A psychiatrist is a doctor of medicine who has had four years of 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 the 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 patients, 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.
II HISTORICAL DEVELOPMENT
Physicians in the Western world began specializing in the treatment of the mentally ill in the 19th 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 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.
The discovery of unconscious sources of behavior—an insight dominated by the psychoanalytic writings of Sigmund Freud in the early 20th century—enriched psychiatric thought and changed the direction of its practice (see Psychoanalysis). 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 1940s and 1950s 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 the mentally ill in the United States began in the mid-1950s 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 1960s and 1970s. 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 1980s, psychiatry had once again shifted in emphasis to the biological, to the relative neglect of psychosocial influences in mental health and illness. See Psychotherapy.
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 internists 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.
Psychiatric treatments fall into two classes: organic and nonorganic forms. Organic treatments, such as drugs, are those that affect the body directly. Nonorganic types of treatment improve the patient’s functioning by psychological means, such as psychotherapy, or by altering the social environment.
Psychotropic drugs (see Psychoactive Drugs) are by far the most commonly used organic treatment. The first to be discovered were the antipsychotics, 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 (see 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 drugs 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 oversedation 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 (see Stress-Related Disorders), and insomnia are often treated with drugs that are commonly called minor tranquilizers. 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 antianxiety drugs (see Drug Dependence). Of the new drugs, the benzodiazepines are the most frequently prescribed, very often in nonpsychiatric settings.
The stimulant drugs, such as amphetamine—a drug that is often abused—have legitimate uses in psychiatry. They help to control overactivity and lack of concentration in hyperactive children (see Hyperactivity) and to stimulate the victims of narcolepsy, a disorder characterized by sudden, uncontrollable episodes of sleep.
B 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 is now used very rarely (see Lobotomy).
The most common nonorganic treatment is psychotherapy. Most psychotherapies conducted by psychiatrists are 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 nonorganic treatment used in psychiatry is milieu therapy. Usually carried out in psychiatric wards, milieu therapy directs social relations among patients and staff toward 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 nonpsychotic 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 nonorganic techniques for all patients, depending on their diagnosis and response to treatment.
Phillip L. Edwardson