Psychiatry History, Theory and Practice

7/31/2019 Psychiatry History, Theory and Practice

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Psychiatry is the medical specialty devoted to the study and treatment of mental disorders . These mental disorders include various affective , behavioural , cognitive and perceptual abnormalities . The term was first coined by the German physician Johann Christian Reil in 1808,and literally means the 'medical treatment of the mind' ( psych- : mind; from Ancient Greek psykh : soul; -iatry : medical treatment; from Gk. itrikos : medical, isthai : to heal). A medical

doctor specializing in psychiatry is a psychiatrist .

Psychiatric assessment typically starts with a mental status examination and the compilation of acase history . Psychological tests and physical examinations may be conducted, including onoccasion the use of neuroimaging or other neurophysiological techniques. Mental disorders arediagnosed in accordance with criteria listed in diagnostic manuals such as the widely used

Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the AmericanPsychiatric Association , and the International Classification of Diseases (ICD), edited and usedby the World Health Organization . The fifth edition of the DSM (DSM-5 ) is scheduled to bepublished in 2013, and its development is expected to be of significant interest to many medicalfields .[3]

Psychiatric treatment applies a variety of modalities, including psychoactive medication , psychotherapy and a wide range of other techniques such as transcranial magnetic stimulation . 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 treatmentwithin psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.

History

Ancient

Although one may trace its germination to the late eighteenth century, the beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century .[4] Starting inthe 5th century BCE, mental disorders, especially those with psychotic traits, were consideredsupernatural in origin .[5] This view existed throughout ancient Greece and Rome .[5] Earlymanuals about mental disorders were created by the Greeks .[4] In the 4th century BCE,Hippocrates theorized that physiological abnormalities may be the root of mental disorders .[5][5] Religious leaders often turned to versions of exorcism to treat mental disorders often utilizingcruel and barbaric methods .[5]

Middle Ages

Main article: Islamic psychology

Specialist hospitals were built in Baghdad in 705 AD, followed by Fes in the early 8th century,and Cairo in 800 AD. [citation needed ]

Physicians who wrote on mental disorders and their treatment in the Medieval Islamic periodincluded Muhammad ibn Zakarya Rzi (Rhazes), the Arab physician Najab ud-din
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Muhammad [citation needed ], and Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West asAvicenna .[6]

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disordersbut were utilized only as custodial institutions and did not provide any type of treatment .[7]

Founded in the 13th century, Bethlem Royal Hospital in London is one of the oldest lunaticasylums .[7] By 1547 the City of London acquired the hospital and continued its function until1948 .[8] It is now part of the National Health Service and is an NHS Foundation Trust .

Many consider Philippe Pinel to be the father of modern psychiatry.

Early modern period

In 1656, Louis XIV of France created a public system of hospitals for those suffering frommental disorders, but as in England, no real treatment was applied .[8] In 1713 the Bethel HospitalNorwich was opened, the first purpose built asylum in England, founded by Mary Chapman [1] .In 1758 English physician William Battie wrote his Treatise on Madness which called fortreatments to be utilized in asylums .[9] Thirty years later, then ruling monarch in England GeorgeIII was known to be suffering from a mental disorder .[5] Following the King's remission in 1789,mental illness came to be seen as something which could be treated and cured .[5] Brilliant Frenchdoctor Philippe Pinel introduced humane treatment approaches to those suffering from mentaldisorders .[5] As a result of his work, the Governor of the Bictre psychiatric hospital in Parisreleased psychiatric patients from their chains in 1793, beginning what has been called the bright epoch of psychiatry .[10] William Tuke adopted the methods outlined by Pinel and that same year

Tuke opened the York Retreat in England .[5]

Tuke's Retreat became a model throughout theworld for humane and moral treatment of patients suffering from mental disorders .[11] The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat andthe Hartford Retreat (now the Institute of Living ).

19th century
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At the turn of the century, England and France combined had only a few hundred individuals inasylums .[12] By the late 1890s and early 1900s, this number had risen to the hundreds of thousands .[12] The United States housed 150,000 patients in mental hospitals by 1904 .[12] Germanspeaking countries housed more than 400 public and private sector asylums .[12] These asylumswere critical to the evolution of psychiatry as they provided places of practice throughout the

world .[12]

On the continent, universities often played a part in the administration of the asylum s[13] and,because of the relationship between the universities and asylums, scores of psychiatrists werebeing educated in Germany .[13] . However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums orpsychiatry .[12] The United Kingdom, unlike Germany, possessed a national body for asylumsuperintendents - the Medico-Psychological Association - established in 1866 under thePresidency of William A.F. Browne .[14]

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, andinfluence. Although based on England 's York Retreat , it would be followed by specialtyinstitutions of every treatment philosophy.

