Psychiatry   

 

Psychiatry is the branch of medicine specializing in mental disorders. Psychiatrists not only diagnose and treat these disorders but also conduct research directed at understanding and preventing them.

 

A psychiatrist is a doctor of medicine who has had postgraduate training in psychiatry. Many psychiatrists take further training in psychoanalysis, child psychiatry, or other subspecialties. Psychiatrists treat patients in private practice, in general hospitals, or in specialized facilities for people who are mentally ill (psychiatric hospitals, outpatient clinics, or community mental-health centers). Some spend part or all of their time doing research or administering mental health programs. By contrast, psychologists, who often work closely with psychiatrists and treat many of the same kinds of patient, are not trained in medicine; consequently, they neither diagnose physical illness nor administer drugs.

 

The province of psychiatry is unusually broad for a medical specialty. Mental disorders may affect most aspects of a patient's life, including physical functioning, behavior, emotions, thought, perception, interpersonal relationships, sexuality, work, and play. These disorders are caused by a poorly understood combination of biological, psychological, and social determinants. Psychiatry's task is to account for the diverse sources and manifestations of mental illness.

 

Historical Development

Physicians in the Western world began specializing in the treatment of people with a mental illness in the end of 18^th century. Known as alienists, psychiatrists of that era worked in large asylums, practicing what was then called moral treatment, a humane approach aimed at quieting mental turmoil and restoring reason. During the second half of the century, psychiatrists abandoned this mode of treatment and, with it, the tacit recognition that mental illness is caused by both psychological and social influences. For a while, their attention focused almost exclusively on biological factors. Drugs and other forms of somatic (physical) treatment were common.

 

The French physician Philip Pinel 1745 – 1826 released psychiatric patients from chains and started practicing more humanistic treatment of the mentally ill. The German psychiatrist Emil Kraepelin identified and classified mental disorders into a system that is the foundation for modern diagnostic practices. Another important figure was the Swiss psychiatrist Eugen Bleuler, who coined the word schizophrenia and described its characteristics.

 

 

 

 

Willhelm Griesinger 1817 – 1868 specialized in psychiatry, authoring Pathology and Treatment in Psychiatry, the first scientific writing on psychiatry. He came to be called the father of German psychiatry.

Griesinger Disease : malnutrition and anemia

Griesinger’s Symptom : is caused by transverse sinus.

 

Theodor Herman Meynert 1833 – 1892 specialized in anatomy and physiology of the nervous system in the cerebrum. The functions of the cerebral cortex, motor nerves and perceptual nerve fibers were clarified by Meynert. In 1873 he was appointed professor of psychiatric neurology at Vienna University, a position he held for the rest of his life. A psychiatry laboratory was established there. In the field of neurological anatomy many medical terms were named after Meynert.

 

 

The discovery of unconscious sources of behavior—an insight dominated by the psychoanalytic writings of Sigmund Freud in the early 20^th century—enriched psychiatric thought and changed the direction of its practice. Attention shifted to processes within the individual psyche, and psychoanalysis came to be regarded as the preferred mode of treatment for most mental disorders. In the 1940’s and 1950’s emphasis shifted again: this time to the social and physical environment. Many psychiatrists had all but ignored biological influences, but others were studying those involved in mental illness and were using somatic forms of treatment such as electroconvulsive therapy (electric shock) and psychosurgery.

 

Dramatic changes in the treatment of mentally ill patients began in the mid-1950’s with the introduction of the first effective drugs for treating psychotic symptoms. Along with drug treatment, new, more liberal and humane policies and treatment strategies were introduced into mental hospitals. More and more patients were treated in community settings in the 1960’s and 1970’s. Support for mental-health research led to significant new discoveries, especially in the understanding of genetic and biochemical determinants in mental illness and the functioning of the brain. Thus, by the 1980’s, psychiatry had once again shifted in emphasis to the biological, to the relative neglect of psychosocial influences in mental health and illness.

 

Sigmund freud 1856 – 1939

Austrian doctor, neurologist, and founder of psychoanalysis. Freud's main contribution was to create an entirely new approach to the understanding of human personality by his demonstration of the existence and force of the unconscious. In addition, he founded a new medical discipline and formulated basic therapeutic procedures that in modified form are applied widely in the present-day treatment of neuroses and psychoses through psychotherapy. Although never accorded full recognition during his lifetime and often questioned by others in the field since then, Freud is generally acknowledged as one of the great creative minds of modern times.

