Initial psychiatric assessment begins with taking a case history and conducting a mental status examination. Laboratory tests, physical examinations, and psychological assessments may also be used. On occasion, neuroimaging or neurophysiological studies are performed.
Disorders
Mental disorders are diagnosed in accordance with diagnostic manuals such as the International Classification of Diseases (ICD), edited by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA). The fifth edition of the DSM (DSM-5) was published in May 2013.
However, its release coincided with a statement by then-NIMH (National Institute of Mental Health) director Thomas Insel noting that the manual lacks validity compared to other medical specialties due to the absence of objective laboratory measures (biomarkers) for diagnosis.
Treatment may include psychotropics (psychiatric medicines), psychotherapy, substance-abuse treatment, and other modalities such as interventional approaches, 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 risk to the individual or community.
Research within psychiatry is conducted by psychiatrists on an interdisciplinary basis with other professionals, including clinical psychologists, epidemiologists, nurses, social workers, and occupational therapists. Psychiatry has been controversial since its inception, facing criticism both internally and externally over its medicalization of mental distress, reliance on pharmaceuticals, use of coercion, influence from the pharmaceutical industry, and its historical role in social control and contentious treatments.
Etymology
The term psychiatry was first coined by the German physician Johann Christian Reil in 1808 and literally means the 'medical treatment of the soul' (ψυχή psych- 'soul' from Ancient Greek psykhē 'soul'; -iatry 'medical treatment' from Gk. ιατρικός iātrikos 'medical' from ιάσθαι iāsthai 'to heal'). A medical doctor specializing in psychiatry is a psychiatrist (for a historical overview, see: Timeline of psychiatry).
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"
Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.
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.
Psychiatry treats mental disorders, which are conventionally divided into three general categories: mental illnesses, severe learning disabilities, and personality disorders. Although the focus of psychiatry has changed little over time, the diagnostic and treatment processes have evolved dramatically and continue to do so.
Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from other medical fields.
Scope of practice
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 in the United States for both specialties and for their subspecialties is offered by a single board, the American Board of Psychiatry and Neurology, one of the member boards of the American Board of Medical Specialties.
Unlike other physicians and neurologists, psychiatrists specialize in the doctor–patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and have postgraduate training called residency (usually four to five years) in psychiatry; the quality and thoroughness of their graduate medical training is identical to that of all other physicians.
Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations. As well, some psychiatrists are trained in interventional psychiatry and can deliver interventional treatments such as electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation and ketamine.
Ethics
The World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists (like other purveyors of professional ethics). 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 the broader Madrid Declaration in 1996. The code was further revised during the organization's general assemblies in 1999, 2002, 2005, and 2011.
The World Psychiatric Association code covers such matters as confidentiality, the death penalty, ethnic or cultural discrimination, euthanasia, genetics, the human dignity of incapacitated patients, media relations, organ transplantation, patient assessment, research ethics, sex selection, coercion, torture, and up-to-date knowledge.
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.[page needed]
Approaches
Psychiatric illnesses can be conceptualised in several different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions.
For example, the Power Threat Meaning Framework (PTMF) is a conceptual approach to understanding mental distress that serves as an alternative to traditional psychiatric diagnostic systems. Rather than viewing distress primarily as a symptom of an underlying mental disorder, the framework emphasizes the role of adversity, trauma, social inequalities, relationships, and cultural contexts in shaping people's experiences, and proposes that many forms of distress can be understood as meaningful responses to difficult circumstances.
Both approaches are considered important in the field of psychiatry, but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The biopsychosocial model is used to explain the multifactorial origins of clinical impairment, recognizing that biological, psychological, and social factors all play a role in health and disease.
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. In recent years, mindfulness practices involving present-moment awareness have gained popularity and have been shown to be effective in psychiatric treatment.
Practitioners
All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are trained 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; employees of hospitals; 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 in the US
Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favorably. This has resulted in a significant shortage of psychiatrists in the United States and elsewhere. Strategies to address this shortfall have included the use of short 'taster' placements early in the medical school curriculum and attempts to extend psychiatry services further using telemedicine technologies and other methods.
Recently, however, there has been an increase in the number of medical students entering into a psychiatry residency. There are several reasons for this surge, including the intriguing nature of the field, growing interest in genetic biomarkers involved in psychiatric diagnoses, and newer pharmaceuticals on the drug market to treat psychiatric illnesses.
Subspecialties
The field of psychiatry has many subspecialties that require additional training and certification by the American Board of Psychiatry and Neurology (ABPN). Such subspecialties include:
- Addiction psychiatry, addiction medicine
- Brain injury medicine
- Child and adolescent psychiatry
- Consultation-liaison psychiatry
- Forensic psychiatry
- Geriatric psychiatry
- Hospice and palliative medicine
- Sleep medicine
Additional psychiatry subspecialties, for which the ABPN does not provide formal certification, include:
- Biological psychiatry
- Community psychiatry
- Cross-cultural psychiatry
- Emergency psychiatry
- Evolutionary psychiatry
- Global mental health
- Learning disabilities
- Military psychiatry
- Neurodevelopmental disorders
- Neuropsychiatry
- Interventional 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 psychiatric disorders. Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system.
Child and adolescent psychiatry is the branch of psychiatry that specializes in work with children, teenagers, and their families. Community psychiatry is an approach that reflects an inclusive public health perspective and is practiced in community mental health services. Cross-cultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.
Emergency psychiatry is the clinical application of psychiatry in emergency settings. Forensic psychiatry utilizes medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions. Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly.
Global mental health is an area of study, research and practice that places a priority on improving mental health and achieving equity in mental health for all people worldwide, although some scholars consider it to be a neo-colonial, culturally insensitive project. Liaison psychiatry is 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 is a branch of medicine dealing with mental disorders attributable to diseases of the nervous system. Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental well-being.
Evolutionary psychiatry (or Darwinian psychiatry) is a theoretical orientation within psychiatry that applies principles from evolutionary biology—such as natural selection, adaptation, mismatch, and trade‑offs—to frame hypotheses about the origins, persistence, and variation of mental disorders.
In larger healthcare organizations, 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.[citation needed]
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.
Research
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.[page needed]
Another thing to consider in research and conducting research in the field of psychiatry is the patients needs and values as Brock mentions their chapter on Informed Consent regarding the need to explain and inform participants about a research study and also act in their best interests, as Hellman and Hellman discuss.
This can face challenges, such as dual-conflict roles in which their conflict roles between being a doctor and a researcher, especially in research involving control groups where some participants are not getting a treatment, where treating people as a merely just a means to an end, as discussed in Kantian morals, and not prioritizing their well-being and ensuring they are informed and given the option of treatments available, even those in research with positive predicted outcomes.
Moreover, when considering participants in research, it is also important to look at labelling and stigma attached as published research can be read and used by the public and cause bias, despite research limitations if they are not addressed and thought-out thoroughly by a reader, and cause people to push labels on people, as Voronka discusses how research can be used and influenced to make homelessness mental health condition instead of a result of structural and capitalist policies, as well as can create a stigma around people deemed so-called at-risk, as Corcoran, Malaspina, and Hercher discuss, raising questions around when to intervene and how research can be harmful.
Diagnostics and evaluation
Present
Diagnostic systems
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. Some clinicians are beginning to utilize genetics and automated speech assessment during the diagnostic process but on the whole these remain research topics.