In 1838, France enacted a law to regulate both the admissions into asylums and asylum servicesacross the country. This was the year in which William A.F. Browne achieved his appointmentas Superintendent of the Crichton Royal at Dumfries in southern Scotland.

Emil Kraepelin studied and promoted ideas of disease classification for mental disorders.

However, the new idea that mental illness could be ameliorated during the mid-nineteenthcentury were disappointed .[15] Psychiatrists were pressured by an ever increasing patientpopulation .[15] The average number of patients in asylums in the United States jumped 927% .[15] Numbers were similar in England and Germany .[15] Overcrowding was rampant in France whereasylums would commonly take in double their maximum capacity .[16] Increases in asylum
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1930s, most asylum and academic psychiatrists in Europe believed that manic depressivedisorder and schizophrenia were inherited, but in the decades after World War II, the conflationof genetics with Nazi racist ideology thoroughly discredited genetics .[33] Now genetics were onceagain thought to play a role in mental illness .[28] Molecular biology opened the door for specificgenes contributing to mental disorders to be identified .[28]

Anti-psychiatry and deinstitutionalization

Main article: Anti-psychiatry

The introduction of psychiatric medications and the use of laboratory tests altered the doctor-patient relationship between psychiatrists and their patients .[34] Psychiatry's shift to the hardsciences had been interpreted as a lack of concern for patients .[34] Anti-psychiatry had becomemore prevalent in the late twentieth century due to this and publications in the media whichconceptualized mental disorders as myths .[35] Others in the movement argued that psychiatry wasa form of social control and demanded that institutionalized psychiatric care, stemming from

Pinel's thereapeutic asylum, be abolished .[36]

Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wantedeliminated .[37] They alleged that ECT damaged the brain and was used as a tool for discipline .[37] While some believe there is no evidence that ECT damages the brain ,[38][39 ][40] there are somecitations that ECT does cause damage .[41][42] Sometimes ECT is used as punishment or as a threatand there have been isolated incidents where the use of ECT was threatened to keep the patients"in line" .[37] The prevalence of psychiatric medication helped initiate deinstitutionalization ,[43] theprocess of discharging patients from psychiatric hospitals to the community .[44] The pressurefrom the anti-psychiatry movements and the ideology of community treatment from the medicalarena helped sustain deinstitutionalization .[43] Thirty-three years after deinstitutionalization

started in the United States, only 19% of the patients in state hospitals remained .[43]

Mentalhealth professionals envisioned a process wherein patients would be discharged intocommunities where they could participate in a normal life while living in a therapeuticatmosphere .[43] Psychiatrists were criticized, however, for failing to develop community-basedsupport and treatment. Community-based facilities were not available because of the politicalinfighting between in-patient and community-based social services, and an unwillingness bysocial services to dispense funding to provide adequately for patients to be discharged intocommunity-based facilities.

Political abuse of psychiatry

See also: Political abuse of psychiatry and Political abuse of psychiatry in the Soviet Union

Psychiatrists around the world have been involved in the suppression of individual rights bystates wherein the definitions of mental disease had been expanded to include politicaldisobedience .[45] :6 Nowadays, in many countries, political prisoners are sometimes confined tomental institutions and abused therein .[46] :3 Psychiatry possesses a built-in capacity for abusewhich is greater than in other areas of medicine .[47] :65 The diagnosis of mental disease can serveas proxy for the designation of social dissidents, allowing the state to hold persons against their
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will and to insist upon therapies that work in favour of ideological conformity and in the broaderinterests of society .[47] :65 In a monolithic state, psychiatry can be used to bypass standard legalprocedures for establishing guilt or innocence and allow political incarceration without theordinary odium attaching to such political trials .[47] :65 In Nazi Germany in the 1940s, the 'duty tocare' was violated on an enormous scale: A reported 300,000 individuals were sterilized and

100,000 killed in Germany alone, as were many thousands further afield, mainly in easternEurope .[48] From the 1960s up to 1986, political abuse of psychiatry was reported to besystematic in the Soviet Union , and to surface on occasion in other Eastern European countriessuch as Romania , Hungary , Czechoslovakia , and Yugoslavia .[47] :66 A "mental health genocide"reminiscent of the Nazi aberrations has been located in the history of South African oppressionduring the apartheid era .[49] A continued misappropriation of the discipline was subsequentlyattributed to the People's Republic of China .[50]