Freud was born in Freiberg (now Príbor, Czech Republic), on May 6, 1856, and educated at the University of Vienna. When he was three years old his family, fleeing from the anti-Semitic riots then raging in Freiberg, moved to Leipzig. Shortly thereafter, the family settled in Vienna, where Freud remained for most of his life.

 

Although his ambition from childhood had been a career in law, Freud decided to become a medical student shortly before he entered the University of Vienna in 1873. Inspired by the scientific investigations of Johann Wolfgang von Goethe, he was driven by an intense desire to study natural science and to solve some of the challenging problems confronting contemporary scientists.

 

In his third year at the University of Vienna Freud began research work on the central nervous system. This was conducted in the physiology laboratory under the direction of the German doctor Ernst Wilhelm von Brücke. Freud found neurological research so engrossing that he neglected the prescribed courses and as a result remained in medical school three years longer than was normally required to qualify as a physician.

 

In 1881, after completing a year of compulsory military service, he received his medical degree. Unwilling to give up his experimental work, however, he remained at the university as a demonstrator in the physiology laboratory. In 1883, at von Brücke's urging, he reluctantly abandoned theoretical research to gain practical experience.

 

The Influence of Charcot

Freud spent three years at the General Hospital of Vienna, devoting himself successively to psychiatry, dermatology, and nervous diseases. In 1885, following his appointment as a lecturer in neuropathology at the University of Vienna, he left his post at the hospital. Later the same year he was awarded a government grant enabling him to spend 19 weeks in Paris as a student of the French neurologist Jean Charcot. As the director of the clinic at the Salpêtrière mental hospital, Charcot was then treating nervous disorders by the use of hypnotic suggestion. Freud's studies under Charcot, which centered largely on hysteria, influenced him greatly in channeling his interests to psychopathology the scientific study of mental disorders.

 

In 1886 Freud established a private practice in Vienna specializing in nervous diseases. He met with violent opposition from the Viennese medical profession because of his strong support of Charcot's unorthodox views on hysteria and hypnotherapy. The resentment he incurred was to delay any acceptance of his subsequent findings on the origins of neurosis.

 

The Beginnings of Psychoanalysis

Freud's first published work, On Aphasia, appeared in 1891; it was a study of the neurological disorder in which the ability to pronounce words or to name common objects is lost as a result of organic brain disease. His final work in neurology was an article, “Infantile Cerebral Paralysis”; this was written for an encyclopedia in 1897 only at the insistence of the editor, since by this time Freud was occupied largely with psychological rather than physiological explanations for mental disorders. His subsequent writings were devoted entirely to that field, which he had named psychoanalysis in 1896.

 

Freud's new orientation was heralded by his collaborative work on hysteria with the Viennese doctor Josef Breuer. The work was presented in 1893 in a preliminary paper and two years later in an expanded form under the title Studies on Hysteria. In this work the symptoms of hysteria were ascribed to manifestations of undischarged emotional energy associated with forgotten psychic traumas. The therapeutic procedure involved the use of a hypnotic state in which the patient was led to recall and re-enact the traumatic experience, thus discharging by catharsis the emotions causing the symptoms. The publication of this work marked the beginning of psychoanalytic theory formulated on the basis of clinical observations.

 

The Unconscious

During the period from 1895 to 1900 Freud developed many of the concepts that were later incorporated into psychoanalytic practice and doctrine. Soon after publishing the studies on hysteria he abandoned the use of hypnosis as a cathartic procedure and replaced it by the investigation of the patient's spontaneous flow of thoughts—called free association—to reveal the unconscious mental processes at the root of the neurotic disturbance.

 

In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is defined as the unconscious defense against awareness of repressed experiences in order to avoid the resulting anxiety. He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech (“Freudian slips”—which Freud claimed were revelations of unconscious wishes).

 

 

Controversial Contributions

Analysis of dreaming led to his theories of infantile sexuality and of the so-called Oedipus complex, which constitutes a purported erotic attachment of the child for the parent of the opposite sex, together with hostile feelings towards the other parent. This aligned to the emphasis on the biological bases for human behavior—particularly sex and aggression—were among Freud's most controversial theories. The term “Freudian” is often used in connection with these theories, many of which were to become major concepts in psychiatry. They were infused with rich symbolism, and were in the main preoccupied with reconciling the conflict between biological factors of human existence and what Freud believed were the civilizing aspects of human behavior: aesthetics, intellectual capacity, and religion. Terms often thought of as Freudian, such as id and ego, are now no longer regarded as exclusive to Freudian theory.

