobotomy . Several ex-patient groups have become anti-psychiatric, often referring to themselves as "survivors ".
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* ^ This article does not enter into that debate or seek to summarize the comparative efficacy literature. It simply explains why managed care insurance companies stopped routinely reimbursing psychiatrists for traditional psychotherapy, without commen