Medicalization of deviance

See also: Medicalization

The concept of medicalization is created by sociologists and used for explaining how medicalknowledge is applied to a series of behaviors, over which medicine exerts control, although thosebehaviors are not self-evidently medical or biological .[51] According to Kittrie, a number of phenomena considered "deviant", such as alcoholism , drug addiction and mental illness , wereoriginally considered as moral, then legal, and now medical problems .[52] :1[53] As a result of theseperceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control .[52] :1 Similarly, Conrad and Schneider concluded their review of the medicalizationof deviance by supposing that three major paradigms may be identified that have reigned overdeviance designations in different historical periods: deviance as sin; deviance as crime; anddeviance as sickness .[52] :1[54] :36 According to Franco Basaglia and his followers, whose approach

pointed out the role of psychiatric institutions in the control and medicalization of deviantbehaviors and social problems, psychiatry is used as the provider of scientific support for socialcontrol to the existing establishment, and the ensuing standards of deviance and normalitybrought about repressive views of discrete social groups .[55] :70 As scholars have long argued,governmental and medical institutions code menaces to authority as mental diseases duringpolitical disturbances .[56] :14

Transinstitutionalization and the aftermath

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged fromstate psychiatric hospitals .[43] Later, though, the Community Mental Health Center's focus wasdiverted to provide psychotherapy sessions for those suffering from acute but mild mentaldisorders .[43] Ultimately there were no arrangements made for actively and severely mentally illpatients who were being discharged from hospitals .[43] Some of those suffering from mentaldisorders drifted into homelessness or ended up in prisons and jails .[43][57] Studies found that 33%of the homeless population and 14% of inmates in prisons and jails were already diagnosed witha mental illness .[43][58]
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In 1973, psychologist David Rosenhan published the Rosenhan experiment , a study questioningthe validity of psychiatric diagnoses .[59] The study arranged for eight individuals with no historyof psychopathology to attempt admission into psychiatric hospitals. The individuals included agraduate student, psychologists, an artist, a housewife, and two physicians, including onepsychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar

disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. Alleight were discharged within 7 to 52 days. In a later part of the study , psychiatric staff werewarned that pseudo-patients might be sent to their institutions, but none were actually sent.Nevertheless, a total of 83 patients out of 193 were believed by at least one staff member to beactors. The study concluded that individuals without mental disorders were indistinguishablefrom those suffering from mental disorders .[59] Critics such as Robert Spitzer placed doubt on thevalidity and credibility of the study, but did concede that the consistency of psychiatric diagnosesneeded improvement .[60]

Psychiatry, like most medical specialties has a continuing, significant need for research into itsdiseases, classifications and treatments .[61] Psychiatry adopts biology's fundamental belief that

disease and health are different elements of an individual's adaptation to an environment .[62]

Butpsychiatry also recognizes that the environment of the human species is complex and includesphysical, cultural, and interpersonal elements .[62] In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings .[62] Psychiatry's difficult task is to bridge the understanding of these factors so that they can bestudied both clinically and physiologically .[62]

Theory and focus

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

The term psychiatry (Greek " ", psychiatrik ), coined by Johann Christian Reil in1808, comes from the Greek " " ( psych : "soul or mind") and "" ( iatros :"healer") .[63][64 ][65] It refers to a field of medicine focused specifically on the mind, aiming tostudy , prevent , and treat mental disorders in humans .[66][67 ][68] It has been described as anintermediary between the world from a social context and the world from the perspective of those who are mentally ill .[69]

Those who specialize in psychiatry are different than most other mental health professionals andphysicians in that they must be familiar with both the social and biological sciences .[67] The

discipline is interested in the operations of different organs and body systems as classified by thepatient's subjective experiences and the objective physiology of the patient .[70] Psychiatry existsto treat mental disorders which are conventionally divided into three very general categories:mental illness , severe learning disability, and personality disorder .[71] While the focus of psychiatry has changed little throughout time, the diagnostic and treatment processes haveevolved dramatically and continue to do so. Since the late 20th century, the field of psychiatryhas continued to become more biological and less conceptually isolated from the field of medicine .[72]
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Scope of practice

Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2002.no dataless than 1010-2020-3030-4040-5050-60