 

In these years he also developed the theory of transference—the process by which emotional attitudes, established originally towards parental figures in childhood, are transferred in later life to others. The end of this period was marked by the appearance of Freud's most important work, The Interpretation of Dreams (1900). Here Freud analyzed many of his own dreams recorded in a three-year period of self-analysis which began in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine.

 

In 1902 Freud was appointed a full professor at the University of Vienna. This honor was granted not in recognition of his contributions but as a result of the efforts of a highly influential patient. The medical world still regarded his work with hostility, and his next writings, The Psychopathology of Everyday Life (1901) and Three Contributions to the Theory of Sexuality (1905), only increased this antagonism. As a result, Freud continued to work virtually alone in what he termed “splendid isolation”.

By 1906, however, Freud had a small number of pupils and followers—including the Austrian psychiatrists William Stekel and Alfred Adler, the Austrian psychologist Otto Rank, the American psychiatrist Abraham Brill, and the Swiss psychiatrists Eugen Bleuler and Carl Gustav Jung. Other notable associates, who joined the circle in 1908, were the Hungarian psychiatrist Sándor Ferenczi and the British psychiatrist Ernest Jones.

 

International Acceptance

Increasing recognition of the psychoanalytic movement made possible the formation in 1910 of a world-wide organization called the International Psychoanalytic Association. As the movement spread, gaining new adherents throughout Europe and the United States, Freud was troubled by the dissension that arose among members of his original circle. Most disturbing were the defections from the group of Adler and Jung, each of whom developed a different theoretical basis for disagreement with Freud's emphasis on the sexual origin of neurosis. Freud met these setbacks by developing further his basic concepts and by elaborating his own views in many publications and lectures.

 

After the onset of World War I Freud devoted little time to clinical observation and concentrated on the application of his theories to the interpretation of religion, mythology, art, and literature. In 1923 he was stricken with cancer of the jaw, which necessitated constant, painful treatment in addition to many surgical operations. Despite his physical suffering he continued his literary activity for the next 16 years, writing mostly on cultural and philosophical problems. Among his other works are Totem and Taboo (1913), The Ego and the Id (1923), New Introductory Lectures on Psychoanalysis (1933), and Moses and Monotheism (1939).

 

When the Germans occupied Austria in 1938, Freud was persuaded by friends to escape with his family to England. He died in London on September 23, 1939.

 

 

Diagnosis

Psychiatrists use a variety of methods to detect specific disorders in their patients. The most fundamental is the psychiatric interview, during which the patient's psychiatric history is taken and mental status is evaluated. The psychiatric history is a picture of the patient's personality characteristics, relationships with others, and past and present experience with psychiatric problems—all told in the patient's words (sometimes supplemented by comments from other family members). Psychiatrists use mental-status examinations much as doctors in general medicine use physical examinations. They elicit and classify aspects of the patient's mental functioning.

 

Some diagnostic methods rely on testing by other specialists. Psychologists administer intelligence and personality tests, as well as tests designed to detect damage to the brain or other parts of the central nervous system. Neurologists also test psychiatric patients for evidence of impairment of the nervous system. Other physicians sometimes examine patients who complain of physical symptoms. Psychiatric social workers explore family and community problems. The psychiatrist integrates all this information in making a diagnosis according to criteria established by the psychiatric profession.

 

Treatment

Psychiatric treatments fall into two classes: organic and non-organic forms. Organic treatments, such as drugs, are those that affect the body directly. Non-organic types of treatment improve the patient's functioning by psychological means, such as psychotherapy, or by altering the social environment.

 

Drugs

Psychotropic drugs are by far the most commonly used organic treatment. The first to be discovered were the anti-psychotics, used primarily to treat schizophrenia. The phenothiazines are the most frequently prescribed class of antipsychotic drugs. Others are the thioxanthenes, butyrophenones, and indoles. All antipsychotic drugs diminish such symptoms as delusions, hallucinations, and thought disorder. Because they can reduce agitation, they are sometimes used to control manic excitement in manic-depressive patients and to calm geriatric patients. Some childhood behavior disorders respond to these drugs.

 

Despite their value, the antipsychotic drugs have drawbacks. The most serious is the neurological condition tardive dyskinesia, which occurs in patients who have taken the drugs over extended periods. The condition is characterized by abnormal movements of the tongue, mouth, and body. It is especially serious because its symptoms do not always disappear when the drug is stopped, and no known treatment for it has been developed.

 

Most psychotropic drugs are chemically synthesized. Lithium carbonate, however, is a naturally occurring element used to prevent, or at least reduce, the severity of shifts of mood in manic-depression. It is especially effective in controlling mania. Psychiatrists must monitor lithium dosages carefully, because only a small margin exists between an effective dose and a toxic one.

 

Three major classes of antidepressant drug are used. The tricyclic and tetracyclic antidepressants, the most frequently prescribed, are used for the most common form of serious depression. Monoamine oxidase (MAO) inhibitors are used for so-called atypical depressions. Serotonin-selective reuptake inhibitors (SSRIs) are effective against both typical and atypical depressions. Although all three classes are quite effective in relieving depression in correctly matched patients, they also have disadvantages. The tricyclics and tetracyclics can take two to five weeks to become effective and can cause such side effects as over sedation and cardiac problems. MAO inhibitors can cause severe hypertension in patients who ingest certain types of food (such as cheese, beer, and wine) or drugs (such as cold medicines). SSRI drugs, such as fluoxetine (Prozac), take 2 to 12 weeks to become effective and can cause headaches, nausea, insomnia, and nervousness.

 

Anxiety, tension (or other stress-related disorders), and insomnia are often treated with drugs that are commonly called minor tranquillizers. Barbiturates have been used for the longest time, but they produce more severe side effects and are more often abused than the newer classes of anti-anxiety drugs. Of the new drugs, the benzodiazepines are the most frequently prescribed, very often in non-psychiatric settings.

The stimulant drugs, such as amphetamine—a drug that is often abused—have legitimate uses in psychiatry. They help to control over-activity and lack of concentration in hyperactive children and to stimulate the victims of narcolepsy, a disorder characterized by sudden, uncontrollable episodes of sleep.

 

Other Organic Treatments

Another organic treatment is electroconvulsive therapy, or ECT, in which seizures similar to those of epilepsy are produced by a current of electricity passed through the forehead. ECT is most commonly used to treat severe depressions that have not responded to drug treatment. It is also sometimes used to treat schizophrenia. Other forms of organic treatment are much less frequently used than drugs and ECT. They include the controversial technique psychosurgery, in which fibers in the brain are severed; this technique (called lobotomy) is now used very rarely.

 

Psychotherapy

The most common non-organic treatment is psychotherapy. Most psychotherapy conducted by psychiatrists is psychodynamic in orientation—that is, they focus on internal psychic conflict and its resolution as a means of restoring mental health. The prototypical psychodynamic therapy is psychoanalysis, which is aimed at untangling the sources of unconscious conflict in the past and restructuring the patient's personality. Psychoanalysis is the treatment in which the patient lies on a couch, with the psychoanalyst out of sight, and says whatever comes to mind. The patient relates dreams, fantasies, and memories, along with thoughts and feelings associated with them. The analyst helps the patient interpret these associations and the meaning of the patient's relationship to the analyst. Because it is lengthy and expensive, often several years in duration, classical psychoanalysis is now infrequently used.

 

More common are shorter forms of psychotherapy that supplement psychoanalytic principles with other theoretical ideas and scientifically derived information. In these types of therapy, psychiatrists are more likely to give the patient advice and try to influence behavior. Some use techniques derived from behavior therapy, which is based on learning theory (although these methods are more commonly used by psychologists).

 

Besides psychotherapy, the other major form of non-organic treatment used in psychiatry is milieu therapy. Usually carried out in psychiatric wards, milieu therapy directs social relations among patients and staff towards therapeutic ends. Ward activities, too, are planned to serve specific therapeutic goals.

In general, psychotherapy is relied on more heavily for the treatment of neuroses and other non-psychotic conditions than it is for psychoses. In psychotic patients, who usually receive psychoactive drugs, psychotherapy is used to improve social and vocational functioning. Milieu therapy is limited to hospitalized patients. Increasingly, psychiatrists use a combination of organic and non-organic techniques for all patients, depending on their diagnosis and response to treatment.