60-8080-100100-120120-140140-150more than 150

While the medical specialty of psychiatry utilizes research in the field of neuroscience , psychology , medicine , biology , biochemistry , and pharmacology ,[73] it has generally beenconsidered a middle ground between neurology and psychology .[74] Unlike other physicians andneurologists, psychiatrists specialize in the doctor-patient relationship and are trained to varying

extents in the use of psychotherapy and other therapeutic communication techniques .[74]

Psychiatrists also differ from psychologists in that they are physicians and the entirety of theirpost-graduate training is revolved around the field of medicine .[75] Psychiatrists can thereforecounsel patients, prescribe medication, order laboratory tests , order neuroimaging , and conductphysical examinations .[76]

Ethics

Like other purveyors of professional ethics , the World Psychiatric Association issues an ethicalcode to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth throughthe 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. TheWorld Psychiatric Association code covers such matters as patient assessment, up-to-dateknowledge, the human dignity of incapacitated patients, confidentiality , research ethics, sexselection, euthanasia ,[77] organ transplantation, torture ,[78][79] the death penalty , media relations,genetics, and ethnic or cultural discrimination .[80] In establishing such ethical codes, theprofession has responded to a number of controversies about the practice of psychiatry.

Subspecialties
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Various subspecialties and/or theoretical approaches exist which are related to the field of psychiatry. They include the following:

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 psychiatric disorders. Biological psychiatry ; an approach to psychiatry that aims to understand mental disordersin terms of the biological function of the nervous system.

Child and adolescent psychiatry ; the branch of psychiatry that specialises in work withchildren, teenagers, and their families.

Community psychiatry ; an approach that reflects an inclusive public health perspectiveand is practiced in community mental health services .[81]

Cross-cultural psychiatry ; a branch of psychiatry concerned with the cultural and ethniccontext of mental disorder and psychiatric services.

Emergency psychiatry ; the clinical application of psychiatry in emergency settings. Forensic psychiatry ; the interface between law and psychiatry.

Geriatric psychiatry ; a branch of psychiatry dealing with the study, prevention, andtreatment of mental disorders in humans with old age. 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. Neuropsychiatry ; branch of medicine dealing with mental disorders attributable to

diseases of the nervous system. Social psychiatry ; a branch of psychiatry that focuses on the interpersonal and cultural

context of mental disorder and mental wellbeing.

In the United States, psychiatry is one of the specialties which qualify for further education andboard-certification in pain medicine , palliative medicine , and sleep medicine .

Approaches

Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mentalillness can be assessed, conversely, through a narrative which tries to incorporate symptoms intoa meaningful life history and to frame them as responses to external conditions. Both approachesare important in the field of psychiatry ,[82] but have not sufficiently reconciled to settlecontroversy over either the selection of a psychiatric paradigm or the specification of

psychopathology . The notion of a "biopsychosocial model " is often used to underline themultifactorial nature of clinical impairment .[83][84 ][85] Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence, but identifies cognition as anirreducible and independent realm in which disorder may occur .[83][84 ][85] The biocognitiveapproach includes a mentalist etiology and provides a dualist revision of the biopsychosocialview, reflecting the efforts of psychiatrist Niall McLaren to bring the discipline into scientificmaturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn .[83][84 ][85]
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Industry and academia

Practitioners

Main article: Psychiatrist

All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are either: 1) clinicians who specialize in psychiatry and are certified intreating mental illness ;[86] or (2) scientists in the academic field of psychiatry who are qualifiedas research doctors in this field. Psychiatrists may also go through significant training to conductpsychotherapy , psychoanalysis and cognitive behavioral therapy , but it is their training asphysicians that differentiates them from other mental health professionals .[86]

Research

An MRI scan of the brain : many mental disorders are thought to be associated withneurobiological abnormalitie s[87]

Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological andpsychological perspectives to understand the nature and treatment of mental disorders .[88] Clinical and research psychiatrists study basic and clinical psychiatric topics at researchinstitutions and publish articles in journals .[73][89 ][90][91] Under the supervision of institutionalreview boards , psychiatric clinical researchers look at topics such as neuroimaging, genetics, andpsychopharmacology in order to enhance diagnostic validity and reliability, to discover newtreatment methods, and to classify new mental disorders .[92]

Clinical application

Diagnostic systems

See also Diagnostic classification and rating scales used in psychiatry
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fMRI images such as these may assist in a diagnosis by ruling out other conditions.

Psychiatric diagnoses take

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Psychiatry History, Theory and Practice

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